Essential Keys To Future Health Insurance Contracting

Pages: 58 - 61
Author(s): 
Kevin C. McDonald, DPM

Who knows what exactly is going to happen with the health-care system in the United States? Two things are likely to happen. There will be an emphasis on controlling costs and there will be an altering of payment models that results in doctors being paid partially based on the quality of care provided and less exclusively on the total volume of care they deliver. There will also likely be some risk sharing as part of the compensation formulas.

One way that insurers believe they can lower the cost of care for their insured patients is to “narrow the network” of providers on their insurance panels. It is logical to think the providers who will not be invited to be on insurance panels will tend to be those judged to provide a lower quality of care, those who deliver care at a higher than average cost and those that have lower patient satisfaction scores than the providers invited to be part of the provider panels.

In addition, clinically integrated networks are developing with a hospital system and an array of doctors and ancillary providers to form a closed network to cover certain subsets of the population in “risk sharing” arrangements with an insurer or even possibly directly to a patient population. These networks are called accountable care organizations (ACOs) when they involve Medicare patients. These networks will typically form bonus pools as part of the provider compensation, which will be paid out so the providers with the best quality, cost and patient satisfaction scores will receive the highest bonuses. The providers with the poorest quality, cost and patient satisfaction scores will receive no bonus and possibly be removed from the network.
The following four-part plan is a strategy in dealing with these pending changes in the American health-care system.

Meeting Benchmarks For Quality Healthcare

The term “quality” has been bandied about ad nauseam in the healthcare arena. It seems that everyone is for “quality health care” but no one has been able to authoritatively measure or define “quality health care.” I believe insurance companies have decided that the quality of your medical records is the major indicator of the quality of your medical care. Consider the following examples.

General considerations. Office visit notes should tell a clear story in which the subjective patient symptoms and the objective physical findings help the reviewer understand how you arrived at the diagnosis and treatment plan. A review of systems that includes bowel habits and a physical exam that includes checking the Babinski reflex does not justify the use of a level 4 code on a perfectly healthy 20-year-old with a hangnail. The complexity of decision-making is the most important factor in determining the level of office visit codes. Inaccurate diagnosis and CPT codes reflect poor quality of care. The use of incorrect modifiers, the unbundling of codes and the routine use of “59” modifiers for established patients with one diagnosis does not show quality of care. Most insurers also do not like to be billed for services deemed to be “non-covered.”

Ancillary testing. A podiatrist providing in-office radiographic and vascular testing in a quality manner will have records that resemble the reports generated for the same services in radiology and vascular specialty offices. A medical record containing a radiology report that consists of “3 views taken, no fracture seen” exhibits a poor quality of care. A quality radiology report in a podiatrist’s medical records should have the following components:

a) the number, specific views and foot laterality taken
b) the indication for the exam
c) a description of findings noted
d) the physician’s impression of the patient’s test
e) the signature of the interpreting physician

Similar documentation for ultrasound, vascular and other types of testing should be in the records of podiatrists providing quality care.

Wound care. Podiatrists providing quality wound care will have notes that resemble those produced at wound care centers. One should describe the wound location, size and characteristics such as wound bed appearance, surrounding tissues, odor, drainage, etc. Subsequent visits should include an assessment of the wound’s progress. Pictures within the record are helpful.

Document any wound debridement procedures with pre- and post-debridement wound measurements, the type and amount of tissue excised (keratotic tissue does not count), the method and tools used for debridement, and the types of dressings and home care instructions provided. Billing for debridement services without this type of documentation reflects a poor quality of care.

Durable medical equipment (DME). Podiatrists dispensing durable medical equipment to patients with private insurance in a quality manner should follow many of the guidelines in place for dispensing DME items to Medicare patients. Namely, the medical record should indicate:

a) the size, type and manufacturer of the device
b) the rationale, treatment goals and fitting process for dispensing the device
c) the instructions and warranty information given.

The quality of your medical care will be measured by the quality of your medical records.

How To Measure Your Per Patient Visit Value

If you attend a podiatric practice management conference, you might hear talk of measuring your “PPV” or your “per patient visit value.” You would measure this by dividing your office collections over a period of time by the number of patients you saw over the same period of time. This can be a useful tool in assessing the comprehensiveness of your care but you must balance it by the cost-efficiency of the treatment you provide based on the presenting pathology. Providers who have a PPV much higher than average without mitigating circumstances may find themselves deselected from insurance panels in the future.

The easiest way for the insurers to measure your cost of care is to divide the dollars “approved to be paid” for your services by the number of patient encounters you provided for their clients. The medical director of a clinically integrated network I belong to indicates that the insurer will be calculating the total cost of the care provided by each peer in the provider group when doing the bonus pool adjustments. This means that providers will pay a small personal price when using expensive surgical implants in comparison with less costly alternatives when performing surgery. Doctors who write the highest number of expensive prescriptions and order the most expensive tests on the provider panel will also be dinged in the bonus calculations.

All participants in the health-care system will have the task of decreasing or eliminating unnecessary costs. Will you be part of the solution or part of the problem?

How Patient Satisfaction Can Influence Payment For Services

The third component upon which the insurance companies will judge you is what your patients reportedly think of you, your staff and your office environment. Providers who are members of a clinically integrated network will receive patient satisfaction scores generated by an outside firm, which will mail surveys to each of your patients seen in this particular network. These scores will be part of the bonus calculations.

Many podiatrists conduct periodic patient surveys. I have found that giving out surveys to a series of consecutive patients with a stamped, addressed envelope they must mail back in to count reveal the most candid information. There should be no “cherry picking” of patients for surveying. I recommend surveying your patients at least annually and that larger practices consider using an outside firm to tabulate the results. Assess all negative comments and evaluations, and correct any valid issues raised, if possible. There should also be an attempt to manage your online reputation in a proactive fashion.
Poor patient satisfaction with your services will not only lead to your phone ringing less often but may also eventually result in a lower payment for the services that you do provide.

Building Relationships With Insurance Companies

Make an effort for your office to be “user-friendly” to the insurance companies. You should keep your credentials current and respond correctly, fully and rapidly to any requests for information. You or your office administrator should check in periodically with your account representatives to build a relationship so when it is time for contract renewals, you are hopefully dealing with a friendly, known entity.

When you receive a records request for an audit, you or your staff should call the auditor, and discuss the goals of the audit. This is an excellent time to ask for payment for the charts provided. It is also smart to ask for a summary of the findings of the audit once it is complete. The insurance company will not ordinarily provide this unless you ask for it. You can then make an attempt to improve your records based on the information gleaned from the auditors.

It is a good idea to be known by the thought and administrative leaders in the medical community so you are considered for any networks being formed in your market area. The engagement of a local health-care consultant may also be a good investment. These people are often former insurance or hospital executives who know all the important players, and have their ear to the ground for any upcoming developments in your area. They can also assist you in favorably negotiating your contracts in many cases.

In Summary

1) Insurance companies will judge the quality of your care by the quality of your records.
2) Companies will measure the cost of your care against your peers (and other provider types).
3) The patients are the true customers of the insurance companies. Patient satisfaction is very important.
4) Sometimes who you know is more important than what you know.

Plan and act accordingly.

Dr. McDonald is the President of InStride Foot and Ankle Specialists, PLLC in Concord, N.C.

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