Practice Priorities for Physicians to Thrive in ACA, Receive Higher Reimbursement

By Cyndy Nayer, February 7, 2014

The promise of value, outcomes, and payment reform are foundational within the ACA (Affordable Care Act) legislation, sometimes called Obamacare.  In order to achieve these reforms, electronic medical records, value-based designs, wellness incentives, expanded coverage through Medicaid, and new entities such as patient-centered medical homes (PCMH) and accountable care organizations (ACO) have been established. The health insurance exchanges (HIX) are now called health insurance marketplaces [and these are often confused with HIE, which are health information exchanges - basically a data repository of claims and predictive analysis]. The new HHS website is improving Healthcare.gov, and it contains with rules and financial information for physicians, employers, and individuals.

These are important changes for physicians and practice management teams to know as they will impact not only how you invoice but how your patients react to prevention, wellness, chronic care management, and more.  It will be imperative for practice managers to understand the limitations from the new insurance plans.  On the other hand, due to the previous updates in the ACA from 2010 till the present, many prevention screenings, refills on chronic care management, and educational opportunities (such as those for obesity and diabetes) are covered at lower costs to the patients or at no-cost.

The shift to accountability in care starts, first, with the provider-patient relationship. TPatients, in some of the new health plans, can receive lower costs for prevention screenings (annual exams for Medicare recipients, as an example).  New individual coverage for patients age 19-26 comes with their parents’ policies.  Others, particularly those who do not receive coverage through their current employer, began purchasing policies through the exchanges and coverage this year..   Successful practices have been asking about insurance changes and ask about the date that the new plan begins coverage.

Additional revisions in the ACA have removed limits on pre-existing conditions, leveled the premiums for women (who were previously classified as higher risk on the basis of their gender), and called for comparative effectiveness research for treatments.

Given the enormity of change, physicians and their practice members and staff may be confused about what some key concepts mean generally and how they relate to their medical practices.  Practices need to be familiar with key concepts in order to diagnose and treat people according to the new insurance plan requirements. Key to success are the changes in reimbursement that are included and what measures of quality, value and outcomes are fundamental to the success of practice management. 

A high-level overview of these concepts and their impact is included in a white paper we have developed that can help you and your practice team be better prepared for the new patients and the new reimbursement requirements. Click here to request and download the white paper.