Is Prior Authorization Criterion Doing More Harm Medical Billing Services

COVID-19 pandemic has changed healthcare industry’s dynamics. The impact might be temporary in some aspects while it can also lead to permanent changes in some situations.

Many changes were suggested to cater the overflowing COVID-19 positive cases. CMS even recommended delaying the nonessential medical procedures to curb down the virus exposure. This certainly was a brave decision as it protected the health of physicians, patients, and medical billing services workers but drag down their financial situation as well.

The prior authorization rule is also under fire for the same reason. Many insurance companies and Medicare payment models are waiving off the prior authorization restriction for diagnostic or surgical procedures for coronavirus.

However, there are many others, which require the pre-authorization segment filled in the claims. Even when the physicians obtain prior authorization, the claim might end up being denied.

Why Prior Authorization is Necessary?

Prior authorization is particularly required for expensive or new medical procedures. If insurance companies don’t pay up for the rendered services or don't prior authorize for the service, medical billing companies will be compelled to ask from the patients, which ultimately will lead to the complicated and frustrating revenue-generating process Mips Reporting.

Getting Authorizations Needs Investment

Getting authorizations is not that simple as one thinks. Physicians have to bear extra costs for that.

Healthcare costs are already getting out of hand as physicians have to maintain quality healthcare. In these drastic times, when reimbursements and payment models are failing to compensate physicians’ revenue problems, prior authorization is a clause that needs relaxation.

Why Prior Authorization is a Problem, Especially Now?

The prior authorization criteria from the insurance companies give more power to insurers rather than physicians and patients. Although, it is physicians, who are spending dimes for the authorization process; and with denial of the claim, the return payment becomes zero. General Surgery Billing Services

On average, medical billing companies spend at least twenty-seven minutes and almost eleven dollars on each authorization action. Every time, having to consult insurers, physicians get the idea that a third party is dictating the healthcare service. 

Moreover, with more medical procedures requiring prior authorization, the more burden physicians will have to bear.

It is not to be blamed upon insurance companies for such strict rules. It is the US healthcare industry whose complex structure is weighing down all stakeholders, be it, patients, medical practitioners, medical billing services, and insurers.

Coronavirus has adverse effects on the healthcare industry. But it certainly is reveling the problematic areas.

Prior authorization (PA) is a cost-containment strategy used by insurance companies to ensure that certain medical procedures, medications, or services are deemed necessary before they can be approved for coverage. While the intention behind prior authorization is to curb unnecessary healthcare costs, its implementation has sparked considerable debate. Many argue that it can lead to delays in care, increased administrative burdens, and even worse health outcomes for patients. In this article, we’ll delve into the impact of prior authorization on medical billing services and the broader healthcare landscape. Neurology Billing Services

Understanding Prior Authorization

Prior authorization requires healthcare providers to obtain approval from an insurance company before providing specific treatments. This process often involves submitting detailed information regarding the patient’s condition, the proposed treatment, and the rationale for its necessity.

The Burden on Healthcare Providers

1. Administrative Challenges
   Medical billing services face significant hurdles due to the complexity of prior authorization. The paperwork and documentation required can be time-consuming, leading to increased administrative costs. Staff must often spend hours on the phone with insurance companies, navigating complex guidelines to secure approvals.

2. Delays in Care
   One of the most pressing issues with prior authorization is the delay it creates in patient care. Patients may experience longer wait times for necessary treatments, which can exacerbate their medical conditions. For instance, if a patient requires a specific medication to manage a chronic illness, delays in authorization could lead to severe health complications.

Impact on Patient Health Outcomes

1. Increased Health Risks
   When patients experience delays due to prior authorization, their health may decline. This is particularly concerning in urgent care situations where timely intervention is crucial. Studies have shown that patients who face delays in necessary treatments often experience poorer health outcomes and higher rates of hospitalization.

2. Frustration and Confusion
   The prior authorization process can be a source of frustration for patients. They may be unaware of the requirements, leading to confusion and anxiety regarding their care. This lack of transparency can erode trust in healthcare providers and the insurance system.

Financial Implications

1. Increased Costs
   The administrative burden of prior authorization doesn’t just affect healthcare providers; it can also lead to increased costs for patients. When treatments are delayed, patients may require more intensive (and expensive) care later on. This cycle can inflate overall healthcare costs, negating the intended savings of prior authorization.

