Accountable Care Organizations (ACOs) represent an innovative delivery model by which different stakeholders in the healthcare system (i.e. providers, hospitals, payers, etc.) will collaborate to provide quality to a population at certain level and share in the savings. Therefore, coordination of billing will be all the more important. Each type of clinical organization currently may have a different billing process. Also, each healthcare entity, whether it is a clinic or hospital, has its own billing software. How are ACO participants going to coordinate with such a set-up? How do vendors that provide billing solutions or third-party billing companies deal with this?
One important strategy is to leverage technology, as much as possible, with the least amount of reliance on paper. Some clinics and hospital systems may be doing their billing still on paper. The capturing of information digitally will allow ACO members to share and communicate financial and clinical data related to billing with some ease. With the greater adoption of interoperability standards such as HL7 and vehicles to transit information such as health information exchanges, the billing information stored in EMRs (electronic medical records) and Practice Management (practice management) systems can be shared among ACO entities regardless of their geographical locations or the information technology applications they are using.
Software vendors that create PM (practice management) software or have it part of their EMR system should be excited because electronic submission of claims is perfect for the limited time frame by which ACO members have to show quality and cost savings. ACO programs usually last only 3 years and data reporting to CMS is expected to start in year 2. Submitting claims on paper results in a much longer response time from payers, especially if the claim is large or complicated. Furthermore, when claims are denied sending remittance advice electronically is a lot quicker and more efficient.
Third party billing companies also have a huge advantage in that they are already experts in compliance which is becoming a larger issue in the wake of healthcare reform and the ACA (Affordable Care Act). For example, the prediction is that in the years to come RACs (Recovery Audit Contractors) will be visiting clinics and hospitals more often. With the electronic submission of clinics and the ability to group clinical data electronically also, thanks to EMRs, the government will be able to audit easier and more frequently. A second competitive edge for third party billing companies is that they have already engineered a very efficient way to help the practice or hospital with their revenue cycle. The reason is that most of these companies get paid on a percentage of monthly revenue from their clients. This efficiency is a perfect “culture match” for the ACO.
As ACOs become more popular and healthcare institutions learn how to make them work, we will began to see a greater need for better billing practices that are more coordinated and efficient. The proper technology and software system will enable ACO participants to meet their goals in providing high-quality care while saving costs that ultimately will translate into shared savings. Software vendors and third party billing companies have a lot to gain from initiative, as long as they understand how to leverage strengths.
Jitesh Chawla, MD
Patagonia Health CMIO