Published - September/October 2021 Edition of BC Advantage Magazine

Fixes for Healthcare: PART TWO
By Dave Jakielo

In my last article, I outlined four ideas that could help streamline our complex healthcare system. To recap, they were:

  1. Implement a National Fee Schedule with geographical adjustments.
  2. Streamline Provider Enrollment; if a provider is in Medicare, they are included in all payers' panels.
  3. Eliminate State Licensure; establish a National License Board.
  4. Price Transparency needs to be easy to navigate and easy to understand before services are rendered.

Now, I would like to make some additional recommendations to help lower costs, bring further efficiencies to the system, and reduce administrative burdens.

First, third-party payers should take on the responsibility of collecting the copays and deductibles directly from the people enrolled in their products since third-party payers invented copays and deductibles to hopefully stifle utilization and reduce their overall cash outlays. The provider should be paid in full for the services they have rendered, and the third-party payer should add the copay or deductible to the enrollee's monthly premium.

The provider should not be on the hook for non-payment of a patient's liability and be forced to carry an accounts receivable while trying to obtain renumeration from their patient. The third-party payer should collect directly from their customer. Making a provider render services for free should be their choice - not a requirement.

My next recommendation is the elimination of the 1500 claim form submission. This could be accomplished if every patient whether covered by a private insurer, Medicaid, or Medicare was issued an Identification Card, like a credit card. Then when a provider renders a service, they would simply swipe the patient's card into a terminal, and after verification, enter a CPT and ICD code for that visit or procedure and the monies would immediately be transferred from the third party's bank account into the provider's bank account. If coverage is nonexistent or the procedure is denied, the provider could arrange for payment immediately rather than have to wait for the claims to be submitted and accepted, or possibly denied in 30 days and then must chase the money due them.

A third idea is that all stand-alone Ambulatory Surgery Centers (ASCs) should be directly tied into or owned by a hospital. In some communities, privately-owned centers are cherry picking patients with the best insurance coverages and leaving the under or uninsured patients to receive their services at the hospital. Thereby shifting the profitable patients to the free-standing centers and raising the cost per patient even higher at the hospital. Having a group of investors at the ASC profiting at the expense of the local hospital just does not seem right.

Everyone is for change and adjustments to our healthcare system if it does not affect them. However, we need to change this way of thinking. The longer we ignore our healthcare crisis, that has been brewing for the past few decades, the more severe the solutions may need to be implemented.

Here are some other thoughts about what could happen if we do not take a proactive approach. Some of these ideas I am in favor of, while others I am not on board with yet and may never be, but I wanted to list them as possibilities that could happen in the future.

  • Eliminate state insurance commissioners. Services should be covered on a nationwide basis, not a decision left to each state.
  • Replace fee for services with another payment method. If we have a "the more you do, the more you make" model, we will never be able to prevent unnecessary services from being rendered.
  • Rethink allowing people to buy into Medicare. This may make the situation worse if third-party payers encourage their sickest patient to leave their plans and join Medicare.
  • Reconsider a single payer system. Wow, would this blow things up. Might be a good idea, but who would be in charge? That is the trillion dollar question.
  • Make healthcare lobbying illegal.
  • Ensure we are allocating monies properly between prevention, treatments, and cures.
  • Providers should be able, with permission, to access a patient's electronic medical record (EMR) regardless of which system houses the record. If I show up in an emergency room in another state, chances are the provider will have to start from scratch to come up with my medical history.

I know we are not going to solve our industry's many issues overnight, but let's at least figure out a way to get the conversation started. The system doesn't just need a band aid; it needs a lobotomy.

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 Dave can be reached via email; phone 412-921-0976.

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