The following guest post is written by Melinna Giannini, President, CEO, and Founder of ABC Coding Solutions (formerly Alternative Link), who has worked in the health insurance industry since the 1980s. She is one of the nation’s leading experts on contracting, billing, and practice management for nursing and other forms of integrative healthcare. Melinna designed ABC codes to fill gaps in national code sets used for managing healthcare reimbursement and outcomes analysis.

The U.S. healthcare system can no longer rely on medicine as its primary form of healthcare. Our U.S. medical schools cannot increase the physician workforce fast enough to keep pace with population growth and the needs of baby boomers.

The physician workforce decreased from 772,000 doctors to 633,000 doctors since 2000. Significantly, the U.S. population grew by 50 million people since 2000. Care shortages, dramatic cost escalations and more people without insurance require immediate action.

Our nation can immediately increase care and reduce costs by maximizing direct patient access to the 2+ million healthcare professionals who are authorized and available to manage non-acute patient care. Rather than routing patients to physicians for non-acute care, we can route them to non-physicians who are legally authorized to manage care without oversight. This minor change in policy will free physicians to better manage acute care, provide patients with timely care and reduce physician oversight charges.

To make this change in our healthcare delivery model, certain government healthcare policies must be modified. For example, Medicare should eliminate its policy of disallowing direct reimbursement to advance practice nurses.

Non-physicians also need an infrastructure to bill public and private insurers for their services in order to:

• Reduce paperwork burdens and costs for both parties
• Increase the accuracy and speed of communications
• Protect providers and payers from fraudulent billing practices
• Identify effective options to more expensive medical care
• Help create more effective federal and state healthcare policies

Available Infrastructure

ABC Coding Solutions offers over 4,500 codes (called ABC codes because they are five alphabetic characters) to fill gaps in the medical coding systems required by the government for filing insurance claims. These codes fit into the established insurance claim filing and reimbursement infrastructure, do not require any modification to current business practices, are multi-dimensional and convey information that is not required of medical codes – primarily because physician scope of practice rules are similar in every state.

Unlike physicians, non-physicians are governed by different scope of practice rules in every state. The ABC coding system has over 20 million references (by code and practitioner type) to state scope of practice rules. By helping determine who can do what in each state, this coding system helps practitioners and payers avoid government fines that can be as high as $10,000 per claim (Fraud and Abuse provisions of HIPAA).

Proof of Concept

In 2003, the U.S. Department of Health and Human Services authorized testing of ABC codes.
Under this authorization, ABC codes have been field tested in over 1.5 million transactions.

Alaska Medicaid, the largest beta test site, reported a 50% cost benefit by using ABC codes to file claims based on behavioral health care services delivered by 500 paraprofessionals to 4,000 underserved people in bush communities of the state from 2004-2007.

In New Mexico, a Medicare HMO increased access to alternative medicine from 500 seniors in 1999 to over 21,000 seniors by 2007 using ABC codes.

The American Nurses Association, representing 2.9 million nurses, included ABC codes as a “recognized” nursing terminology in 2000 and has encouraged adoption of ABC codes since that time.

View Melinna Giannini’s speech to the National Press Club below:

This entry was posted on Monday, May 18th, 2009 at 12:53 pm and is filed under Coverage Policy, Guest Posts, Health Professions, Insurance, Policy. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.