First, let’s make one thing clear: U.S. Healthcare is in great shape…period. It is the finest on Earth. There’s nothing wrong with Healthcare. What’s wrong is in healthcare reimbursement issues and the fallout from those as they impact every level of healthcare. I’ve been in Medical Reimbursement Management for 25 years and work with and for healthcare providers in virtually every field of medicine. If we can simply repair provider reimbursement, healthcare will be fine. And we can offer affordable healthcare to all without any pre-existing condition restrictions. How?
Healthcare providers in today’s world do not get paid timely and sometimes do not get paid at all for services they provide – even from insurance companies. Wait a minute: government intervention into this will not correct that problem. We’ve seen that debacle already with Obamacare. Everything necessary to correct this problem already exists, believe it or not. It all began years ago with HCFA (the Healthcare Finance Administration) that has been renamed CMS, or Centers for Medicare and Medicaid Services. This department of the U.S. government exists primarily to be the watchdog over government health insurance programs and their financing. It is a monstrosity that is primarily responsible for almost 20% of the U.S. economy. How so?
There is no building in D.C. with “Medicare” or “Medicaid” on the side. Medicare patients’ bills are not sent to a Medicare office with people who pay for Medicare patients’ medical procedures. CMS contracts with private insurance companies around the nation to process patient claims and pay those with funds provided by CMS. When a Medicare patient calls the toll free customer service number on the back of their Medicare card and someone answers “Medicare,” they are NOT talking to Medicare, but someone at that private insurance company responsible for their claims. By accident in doing this our government has done a good thing: outsourcing rather than hiring tens of thousands of employees to do this work that is done much better in the private sector.
In this process, the main element necessary to right the Healthcare ship was created years ago under Medicare Part B. There are two main parts to Medicare – Part A and Part B. Part A is for hospital reimbursement for Medicare, Part B is for all other types of medical providers: physicians, out patient clinics, medical transportation, etc. Part A is a financial horror and is horribly abused. But under Part B the old HCFA created a fee schedule under which every type of medical treatment is identified and an exact reimbursement amount under Medicare is set. Obviously the cost for treatments vary from place to place, so these fee schedule allowables are set based on zip codes. You will hear arguments from Part B providers as to the fairness of Part B fee schedule reimbursement amounts, but my 3-step solution will address those concerns and others.
First, let’s do away with Part A and create a fee schedule that works for all private insured and government insured healthcare procedures. Structure it identically as the current Part B Medicare fee schedule, adjusted by zip code. (Example: an MRI in Manhattan costs more than an MRI in Ruston, Louisiana for obvious reasons, so the Part B fee reimbursement for that MRI is higher in Manhattan than in Ruston) Trust me when I say every medical procedure has been included on the Part B fee schedule and is universally available – several hundred thousand.
Secondly, make this Fee Schedule a universal requirement for all insurers and healthcare providers – private and governmental. How? Remember, private insurance companies contract with CMS to process Medicare claims and make millions of dollars for that work. To be eligible to do so each insurance company will be required to adhere to that fee schedule for reimbursement to providers not just for Medicare patients, but for private patients as well. Healthcare providers to be able to treat Medicare patients and receive reimbursement for doing so must accept fee schedule allowable amounts as payment in full for all patients – not just Medicare.
The third step is actually multiple small steps that cleanup this process. They include removing restrictions for insurers from selling policies across state lines (which will drive policy premiums down because of competition), continuing the current restriction against pre-existing conditions for insuring patients. Assuring all healthcare providers they will be paid for their services in no more than 45 calendar days from the date insurance companies receive an accurate, correctly coded and documented claim for services provided will excite doctors and facilities who often spend months fighting to receive accurate and timely payments for their services. Patient medical records must be made available in electronic format and maintained for every patient so that when going from doctor to doctor, those records are made available immediately so that any necessary medical information for appropriate and timely patient treatment is there always.
These three steps will sew up 90% of the issues with U.S. healthcare while immediately stopping damage to actual healthcare that is happening now under Obamacare. We do not have a healthcare problem in America, we have a Healthcare reimbursement problem. And it is fixable. Taking care of this 90% will go a long way to take care of the other 10%: quality healthcare for indigents. With Medicaid made available with similar reimbursement processes in place using the same fee schedule for payment, no one will ever again have to visit an emergency room to receive non-emergency care. And physicians and facilities will receive reimbursement for treating those Americans just as those with other insurance.
This could quickly be a reasonable fix for this problem through a true partnership between the government and private sector. This would be a business model using this philosophy: no one knows everything about everything. But what is necessary to be known in healthcare is always available. There are people who know and understand each part of the process. Put all those together and you put all the information in place necessary to handle U.S. Healthcare Reimbursement. We can do so without destroying our Healthcare. And correcting Healthcare Reimbursement will assure the top physicians, technicians, and facilities remain available and are financially viable.