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Surviving and
Thriving with
the Affordable
Care Act
DPMs can adapt, change,
and be successful
under Obamacare.

dictate policy that adversely affects
he Affordable Care Act
Out-of-Pocket Costs
(ACA), kn ow n m ore
our offices, ‘similar to the Medicare/
One trend that some people are
commonly (and som e­
Medicaid programs.’ While it’s true
blaming on the ACA is the rise of
that we faced many changes (insur­
tim es pejoratively) as
high-deductible insurance plans,
ance, coding, and handling) with
Obamacare, has resulted
higher co-pays, and, for the patient,
these programs, and we complained
in enorm ous and unprecedented
more out-of-pocket costs. In other
changes to the healthcare market
in the United States. The reaction
on the part of many is to panic and
One trend that some people are blaming
assum e the worst, which seems
questionable given that the full im­
on the ACA is the rise of high-deductible insurance
plementation of the Act is several
plans, higher co-pays, and, for the patient,
years off.
Lynn Homimore out-of-pocket costs.
sak, PRT, princi­
pal owner, con­
sultant and coach
of SOS H ealth ­
heartily, we are still here. We adapt­
words, when patients come into your
c a re M a n a g e ­
ed; and despite initial negative per­
office, there’s a very good likelihood
ment Solutions,
ception, many offices visited nation­
that they will owe more money up­
LLC says, “Using
wide that accepted change experi­
front for services. Although it’s clear
a broad brush, I
enced success.”
that higher-deductible health insur­
w ould say the
So with that in mind, this article
ance plans are indeed a trend, it can’t
biggest hurdle for doctors across the
will look at several things that are
actually be blamed on the ACA. A
board (as with any new program) is
definitely happening that are at least
Kaiser Family Foundation study in­
adapting to change. I do hear rum­
partly related to the ACA, and how
dicates that these health plans have
podiatrists can adapt, change, and be
blings that because it is a product
been on the increase since at least
of the ‘Federal Government,’ it will
Continued on page 72



S u rvivin g ACA (from page 71)

2006 and were caused more by
health insurance companies pushing
more and more costs onto employ­
ees. In addition, in 2003, Congress
passed legislation allowing health
savings accounts (HSA) to be paired
with high-deductible plans. Although
the ACA isn’t a direct cause, it is con­
tinuing the trend.
So what is a podiatrist to do?
“We have to be more fiscally respon­
sible than ever,”
say s Jo h n V.
Guiliana, DPM,
MS, E xecutive
Vice P resid en t
of Nemo Capital
P a rtn e rs, LLC,
w h ic h am o n g
its n u m e ro u s
serv ices offers Dr. Guiliana
practice manage­
ment consulting. “We have to have
policies and procedures—it all boils
down to our business processes—
that optimize the collections at the
time of service.” That can mean com­
municating to all the staff and the
billing company to be alert to a pa­
tient’s balances, to be alert regarding
the patient’s co-pays, co-insuranc­
es, and deductibles. Not only know
what their health plans say, but be
prepared to collect fees owed at the
point of patient contact.
F rank Kase,
DPM, with Bur­
bank Podiatry As­
sociates Group,
APC, and Chair­
man of the Califor­
nia Podiatric Med­
ical A ssociation
(CPMA) H ealth
Dr. Kase
Policy Committee,
agrees. “What a
podiatrist has to do to survive, more
importantly than ever, is to verify
eligibility. Those words are going
to become paramount in any office
practice. You’ve got to verify eligi­
bility and benefits; so, for example,
when patients come in, we know
what their deductible is, how much
has been met, and what their co-pay
is. So, when we perform a service,
we know what percentage of their
service is going to be covered, how

much is going toward the deductible,
how much toward the co-pay.”
There are now a number of on­
line services that provide immedi­
ate access to that information. The

plementation of the ACA, but these
days the situation has become more
extreme. Insurance providers are
finding themselves in an increasingly
competitive marketplace—one that is

Insurers are going to be very carefully
evaluating what plans they offer to patients, and what
their contracts with providers are like.
key, however, is to try to change the
mindset of patients who expect to pay
later, even when it’s clear that they
owe money at the visit. Changing pa­
tients’ attitudes about taking respon­
sibility for their own healthcare may
be the biggest challenge of all.
Homisak also adds, “Be trans­
parent in your billing. Discuss fees.
Don’t keep the patient in the dark
until it’s time for them to pay their
One interesting approach is a
credit card designed specifically for
healthcare services. There are a cou­
ple of services currently available
th at provide a
credit card that
is healthcare serv ic e s -s p e c ific .
L arry K osova,
DPM, Family Po­
diatry Center (Na­
perville, IL), says
it comes down to
people trying to Dr. Kosova
pay off a deduct­
ible with small monthly payments.
"If they have a $5,000 deductible and
they’re trying to pay $25 per month,
we try to put a stop to that. We’re
more than willing to work with pa­
tients, though.” By utilizing a health­
care credit service, the doctor gets
paid immediately, paying a slight fee
to offer the service, and the patient
arranges monthly payments with de­
layed interest. Patients, of course,
could just use their own credit cards,
but healthcare practice credit pro­
grams often offer low or delayed in­
terested rates.
Reviewing Contracts—Carefully!
The careful reviewing of con­
tracts was good advice before the im­


