Stop the headaches: Seek reimbursement for services

Saturday, November 30, 2002

You have heard it said that "insanity is doing the same thing over and over and expecting different results." When do you think we as an industry will accept that well-known definition? How long must we endure the pain of knocking our heads against a proverbial wall and wondering why our headaches won't go away? It seems to me that the time for serious change…thoughtful change…is now.

Some of my colleagues disagree with me on the points I am about to make. You may as well, and I respect those with whom I have differing opinions. But, as America anticipates 77 million new enrollees in the Medicare program in the next decade alone, we must collaborate on new approaches to reimbursement for health care.

Home care is one of the key answers to the economic questions related to health care that lie ahead. We all know that in appropriate instances, patient care in the home is a small fraction of the cost of institutional care. Therefore, we had better "get this right" if we are to truly have a positive impact on payers, consumers and providers.

One of the proposals that I offer for industry consideration is a new provider qualification and payment formulary that not only sets the parameters for the professional expertise needed to provide various products, but also recognizes that expertise in the payment calculation. The formulary would be based on three key components and would be linked to a matrix that matches the three components. These components include expanded HCPCS; a new functional analysis coding system; and a new professional services coding system. Allow me to elaborate.

The current HCPCS system needs improvement with additional, specific codes. HIPAA will no doubt drive this element. But we need to drive it, as well, with an industry advisory/governing council for coding that will both increase the number of codes and streamline the coding process for new products and technology.

A functional analysis coding system would allow a consumer's environmental, caregiver, employment, and other related circumstances to be built into the equation. A person who is truly bed-confined has different needs than the active disabled consumer who has a full-time job. Taking these additional situations into consideration is important in determining the appropriate products and related reimbursement.

Codes for professional services are also needed if highly qualified individuals in the industry are to receive the recognition they deserve. They would also prohibit or limit unqualified personnel from providing products. Appropriate testing and training of all personnel within a provider's company are essential in raising the professional standards of the industry. These codes, based on an industry-determined scale, also figure importantly into the matrix pricing concept.

Now, about the matrix: I like it because it makes good, common sense to all parties. It is fair. It brings sophistication to the industry. And, it helps define what services should accompany products in a variety of settings. A matrix can be used to rate a piece of equipment for low, medium or high customer service and professional service, for instance. It can also be used to designate the appropriate staff level required (i.e. RTS), as well as a description of the service provided.

I sincerely hope that these thoughts will pique the readers' interest and that the discussions will continue as to how we can "become sane" by doing something different…something beneficial to all concerned…something that is fair to all.

We may disagree on which road is the best to take, but let's all be heading for the same destination that produces excellence in home care and economic improvement for payers and providers alike.

David Miller is CEO of The MED Group in Lubbock, Texas.