Reimbursement Ethics and Compliance: Impact of Health

Reimbursement Ethics and Compliance: Impact of Health Care Reform on Medical Coding and Billing

"Medical billing and coding lays the foundation for any successful healthcare provider," yet its common practices are undergoing significant changes under the recent proposal for health care reform (Griffey, 2013). The nature of medical coding and billing is increasingly becoming more and more complicated. The recent healthcare reform legislation, passed in 2010, promises to complicate the situation even further. Such reforms will undoubtedly have a huge impact on medical billing and coding processes.

The reform bill was a monumental piece of legislation passed by Pres. Obama and his Democratic supporters in 2010. There are a number of stipulations which aim to help increase access to appropriate health care for millions of Americans who are currently without any coverage, helping lower the cost of premiums too much more affordable rate for most Americans but also increasing the coverage of Medicaid and Medicare. Additionally, the statutes presented in the Health Care Reform Bill would essentially help "reduce the deficit by $143 billion over the first ten years" (Jackson & Nolen, 2010). Most significantly, the reform is helping put a stop to insurance companies denying coverage for those individuals who have a pre-existing condition. This is a huge move, one which will help stop some of the discriminatory practices currently commonplace within the healthcare insurance industry. However, it is an incredibly costly endeavor, at a price tag of about $940 billion over the span of ten years (Jackson & Nolen, 2010). The reform will undoubtedly impact a number of areas within the healthcare industry, including medical billing and coding. The final components of the healthcare reform laws are set to begin in the start of 2014.

The nature of medical billing has been changing dramatically in recent years. Medical billing previously used ICD-9 as the standard for coding medical reimbursements. Yet, this has morphed into a new process which is being taught by most school today, which uses ICD-10. According to the research, "with over five times as many codes, going from 13,000 to 68,000, the ICD-10 system offers much more specificity when labeling treatments" (Griffey, 2013). So many more codes allow for much more streamlined process, where there is much less paperwork and much clearer medical billing processes. The current health care reform will also facilitate the decrease in paperwork involved both in terms of the patient and the medical billing professionals. The number of coding systems will obviously continue to increase as "coverage expands and new rules for pre-existing conditions come into effect" under the health care reform (Eastaugh & Sternal-Johnson, 2010). These changes are only increasing with the upcoming developments of the healthcare reform stipulated in the Healthcare Reform Bill, recently passed in 2010. In regards to the ban on insurance companies denying coverage for pre-existing conditions, this will open up a whole new genre of reimbursement claims for medical billing professionals. Billing will have to implement new codes and coding procedures to deal with pre-existing conditions, as well as expanded Medicaid and Medicare coverage.

There are a number of implications of the healthcare reform on medical billing. According to the research, "regulatory reform in the healthcare industry may leave you asking how the medical billing and coding world will change, but the goals and responsibilities remain the same: handling accounts receivable and revenue cycle management" (Griffey, 2013). As such, the primary and goal will be the same, yet the practices used to get to that goal will be increasingly different than seen in previous generations. Essentially, the workload for medical billing professionals will become increasingly complicated, as more and more individuals claim reimbursements for a wider variety of conditions and ailments. Thus, "the only things that change other processes for handling reimbursement requests, the complexity of the needed coding and privacy requirements mandated through HIPAA" and the upcoming changes presented in the Healthcare Reform Bill, which are going to be finalized by 2014 (Griffey, 2013).

Increasing coverage under Medicaid and Medicare mean a lot of changes within medical billing practices as well. The research shows there will be increased reimbursements from Medicaid (PRN News, 2013). Essentially, the reform "expands Medicaid to include 133% of federal poverty level which is $29,327 for a family of four" (Jackson & Nolen, 2010). Also, the bill is expanding Medicaid coverage to "childless adults" in 2014 (Jackson & Nolen, 2010). This will increase the number of individuals using Medicare and Medicaid as a way to help pay for their health care costs. According to the research, "physicians that normally might be reluctant to see Medicaid patients due to meager reimbursements will be more willing if they know that the payoff will be better. The billing and coding industries that serve them will benefit as well from increased physician revenue" (PRN News, 2013). This means that more attention must be paid to the coding involving Medicare and Medicaid cases.

Possible influences of mandatory compliance programs on the coding practice -- how will it be different than the current state of coding? In order to meet this growing demand for healthcare needs, more medical professionals will be needed, including those working in medical coding and billing. Essentially, "the need for billing and coding professionals is going to increase because of the increased number of people who will be submitting claims to insurance as well is expanded Medicare and Medicaid coverage" (Eastaugh & Sternal-Johnson, 2010). More medical billing staff will be needed by individual healthcare facilities in order to appropriately handle the increasing workload that the reforms would entail. This means new hires and a larger workforce within the medical billing industry. According to the research, "obviously there will be extensive training required for all current billing professionals to learn all the new rules" (Eastaugh & Sternal-Johnson, 2010). This would require more training, both for new hires and those medical billing professionals that will need to be retrained on new procedures under the reform statutes. The new heath care reforms will also help provide more funding for all types of training and educational programs for already established and beginning medical professionals (PRN News, 2013). This means that the need for more training to meet new practices in medical billing will be met with greater level of funding, and thus will provide a strong level of efficiency in helping medical billing professionals understand the nature of the new changes.