A New Healthcare Model?

A closer look at universal healthcare

While many Americans understand the basic economics of our existing healthcare system, healthcare reform is front-and-center in the 2008 election cycle. One of the most discussed and dramatic changes being proposed is universal healthcare. Once viewed as impossible, universal healthcare now seems more possible than ever. Consider that Massachusetts, California, Maine, Vermont and Hawaii have created, or are currently considering implementing, universal or near-universal systems.

While many Americans understand the market-based model, universal healthcare is a very nebulous and undefined idea in the American political discussion. This leaves many of us asking: What is universal healthcare and what does it mean for the modern healthcare industry?

Coverage for all citizens

Whether one calls it universal healthcare or universal coverage, the goal is the same: to extend healthcare coverage to every citizen by either private insurance or government programs. Beyond that common goal, proponents often vary greatly on how to achieve it.

Understanding the differences between the primary methods of implementation around the world is the key to assessing what effect any such healthcare reform will have on patients, providers and payers in the US.

What are the most common forms of universal healthcare?

Compulsory Insurance - Currently used in Massachusetts, Germany and Belgium

The compulsory insurance model uses legislation to require every citizen to purchase affordable health insurance. A government oversight board creates the definition of affordable after negotiating with pharmaceutical and insurance companies to mediate their potential liability. In the Massachusetts model, which took effect in 2006, citizens who do not qualify for poverty/low-income assistance must buy insurance or face yearly fines assessed on their income tax. Legislation also expands coverage for the poor and penalizes employers who do not offer healthcare coverage.

Taxation - Currently used in England, Australia and India

Taxation is a very different way to achieve universal healthcare. In this model, which has been used in England since the end of World War II, insurance is almost entirely eliminated and the healthcare system is regulated by the government and funded from the public tax pool. Hospitals and high-level healthcare infrastructure are overseen by government agencies, while doctors and staff are a mixture of private and government employees. Some countries have also used the taxation model, but left direct control up to state or provincial governments.

Combined - Currently used in Canada, Singapore and the Netherlands

Several countries have taken this dual-level approach to universal healthcare wherein primary care is directly funded by tax dollars collect from the general public. Private insurance companies still exist to offer supplemental coverage for extra services like dental, vision, elective procedures, extended hospital stay, upgraded facilities for hospital stays and other services deemed outside of primary care. Often, such as in Canada, almost all hospitals are publicly managed. The amount of public and private mixture varies between each version implemented by a nation or state.

The reforms to the healthcare industry discussed during this election cycle are sure to be as complex and difficult as the problems facing our industry in general. Whether any politician in America rallies enough public and political support to implement a universal healthcare system, there is an undeniable urge on all sides to change the business of healthcare for the better. Everyone agrees that increasing efficiency, reducing costs and improving overall care are of vital importance to any plan, but how we achieve those goals, it appears, will remain open to debate.

Efficient Healthcare Collections – Back Office to Front Office

...Uncollected receivables related to CDHP are forecasted to reach $38B in 2008 growing to $82B in 2012
...$0.38 of every physician dollar is related to bad debt
...Approximately 12% of healthcare spend is the patient’s responsibility and growing*

What is the impact of these trends to the provider?

Increased patient co-pays, coinsurance and deductibles both for traditional insurance plans and consumer driven health plans resulting in increased provider administrative cost to collect based on current payment collection processes.

The increasing shift of financial responsibility from employer and health plan to patients requires providers to manage their accounts receivable more efficiently. Providers can no longer rely solely on current back end billing processes and on private insurance or government programs for the bulk of the health service payments. Providers need to implement ways to identify patient responsibility prior to, or at the point of, service and begin to stave off the increasing administrative cost related to collecting patient payments.

The patient landscape is also fast evolving to where the member is not just a patient but is a retail consumer. As with any retail environment, consumers are beginning to shop around for services. In order to maintain a competitive edge and ensure streamlined administrative costs, providers need to provide an efficient solution for cost and quality transparency of their services.

