Nitin Chhoda discusses the current status of healthcare insurance in the country and how practice management, patients, as well as the insurance companies deal with the situation.


Healthcare is a complicated and convoluted process in the U.S. that involves patients, practitioners, insurance providers and a multitude of clearinghouses established specifically for processing, verifying and paying claims.

Each entity has its own set of rules, regulations and protocols governing covered expenses and how reimbursement claims must be submitted. The system has patients confused and healthcare providers fighting for revenues.

The multi-tiered healthcare system in the U.S. is a slow and ponderous process, but one that’s essential for the financial stability of practices and to ease the pain and suffering of patients. Due to the many facets of the industry, it can leave even insured patients with insufficient coverage or none when they need it most, while clinicians are buried in a mountain of paperwork and rejected claims.

Reactive healthcare is the new normal

Until recently, healthcare was a reactive system focused on treating ailments and illnesses as they appeared.  The beginning of the 21st century saw a shift in the thinking of insurance company executives toward preventative measures and ways for clients to avoid becoming ill or developing conditions such as diabetes and heart disease.

It’s a high goal that can mitigate a wide range of expensive healthcare problems, but doesn’t factor in variables such as genetic predispositions, or work and environmental elements. It’s a system that penalizes the elderly, infirm and those experiencing ongoing health issues or who require extensive treatment.

Insurance creates conundrums for the insured

When the Affordable Health Care Act is fully implemented, millions of previously uninsured individuals will have access to a core group of services through insurance policies obtained through their employment or a healthcare practice management insurance exchange.

Unfortunately, as insurance companies increase deductibles, co-pays and other costs, patients are delaying or failing to seek treatment and practitioners are experiencing distinct drops in revenues.

Today’s healthcare insurance may not cover specific services patients need or may require thousands in out-of-pocket costs clients can’t afford.

Healthcare insurance providers are forcing patients to shoulder more of the cost burden and setting limitations on costs and treatments. The result is that many clients that have insurance are no better off than those without.

Creating revenue strategies is a multi-pronged process

To ensure sufficient cash flow, clinicians must develop and implement strategic plans to contract with the best paying providers and examine client insurance coverage closely before beginning treatment. In some instances, clinicians may need to refer patients to other facilities or resources to obtain whatever treatment is insurance

The technology embodied in an electronic medical record (EMR) system is a clinician’s best friend for verifying insurance, providing enhanced documentation and submitting reimbursement claims.

EMRs empower practitioners, providing them with the tools to manage client treatment needs against their insurance coverage.

EMRs can identify claims that may pose potential problems, while offering electronic reimbursement submissions to facilitate payment turnaround times.

The structure of the healthcare system in the U.S. is difficult to navigate for patients and practitioners and the new direction being taken by insurance companies is actually narrowing options for the insured and creating financial hardships for practice owners. To remain solvent, clinicians will be required to make hard decisions about the patients they treat, the insurance they accept and the providers with which they contract.