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How Extending Medicaid Raise Affects Patient Inflow and Billing

by | May 25, 2015 | Articles, Resources | 0 comments

Extending Medicaid RaiseDuring the last week of July, two senators introduced a bill that would extend Medicaid payment boost for primary care physicians (PCPs) for another two years through 2016. Though this will give clinicians an opportunity to make extra income, they will have to overcome several challenges in their billing procedures to earn that. The major reason for these challenges is the huge influx of patients with Medicaid coverage.

Significant Provisions of Senators Bill

  • To ensure sufficient payment for primary care services and vaccinations, and the physician specialties and subspecialties that provide them and thereby enhance patients’ access to primary care. Lack of primary care access will cause delay in providing the needed care for patients and make them resort to obtaining care from emergency room or urgent care clinic.
  • To encourage the continued funding of the Medicaid Primary Care Pay Parity Program so that family medicine, pediatrics, and internal medicine physicians and related internal medicine and pediatric subspecialists can keep on receiving Medicare-level reimbursement rates for providing primary care and immunization services to Medicaid patients.
  • To include physicians practicing obstetrics and gynecology as qualified specialists if minimum 60 percent of their Medicaid billings comprised of primary care services as defined under current law.

Reason for Huge Inflow of Patients

Earlier, many primary care physician practices found it was not affordable to take too many patients receiving subsidized care as the payment rate was much lower than what private insurance companies pay them and limited the number of Medicaid patients they saw while some even refused to accept such patients. When Medicaid payment rate was increased through Affordable Care Act’s primary care rate increase (PCRI) provision that temporarily increased Medicaid payment rate to physicians delivering primary care services, PCPs started to accept more patients with Medicaid coverage. According to a study by the Ohio State Medical Association (OSMA), increase in payment rates prompted around 40 percent of the physicians (who were attested to receive raised Medicaid payment rates) to accept more patients with Medicaid coverage.

As the population enrolled in Medicaid is increasing sharply, it is very important to maintain access to primary care services by ensuring comparable rates under Medicaid for these services. These comparable Medicaid payments can remain as incentives to eligible physicians for maintaining or increasing their Medicaid patient population regardless of whether a particular state expands its Medicaid program or not. However, a survey by the American College of Physicians says that around half of the participants in the existing Medicaid Primary Care Pay Parity Program would have to reduce the number of Medicaid patients they see or withdraw the program if it is expired at the end of this year. Since the proposed bill can help physicians to continue receiving enhanced payment, they can accept the surging Medicaid patients. This will result in huge influx of patients through which PCPs can improve their revenue further.

Impact on Billing

While handling surging number of patients, PCPs face the following challenges across the billing phase such as:

  • When more patients visit the practice than earlier, it will be really tedious to verify the insurance details of each patient and confirm whether they actually hold the coverage. This will cause delay in scheduling appointment for the patient to consult PCPs and thereby increase patient wait time. If the wait time extended beyond a favorable limit, it could result in losing patients.
  • Documenting all patient details and assigning appropriate ICD and CPT codes can be challenging in case of huge inflow. If this process is delayed, it will be late to file the claims and the insurer may reject the claim. While handling a number of cases and assigning codes hastily to submit medical claims within deadline, there is a greater chance for making coding errors.
  • Though PCPs can move on with the appeal process on claim rejection to prove their point, they may not get enough time to handle this process amidst their busy schedule. This will lead to poor denial management and a drop in revenue.

If physician office staffs are unable to handle the new challenges, obtaining support from a third party billing service is advisable after ensuring that they follow effective coding and billing practices and are HIPAA compliant. With this, PCPs can manage their medical billing processes well and at the same time focus their time and resources on patients.