We all know about the big government health care debate by now. We may not know specifics, but there seems to be a
lot of players on both sides of the fence trying to find a way to either get something passed or get the entire idea killed.
This is not a political article. Instead, it's a "what-if" article. What if one of the two talked about forms of
governmental health care is passed. How could that affect medical claims submissions?
First, a down and dirty on the two basic types of government plans being discussed.
Single payer means that the
government would be the only source of health insurance coverage in the country. It's what
some refer to that other countries have as socialized medicine. The government would be the main insurance company in
the country, and every person would be covered.
Public option
basically says that the government creates its own insurance plan, and people have the option of signing
up with the government's plan versus signing up with other plans. It would compete with other insurance plans offered
companies, and the price it would offer would be expected to bring down the rates of other insurance companies so they
would still be a viable option for some companies.
To get this out of the way, neither plan would eliminate insurance companies. Some might fold, but the truth is
that we're seeing fewer insurance companies already, as larger ones are taking over smaller companies, so we're having
our options reduced anyway. But none would go away. In most countries that have single payer processes, there are
still insurance companies for those who want to pay. They pay because, in many communities, the system does bog down
with the government option, whereas having your own insurance plan gets you immediate access to a doctor every time, and
procedures are performed within days and not within months, sometimes many months. Sicko got some of it correct, some of
it incorrect.
Let's talk single option first. If this country went with a single option plan, it would work a lot like Medicare
does now. The government would contract with intermediaries throughout the country to manage the plan. Most would
have to submit claims and records electronically, although it might not be immediately available.
The problem would be in scope. With a single option, these intermediaries will be hard pressed to handle the volume
of phone calls that would come in, and we all know that we'd have the phones ringing as soon as we had unpaid or
denied claims. Think of Tricare; scary thought.
Not only would intermediaries have to increase staff, but billing offices might have to increase staff also. Think
of it this way. Even with a single payer option, it wouldn't eliminate Medicare, Medicaid, Compensation, or No Fault.
That means you still have the same staffing you have for those insurances now. The government plan would become the
Blues, Commercial, HMO plans all rolled up together. Except those plans would also still exist. Getting claims out
the door might not be so difficult; getting them paid, and all the follow up that will be involved, could be another
matter. With time, things might calm down some, but initially, hospitals and physicians are going to have a lot of
financial issues to deal with.
Public option is another matter. Think of Medicare and Medicaid HMOs. In essence, the government's plan would
work just like those plans do, acting like a regular insurance company. The problem would be that their
reimbursements would probably be lower than what hospitals and physicians get now. After all, Medicare isn't anyone's
highest payer, and a government plan, which will at least initially have lower premiums than most of the other
insurance companies, would compete pretty well with private plans.
Though it hasn't been stated, it has been implied that the government's plan wouldn't be offered to everyone,
although everyone would still be expected to be covered in some fashion. Large corporations would have to still
get their own insurance plan for their employees, and the government's option wouldn't be available for them.
Therefore, insurance companies would still have a market they could aim for.
This means that your staffing might not have to change at all, or if it does, minimally. The government
would hire intermediaries once again, and you will probably already be set up to send claims out electronically.
Follow up would once again be the issue, but there would be fewer people within the government option, so the
need to drastically increase staff wouldn't be there.
This is all speculation based on what we know and can perceive today. One never knows what other options
Congress might come up with after they get back to work in September. One thing is certain. Whether a
health care plan is passed or not, billing offices need to get their other processes in place, because the
billing landscape is going to change one way or another.