Two bar graphs, once in orange with the word "Costs" and another blue with the word "Protects" below it. The costs line is falling and the profits line is increasing. Learn more about Financial Management and Health Insurance Exchanges in our latest insights article.

Financial management is vial in healthcare

Health insurance exchanges are a set of state-regulated and standardized health care plans in the United States, from which individuals may purchase health insurance eligible for federal subsidies. All exchanges must be fully certified and operational by January 1, 2014 under healthcare reform.

Examples of Health Insurance Exchanges

Health insurance exchanges of this type were intended as a governmental entity to help insurers comply with consumer protections and to compete in cost-efficient ways, and to facilitate the expansion of insurance coverage to more people. Exchanges are not themselves insurers, so they do not bear risk themselves, but determine the insurance companies that are allowed to participate in them. Ideally, a well-designed exchange will promote insurance transparency and accountability, facilitate increased enrollment and the delivery of subsidies, and play roles in spreading risk to ensure that the costs associated with those with high medical needs are shared more broadly across large groups rather than spread across just a few beneficiaries. This is what has occurred in the state-run Health Connector exchange in Massachusetts. Some hope that insurance exchanges also will help to contain overall costs in relation to the financial management of healthcare.

Hospitals will see some increase in revenue as the uninsured gain medical coverage through Medicaid or still-to-be-formed insurance exchanges. They also, however, will see cuts in Medicare and Medicaid as well as unevenly shared payments, and will still have a sizable self-pay population as businesses shift greater numbers of employees to high deductible or consumer-driven health plans.

New healthcare law will further complicate the revenue cycle for hospitals by fostering alignment with physicians and bundling payment. Providers will have to manage the revenue cycle from both the hospital and the physician side and coordinate processes within financial clearance, eligibility, and price estimates as they move to accommodate patients throughout the healthcare encounter.

Faced with having to do more with less, hospitals will be challenged to protect revenue and accelerate and increase cash collection, avoiding process failures that result in a denial or a decrease in payment due to medical necessity. They also will likely consolidate or leverage front-end resources to gain more efficiency from the technologies and processes they already employ.

As an ultimate strategy, hospitals should focus on revenue cycle initiatives that drive optimal performance: charge capture, pricing, and patient access. There is this sweeping vision of a ‘no-wrong-door’ enrollment system within the exchanges through which millions of people will have their eligibility determined in real-time.