order to fully appreciate the impact ACOs will have on 3rd party medical
billing companies, it’s important to understand what the ACO is and what it’s
meant to accomplish. The ACO, or Accountable
Care Organization, is destined to play an increasing role in Medicare
healthcare delivery in 2012 and beyond.
As part of the healthcare reform movement, the idea behind the ACO
- Providers will form groups that span practices and specialties,
and will serve a specified group of Medicare patients.
- Technology will allow the sharing of information between
these providers, allowing for greater efficiencies and results tracking.
- The providers will collaborate among themselves to make sure
they are delivering the most affordable and effective care.
- The government will provide financial incentives if costs
are controlled or reduced.
when increased government scrutiny (some would say micromanagement),
regulations (HIPAA) and revenue cycle management are figured into the equation,
the task of forming and managing ACOs becomes considerably more complex:
- The CMS (Centers for Medicare and Medicaid Management) first
issued its rules for ACOs in March of 2011.
The original document spanned 400 plus pages, and solicited questions
and comments from concerned parties. In
October, the final rules were released and expanded to nearly 700 pages. Will ACOs be able to keep up with ongoing
changes, or will compliance ultimately end up being a major cost increase
- With the cross pollination of services will come the need
for cross pollinization of confidential medical information. With HIPAA the law of the land, will the
exchange of information, mostly through technology, also increase the
vulnerability of confidential patient information?
- Like the HMOs in the 1990s, will the financial incentives
lead to compromises in the level of care provided in order to control costs?
and Third Party Billing Companies
physicians and other healthcare providers rely largely on third party medical
billing companies. This opens the door
to a whole host of problems:
- If physicians’ team up to form an ACO and different billing
services were utilized by different providers within the organization, how does
the ACO decide which service to use?
- Since all services must now be coordinated between
providers, all billing must also be coordinated. While it would seem that this would be an
easily accomplished through technology, there are risks.
- If technology is to be utilized to streamline these
processes, how is security going to be managed? Does the proper technology exist?
- Just like the physicians themselves, the billing companies
are going to have to keep up with the latest regulatory changes.
- Even without regulatory changes, the financial incentives
for meeting cost goals are going to be complex to track. This will be another challenge for third
all this sounds daunting, the risk for 3rd party billing companies is dwarfed
by the opportunity. At no time in
medical history has there been a greater need for expertise, technology,
compliance assistance etc. There is
simply no entity in existence positioned to meet these needs better than the
third party medical billing companies.
Most already have state of the art technology in place and have had to
be on the cutting edge when it comes to compliance and expertise in order to
survive. In addition, physicians and
healthcare providers will need help in order to make sure they themselves are
conforming to all the requirements inherent in the formation of their
ACOs. This represents another great
opportunity for third party billers; that is, consulting services to make sure
that their clients’ ACOs are meeting the ever-changing requirements and
anything new and innovative, the ACO is not without its foes. And, like anything that deals with the health
and welfare of the population, change is a constant. By leveraging their essential functionality
with the potential value-adds referred to above, the 3rd party medical billing
industry can not only be an essential cog in the ACO mechanism, but can also
ensure that the Medicare healthcare providers have the time and resources to
concentrate on their real priority: providing healthcare to our aging
Brad Lund is the Executive Director of HBMA.