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Achieve Appropriate ASC Reimbursement With Patient Protection and Affordable Care Act: Q&A With Greg Maldonado of American National Medical Management


This article is sponsored by American National Medical Management.ANMM logo

Gregory MaldonadoGreg Maldonado, President of American National Medical Management, discusses how ambulatory surgery center administrators can use the Patient Protection and Affordable Care Act (PPACA) to maximize reimbursement based on the patient’s insurance plan.


Q: What should providers know about how PPACA affects private medical coverage?

Greg Maldonado: PPACA healthcare laws are specifically designed to protect patients and mandates how insurance companies must legally adjudicate claims. The laws hold insurance companies accountable to the payment structures outlined in the patient’s health care plan. Most providers, however, aren’t familiar enough with the relevant sections of PPACA to utilize its full potential.

Really read the words within the PPACA acronym, "Patient Protection and Affordable Care Act." Pay close attention to the "Patient Protection" portion. This part of the law was created to protect the consumer. It is a consumer protection law which allows the patient to better utilize their healthcare benefits and ensure insurance companies are adequately reimbursing for the services provided.

Q: How can ASC leaders make sure their claims are processed appropriately?

GM: It is crucial that ASC leaders either read and understand the PPACA law or hire an expert to help them. The "Patient Protection" part is applicable now, while the "Affordable Care Act" is still being implemented with the health insurance exchanges. A good understanding of PPACA will allow one to utilize and implement its provisions; forward-looking ASCs should not wait to see what their competitors do, but should rather be an industry leader and capitalize on the laws now.

Barring an act of Congress, PPACA is here to stay. Rather than waiting see how it will affect your ASC, use it to your advantage now.

Q: What challenges can providers expect with PPACA?

GM: The biggest challenge is that PPACA is new; there are no precedents in the form of case law. The Employee Retirement Income Security Act (ERISA), enacted in 1974, is the original healthcare law, yet few providers are aware of it, or how to use it to their advantage. By finding experts who are well-versed in both PPACA and ERISA, ASCs can not only maximize their own profits, but also offer the maximum benefit to their patients.

Most providers, billers, and patients are completely unaware of how the PPACA laws work. Additionally, insurance companies do not have the infrastructure to properly adjudicate claims according to PPACA just as they have not had the infrastructure to process claims according to ERISA. Until they understand the law, providers cannot hold the insurance companies accountable. I recommend that providers either become an expert or partner with an expert to help empower the patient and achieve adequate reimbursement.

 Q: What can providers do now to prepare for these changes?

GM: While PPACA has been in effect since March, 2010, it is still a mystery to most providers.  In order to ensure that insurance companies pay what they are required to according to the patient’s benefit plan, each of us must fully understand our legal rights and how to use them.

Providers are often, justifiably, so focused on patient care that they forget there are laws in place that govern the claims process. Understanding the law will help providers draft an effective game plan to ensure they receive proper reimbursement. By partnering with an expert well-versed in the complexities of the reimbursement cycle, providers are free to devote their full attention to patient care.
Q: Do these laws only apply to out-of-network contracts or do they apply to in-network coverage as well?

GM: They apply to both. Whether a physician has a contract or not, the laws remain the same The difference, however, is that  once you sign a contract, you agree to the terms of the contract and therefore waive some legal rights, although there are certain situations (such as recoupment) where the laws remain in effect With education comes power; if you are educated about the laws that govern the claims process you can overcome most reimbursement underpayments and denials  In today's medical world, providers often rely on insurance companies to dictate how claims should be processed and that can leave providers at a disadvantage. Educate yourself and don’t accept unfair contractual terms.  

Q: How can providers utilize PPACA in competitive healthcare markets?

GM: Providers need to understand that they don't really hold the power when it comes to healthcare claims; the power belongs to the patient. The "PP" stands for "Patient Protection," not "Provider Protection." Providers have no appeal rights without proper legal documentation from the patient. Oftentimes patients are faced with the burden of appealing a decision, a complicated process that requires documentation they may not have and utilizes medical and legal terminology with which they may not be familiar. The provider must work on behalf of the patient to file a successful legal appeal.

Empower yourself to stop allowing insurance companies to dictate medical care for your patients. Insurance companies are not physicians and therefore should not be responsible for determining the medical needs of a patient. If you can use law as it is written and hold insurance companies accountable to pay the claim in full and reduce your patient’s out-of-pocket costs, everyone is better for it.

Q: Beyond the obvious financial benefits of receiving appropriate reimbursement, how does collecting in full from insurance companies impact the ASC?

GM: When providers receive adequate reimbursement, they are not only able to provide state-of-the-art care to their patients; they are also able to cover their own costs. This allows them to better focus on providing high quality care rather than trying to collect unpaid balances from patients. When the insurance company properly adjudicates a claim, it removes the burden from the provider to balance bill the patient, and thus eliminates conflict and improves care.  The doctor can focus on practicing medicine, and the patient can focus on recovery, as it should be.

Do not hesitate to contact an expert if you have any questions about the legalities of the healthcare claims process. It is imperative that physicians and ASC leaders do their due diligence and ensure patients are getting the best care available and that insurance companies pay the claims according to the patient’s plan.  This is not simply a legal imperative, but a moral and ethical one as well.

More Articles on Surgery Centers:
6 ASC Administrators on How Their Surgery Centers Are Responding to Healthcare Reform

4 Things Great ASC Administrators Do to Prepare for the Future

6 Steps to Hire a Staff That Makes Your Surgery Center Shine


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