to the benefit of consumers, requir­
ing those insurance companies to be
far more transparent in their costs
and what they cover. This is at least
partly due to the implementation of
health insurance exchanges, the socalled health insurance marketplac­
es where people acquiring insurance
outside of an employer can shop for
plans. The result, at least on one
level, is that insurers are going to be
very carefully evaluating what plans
they offer to patients, and what their
contracts with providers are like.
Kase, speaking prim arily on
California issues, says, “With Cal­
ifornia Blue Cross/Blue Shield, the
policies I’m most familiar with, po­
diatrists take a substantial discount
on your standard BC/BS fees. More
importantly, if you agree to take the
substantial discount on your BC/BS
fees, in the case of Blue Cross, you
are now obligated to accept those
fees for all of Blue Cross’s individual
plans. So, in other words, by taking
those Blue Cross reduced fees on the
exchange, you’ve now agreed to Blue
Cross reduced fees for all individual
plans—not the group, but the indi­
On a related note, Kase goes on
to speak of a notice that Anthem Blue
Cross recently sent to over 11,000
medical practices. The insurer had
added an addendum with new regu­
latory requirements, some of which
are part of Covered California. Ac­
cording to the California Medical As­
sociation website:
“One provision of significant con­
cern is language in section 12 that
removes a participating physician’s
ability to opt out of the individual/
exchange product without affecting
Continued on page 74

Surviving ACA (from page 72)
the underlying prudent buyer con­
tract, as is allowed currently. Effec­
tive July 1, the only option for phy­
sicians who wish to opt out of the
individual/exchange product is to ter­
minate the underlying Prudent Buyer
PPO agreement...Physicians do have
the right to opt out of the Anthem ex­
change product without affecting the
underlying Prudent Buyer PPO con­
tract if Anthem receives notice before
the effective date of the addendum,
July 1, 2014. The notice must be re­
ceived by Anthem by June 30.”
“So,” says Kase, “it is more and
more important to review your con­
tracts. You have to know what’s in
them, and if you’re incapable of re­
viewing a healthcare contract, you
have to get a healthcare attorney to
review them for you, or to review it
with you so they can advise you as to
the provisions you’re signing for.”
Decreasing Reimbursement
Again, although it’s clear that re­
imbursement for healthcare services
are going down, this was a trend well
in effect prior to the implementation
of the ACA. Not surprisingly, accord­
ing to a report released by CareCloud
and QuantiaMD, 65% of physicians
view declining reimbursement rates
as the biggest element negatively af­

paid from the $5000 that the custom­
er is responsible for. The solution,
just like with a concierge practice, is
that you have to provide value.”
But before a discussion of value,
a discussion of basic business prac­
tices is worthwhile. Typically in a
“normal” business (i.e., not health­
care), if the core costs of a product

Pushing aside politics,
the overall aim of the ACA was what is called
the Triple Aim: to improving the experience of care,
improving the health of populations,
and reducing per capita costs of healthcare.
rise, the retailer/service provider tries
to pass the costs onto the customer
through higher pricing. That’s not al­
ways possible in healthcare. Typical
non-medical businesses often hit re­
sistance on raising prices as well, and
have to look at various approaches to
maintaining their profit margins.
As mentioned before, make sure
you get paid w hat’s owed. Aside
from ensuring that patients pay their
co-pays, verify that what you do sub­
mit to payers is correct and payments
get made. Get a professional billing
service if too much money is slipping

Get a professional billing service
if too much money is slipping out the door and make
sure the service is doing their job properly.
fecting their practice’s profitability.
The dichotomy here, of course,
is that if, as mentioned earlier, more
and more patients have high deduct­
ibles, then your services are being
paid up front with cash instead of
by insurance plans. Guiliana says,
“When the topic of concierge practic­
es comes up and doctors are curious
about them, I often say you might
not realize it, but you could possibly
have a concierge practice right now
and not know it. The insurance car­
riers are paying you virtually nothing
in some instances, and it’s all being

your regular medical supplier with
those of other companies. If you basi­
cally lay out your inventory from the
previous year to a variety of vendors
who can supply the same customer
service and the same products, you
might get a better deal.”
The APMA, for instance, has a
group purchasing plan through Office

out the door and make sure the ser­
vice is doing its job properly. Guil­
iana says, “We have to look at our
expenses, seek out and do some due
diligence on how we can cut those
expenses, of course without compro­
mising quality.”
One idea Guiliana suggests for
reducing expenses is to consider
putting out a bid for your medical
supplies. “Medical supplies are one
of those things that often creep up­
wards, just like our insurance costs
can creep upwards. Many times, you
should be comparing the prices of


