Changes in Healthcare Means Limiting Freedom

Gregg Phillips

Healthcare providers have limited freedom to run their businesses due to rate cuts, price fixing and needless regulations.

AutoGov is a typical small software company. Our customers are healthcare providers such as nursing homes, hospitals and home health companies. We are entangled in the never ending struggle balance scarce resources against the needs of our customers to ensure high service levels are maintained while offering a disruptive product.

We are free to charge whatever we choose is the optimum price for CaseVue. We spend weeks analyzing our costs against feedback we receive from our customers. If we are right, the market rewards our decisions. If we are wrong, we are punished. But, they are always our decision.

Troubling trends have emerged for our customers, however. They are increasingly hamstrung by government sponsored price fixing - eliminating a key freedom that business leaders require to be successful. For many of these providers (aka businesses) the inability to set prices as they see fit requires doors to close, further limiting capacity in this $3 trillion industry.

We watch as politicians, faceless bureaucrats and and the well meaning healthcare advocates make decisions that ultimately stifle their ability to survive. The basic laws of supply and demand are ignored.

Price fixing and monopolies are always bad in free market economies.

Businesses, including healthcare businesses will fail. Hospitals and nursing homes will close. Home health providers will struggle to recruit quality care givers. Drug companies will discontinue key research.

Our customers are watching helplessly as decisions are made and rates are set, or rather fixed, that ensure their rights and freedoms to run their businesses are reduced or eliminated.

Fair warning to all involved, this will not end well.

We all deserve the opportunity to succeed.

Solving a Medicaid Claim Mystery

Gregg Phillips

Believe it or not there are some things about the Medicaid program that are simple.  For example, while there seems to be a great mystery surrounding what makes a Medicaid claim payable, it is it is really not a mystery at all.

Three simple fact items must be present to pay a Medicaid claim.  A claim must be submitted:

1. by an Eligible Provider: A provider submitting a claim for Medicaid reimbursement must be properly enrolled as an official Medicaid provider.   Each state conducts separate provider enrollment providers must enroll in every state where they provide services.

2. on behalf of an Eligible Recipient: To become eligible for Medicaid, a person must be determined eligible by the state in which he or she lives.  A Medicaid application must be completed and a variety of documents must be submitted. Generally, there are five specific components of the determination. The applicant must prove their identity.  They must be a citizen of the U.S. and a resident of the state in which they are applying for assistance. Finally, the applicant must meet certain maximum dollar amounts for assets and income. Once eligibility is determined, the individual will remain eligible until a change in circumstances renders them ineligible. Redeterminations are conducted on a regular basis, generally annually.

3. for an Eligible Service: Medicaid program services that are available to recipients vary from state to state. Providers have some flexibility but must render services in accordance with approved services.  Many rules and regulations govern the provision and frequency of these services.  For example, many states require high cost or unusual services to undergo a process called prior authorization before the service can be rendered and payment remitted.  

With each of these three items properly documented, Medicaid claims should sail through a state’s Medicaid payment system.

Investors see health reform's potential by Sarah Kaliff POLITICO

Rose Hayden

Now we're seeing more talk about the business opportunities and possibilities for insurers and managed care organizations with health care reform.  "The Congressional Budget Office estimates 32 million Americans will gain health insurance by 2019 if the law stands."

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