A famous Greek philosopher, Heraclitus of Ephesus once said, “Everything changes and nothing stands still.” From that phrase came some modern diminutions, such as, “Nothing endures but change.” How true this is in our current healthcare system today. Change is all around us.
So what is the In the impact of healthcare reform on hospital denials?
In 2010, we witnessed the largest reform or change in our healthcare system with the Patient Protection and Affordable Care Act or the Affordable Care Act (ACA) for short. Such a comprehensive change was not seen since the 1960’s when Medicare was enacted. Now, we are witnessing another change with the attempts to repeal and replace the PPACA with other healthcare plans being offered by Congress.
There are multiple proposals on healthcare reform currently in play such as The Health Care Freedom Act, 2017, Graham-Cassidy-Heller Amendment, The Better Care Reconciliation Act of 2017 – updated 7.20.17, Obamacare Repeal Reconciliation Act of 2017, The Better Care Reconciliation Act of 2017 – Updated 7.13.17, includes Cruz amendment and The American Health Care Act, as passed by the House of Representatives on May 4, 2017. http://www.kff.org/interactive/proposals-to-replace-the-affordable-care-act/
The main concern with these healthcare reform plans seems to center on the limitation on the growth of Medicaid expansion. Some of these plans want to leave the decision to expand up to the states or provide block grants to the states rather than per capita funding.
If you are a facility with a heavy Medicaid population, you may see an increase in uncompensated care. Some of the plans will remove the Individual Mandate which will decrease the amount of people currently enrolled in a healthcare plan. Some will also rollback the Employer Mandate for providing health insurance for companies with more than 50 employees. At this point in time, without knowing the final outcome of which healthcare plan will be employed, we can only make projected guesses on the financial impact on healthcare facilities.
While it’s important to know that change is ever constant in the healthcare industry, the good news is that there is a positive solution to combating these potential losses.
First, you must understand the specific financial impact for your own facility once the final reform decisions have been made.
Secondly, you need to have an effective Clinical Appeals team as “change agents” able to combat these denials. This team should have a proven track record of overturning difficult denials with clinically experienced nurses with knowledge of commercial and government insurance plans including Medicare, Medicaid, HMO/PPO and Managed Care plans.
This team also needs to understand and apply nationally recognized clinical criteria, payer specific criteria and applicable healthcare laws to the denial at hand. And finally, it is vital that this team provide your facility with a root cause analysis to understand why the denial occurred in the first place and provide specific recommendations to prevent future denials. So, although healthcare reform will continue to take on many different forms in the years to come, you do not have to simply “endure” this change.
An effective Clinical Appeals team can provide your facility with the opportunity to combat potential healthcare denials with a positive outcome.