By Jack Duffy
Executive Vice President
The good news may be that only a small number of expected enrollees have been able to complete the process. The much more concerning revelation this week is that 60% of the software needed to process payments and pay providers is incomplete and untested. The plan is to complete and test prior to the March go-live; however, based off recent past performance, this goal may be yet another illusion. In markets where there is activity, hospitals and physicians may be subject to another expensive delay in processing and build unpaid inventories for services. In a time when every dollar is critical, this risk will threaten jobs in our community and becomes another unacceptable consequence of a poorly planned and executed program.
What can you do?
First, identify the entities and carriers who have agreed to participate in your community. This should be treated the same way HIPPA 5010 was installed a couple of years ago.
Then, ask these important questions:
- Do they have a way to collect and post premiums?
- If this process might be delayed is there a plan to pay for service in advance of collection premium?
- Will the established payment mechanisms be used or are new processes required? This includes electronic EOB’s, 835 messages, ACH transfers and other processes.
- Will you need new or additional contracts to cover these relationships?
- Will it use new or established networks?
- If federally funded, will it pay Medicaid rates or a new payment schedule?
- Are there service limitations similar to those imposed on Physical Therapy?
- Will you be able to use existing clearing houses for eligibility, and will select services require prior authorization?
- This should be treated as a starter set of critical questions that need to be reviewed prior to go-live. Testimony before Congress revealed that 60% of the required software is not complete, making the chance of multiple points of failure highly probable.
In addition to reviewing the above questions, providers should contact their service bureaus and PFS software vendors. A checklist of needed reports and plan identification should be established. A testing plan should be agreed upon, including test date for all components of the transaction. Also, if one or more community members are sponsoring ACOs, are the computer systems including capitation accounting and global payment processes maturing in an acceptable way?
Although a number of states have not yet accepted the federal program, I believe this is a major step towards the nationalization of healthcare. This is a process full of political issues; however, the transformation of our current system is taking a significant step with the introduction of this program.
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