2. Insurance Rejections
   If a prior authorization request is denied, patients may find themselves liable for the full cost of care. This can lead to financial strain and may deter individuals from seeking necessary treatments altogether.

Alternatives to Prior Authorization

1. Value-Based Care
   Shifting toward value-based care models could alleviate some of the issues associated with prior authorization. By focusing on patient outcomes rather than procedural approvals, healthcare providers may be better equipped to deliver timely care without excessive administrative burdens.

2. Streamlined Processes
   Implementing more efficient prior authorization processes, such as automated systems, could reduce delays and administrative workloads. By harnessing technology, medical billing services can expedite approvals and enhance communication between providers and insurers.

The Counter Action

Some insurance companies are resolving this issue themselves by suspending referrals and prior authorization conditions and requesting notification within a day of any inpatient and outpatient medical service. There are, however, some exclusive cases such as, for transplant and genetic cases.

This service applies to all areas of physicians, even if they don’t belong to a network. It will not only reduce administrative burden over medical billing and coding services but also free up resources, which are consumed up during the delayed billing services.

Some states are working to empower patients and physicians, but the problem is that each state is working on its own, without any collective effort. Therefore, the confusion arises about the after-effects or long terms prerequisites of the COVID -19 counter-strategy.

The authorities say that it is in the best interest of the healthcare industry to continue the practice of prior authorization to avoid surprise medical bills. Popular opinion is that authorities might not know how surprise bills will be unfolded in the future.

The uncertainty and ambiguity disguised in temporary and permanent changes might find solace in technology incorporation.

Read More: QPP MIPS 2020 Reporting Guidelines for Chiropractors Reporting Services

Prior authorization generally consists of three steps:

•        ICD-10 codes incorporation
•        Automated data submission
•       Retrieval data process

With technology, these steps can be a lot smoother than before. The per authorization cost will be reduced, and of course, time consumption will also be minimum.

Even if the changes prolong, physicians and medical billing companies can enjoy a relaxed working environment. Prior authorization is surely an administrative burden but it encompasses lots of financial benefits. Healthcare professionals need to understand the requirement and adopt methods to make it a primary billing function.

There are opportunities to improve the system, and this time, we may be able to realize what’s best for all stakeholders.

Physicians Guide: Briefing QPP MIPS Cost Category and Managed in Finance Program

 

Under MACRA (Medicare Access and CHIP Reauthorization Act), clinicians can participate in either two payment models, a Merit-based Incentive Payment System (MIPS), or an Advanced Alternative Payment Model (AAPM), defined as Quality Payment Program (QPP).

In MIPs Reporting, eligible physicians are required to submit yearly data to CMS to receive a total score. There are four performance categories, Quality, Improvement Activities (IA), Promoting Interoperability (PI), and Cost, for which data is recorded and analyzed.

Today, we are discussing the Cost category and its reporting.

Let’s keep going.

Cost Performance Category

The cost category weighs 15% of the total MIPS score for the performance year 2020.

Reporting Requirements

CMS doesn’t expect any data submission for the cost category. They analyze the performance by reviewing claims data.

The following factors impact the analysis of this performance.

1. Medicare Spending per Beneficiary (MSPB)
2. Total per Capita Cost
3. Eight episode-based cost measures

Medicare Spending per Beneficiary (MSPB)

The MSPB assessment refers to the Medicare Part A and B costs generally incurred in an episode.

An episode includes the dates falling between three days prior to an Inpatient Prospective Payment System (IPPS) hospital admission (an index admission) and 30 days post-hospital discharge. It measures the actual cost of episodes as per their expected expenditure. General Surgery Billing Services

To score for this measure, physicians or MIPS Qualified Registry on their behalf need to consider the following aspects.

Physicians, who don’t treat in-house patients don’t qualify for an episode, and no points will be awarded.

Episodes will be attributed to those clinicians, who provide the plurality of Medicare Part B services to a beneficiary during the index admission.

Physicians must report at least 35 cases to get a score for this category.

Total per Capita Cost

The total per capita cast measure analyzes all Medicare Part A and B costs for each attributed beneficiary.  However, the following factors are to be considered for maximum points in MIPS.

Clinicians are supposed to be attributed to at least 20 beneficiaries.

