Free EMR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Join thousands of healthcare pros who subscribe to EMR and HIPAA for FREE!!

Have We Forgotten About Health Insurance Exchanges (HIX)?

Posted on April 10, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

When Healthcare.gov ran into problems we heard all about the health insurance exchanges (HIX). Since Healthcare.gov hasn’t run into any issues we aren’t hearing about health insurance exchanges nearly as much. The exception might be the states that were running their own HIX and failed. I’ve seen a number of those stories out there.

However, I think that the HIXs have largely left the healthcare dialogue in general. I’m sure the payors involved in the exchanges are still highly involved, but most people aren’t following it.

This was driven home to me when I saw the following two tweets and images about HIXs.

I’ll admit that I haven’t dug into the exchanges lately either other than when I tried them out at the end of last year when I had to find a new insurance company (Side note: the price on the HIX was more than what I could get separate and they weren’t offering me a subsidy, so I didn’t end up using the HIX). Since I haven’t been involved or watched what’s happening with HIXs, I can’t say if they’re a good or a bad thing. What I do know is that they’re playing a huge role in healthcare and how and what health insurance people are getting. So, maybe we should be paying more attention.

Maybe some of my readers are following it a lot closer than I am doing. If you are, please enlighten us in the comments.

Interview with Barry Haitoff, CEO of Medical Management Corporation of America

Posted on January 20, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The following is an interview with Barry Haitoff, CEO of Medical Management Corporation of America.
Barry Haitoff

Tell us about Medical Management Corporation of America (MMCOA).
MMCOA helps physicians and physician groups increase collections, assure compliance, manage overhead and navigate the maze of EMR/EHR, Meaninful Use, PQRS and other Government incentive programs and regulations. With a focus on revenue cycle management, MMCOA helps our clients stay ahead of the curve with things like the transition to ICD-10.

What are the keys to running a good medical billing company?
Like any successful business, I believe the 2 most important assets are people and systems. We hire, retain and cultivate quality individuals and empower them with state of the art systems and technology. We never settle for status quo and continue to look for better ways of doing things. My style of leadership is one of servitude. It is my goal to provide all staff members a great work environment, financial incentives and proper tools to perform their functions.

What’s your take on the economics of outsourcing medical billing? Where’s the ROI for an office that’s considering going with an outside medical billing company like yours?
I tell physicians, “do what you do best and outsource the rest”. Your tax work is handled by a professional accountant, your legal work is handled by a professional attorney, who is handling your billing? Outsourcing your billing can sometimes be more expensive than keeping it in-house, however, the return should far outweigh the added cost.

Most practices do not have adequate resources in their billing department to do the right job. A great deal of money winds up being left on the table. There is a reason that the tallest buildings in most metropolitan cities are owned by insurance companies. A quality billing company will increase your collections at a rate that will far exceed the fee.

In addition, because the typical fee structure is based on a percentage of collections, not only does the billing company have “skin in the game” to do a good job, the billing overhead of the practice is better managed. If one or more physicians are out of the office on vacation resulting in lower charges, that eventually results in lower collections. With billing in-house the practice still pays salaries, benefits, software licenses etc. All the fixed costs remain in place regardless of collections that month. With outsourced billing company, the practice’s cost for billing is directly in proportion to the amount collected that month.

What are some of the biggest changes to medical billing that have happened over the past couple years?
EMR/EHR, PQRS, ePrescribing, HIPAA, Meaningful Use, Accountable Care Organizations, Value/Quality based reimbursement, Bundling, Health Insurance Exchanges, added governmental regulations, OIG compliance and soon…..ICD-10, ICD-10, ICD-10. ICD-10 will prove to be the biggest challenge to date. We’re ready!

How is medical billing going to be impacted by things like ACOs (Accountable Care Organizations) and value based reimbursement?
Someone will still need to make sure that services rendered are reimbursed properly. More challenging, someone will need to distribute funds appropriately to the myriad of providers involved. There will be a greater need for revenue cycle management as payments are bundled.

