Healthcare Reform

Navigating the Affordable Care Act

As new regulations fall into place, keeping an office efficient ismore important than ever

By Ron Rosenberg, P.A., M.P.H.

The Affordable Care Act (ACA) will continue to impact ophthalmology practices at several levels. These include new regulations on the practice as a business entity (similar to any other business), as well as changes in the health insurance environment, in which the practice provides clinical services.

This article will focus on changes that will have the greatest impact on the practice as a provider of healthcare services and the changes that the staff will need to accommodate.

More Patients

Overall, the biggest change for ophthalmology practices in general will be more patients covered by insurance. The three features of the ACA that will cause this are:

■ Expanded Medicaid.

■ An individual insurance mandate.

■ Insurance exchanges for comparison shopping.

The ACA expands the eligibility requirement for Medicaid by raising the income threshold. This will result in more patients eligible for this program, including patients covered by Medicaid as their primary insurance and seniors who previously had Medicare without a supplement who will now have Medicaid as their secondary insurance. Barring any unforeseen changes, the practice’s logistics in accommodating these new Medicaid beneficiaries will be no different than those currently utilized, except for increased volume.

Under the ACA, there is a mandate that each and every U.S. citizen carries health insurance. This can be purchased through traditional employer-provided insurance or purchased directly by the individual. Low-income individuals, who do not get an employer-provided plan and do not qualify for Medicaid, may be eligible for premium subsidies from the government. The overall impact will be a large number of young, healthy previously “self-insured” Americans who are now covered. Unless the benefits under these plans include routine eye care, there should be little impact on most ophthalmology practices since the patient demographics in ophthalmology subspecialties – pediatric ophthalmology excepted – are mostly older patients.

State Exchanges

Another aspect of the ACA is the development of state-managed insurance exchanges. With these exchanges, employers can “comparison-shop” for insurance plans. The exchanges will contract with existing insurance carriers that may offer lower-cost insurance products to be sold through the exchange. The exchanges will facilitate the presentation of the plans and rates, and after the employer chooses a plan and the employees select that plan, the employee’s relationship with the practice is similar to that of any other insured patient. The relationship between the practice and the insurance carrier will not significantly change.

The expansion of Medicaid, the mandate that everyone purchase insurance, and the probability of new, lower premium and benefits insurance products, will not necessarily present new challenges to your practice, but rather will make it even more important to have business processes in place to deal with existing challenges. Here are four items to keep in mind that could help make an ophthalmic office run more efficiently as the ACA falls into place:

1 Ensure certainty about insurance contracts.

Practices should review which carriers are contracted and with which products the practice participates. A surveillance system to identify new products, with the ability to decline participation in specific products, may come out of the ACA. Be sure to review the benefits and rules of each product. Consider,

■ Allowable payment levels.

■ Co-payments and deductibles.

■ Claims submission rules.

■ Referral and pre-authorization requirement.

■ Covered and non-covered services.

2 Develop a mix of both automated and manual insurance verification.

To eliminate time wasted on mistakes, redouble verification efforts. Make sure each scheduled patient has the correct insurance product identified in their registration and that the practice is a participating provider for that insurance product. These checks can also be applied to co-payments and deductible amounts.

3 Outline financial policies.

Create financial policies that are comprehensive and clearly communicate to the patient the relationships between the patient, the insurance, and the practice. Issues addressed should include:

■ Co-payment payable at time of service.

■ Non-covered services (e.g., refractions, etc.) are payable at time of service.

■ If the practice/physician is not contracted with the patient’s insurance, services are payable at the time of service.

4 Work with practice management software.

Invest in systems that enable scheduling and front desk personnel to manage the practice’s patients in a somewhat modified insurance environment. A sophisticated practice management software system should include:

■ Insurance auto-verification.

■ Messages that provide information on co-payments, deductibles, and old balances.

■ Information about insurance products and plans with which the practice and providers are contracted.

■ “Scripts” that guide the staff in dealing with difficult situations. OP

Ron Rosenberg, P.A., M.P.H. is the President of the Practice Management Resource group, a firm that provides consulting services and outsourced billing for ophthalmology practices.