Attribution refers to:

A beneficiary refers to a tax identification number-national provider identifier (TIN-NPI), provided if the beneficiary (patient) received primary healthcare services from primary care physicians, nurse practitioners, physician assistants, or clinical nurse specialists under the same TIN.

If the beneficiary doesn’t qualify as per the above-mentioned requirement, he/she will be attributed to the TIN-NPI, if they received services from specialist physicians within a TIN than from physicians in any other TIN.

New episode-based cost measures don’t apply to family physicians.

CMS is working on developing new episode-based measures in the future to fit diverse needs. Given below are the episode-based cost measures.

• Elective Outpatient Percutaneous Coronary Intervention
• Intracranial Hemorrhage or Cerebral Infarction
• Knee Arthroplasty
• Revascularization for Lower Extremity Chronic Critical Limb Ischemia
• Routine Cataract Removal with Intraocular Lens Implantation
• Screening/Surveillance Colonoscopy
• Simple Pneumonia with Hospitalization
• ST-Elevation Myocardial Infarction with Percutaneous Coronary Intervention
• Acute Kidney Injury Requiring New Inpatient Dialysis
• Elective Primary Hip Arthroplasty
• Femoral or Inguinal Hernia Repair
• Hemodialysis Access Creation
• Inpatient Chronic Obstructive Pulmonary Disease Exacerbation
• Lower Gastrointestinal Hemorrhage
• Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
• Lumpectomy, Partial Mastectomy, Simple Mastectomy
• Non-Emergent Coronary Artery Bypass Graft
• Psychoses/Related Conditions   Renal or Ureteral Stone Surgical Treatment

It is to be noted that cost measures are risk-adjusted (based on the hierarchal condition category (HCC) risk scores) for the difference in patients’ medical conditions. For Instance, for multiple chronic conditions affecting physician’s performance.

The performance benchmarks are set based on the data collected by the CMS.

A measure will be benchmarked if it has 20 groups or individual clinicians who attribute to the measure’s minimum case.

For a fact, any measure without a benchmark cannot be scored or included in the performance category scorecard.

Eligible clinicians can be assigned up to 10 points on average of all scored cost measures concerning the performance benchmark.

For group participation in QPP MIPS, the final score will be the aggregated value of all individual scores under the TIN.

For Instance, if a clinician has 8 attributes and another has 12 attributed cases, so the group will receive a collective score as they reached the minimum threshold point 20.

If any individual or group doesn’t receive a score for this category, the weight will be redistributed to the Quality performance category.

Hey there, fellow physicians! As the healthcare landscape continues to evolve, understanding the intricacies of quality payment programs (QPP) is essential for providing optimal patient care and maintaining financial stability. In this guide, we’ll delve into the MIPS (Merit-based Incentive Payment System) Cost Category, explore how it’s managed within the finance program, and provide strategies for improving your scores. Let’s get started!

What is QPP?

The Quality Payment Program (QPP) is a comprehensive initiative by the Centers for Medicare & Medicaid Services (CMS) aimed at enhancing healthcare quality while reducing costs. Through the QPP, physicians can participate in MIPS or Advanced Alternative Payment Models (APMs). MIPS is designed to evaluate and reward healthcare providers based on their performance in various categories, including quality, improvement activities, promoting interoperability, and cost.

Overview of MIPS

MIPS combines several existing quality reporting programs into a single framework. This system allows for a more streamlined approach to measuring performance and incentivizing better care. One of the critical components of MIPS is the Cost Category, which examines how efficiently providers manage resources in delivering patient care.

Understanding the MIPS Cost Category

Definition of the Cost Category

The MIPS Cost Category evaluates the total cost of care provided to Medicare beneficiaries. It looks at how well healthcare providers manage resources while maintaining high-quality care.

Importance of the Cost Category in MIPS

Understanding the cost category is crucial for healthcare providers. It not only impacts reimbursement rates but also reflects on the overall performance of a practice. Providers who manage costs effectively can receive positive adjustments to their Medicare payments. Neurology Billing Services

How the Cost Category is Measured

The cost category is measured through various metrics, including total cost of care, Medicare spending per beneficiary, and episode-based measures. CMS uses claims data to evaluate these metrics, which means the efficiency of your practice is constantly under review.