Is healthcare ready for ICD-10? What are you doing to make sure you’re ready?
Our research to date says no. Providers and staff are not yet trained. Insurance carriers and software vendors have not yet successfully tested.

We have established an ICD-10 committee headed by our Director of Healthcare Informatics. We have begun informing and educating our clients and staff, researching tools, attending training sessions, initiating dialogue with our software vendors and staying up to date.

In what ways has the Accountable Care Act (Obamacare) and the health insurance exchanges impacted your clients?
I’d say that it’s caused a whirlwind of confusion. Providers must take the time to determine which HIX plan networks they’re in, so as not to provide care outside of a contracted relationship with the HIX plans, which predominantly lack out-of-network coverage. We expect our clients to become busier. We expect the additional covered lives to find their way into our clients’ offices. We have helped our clients figure out if they are participants in the Exchanges in their area.

A number of EHR companies have started doing medical billing. How do you differentiate the services you offer versus an EHR vendor?
Most of the EHR vendors that have just started doing medical billing, just started doing medical billing. MMCOA has been in business for 18 years, growing primarily by word of mouth. Some of the EHR vendors are publicly held companies whose most important stake holder is their shareholders. Our most important stakeholder is our clients. We have had clients leave us for those solutions and have since come back. We will continue to provide quality service on a consistent basis and will never sacrifice integrity for growth.

What are the biggest revenue cycle management issues you see in organizations?
Not enough staff. Outdated or inadequate technology. Lack of leadership. Lack of ongoing training. Lack of incentive.

Where do you see revenue cycle management going in the future?
My crystal ball is broken right now. Seriously though, there is a lot of consolidation in our industry and the smaller billing companies will likely go out of business or be acquired. Physicians and physician groups will continue to need assistance with their reimbursements. Unless all healthcare providers wind up employed by an ACO, Hospital System or other Healthcare entity with adequate revenue cycle management expertise, there will be a need for continued navigation of the maze we know as healthcare revenue cycle management.

Medical Management Corporation of America, a leading provider of medical billing services, is a proud sponsor of EMR and HIPAA.

Health Insurance Exchange Q&A with John Kelly from Edifecs

Posted on September 27, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The following is an interview about Health Insurance Exchanges with John Kelly, Principal Business Advisor, Edifecs.
John Kelly
1. Where are we at with Health Insurance Exchanges (HIX)? What are the timelines for their implementation?

The Patient Protection and Affordable Care Act (ACA) mandates creation of a retail market for health insurance, where individuals can shop, compare and buy healthcare coverage much the same way as they would a car. The goal is to provide greater access to healthcare coverage and eventually lower costs. While the ACA initiated the health insurance exchanges (HIXs) as the first step in creating a new retail market for healthcare, it specifically did not stipulate the Federal and State exchanges as the stated goal of the legislation. The stated goal was to reform the way Americans purchased their healthcare. Before the October 1st deadline has even arrived, the HIX model is already evolving beyond the federally funded exchanges. Private exchanges are already up and running and private websites (eHealth Insurance, et al.) have begun to integrate with public infrastructure. Much of the country has focused on the open enrollment date, but the real challenges come afterward, as the industry deals with the operational realities of participating on HIXs over the long term.

The public exchanges are due to launch next week, and open enrollment runs through March 31, 2014. Starting January 1, 2014 all health plans purchased through the insurance exchanges will go into effect, meaning those who bought their health insurance on an exchange will be covered.

2. This is implemented on a state-by-state basis, right? Are all 50 states ready?

There are numerous exchanges. Each state had the option to establish its own state-operated HIX or participate in the Federally Facilitated Marketplace (FFM). Thirty-three states chose the FFM, 15 states plus the District of Columbia are running their own marketplaces, and two states are partnering with the federal government to run their exchange.

In addition to the state-run marketplaces, another major component is the Data Services Hub, which is a tool developed by The Centers for Medicare & Medicaid Services (CMS) to interact with all 51 exchanges, verify applicant information and determine eligibility for enrollment in select health plans and subsidy programs.