Providers are starting to implement ways to identify patient responsibility prior to the patient leaving the office and are beginning to ensure the patient has a true understanding of their financial obligations at the time of service. Several industry solutions offer providers the ability to estimate patient cost of service delivered – either before or at the point of service, based on a combination of provider historical paid claims data, provider contract rates with payers, patient benefit information or fee schedules. Adopting these solutions gives the provider the ability to understand patient responsibility and set the expectation with the patient for payment. The impetus for the payment assurance solutions in the industry is to enable and empower the provider with patient responsibility data, as well as to enable the provider to understand the patient’s ability to pay and to complete the cycle by enabling the patient collection. All of this can be accomplished with decreased administrative burden to collect payment.

Research has shown that if a patient expects and understands their responsibility, they are more likely to make plans to pay for the service; and a provider’s chances of getting the patient payment is highest when they present it to the patient at point of service so a payment plan can be setup prior to a patient leaving the office.

Patient responsibility and financial liability solutions will not only increase upfront collections, but it can also directly impact the ability to collect efficiently post-discharge, including how to direct outsourced collections efforts. In addition, it can also streamline efforts to qualify patients for charity care and government programs and ensure that charity practices are implemented consistently. For everyone's benefit, patients who qualify for charity discount programs can be enrolled in them right away, on the front end, saving both parties time and money.

Point of Service collection encounters can be successful even if you don’t get a dollar, as long as the patient walks away from the office understanding why he or she owes the $200 and thinking about how to pay it. At this particular juncture in the consumerism movement, educating the customers of their financial responsibility is just as important.

Provider offices must be prepared not just to deliver accurate and timely information about a consumer/patient’s benefits on the spot, but also to explain that information in terms that make sense to the consumer, to listen to the consumer’s response and react appropriately, and then to bring the conversation to a close in that satisfies both parties.

Patients are beginning to carry the majority of uncompensated care, yet most provider offices lack the necessary tools and technology to optimize patient collections, or to ensure that charity care and public assistance patients don’t fall through the cracks. With the increasing number of patient out of pocket payments, providers will need to adopt solutions to better understand patient responsibility and begin to have the conversations with patients about their out of pocket costs and payment plans in order to maintain a viable revenue cycle.

*Source: March 2007 Kaiser Commission on Medicaid and the Uninsured & Forrester March 7, 2005 report on Will Health Plans profit from HSAs; nTelagent April 2008 report

It's Almost Payment Time... Do You Know Where Your Claims Are?

Improve claim visibility with Emdeon VisionSM for Claim Management

Determining the status of your claims once they have been submitted has always been a painful and time consuming process, but with Emdeon Vision for Claim Management providers can track any claim on the largest network in healthcare, all from one place. This powerful web-based application gives providers a simplified, end-to-end view into the claim cycle through one secure system.

Clear and concise monitoring

With Emdeon Vision for Claim Management, once the claim has been submitted you will be able to monitor its progress through centralized and easy-to-read claim summaries. This will replace the need to call multiple payers and visit multiple websites to get updated claim statuses. These summaries allow you to quickly scan all claims and focus staff attention on ones that require further work, then sort and search claims according to a variety of different elements. Having the ability to quickly rework the claim also helps reduce or eliminate painful delays in your cash flow. Since all searches are done electronically, you will no longer need to worry about patients in your office overhearing the sensitive information that is sometimes exchanged over the phone.

Reduce rejections and delays

Every provider has to deal with some level of claim rejections, but with Emdeon Vision for Claim Management you will be able to view and take corrective action on incorrect codes that can save weeks over manual processes. You can also expect to get accurate and detailed monitoring thanks to intuitive reports. The reports can quickly reveal important trends like where your claims are being delayed, and you'll get them in consistent formats to eliminate the labor-intensive task of monitoring paper claims. Spotting trends in rejections can also lead to higher first-pass acceptance rates and save you even more time and money.

Emdeon Vision for Claim Management combines all of these valuable features into one easy-to-use and centralized solution that greatly increases your ability to see what's happening with your claims almost as it happens. You will have the same great insight and monitoring capabilities as the nation's leading payer groups, which improves your ability to predict and manage cash flow while focusing more on the cornerstone of your healthcare business: your patients.

To find out more about how we can improve your claim management, contact us today at 866.558.3581 or contact us online.

Physician's Corner

Answers to questions submitted from some of our physician readers

How do I enroll with a payer for electronic funds transfers (EFT) or electronic remittance advice (ERA)?

