Those quality measures do not necessarily
define you as a doctor!
No matter which specialty you're in
or which level of practice you're in,
whether you just graduated,
whether you've been in practice for a long time,
it's very important to understand
how insurance companies pay you.
There's various levels of compensation
be that from an HMO Plan, PPO Plan, or Medicare.
For the time being most HMOs compensate you based on
computation with come sort of incentives depending
upon what kind of care you provide for your patients.
There's a certain set of
"quality measures" that if you perform well
you will get a bonus from your HMO plan.
For instance, if your asthmatic patients get albuterol
or if your diabetic patients get A1Cs checked twice year,
even if you're a specialist, if you still care for
those patients and if those patients get those
"quality markers" you will get
a bonus from your HMO plan, but certain
HMO plans will not pay you for service.
For years, some physicians would take advantage
of this opportunity where they would not necessarily
see their HMO patients, just collect computation
and sort of profit from that but things are changing.
This is no longer going to be the case
going forward for most HMO plans
because the emphasis will be on quality.
They want to make sure you don't
just have those patients in your panel
but you do quality care
and based on that you'll get a bonus.
What that bonus is depends on your plan.
As far as the PPO plans, of course,
for the time being you're being paid for service.
You see the patient in the office,
you do a procedure in the office,
or you follow them in a hospital,
it doesn't matter, you code for
that level of service and you get paid.
This will also be changing in the next couple of years
because, again, insurance plans will tie
a lot of your compensation into quality measures.
There's a debate going on right now whether those
quality measures are really measuring quality.
For instance, the way that you taking care of
your hypertensive patients is measured by
the last blood pressure in the chart for the year.
Well, something could have happened that day
and your patient may have a high blood pressure
and based on that you don't get checkpoint
for that quote unquote "quality measure."
I keep saying quote, unquote
because those quality measures do not
necessarily define you as a doctor.
They do not necessarily tell patients that you're
better or worse doctor if you don't have
a 100 percent score on certain quality indicators
but the truth of the matter is
that those are the things that we have to do,
that we have to sort of be governed by
and it's up to us to report those measures
and it's up to us to let insurance companies
see that we doing all that
and the important thing is
that moving forward even PPO plans will
concentrate more on quality rather than quantity.
So when you just see the patient in the office
and you provide a certain level of service,
you still bill for it but in years to come
you won't just get that particular compensation
from seeing them in the office a lot of it
will be tied to quality measures.
And Medicare, of course, beginning this year
you've all heard of MIPS and MACRA provisions.
MIPS are the MACRA provision
and it's a very complex structure.
It is not very difficult to implement
but it is quite cumbersome.
It will be interesting to see
what many physicians do with that
because again the burden is on the doctor
to show that you're doing good work.
It's kinds like the opposite of, you know,
you're guilty until you're proven innocent.
So basically it's assumed that you're not
doing the right work until you actually show it.
Depends on your setting,
depends on your electronic medical record
and which setting you practice in.
It's obviously much harder to comply
with all these measures if you're an independent physician
and it is much easier if you are
employed by a large organization, such as a hospital,
because they do many things for you.
In all, this leads us to the actual billing and coding.
How to actually code for your visits...
What do you do in the office...
and we'll talk about this at greater length
in a later video and of course at our seminars.
We hope you enjoyed the video.
Reimbursement Rx was founded to educate residents
and practicing physicians on how to navigate
the business of medicine from the doctor's side.
To stay up-to-date with our latest insights,
please like Reimbursement Rx on Facebook,
subscribe to Reimbursement Rx on YouTube
and check us out online at reimbursementrx.org.
Thank you for watching.
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