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Top Challenges Number 2: Getting paid


Medical Economics counts down the top challenges facing physicians in 2020.

It has never been such a challenging time to be a physician. Every physician, whether they own their own practice or are employed by a hospital or larger health system, must navigate a host of obstacles each and every day: Payment hassles, staffing issues, patient communication obstacles, technology burdens, long hours and burnout, and much more. 

Each December, Medical Economics presents its list of the top challenges facing physicians going into the next year. This year we focused not only on the challenges, but also practical tips physicians can start using right away to make practicing easier.

Challenge 2: Getting paid

Treating patients and managing a practice are challenging enough. But for today’s physicians, simply getting paid is often a struggle. It means navigating an increasingly complex reimbursement landscape marked by myriad programs linked to quality metrics and outcomes. It also means seeing that the practice is documenting and coding accurately so as to avoid denials and ensure proper reimbursement levels. Also, more patients have high-deductible health plans, which means practices are often on the hook for collecting from patients.

Here are some tips from experts for navigating these challenges.

Focus on outcomes

Value-based payment is not going away, so even physicians who are still largely reimbursed via fee-for-service need to learn about quality metrics and the various value-based programs created by both public and private payers.

As Medicare continues to move into value-based care and private payers add more incentives focused on outcomes, data becomes increasingly important for a practice’s reimbursement outlook. Physicians in the MIPS program must track and submit data on a dizzying array of measures, and many private payer contracts have similar metrics that require data as their proof point.

If a practice does not have the data to prove patients are achieving desired outcomes, reimbursement can take a substantial hit-up to 9 percent just from MIPS by 2022. Combine this with private payer contracts that continue to incentivize value-based outcomes, and a substantial part of practice reimbursement could be endangered by a lack of performance data, experts say.

“Carriers are doing deals that generally reward physicians in value-based contracts, but minimize reimbursement increases if they are not involved in value-based benefits,” says Ken Goulet, former executive vice president of Anthem Inc. and current board member at OODA Health, which focuses on streamlining interactions between payers and providers.

Goulet says that while fee-for-service won’t be completely eliminated, doctors can expect to see diminishing reimbursements in 2020 and beyond.

Changes coming in 2021

2020 looks to be a transition year on the payment front, as many programs and changes expected to go into effect this year have been delayed until 2021. These include new CMS-created primary care models and a streamlining of evaluation and management level-of-care coding.

CMS announced in October its newest alternative payment model, Primary Care First, has been delayed until January 2021. Primary Care First is geared toward primary care practices that are ready to accept financial risk (i.e., payment reduction for missing quality goals) in exchange for more flexibility, increased transparency, and performance-based payments that reward participants for outcomes, according to CMS. In addition, CMS will provide higher-than- historical Medicare fee-for-service payments for practices that care for complex, chronically ill patients.

In terms of E/M changes, CMS is:

  • Reducing from five to four the number of levels for office/outpatient E/M visits for new patients

  • revising the code definitions

  • changing the times and medical decision-making process for all the codes,

  • requiring performance of history and exam only as medically appropriate, and

  • allowing clinicians to choose the E/M visit level based on either medical decision-making or time.

How to avoid E/M denials

Here are four tips to help physicians avoid denials due to incorrect E/M levels:

1. Ensure the E/M code supports the specific patient encounter.
Not every patient with a chronic condition will justify reporting CPT code 99213. Some cases may be exacerbated and/or require medication management and referrals to specialists while others may be relatively straightforward and controlled.

2. Refer to the E/M guidelines
Assigning an E/M code is not a subjective process. Instead, physicians should refer to the 1995 or 1997 E/M guidelines for specific requirements for time-based billing as well as billing based on the three key components: history, exam, and medical decision-making. The most common mistake physicians make when applying these guidelines is under-documenting E/M level 4 and 5 visits for new patients. More specifically, they omit one or more systems in the requisite general multi-system exam or they omit a complete past family and social history.

3. Be cautious with copy and pastefunctionality.
Copy and paste can save time, but it can also cause serious compliance problems. That’s because when physicians automatically bring historical information from a previous encounter forward into their current note, they may inadvertently inflate the E/M level. Best practice is to validate any information copied forward to ensure its accurate and relevant to the current encounter-or turn off the functionality altogether.

4. Watch out for pre-populated EHR templates.
Pre-populated templates not only cause up-coding (e.g., if certain body systems are always indicated as having been reviewed even when they’re not relevant to the current encounter), they can also lead to contradictions that raise red flags with payers. For example, if a physician diagnoses a patient with strep throat, and the template defaults to a normal exam for ear, nose, and throat, it could open the door for a post-payment audit. Physicians should ensure their documentation is aligned with the patient’s diagnosis even if it means manually unchecking certain boxes in the template.

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