Medicare: All Medicare payers offer an EFT solution. To get paid electronically for government-related claims, download and fill out the CMS588 form from the CMS website. Mail the form, with the original signature (no facsimile signatures can be accepted), to the Medicare contractor that services your geographical area.

For additional information, on the use of EFT for provider payments, refer to the Medicare Claims Processing Manual, (Pub. 100-04), Chapter 24, Section 40.7.

Medicaid: To sign up for EFT, go to your state Medicaid website and research to see who state Medicaid processor is. Each state website will have their enrollment instructions and process posted.

Blue Cross Blue Shield All Blues plans have enrollment instructions on their individual websites.

Commercial: Each Commercial payer that offers an EFT solution has their own enrollment process. You will need to contact the payer directly to inquire about their specific EFT process and availability.

If you have a question you would like answered in our next newsletter, please submit your question to contact@emdeon.com.

New Payers on Board

New payers added this quarter

Emdeon Business Services is pleased to announce the following
payers as part of our constantly expanding network:

• Advantage by Bridgeway Health Solutions - Claims
• Advantage by Buckeye Community Health Plan - Claims
• Advantage by Managed Health Services - Claims
• Advantage by Superior HealthPlan - Claims
• Aequitas Capital Management - Claims
• American Benefit Plan Administrators - Claims
• AmeriChoice by UnitedHealthcare-New York - ERA
• AmeriChoice of New Jersey, Inc. (Medicaid NJ) - Claims
• Banner Health - Claims
• BCBS Utah FEP - Claims
• Beacon Health Strategies - Claims
• Blue Cross Blue Shield - Montana - ERA
• Blue Cross Blue Shield of Montana - ERA
• Blue Shield Washington - Claims
• Care To Care - Claims
• Cedars-Sinai Medical Network Services - Claims
• Central SeniorCare - Claims
• Custom Design Benefits Inc. - Claims
• Dept. of Human Services - ERA
• Eastland Medical Group - Claims
• Elder HLTH Maryland - Claims
• Fidelis Secure Care - Claims
• First Priority - ERA
• Global Care Inc. - Claims
• Health Systems International - ECOH - Claims
• Healthcare Resources NW - Claims
• HealthPartners - Claims
• HIP - Health Insurance Plan of Greater New York - ERA
• Independence Administrators - Claims
• InterCare Health Plans Inc. - Claims
• International Educational Exchange Services, Inc. (IEES) - Claims
• Johns Hopkins Healthcare (USFHP) - ERA
• Kaiser PPO - Claims
• Korean American Medical Group - Claims
• Manatee Service Center (Bradenton, FL) - Claims
• MedDirect - Claims
• Medicare Regional Home Health & Hospice - Golf Coast & Mid West - Claims
• New Century Health - Vista Cardiology - Claims
• Noridian Medicare - ERA
• Optima Health Plan - Claims
• Optima Insurance Company - Claims
• Partnership Health of California-CAPHP - ERA
• Piedmont Behavioral Health - Claims
• Pittman & Associates - ERA
• Progressive Benefit Services, Inc. - Claims
• Riverside San Bernardino County Indian Health Inc. - Claims
• Rwdsu Benefit Fund - Claims
• SelectCare of Texas (HPN) Heritage Physicians Network - Claims
• Sentara Family Care - Claims
• Sentara Health Management - Claims
• Southern Cal Physicians Managed Care Services - Claims
• Stones River Regional IPA- Windsor - Claims
• Texas Children’s HEALTH - Claims
• TrailBlazer Health Enterprises - Claims
• UAHC Health Plan of Tennessee - Claims
• Ucare Minnesota - Claims
• United AmeriChoice of Wisconsin - ERA
• United Healthcare of River Valley - ERA
• United Healthcare of the Mid-Atlantic, Inc. - ERA
• United Medical Resources - ERA
• Universal Health Care, Inc - ERA
• Value Options PA - Claims
• Verdugo Hills Medical Group - Claims
• Viva Health Plan - Claims
• VNS Choice Medicare - Claims
• WellPath - Claims
• West Corvina Medical Group - Claims
• WestLake Financial Group, Inc. - Claims
• WPP-ElderCare Wisconsin - Claims

For a complete list of the payers in our network, visit our website.

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