One Expert’s Insights into Healthcare Changes That Could Impact Your Practice

We asked Eric Brodsky, healthcare consultant with close to 30 years experience, his thoughts on upcoming changes he sees in healthcare, and how those changes might impact independent physician practices.  There are four areas Eric focused on in his answer.  Here are some of Eric’s insights into the changing landscape of the healthcare industry.

Healthcare changes that could impact your practice:

1. Changes in payment structure

The emergence of pay for performance and shared savings payment methodologies will put us in a far different place than we have been with fee-for-service.  Rather than being reimbursed based on quantity, as we currently are in a fee-for-service environment, reimbursement is shifting to payment for quality outcomes.  Some of these methodologies, such as MACRA, are intended to be budget neutral.  Those who are prepared will see the upside in their reimbursement, and those who are not prepared may not survive in this new environment, as they will see a reduction in their reimbursement.

2. We will continue to see increased payor edits

With the emergence of EMRs, we all (practices and payors alike) have a tremendous amount of data at our fingertips.  Because it is available and attainable, we’re seeing that payors keep wanting more and more data.  As a result, we’re going to continue to see more claims being put into a pending and denied status because they are not meeting the criteria at this increased threshold.

3. Increase in ICD-10 codes as of October 1st

We all adjusted to the tremendous increase in the number of diagnosis codes we needed to keep track of after moving from ICD-9 to ICD-10 last year.  Just when we were getting comfortable, they expanded the ICD-10 code set even further on October 1st.  The amount of choices available for diagnosis coding is making it more and more difficult to code in the exam room.  Some specialties are affected more than others, but all continue to feel the challenges in the level of specificity required with ICD-10, and the associated costs of administering this are new line items in practice’s budgets.

4. Pre-certification will continue to become increasingly difficult

Challenges to medical necessity during pre-certification will continue.  As we are moving to a new reimbursement environment, utilization and medical necessity will be increasingly scrutinized.  We hope we will not see reason go by the wayside as a result.  For example, services provided by obstetricians to pregnant women should be given the medical necessity benefit of the doubt, as the pregnancy necessitates the need for specific care.