Why do you need to know about these 4 key reimbursement areas?
Consider expanding your knowledge, certify your expertise, and bring something unique to the table.
The healthcare reimbursement system, with its coding, coverage, and payment is massive. For those of us working in healthcare, whether we know it or not, we are supporting that system. One of the biggest driving factors is standardization: a unique aspect of the United States healthcare system due to laws such as HIPAA and the Medicare Modernization Act of 2003.
To keep the system running and ensure patient access to care, reimbursement professionals are required to have an ever expanding knowledge base of all of the systems, rules and regulations. Yet, only a few select people know these four categories, which can take you from being a specialist, to a recognized expert. Each of them are extremely valuable insights to bring to your work.
Here are the four categories based on level of importance for career growth, based on our expert opinion.
1. Reimbursement Strategy
It's not a game. It's how patients get access to care, and how new innovations get covered.
Do you think that reimbursement is submitting a claim to insurance, getting an EOB and calling the payer to get an authorization? Well, think again! Reimbursement actually has 3 components, which the Strategic Reimbursement experts call “Coverage”, “Coding” and “Payment”. These three elements are what makes that claim submission, EOB and authorization possible, because these three things are what CMS and Payers/Insurance consider when making a decision to cover something or not.
Coverage involves the medical necessity, scientific evidence and demand from the market. Coding is the language of reimbursement, and if your product doesn’t have a code, then forget about getting reimbursement. Payment are the rules and policies about the rates of pay and agreements such as capitation. Who sets all of these things? Well, Reimbursement Strategy executives do. They bring all these elements together and help big organizations navigate these challenging areas. Large consulting companies who provide these services can charge millions of dollars to big companies to make this happen.
2. Market Access Processes
It's a whole industry that ties reimbursement to bringing medical services, drugs and products to market.
There’s an app for that…..meaning an “application” of course. Not the kind on your phone, but something you actually send to be approved. It’s a standardized process for bringing products and services into the healthcare system with their own reimbursement codes. Ever wonder how those procedure and diagnosis codes are made or who makes them? Companies apply for them! Did you know that there are special organizations in the government that are responsible for it? Did you know they are different depending on whether it is a product or service, and if the product is a drug, device or diagnostic?
If you have a code for your product or procedure, then you basically have a way for people to start providing it to patients, and getting it reimbursed by insurance. The people who know how to take a company’s product, pharmaceutical or service into the market are highly valued by big companies, with the most successful charging rates of up to $500 an hour.
3. U.S. Health Laws and Regulations
Think you know the law about reimbursement? Think again: the penalties for not knowing are huge,
The U.S. code, the Federal Register, the Code of Federal regulations. Each of these key Federal government legal/regulatory codes and publications describe all the rules for healthcare payment. When you get an e-mail from a payer saying “we are changing this procedure,” 99% of the time it is based on a rule change from the big bosses at CMS.
But what if you were the one to bring that information forward to your stakeholders? Compliance is also key, so knowing where all of the reimbursement rules and laws are is key start to being a successful reimbursement expert. By the way, some laws, such as Healthcare Fraud Statues, carry huge penalties including fines and imprisonment for the offenders.
4. Health Economics
You don't have to be an economist to know how this sets the stage for Value Based Healthcare
Put your thinking cap on. This is where science and reimbursement come together. A field that is becoming very important is health economics. Does your hospital want to strike a special deal with a payer? Think twice about doing it without some health economic data. Using big data from provider, insurance companies and government sources, health economic experts study the cost of healthcare and determine key questions to help shape the future of healthcare delivery in terms of dollars and cents. That means that you can create models to compare the use of a new innovative medication versus the standard of care.
With that information, there are infinite possibilities for new programs, and showing the value of your organization to partners such as private insurance, Medicaid and CMS.