The following is a guest blog post by Keith J. Saunders, Esq., Founder & CEO of FHAS.
The utilization of technology to enhance and improve the patient experience is among today’s leading topics in healthcare. Recent technological developments have permitted improved access to healthcare, high quality care delivered in the most cost effective manner possible, and patient data to be acquired and leveraged to furnish more effective services. Whether through an Apple watch, telemedicine to rural or underserved areas, electronic medical record systems, clinical informatics, or delivery of care through robotic technology, there are many amazing opportunities to improve and enhance the patient experience.
One area which is frequently overlooked for enhancement of the patient experience is the integration of these modalities into the reimbursement system. No matter how innovative and effective the technology may be, at the end of the day the services or items in question need to be paid for by the patient’s insurance coverage.
Whether you are involved in product design or make purchasing decisions, one crucial element you should take into account in the design and deployment of new technology is how to pay for it. The following reimbursement decision algorithm can help to expedite that decision.
1. Is this a covered item or service?
The answer to this initial question can be found in the scope of coverage issued by the respective third party payors, both government and private. If you are seeking to have an item paid for by the Medicare program, your first stop should be the Medicare Benefit Policy Manual. If you are seeking to have an item paid for by the Medicaid program, consult the guidelines of the respective Medicaid program offered by the state in which the beneficiary resides. A general listing of essential benefits required to be offered under the Medicaid program may be found at the CMS Medicaid/CHIP homepage.
Similarly, commercial insurers publish their own benefit policies on their corporate websites which set forth what services and products are covered by their various products. After you have determined that an item is a covered service, the next step is to ascertain under what circumstances it will be afforded coverage by the payor, and to what degree.
2. Under what circumstances will a payor cover an item?
The answer to this question is typically found within the coverage and payment guidelines issued by third-party payors. The good news is that these policies are usually quite detailed and subjective. The bad news is that you may have to conduct extensive research to determine how they are applied. A good place to start for the Medicare program is at the National Coverage Determinations manual (NCD). The NCD will provide a general scope of coverage for a device or service, but to find more comprehensive guidance regarding coverage, you should go to the websites of the Medicare Administrative Contractors (MACs). The MAC websites will furnish detailed guidance regarding coverage and payment guidelines for specific items and services covered under the Medicare program.
The process for Medicaid is similar in that each state program maintains coverage criteria either directly or through the entities selected for delivery of benefits, such as Medicaid managed care plans.
Commercial insurers, such a Blue Cross Blue Shield, likewise maintain their coverage and payment guidelines online for review, which set forth the scope and conditions for reimbursement for services or items.
3. What documentation or information do I need to capture to ensure coverage of an item or service?
The answers to this question can also be found in the coverage and payment guidelines referenced above. Typically the coverage and payment guidelines specify the type of information required by a payor to make a payment determination. This is a critical component of the payment determination process and represents perhaps the area of greatest peril for the deployment of new technology.
If you are deploying new technologies or procedures, I would strongly recommend that you familiarize yourself with the payment rules for the third party payors you are seeking to bill for your service. The greatest technology in the world is of little value if payment is impaired due to the failure to tailor your technology to the coverage and payment guidelines. Similarly, if you are seeking to purchase a new technology or service as a healthcare provider, you must likewise consider how you will pay for the device or service.
The enhanced patient experience which we are all seeking through improved quality and efficiency can only be attained if reimbursement is on our radar. By doing so, we can ensure that our constituencies receive the benefit of innovative technology while maintaining financial peace of mind.
If you don’t have that peace of mind and the above steps seem too overwhelming, you can also reach out to a trusted claims review partner with expertise in reimbursement, like FHAS. Not getting paid because you’re using innovative technology is almost always an avoidable outcome.
FHAS, a URAC accredited IRO and ISO 9001 certified company, is one of the largest independent providers of “healthcare as a service” (HAAS) for government and commercial clients with a particular focus on adjudication services and medical claims’ review services. In 1996, FHAS began furnishing Medicare Fair Hearing Services to Durable Medical Equipment (DME) Administrative contractors located throughout the United States. Since that time, FHAS has expanded its scope of appeals services to include complex medical reviews for the following: Medicare Parts A, B, PDRC Appeals, and DME Appeals, internal and external health plan appeals, and the entire Pennsylvania Medicaid fair hearing process. FHAS utilizes a network of board certified physicians, legal professionals, and other healthcare professionals with diverse specialties, who have the expertise to render decisions for external review requests. In addition to professional services, FHAS provides enterprise-grade software solutions to healthcare and insurance industries. Their newest product Cogno-Solve is a comprehensive, RPA software platform that automates claims and appeals decision-making functions.