Balancing ACO Objective with Physician Reimbursement Maximization

As the U.S. healthcare sector looks up the Accountable Care Organization (ACO) Concept of healthcare delivery with great expectation, physician community is quite apprehensive about their ability to garner reimbursements under a new healthcare delivery altogether. While ACO itself is not a novel concept – there have been umpteen examples of institutions operating on ACO lines – the urgency is such that it warrants an immediate action by the physician community, who can effectively bring down the spiraling healthcare expenditure while promoting quality medical care for an ever growing patient base.

While the Federal Healthcare Department seeks to bring the unsustainable growth rate in healthcare rates – estimated to be 17.3% of the gross domestic product and projected to be 19.3% by 2019 – there needs to be complementary effort that can rein in spiraling U.S. healthcare costs, expand access, promote wellness and improve the consistency of quality outcomes. Although the task needs to be jointly accomplished by the physicians, health insurance carriers, and policy makers, the role of physicians becomes quite pronounced as they hold the key to success or otherwise of the Accountable Care Concept.

Notwithstanding their apprehension about their ability to garner a steady flow of reimbursements under the ACO Model – in an ACO, providers will no longer be rewarded for the volume of care provided to those who are sick; instead they will be paid based on their ability to keep people healthy with minimal procedures – physicians would do well to integrate their operational model for better patient experience. Once they can build goodwill based on better patient experience, the volume will take care of itself as satisfied patients themselves become brand ambassadors for promoting physicians’ services amongst newer markets. But, before all this can happen, physicians, willing to be in an ACO Model, need to:

  • Have people‐centered health homes that deliver primary care and coordinate with other providers as patients move across the delivery system.
  • Try new approaches to primary, specialty and hospital care to reward care coordination, efficiency and productivity.
  • Have tightly integrated relationships with specialists, ancillary providers and hospitals so they are similarly focused and aligned on achieving high‐value outcomes.
  • Practice Provider/Payer Partnerships and Reimbursement Models that reward improved outcomes, rewarding value over volume.
  • Have Population Health Information Infrastructure, including health information exchanges, to enable care coordination across a designated population.

Thus, with an open-mined outlook to ACOs – widely viewed as a way to move from the fragmentation and volume orientation of our existing fee‐for‐service system towards pay-for-value system – physician community can look to work cooperatively across the care continuum to help patients reach wellness goals and achieve common measures of success.

As physician embarks on an integrated system of healthcare delivery, they would be well-off having an advisory from competent Medical Billing Companies that can offer balanced approach for both operational as well as revenue optimization. – with proven credentials for offering cost-optimizing and revenue- maximizing Medical Billing Revenue Cycle Management Suit, complete with Patient Scheduling and Reminders, Patient enrollment, Insurance Enrollment, Insurance verification, Insurance Authorizations, Coding and audits, Billing and Reconciling of Accounts, Account Analysis and Denial Management, AR management, and Financial Management Reporting – should be able to play a pivotal role in making physicians’ transition to ACO Model smoother and fruitful.

Combined alliance of such pro-developmental physician community and medical billing companies can greatly contribute the national goal of providing coordinated, quality and cost‐effective healthcare services to an estimated 32 million Americans.