Top Challenges Physicians Face in the Present Day Healthcare Environment

by | Last updated Dec 14, 2023 | Published on Oct 19, 2015 | Healthcare News

Top Challenges
Share this:

Each year healthcare professionals face many changes and challenges in their profession. Ranging from regulatory burdens to delay in payments, physicians are confronted with a wide range of issues. Here are some of the top concerns.

ICD 10 implementation – Effective from Oct 1, 2015, physician practices are getting ready to use ICD-10 codes. Early preparations can avoid disruption of claim payments later in 2015. By this time their back end systems and software systems should be updated to bill properly with ICD-10. However, to the relief of physicians, CMS has announced a one year grace period for ICD-10 implementation, during which they will not deny payment based on ICD-10 medical coding errors.

Also, the transition may not cost as much as previously expected. Practices are reporting that out-of-pocket expenses to prepare for the implementation are far lower than initial estimates. According to the American Health Information Management Association, “the average ICD-10-related expenditures for a physician practice with six or fewer providers are $8,167 with average expenditures per provider of $3,430.”

Healthcare providers can also make use of the training materials, the Centers for Medicare and Medicaid Services (CMS) has provided on its site.

HIPAA compliance – Keeping patient health information secure is growing more complicated. The Health Insurance Portability and Accountability Act (HIPAA), the law protecting patient privacy, is a major liability for physicians in the digital age. Practices that are found to be non-compliant with HIPAA regulations could face fines and penalties. It is crucial to follow all internal security policies and procedures to check for HIPAA compliance. Along with training staffs on proper HIPAA guidelines, practices also need to ensure that proper security tools such as firewalls and antivirus software, are being used in the office at all times.

In the recent HIPAA conference, OCR officials indicated that the random audits will start again in 2016. The audit program allows the OCR to gain invaluable feedback on aspects of HIPAA that are causing problems for covered entities. The main aim of the audit is to develop new guidance to help healthcare providers, insurers and their business associates, and introduce the necessary safeguards to keep Protected Health Information secure. The second purpose is to ensure that covered entities are adhering to HIPAA rules. Disregarding HIPAA rules will result in fines to covered entities.

Reimbursement Delays – Physicians also face payment challenges from government agencies, including Medicaid. While Medicaid, the federal/state program takes the longest to pay claims, it also has the highest claims denial rate. With large numbers of newly-insured Medicaid patients entering the market, physicians must be careful to protect themselves against Medicaid claim denials. Challenges in getting on-time payment also stem from the Affordable Care Act (ACA) and how reimbursement models are shifting from the fee-for-service model to value-based payment models. More and more insurers are increasingly adopting value-based payment models. The challenges are likely to grow this year for some of those who work with Medicare patients. Submit a “clean” claim and make sure to avoid losing money from denials.

Collecting co-pays and deductibles – Some doctors are concerned about the challenge of collecting co-pays and deductibles from patients who sign up under the new Obamacare plans, and new Meaningful Use (MU) regulations put physicians at risk for financial penalties. Patients who sign up for plans under the ACA have a 90-day window within which to pay premiums. The American Medical Association (AMA) and other physician advocate groups warn that physicians can get stuck with bills from enrollees who take advantage of medical services during that time but then fail to pay premiums.

The American Medical Association also encourages providers to verify insurance eligibility before a patient’s visit and to document the information. Physicians should collect co-payments at the time of service and widen the window for payment options. Make sure to remind patients about payment plans, other options and online portals if available.

Administrative burden – More and more paperwork is being required by insurance companies and the government. This mounting paperwork is keeping physicians from spending enough time with patients. Prior authorizations are a major source of growing file work. More and more payers are requiring prior authorizations for more drugs and procedures.

Implementing and operating an EHR system is also a major time drainer and affects productivity. However, to meet Medicare’s new guidelines and not to be punished financially on the back end, physicians must introduce Electronic Health Record (EHR) software in their offices.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

More from This Author