Some states are more prepared than others, having made investments in customer service hotlines, technology testing, and consumer education campaigns. Generally, these states made early decisions to participate, so their implementations are more mature, though I doubt any would say they are all set to go. As enrollment gets underway, all of the exchanges will engage in constant improvements (much like any large technology project) to iron out bugs and improve functionality. For the states that didn’t make those investments, it will be a more difficult process.

3. What do health insurance exchanges mean for the health plans? What’s their reaction to the health insurance exchanges?

HIXs are creating a disruptive force for insurers and purchasers, a force that will change the way they conduct business. For insurers, it will change everything from attracting consumers to their end-to-end administrative processes (member enrollment, system integration, payment transactions, etc.).

It hasn’t been easy, particularly because of the compressed timeline between the federal government releasing detailed guidelines and the go-live date of October 1, 2013. Insurers are trying to balance caution with the prospect of 30 million enrollees and $200 billion in revenue within the next decade.

Many health insurers have realized they already participate in Medicare and Medicaid, a form of retail healthcare purchasing, so why not exploit the opportunity of these new exchanges? The reward potential is compelling, especially for regional plans that can now compete with national plans for employers who may choose to migrate to “defined contribution” plans. This is likely to be the largest open enrollment period in history nationwide. While it is not an ideal situation to increase enrollment under such a tight timeline, many realize the potential opportunities and are committed to making it work.

Perhaps the biggest change for plans is that they will have to learn to compete for members and customers, rather than employer groups and brokers. The shift away from competing for members began in the early 1990’s with “sole source” health plan marketing. Plans will need to re-learn some old skills. Plans will need to compete much more consciously on value as opposed to just cost. This was the primary and clear intent of the ACA.

4. What do the health insurance exchanges mean for an employer?

Up until recently, the consensus in the industry was that most employers would stick with the conventional employer-sponsored benefits system, rather than switch to a defined contribution plan. But as this recent Wall Street Journal article explains, many employers are now moving toward providing employees a sum of money to go buy their own coverage. This trend indicates that many companies are looking at HIXs as a way to control the increase in their healthcare benefit costs, while perhaps more importantly, providing their employees with greater choice. This is a huge sea change. While employers have known they need to continue offering healthcare coverage to attract the most talented workforce, they have been struggling with the spiraling costs. Many now see HIXs as an ideal solution.

5. What do the health insurance exchanges mean for patients?

These exchanges are part of a greater trend toward patients playing a larger, more active role in their own healthcare. For selecting a healthcare plan, HIXs are shifting decision-making from employers to their employees; in essence returning healthcare to a direct-to-consumer sales model that will redefine consumer expectations, customer service and healthcare consumer marketing. The overall success of this shift will be based upon the ability of consumers to be better purchasers. There is certainly more risk and effort involved, but the upside is a significant increase in choice and a strong incentive for the plans to compete aggressively on value for dollar.

6. What broader goals do you see the health insurance exchanges bringing to healthcare?

As I mentioned above, one mandate in the ACA is to establish a retail marketplace for healthcare as a means to improving access to healthcare and inevitably lowering costs. HIXs are the current manifestation of that goal, and it’s a positive disruption in the market. As we’ve seen with other such market force change, we may be able to predict the disruption, but we can only guess at the form it will take after the first wave of innovation and market reaction.

7. What are the biggest challenges for health insurance exchanges?

There are a lot of moving pieces, and as with any large technology project, there are always going to be bugs to be fixed and improvements to be made. There is no reason to believe each state’s marketplace won’t go live on October 1 or soon after; however, many won’t be perfect. This launch is similar to the “soft launch” of a retail store opening, and it may take a few months to get everything working. It will probably take a couple of open enrollment cycles to achieve a steady state. The long-term challenge is the same as any insurance product; will the actuarial base support the financial health of the system over time? As this is a market rooted in Federal Law, similar to the experience seen in the Commonwealth of Massachusetts Connector (“Romney Care”), I suspect the system will demonstrate remarkable inertia and will roll slowly toward equilibrium.

These Exchanges have no choice but to continuously improve. By March 2014, I expect the industry will be thinking, “It could have been a lot worse, but we made it,” and they’ll be moving forward to make the next open enrollment much smoother.