Oncoming battle for reimbursement

September 25, 2012

The fight to get paid is continuing for providers. Discover how this battle might play out.

Editor's note: In this issue, Medical Economics takes a look at payer-related issues facing you and your colleagues. Our October 10, 2012, issue will feature related results from our State of Primary Care survey of practicing physicians and interviews with other thought leaders in this arena.

Perhaps now more than ever, the relationship between physicians and payers faces an uncertain, rapidly changing future. New technologies, evolving concepts for care delivery, and new legislation and regulations are all exerting new financial pressures.

Even a partial lineup of recent or pending changes affecting the payer and provider relationship is daunting-from questions about increasing denials to the inherent challenges of implementing the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10).

Trends regarding physician reimbursement, says Virginia Martin, CMA, CPC, CHCO, CHBC, of Healthcare Consulting Associates of N.W. Ohio Inc., Waterville, "are all headed down." Multiple factors are at work, she says, but a principal reason is insurers' pursuit of profits.

Practices should be reimbursed based on actual cost plus a markup, he says, noting that healthcare is the only business that's run the way it is.

"As long as medical practices choose to have business partners that are inherently dishonest and unethical," that is, commercial payers, "they will not realize the full value of what they do," he says.

"It's not going to be pretty" over the next 4 to 5 years, especially for smaller practices, adds Annie Boynton, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT, a member of the American Academy of Professional Coders National Advisory Board. She predicts that practices will be more likely to merge because of economic pressures.

In the face of all this news, some observers are nonetheless guardedly optimistic.

"The tension between the payers and the doctors has been lowered a notch or two," says Charles Cutler, MD, FACP, member and chairman-elect of the American College of Physicians (ACP) Board of Regents.

Glen Stream, MD, MBI, FAAFP, president of the American Academy of Family Physicians (AAFP), broadly agrees. "There's been a significant recognition by commercial payers that they need to support primary care payments," he says.