The most common misconception regarding medical-practice reimbursement is that it’s about nothing more than money. In fact, reimbursement is about much more than the dollar numbers associated with CPT® codes in payors’ various fee schedules, and any discussion of it that doesn’t also touch on process, strategy, and service is incomplete.
With today’s business-intelligence tools, forward-thinking practices are better able than ever before to understand the multifaceted nature of reimbursement. Even if two payors offer exactly the same reimbursement rates for a procedure, one might reimburse more quickly (or with greater ease) than another, meaning that there is a process impact associated with the second. Without revenue-cycle management, overlaid with business-intelligence tools, these trends are difficult to detect.
The same concept applies to the practice’s longer-term strategy. As payors increasingly require their practices to adhere to state- or locality-based fee schedules, they gain the upper hand in contract discussions, and practices might need to make strategic decisions to secure the reimbursement rates that they want. For instance, if the practice adds an interventional radiologist, thereby becoming the only organization offering that service line within a 100-mile radius, it can regain its advantage in negotiations.
Health-care reform throws a wrench into our current predictive analysis of reimbursement; however, it also provides a unique opportunity: Smart practices can begin aggregating data from the start of the new-patient influx, tracking for themselves which demographic groups, if any, become more strongly represented; which patients trend away from self-payment (and which, if any, trend toward it); and what the impact of increased utilization of preventive imaging is on downstream radiology revenue. These made-from-scratch insights will enable practices to serve their patients, referrers, and hospitals better in the health-care environment of tomorrow.
When practices think of reimbursement as merely money, they are blind to the nuances of the payor–provider relationship that can make or break their future success. Business intelligence reveals the multifaceted nature of a practice’s current and future reimbursement outlook, empowering its leaders to operate strategically—even in uncertain times.
Taylor Moorehead is a partner with Zotec Partners.