Components of the MIPS Cost Category

Total Cost of Care

This metric assesses the overall expenses incurred for a patient’s care across a specific timeframe. The goal is to promote cost-effective treatment methods without compromising quality.

Medicare Spending per Beneficiary

This measure looks at the average costs associated with treating a Medicare beneficiary during a specified period. It takes into account all claims submitted for the beneficiary, allowing for a comprehensive view of spending patterns.

Episode-Based Measures

These measures evaluate the costs associated with specific episodes of care, such as surgeries or chronic disease management. By focusing on episodes, providers can pinpoint areas for improvement and implement cost-saving strategies.

The Role of Managed Care in MIPS

Definition of Managed Care

Managed care refers to a variety of techniques designed to reduce the cost of healthcare while improving the quality of care. This includes coordinating care among providers and utilizing preventive care to reduce unnecessary expenses.

How Managed Care Influences Costs

Managed care can significantly influence the cost category by promoting efficiency and reducing duplication of services. By managing resources effectively, healthcare providers can deliver better care while also saving money.

Benefits of Managed Care in MIPS

Implementing managed care strategies can lead to improved MIPS scores, as providers who coordinate care and focus on prevention typically see lower costs and better outcomes. It’s a win-win for both patients and providers!

Strategies for Improving MIPS Cost Scores

Data Analysis and Reporting

Understanding your practice’s data is essential. Analyzing claims data can reveal trends and identify areas for improvement. Regular reporting can also help in tracking progress toward cost management goals.

Engaging Patients in Care

Active patient engagement can lead to better health outcomes and reduced costs. Educating patients about their conditions and treatment options empowers them to take charge of their health, which can lead to fewer unnecessary visits and interventions.

Coordinating Care with Other Providers

Collaboration with other healthcare providers is vital. By ensuring that all members of a patient’s care team are on the same page, you can reduce the risk of duplicated services and streamline the overall care process.

Challenges in Managing MIPS Cost Category

Variability in Patient Populations

One of the biggest challenges is the variability in patient populations. Different patients have unique needs and complexities, making it difficult to apply a one-size-fits-all approach to cost management.

Data Collection and Reporting Issues

Collecting accurate data for reporting can be daunting. Many providers struggle with the administrative burden associated with data collection, which can lead to inaccuracies in reporting and ultimately impact MIPS scores.

Balancing Cost and Quality

Striking the right balance between cost savings and quality care is essential. Providers must ensure that cost-cutting measures do not compromise the quality of care provided to patients.

Future Trends in MIPS Cost Management

Advancements in Technology

Technology will continue to play a significant role in MIPS cost management. Innovations such as telehealth and data analytics tools can enhance care delivery and improve efficiency, leading to better cost management.

Policy Changes and Their Impact

Healthcare policies are constantly evolving. Staying informed about changes in legislation and CMS guidelines can help providers adapt their strategies to maintain compliance and optimize their MIPS performance.

The Shift Towards Value-Based Care

As the healthcare landscape shifts towards value-based care, understanding cost management will become even more critical. Providers must be prepared to adapt their practices to thrive in this new environment.

Read More: What Quality Measures Can Physicians Report for MIPS 2020 Reporting Services?

Conclusion

In summary, understanding the MIPS Cost Category and its implications is essential for physicians aiming to succeed in the evolving healthcare landscape. By embracing managed care strategies, leveraging technology, and focusing on patient engagement, providers can enhance their cost management efforts and ultimately improve their MIPS scores.

Let’s take these insights and implement them into our practices for better patient care and financial sustainability.

FAQs

What is the purpose of the MIPS cost category?

The MIPS cost category aims to evaluate how efficiently healthcare providers manage resources while delivering care to Medicare beneficiaries. It impacts reimbursement rates and reflects overall practice performance.

How can physicians improve their cost category scores?

Physicians can improve their scores by engaging patients, coordinating care with other providers, analyzing data for trends, and implementing cost-saving strategies without compromising quality.

What role does managed care play in MIPS?

Managed care helps control healthcare costs while improving quality by coordinating care, promoting preventive measures, and reducing unnecessary services.

Are there penalties for low cost category scores?

Yes, providers with low cost category scores may face penalties in the form of reduced Medicare reimbursements.

How can technology help in managing MIPS costs?

Technology can enhance data analytics, streamline reporting processes, and facilitate telehealth services, all of which contribute to better cost management and improved care delivery.