Depot. Kosova says, “I think buying
things through a group club is the
way people are going to save in the
future; re-negotiating rents, re-nego­
tiating with employees. 1 also think
using technology appropriately can
save money.”
Guiliana is quick to point out a
related truism: “This is something
that needs to be delegated. The phy­
sician shouldn’t be doing this. A po­
diatrist’s time needs to be absolutely
cost-effective, because there’s an ex­
traordinary amount of waste in the
typical medical practice.”
In short, yes, reimbursement is
going to be tighter and tighter. Faced
with this environment, a typical busi­
ness responds in several ways: in­
creasing business volume through
marketing and other methods, adding
secondary sales items, and increasing
efficiency and cutting costs in other
places—all topics covered through­
out the year in the pages of Podiatry
About That Quality Thing...
Pushing aside politics, the overall
aim of the ACA was what is called
the Triple Aim: to improving the
experience of care, improving the
health of populations, and reducing
per capita costs of healthcare. On the
face of it, all three of those aims are
desirable. Meeting those goals, how­
ever, is difficult and everyone has an
opinion as to whether the thousands
Continued on page 76



S u r v iv in g A C A (from page 74)

of pages of rules and regulations cre­
ated by the ACA will do so. In some
ways, it’s an enormous social exper­
iment, and only time will tell if it’s

Are we utilizing time optimally, are
we utilizing our physician extenders
optimally, delegating tasks to staff
to allow the schedule to flow better?
We’ve really got to look at what pa­
tients consider valuable by perform­

By law, primary physicians
can only belong to one ACO. Specialists, like podiatric
physicians, can belong to more than one.
successful. In the meantime, staying
in business and continuing to provide
the highest quality healthcare are pri­
orities, no matter how challenging.
Guiliana says, “Now that patients
are footing most of this bill, they are
seeking value. And we’ve got to be
conscious again of our business prac­
tices and some of the flawed process­
es that led us into long waiting times,
how we schedule patients, and so on.

ing patient satisfaction surveys and
responding to those surveys.”
As the expression goes, When
you’re up to your neck in alligators,
it’s hard to remember that it’s your
job to drain the swamp. When you’re
up to your neck in government reg­
ulations and changes in insurance
policy, it’s hard to remember that it’s
your job to take care of the patient.
“I have a sort of policy with pa­

tients,” says Kosova, “that I don’t
really look at their insurance. We get
a list of what they have and what’s
covered, but I don’t look at the insur­
ance at all. I do that on purpose be­
cause we have HMOs, and we have
insurance that’s good and some that
aren’t good, but I don’t want to base
my treatment on what insurance they
have. I think that’s poor medicine.
If 1 can’t do what I normally do to
treat patients and I’m not going to
get paid for it, they might as well
go somewhere else because they’re
going to get poor treatm ent. I’m
going to possibly set myself up for
a lawsuit because I didn’t do some­
thing that I normally do for someone
else because it just so happens that
XYZ HMO won’t let me do it. I think
that’s a problem.”
A c c o u n ta b le C a re O r g a n iz a tio n s

One aspect of the ACA is the de­
velopment of Accountable Care OrgaContinued on page 77

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Surviving ACA (from page 76)
nizations (ACOs), which are essen­
tially a push for networks of physi­
cians and hospitals. I’ve written ex­
tensively about this in “The ABCs of
ACOs” (Podiatry Management, Sep­
tember 2013), but it’s unclear how
big an impact ACOs will have on
podiatry. As I wrote then, “Cutting
costs and increasing the quality of
healthcare might be a good thing and
ACOs might be a path toward that
goal. There is the concern of being
cut out of what is probably going to
be the trend in healthcare.”
By law, primary physicians can
belong to only one ACO. Specialists,
like podiatric physicians, can belong
to more than one. Some local restric­
tions by medical associations may
exist, but by law, podiatrists can be­
long to more than one. “My sugges­
tion for podiatric physicians who join
ACOs is to get involved in the lead­
ership positions, the financial posi­
tions, and the governance positions,”
says Kase.

as Lynn Homisak says,
“ACA is likely not the
final iteration of public
healthcare in our life­
time. Endeavor to be
the best. Successful po­
diatrists continue to be
successful.” PM

M a rk T e rry is a freelance w riter, editor,
author and ghostw riter specializing in
healthcare, medicine and biotechnology.
He has w ritte n over 700 magazine and
trade journal articles, 20 books, and dozens
o f w hite papers, market research reports
and other materials. For m ore information,
visit his websites: w w w .m a rkte rryw rite r.
com and w w w .m .


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The full name of the ACA is The
Patient Protection and Affordable
Care Act. It is over a thousand pages
long. Government agencies and in­
surers have responded with tens of
thousands of pages of rules and reg­
ulations and laws to implement it. It
is, without a doubt, disruptive ... at
the moment.
One of the goals of the ACA is to
provide health insurance coverage
for everyone in the United States—
that means an additional 30 million
or more potential patients. It also
legislated that insurers couldn’t turn
down potential patients on the basis
of pre-existing conditions; it allowed
kids to stay on their parents’ health
insurance plans until the age of 26.
It also ended lifetime limits on cov­
erage, forces insurance companies
to publicly justify any unreasonable
rate hikes, and ended arbitrary with­
drawals of insurance coverage. There
are many very positive things in the
law, primarily for patients. Its effects
on healthcare providers—podiatric
physicians, hospitals, laboratories—
are dramatic, and arguably nega­
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