Healthcare Reform Makes Private Insurers Act Like Medicare, Medicaid

Editor’s Note: This article is the first in a two-part series by Shanna Rogers. The second installment will be published tomorrow on insidePatientFinance.com.

One growing trend emerging from the Patient Protection and Affordable Care Act (ACA) is that the private sector is starting to act more like the public sector.

One of the compromises that enabled healthcare reform to win acceptance in Congress is that private insurers will begin acting more like their public counterparts, namely Medicare. As more of the provisions of the ACA come on line, expect all payors to work more alike rather than different.

The ACA impresses upon private payors the need to be compliant with data standards and streamlined claims processes that will eventually make all payors seem like a single payor. Data sets and transaction standards should be made available or even required from private payors.

In many respects this merging of workflows between public and private payors will be a good thing for healthcare providers, and will streamline what today is a hodge-podge of workflows, each one different for each payor. Providers will see more claims rejected based upon the ANSI code sets and HIPAA transactions intended to standardize denials. This will enable providers to assess and track denials more efficiently, allowing for root cause analysis. Currently this isn’t possible with the multitude of practice management/hospital billing systems unless the provider has made a significant investment in a business intelligence platform.

For small insurers, the future is not bright. It requires substantial resources into infrastructure and other systems to bring claims processing platforms into compliance. There are even regional insurers who may find the cost too high, and therefore expect to see more consolidation in the form of acquisition and mergers among the smaller players in the market.

While this trend is ostensibly good news for providers, one area of concern will be denials management. While the future under ACA will mean more patients have insurance, it also means that insurers will scrutinize claims even more closely to insure compliance. The same market forces and regulations that are forcing payors to become more sophisticated will also mean that providers will have to step up as well.

NEXT IN THE SERIES: DENIALS MANAGEMENT

About Shanna Rogers

Shanna Rogers is a supervisor with ProSource Billing, Inc., a part of the Array Services Group family of companies. Shanna  has 13 years of Revenue Cycle experience working with many types of organizations. She has been with ProSource Billing  for the last 10 years contributing to and managing projects.