Highmark, which has struggled with losses on patients covered through the federal marketplace, is introducing a new incentive program meant to allow the Pittsburgh health insurer to more fully collect on services rendered.
Patients are unlikely to see a difference during their office visits, but Highmark is making up to $5.5 million available for some 2,800 doctors statewide who submit claims with complete diagnosis information for patients with Medicare Advantage or Affordable Care Act coverage.
Better documentation will allow Highmark to claim more reimbursement from federal payors, which is based on the severity of the patient’s overall condition.
“The trick is how do we help doctors get this into their regular workflow,” said Amy Fahrenkopf, Highmark medical director. “We want to make sure that we’re funding the transformation to value-based care.”
Even with the shift to electronic medical records in recent years that was supposed to streamline recordkeeping, doctors find documentation burdensome and feel it can reduce the amount of time for patients.
“It has created an environment where you feel that you’re never done,” said Larry John, a family practice physician in Aspinwall and president of the Allegheny County Medical Society. “It’s emotionally and intellectually time consuming and demanding.”
For that reason, doctors often document a patient’s most immediate issue rather than a complete list of health problems in submitting a claim, resulting in Highmark receiving lower reimbursement from the federal government.
Now, for every fully documented patient record that doctors submit to the insurer, Highmark will pay doctors a bonus ranging up to $165.
For people with health care coverage through the government marketplace, only 25 percent of diagnosis forms submitted by doctors were complete in the past, Dr. Fahrenkopf said. Compliance for Medicare Advantage patients was better at 30 percent to 50 percent.
The incentive program comes a month after Highmark reduced payments by 4 percent to primary care doctors who treat people with ACA coverage. The insurer lost $590 million on the policies in 2015.
Dr. John praised Highmark for the new incentive funding, saying it recognizes the work of primary care doctors while allowing the insurer to collect the full amount of allowable reimbursement.
“It’s a step in the right direction,” Dr. John said. “It recognizes the hard work family physicians do on a daily basis.”
Date: May 6, 2016