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Archive for August, 2011

Manufacturer Rebates Offset Mounting Costs of Medicaid Brand-Name Drugs

Tuesday, August 23rd, 2011

Prices and payment amounts for Medicaid brand-name drugs soared at around three times the inflation rate between 2005 and 2010, reports the Office of the Inspector General. These significant increases, however, were offset by savings created by the Medicaid drug rebate program.

Reports issued by AARP reveal that wholesale acquisition costs (WAC) for the most widely used brand-name prescription drugs have significantly increased since 2002. Addressing Senator Bill Nelson’s concern over AARP’s findings, OIG reviewed drug pricing changes and their impact on Government health care programs like Medicaid. The study examined changes in WACs, average manufacturer prices (AMP) and Medicaid payment amounts for brand-name drugs from 2005-2010. OIG also looked at the effect of rebates paid by drug manufacturers as part of the rebate program.

WACs, AMPs and Medicaid payment amounts increased between 34 and 40 percent at the median over the five-year period, while the inflation rate increased by just 13 percent. Increases in prices and payment amounts for brand-name drugs didn’t just outpace overall inflation though, they outpaced the inflation rate in each of the five years under review. The Office of the Inspector General did find that the per-unit net cost to Medicaid increased at a lower rate than other points of comparison between 2005 and 2009 when the per-unit payment amounts for Medicaid brand-name drugs were adjusted to account for the rebate amounts paid to States by manufacturers. Medicaid’s rebate-adjusted payment amounts for brand-name drugs actually declined at the median in 3 of 4 years.

The results of the study indicate that price increases for brand-name drugs don’t necessarily result in corresponding increases in Medicaid costs. Medicaid’s net costs for brand-name drugs actually increased at a lower rate than other points of comparison, including the inflation rate, due to the savings generated by the rebate program.

New Payor Reporting Tool

Wednesday, August 17th, 2011

The CPR Committee recently introduced its “CPR Reporting Tool,” which was developed as a resource for CPR communications with payers, to HBMA’s website. The tool documents significant quantifiable issues so that CPR and payors can jointly work to solidify reasons for improvement or change on behalf of HBMA membership and was originally designed to address only commercial payor claims issues. It was expanded, however, to include all payors including Medicare and Medicaid and provider enrollment issues.

Using the HBMA Heal The Claims survey conducted in April 2009, CPR developed a Top 10 List of payor issues, from which the reporting tool evolved, as a dynamic real-time survey approach to collecting information from HBMA membership. The tool has been designed using radio buttons and drop down menus—ideal for quick entry—and also features a “Comments” field.

The “Frequency” field is an important part of claims denials. It is meant to capture the amount of times you experience a particular recurring denial program that usually represented a programmatic issues with the payor’s adjudication system.

Improvements for Payers, Billers and Providers: Part 2

Thursday, August 11th, 2011

A myriad of issues affect medical bill management companies. Earlier this week, we discussed challenges facing billing and insurance companies, patients and providers, so here is the rest of the list:

Challenge: Incorrect claims adjudication based on the specialty of a physician.

Solution: Implementation of a mechanism that better enables claims adjudication for physicians with dual specialties.

Challenge: Loading of contract payment terms across multiple systems is inconsistent.

Solution: It is important for payers to make sure contract payment terms are loaded consistently across systems. Also, clearly identify the correct arrangements so provider staff can verify that the claims are paid accordingly.

Challenge: Websites are outdated.

Solution: Payers can help reduce most of the inaccurate claims submissions stemming from inaccurate or outdated information by providing physicians with real time information on their members eligibility and claims history.

Challenge: Authorization systems are outdated.

Solution: Replace the ineffective system—in which PCPs fax authorizations for specialists—with automated information technology so payers can help reduce the amount of paper, facilitate reimbursement and speed things up.

Challenge: Credentialing processes are unregulated.

Solution: Payers could increase the speed and efficiency of the present system (from several months to just 60 days) by applying a consistent process for enrolling or credentialing physicians.

Stay tuned for more from the official Integrated Medical Management Inc. blog!

Improvements for Payers, Billers and Providers: Part I

Tuesday, August 9th, 2011

The Healthcare Billing and Management Association recently identified 10 major challenges to payer relations—and offered solutions. Here is a summary of the article courtesy of Integrated Medical Management:

Challenge: Electronic payment is wrought with confusing codes and non-standard remarks.

Solution: Select from a standard, nationally recognized set of remarks for consistent coding across organizations. Also, explain why a claim is denied and subsequently offer ways to resolve the issue. This would streamline processing and benefit all parties involved.

Challenge: Unpredictable benefit information and separate mailings (with paper payment files).

Solution: Consistent with the Patient Friendly Billing Project recommendations, standard and easy-to-read formats would allow claims to be processed quicker. Additionally, grouping EOBs and checks together would up efficiency and limit misunderstandings, phone calls and the need for looking at one claim multiple times.

Challenge: The claims appeals process is inefficient.

Solution: Provide a clear outline of the process and give providers online access to claims statuses and appeals in addition to a timeline for a response. This would save time and money wasted when claims are tracked down individually.

Challenge: Denials for several visits from several specialists on the same day. When a patient sees multiple specialists in a hospital in one day, oftentimes only the first provider to submit their claim gets paid.

Solution: If payers’ systems were able to edit same-day services by provider specialty, there would be less inquiries and less cost (because claims wouldn’t be handled multiple times).

Check back for Part 2 of the list dealing with medical revenue management later this week!

Making the Most of Revenue Cycle Technology

Friday, August 5th, 2011

Obtaining appropriate reimbursement is becoming more of a challenge as the demands of health care reform grow. Companies billing for medical services are increasingly looking to revenue cycle management solutions to simplify claims processing and meet new standards (like the version 5010 format and ICD-10 code set requirements, to name a few).

As Las Vegas based billing specialists, we have some tips for getting the most out of revenue cycle management technology:

  • Make sure there is buy-in from the start by engaging staff members who might use the technology throughout the entire selection process.
  • Prepare your staff for industry changes by involving them in continued education with trade organizations like HBNA.
  • Look to your technology partner for ongoing training and customer support so you realize the full potential of the technology.
  • Before adopting a new technology solution, confirm that it will fit seamlessly within your existing workflow.
  • When choosing a new technology system, make sure that it extends your existing abilities by keeping your organization ahead of the curve.