He has a considerable background in reimbursement methodologies and financial analysis. He understands the current and emerging challenges that face the healthcare providers and partners with clients to address these issues and create opportunities.
Here Dana tells us about CodeToolz and offers his insight in the evolving world of medical reimbursement. Read on:
Tell us about CodeToolz. What services do you offer? Who should be using them?
CodeToolz was founded on a simple principle: “physician, protect thyself”.
CodeToolz is a cloud-based (no software to download or update) Managed Care Contracting and Fee Schedule analysis tool.
CodeToolz allows the physician to 1. determine the exact contract allowable from each payer for all services performed, .) avoid any under-billings, 3. analyze any “proposed” changes in payment terms by the payer and 4. verify they are getting paid the contracted rate.
Our services are for those providers that use CPT® codes to bill for services rendered and paid via a fee-for-service contract.
What do you feel differentiates your service and sets you apart?
We are “laser-focused” on the managed care contract (MCC) between the provider and the payer, specifically the “payment terms” and “amendment”.
The payment terms constitute the contract money allowable for each CPT® code used and the amendment requires the provider to object to the payer’s offer within 30 days or the provider has accepted, i.e., “Following (30) days written notice. Failure to object constitutes agreement.”
This failure to object is often disastrous for providers as payer contract offers rarely increase, in fact the opposite occurs. Payers are constantly trying to decrease costs; they achieve this by decreasing contract allowables to providers.
Tell us about your journey into the world of Medical Billing. How did you get into the field?
I started my healthcare career as a Surgical Assistant in the USAF (10 years) in a Level 1 Trauma Center. After departing the USAF, I obtained Accounting and Finance degrees from Texas State University and was subsequently hired as a Controller for a large surgical group.
It was at this point I realized, what good is it to set up first-class billing procedures and have your claims paid expeditiously when the contract payment terms are so dismal? This inevitably led to CodeToolz.
How has medical reimbursement evolved since you started your career?
As the pieces of the health reform act fell into place, the expenditures required to keep up with the various requirements added yet another layer of stress to private sector physicians running independent practices.
The new health care act (and decreasing contract allowables) has brought physicians to an inevitable crossroads. A majority will either move to an intimate, boutique practice model or forego traditional practices altogether, opting for the abundant resources offered by larger entities in exchange for their independence.
From where you sit, what are the biggest challenges or pain points facing medical practices today when it comes to billing?
ICD-10 Implementation. Meaningful Use. Pay-for-Performance, etc.
With all of the administrative burdens placed on physicians by the Affordable Care Act, coupled with the fact that they are seeing so many patients per day – proper contract management is getting lost in the shuffle.
Managed care contracting is an integral part of medicine for virtually all health care providers.
Not managing or accepting bad contracts will have a severe negative impact on physician and group practice revenues.
How has the Affordable Care Act affected reimbursements?
Under Affordable Care Act (ACA), doctors have been strained by costly new regulations, complex payment “reforms” that tie their reimbursements to complex federal reporting requirements, and mandates that they install and make “meaningful” use of electronic health records.
The proportion of patient’s that doctors see are rapidly shifting away from commercial health plans and toward healthcare exchanges, which often times pay doctors pennies on the dollar that they were previously reimbursed under private insurance.
Doctors are opting out of these exchange plans for many reasons; chief among them is the fact that exchange plans offer significantly lower reimbursement rates than private market plans.
What about patient pay?
The proliferation of high-deductible plans (HDHP’s) is making consumers more price sensitive. Paying more out of pocket encourages people to shop for healthcare services.
Rising healthcare costs don’t only affect patients – they threaten providers as well. As more and more people forego essential medical care due to insurmountable costs, practices lose patients.
Some providers are addressing this issue by going after self-pay patients. With self-pay patients, providers do not have to submit insurance claims, and patients pay their bill while they are still at the clinic; no lengthy collection process or accepting deep discounts from the payer.
Providers must rethink and retool their strategy for self-pay patients to include patients with high deductible health plans. The keys here are patient education and, literally, asking for payment.
Physician’s knowledge of their contracts and allowables are essential in determining how much to collect from their patients with HDHP’s.
What do all medical practices need to be doing now to improve their reimbursements?
A good managed care contract (MCC), like any other form of business agreement, is clear, comprehensive and concise. It will conform to both the intent of the parties, setting out their respective rights and responsibilities, and the requirements of state and federal law.
The central goal of CodeToolz is to help medical providers increase their revenue. We do this with advanced MCC analysis and negotiations techniques.
One of the most important factors for providers to remember is that the best contract in the world may not be suitable for a particular provider.
With continued downward pressure on managed care reimbursement rates and the move to increasingly complex payment schemes, healthcare providers should be seeking solutions for their managed care needs.
CodeToolz comes to the aid of anxious, overextended physicians working to improve reimbursements.
What is your strategy for competing with major players like Athenahealth, eClinicalWorks and McKesson?
We believe in keeping it simple. We believe in being focused.
Focusing on the efficiency of any business is the key to getting the most out of lean, and ultimately improving our service and client satisfaction.
Although these larger players have an array of services, some better than others, simplicity gets lost; ultimately leading to increased physician expenses.
Smaller businesses with the right combination of people can be more agile and flexible.
It all starts with the managed care contract, without question, we are efficient and effective – while keeping it simple.
What headlines or trends in revenue management and billing are you following right now? Why do they interest you?
The Pay for Performance Model of Healthcare Reimbursement.
In a pay for performance model (P4P), providers are compensated for services based on how well they meet predefined quality, outcome and/or efficiency metrics.
As payers begin to shift to performance-based reimbursements, physicians with high percentages of non-adherent patients stand to potentially see reimbursements fall.
If not strictly managed, the financial risk(s) will shift from the payers to the providers (decreasing reimbursements).
Our goal at CodeToolz is (and always has been) to protect the provider when it comes to managed care contracts and reimbursements.
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