How has the Affordable Care Act impacted your payments?

January 31, 2015

Does it seem you worked harder for less money in 2014?  The answer may be found by reviewing claims submitted to new healthcare plans created by the Affordable Care Act. We did just that and found some very interesting shifts.

During the last part of 2014, some of our clients had fewer charge dollars going to traditional Medicaid, moving instead into new managed medical assistance and exchange plans.  With this change, we have seen the collection percentage (payments divided by charges) decline compared to what traditional Medicaid had been paying.

One finding from our audit: If you are not contracted with a certain plan, your claims may be denied as “non-contracted” or “prior authorization required.” The necessary form to obtain authorization is available on the plan’s website, but as a pathologist, are you pre-authorizing lab services?  Likely, the answer is no.

Take a look at the following 2014 year-end review we conducted for one of our groups. Beginning in June 2014, the shift began from traditional Medicaid claims into other non-state plans.  Note the decreases in collection percentage for these other payers.

Plan Total Charges Total Payments Collection %
Medicaid $741,956 $47,939 6.5%
Medipass/Medicaid $208,207 $12,649 6.1%
Insurance A $162,153 $9,336 5.8%
Insurance B $131,648 $5,980 4.5%
Insurance C $111,769 $5,511 4.9%
Insurance D $56,573 $2,055 3.6%
Insurance E $48,252 $2,357 4.9%


Did your state move into government-sponsored managed medical assistance and exchange plans in 2014?  Do you know what these plans are and if you are considered a participating provider?  This review is well worth your while. You need to determine if your claims are being properly paid, and if you should be contracted with these individual exchange plans.

There are also issues with longevity; we have seen two of these Medicaid exchange plans go bankrupt already within the first year, leaving our groups with large losses.

Are you auditing this? How are you handling this problem? Do you know your direct losses?

Contact Vachette Pathology at 517-486-4262.  We can help stop this loss and work with you or your biller to correct the problem.

Who's reviewing revenue strategy with you at this time?

Are you billing all the correct CPT codes? You’d be surprised at what you might be missing. We will review your Fee Schedule/Charge Master at no cost.

That’s right. For free.

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