Published - July/August 2021 Edition of BC Advantage Magazine

Fixes for Healthcare: PART ONE
By Dave Jakielo

Many people talk about our dysfunctional, broken, out-of-control healthcare system, but few offer ideas to try to minimize the bureaucracy, reduce the administrative burdens, and change the economic incentives.

Not much ever changes for the better, because of all the special interest groups and humongous profits available for Pharmaceutical Firms, Third Party Insurers, For-Profit Hospitals, etc.

However, in this article and my next, I will present some timely, concrete ideas that should be considered as possible improvements to the current healthcare maze we find ourselves struggling to get through.

First, there should be a mandatory National Fee Schedule, the same price paid for every CPT code by every payer with an adjustment allowance for geographical differences. Obviously, an office visit in Cedar Rapids, Iowa should not be reimbursed at the same level as one performed in San Francisco, California. However, we need to eliminate that a simple office visit, a 99212, can have a payment range between $50 to $75 dollars depending on how good of a negotiator you are with the various third-party payers. I have seen payment variances for the same CPT code even when independent practice providers are in the same medical office building.

A National Fee Schedule would eliminate the need for the provider to negotiate with a plethora of third-party payers, and more importantly, it would not financially penalize the patient if the provider is out of network.

Secondly, another royal pain plaguing our system is known as Provider Enrollment, which is required by each third-party payer, and states that a provider aims to be considered a participating provider, with expectations of receiving direct payment. My idea is that if a provider has been approved, enrolled, and received a National Provider Identifier (NPI) from Medicare, every other third party must honor that and cannot require the provider to jump through their bureaucratic hoops to be deemed participating. The NPI should work with every third-party payer.

Next, we should eliminate the requirement for individual state licensures. A radiologist is a radiologist is a radiologist; why should they need to complete individual applications for each state in which they want to practice? According to the AMA, state licensing boards and statutes can be complex and vary from state to state depending on each jurisdiction's resources, regulations, and state laws. Let's license the provider at a national level that will allow them to practice anywhere in the United States and their territories.

Lastly, we need to put some teeth in the Price Transparency laws. There is no other industry where you do not know what the service or product will cost until after you have made the purchase. Even the auto repair shop I go to calls me with an estimate so I can authorize the repair before I must take out a second mortgage. Some providers have gotten on board and do inform their patient what their co-pay and deductible amounts will be before rendering services, but this is a minority of providers. And we are all clueless about ancillary services, such as lab tests, radiological services, anesthesia charges, etc.

We always hear about how the number one cause of bankruptcy in the United States is medical expense. How can we allow our friends and neighbors to be destroyed economically because they are facing a devastating disease or suffered a tragic accident?

I think before we worry about forgiving students their college debt, we should use that money to assist people who face staggering hospital bills. Going to college was a choice and you knew the price tag. Having a serious illness or an unfortunate accident was not that person's choice.

Above, I have described four problematic issues we have with our current healthcare system and some possible solutions to rectify these situations. It seems all we do is debate what we could do, and no one is willing to take any action because it may have a negative impact on them and their specific interests.

Well, if we do not start taking some action and begin eliminating the bureaucratic hoops we all have to jump through, our fractured system will only get worse and worse. Why don't we become proactive and start fixing the problems before the entire system implodes?

Dave Jakielo, is an International Speaker, Consultant dedicated to the Medical Billing Industry, Executive Coach, and Author, and is President of Seminars & Consulting. Dave is a Founder and past President of Healthcare Business and Management Association and the National Speakers Association, Pittsburgh. Sign up for his FREE weekly Success Tips at www.Davespeaks.com. Dave can be reached via email Dave@Davespeaks.com; phone 412-921-0976.

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