The University of New Mexico (UNM) Center for Social Policy (CSP) was commissioned by the New Mexico Legislative Council Service to conduct a research study on medical billing and claims in the state. The primary purpose of the study was to analyze the billing and claims process in New Mexico from the perspective of the healthcare professionals who work on billing related issues as part of their regular work duties.
The study focused specifically on how much time and energy clinicians spend on billing related issues that may take valuable time away from interacting with patients and how under the current system it impacts patient care and clinicians who work with patients.
The researchers engaged healthcare professionals in focus group discussions, analyzing qualitative focus group and interview data from a total of 31 claims and clinical workers employed at various health facilities across New Mexico, to address the following themes:
- How much staffing, and overall infrastructure do different health facilities across the state currently have, and what are the ideal levels of both required to effectively manage patient loads?
- How much time is invested in each respective steps of the billing, coding, and claims processes across the state?
- How does the type of insurance coverage patients have in New Mexico impact the billing, coding, and claims process?
- What impact do the current billing, coding, and claims systems have on patient care and the satisfaction levels of healthcare professionals in the state?
The researchers found as follows:
The medical billing revenue cycle, which is the process that manages all financial aspects of patient care, is highly complex and time intensive which has adverse impacts on patient care and clinician well-being. While some facility-specific solutions are helpful in streamlining billing and making it more efficient, systemic problems that include frequently changing and stringent rules and guidelines imposed by insurance companies and federal agencies dictate how care is provided. Some solutions, such as outsourcing billing and health care claims more generally seem to cause more problems rather than making billing more efficient or cost effective.
Billing and claims are more difficult for more complex and specialized care and in rural areas across the state. Highly specialized care, which also tends to be more costly, often requires clinicians to receive prior authorization from insurance companies before any care, treatment, or medication can be administered or prescribed, adding excessive time and paperwork before patients can be seen, which is a challenge in a state where patients experience long wait times and/or are even unable to see specialists due to staffing shortages and overburdened health systems.
Rural communities, in particular those serving low-income populations, struggle with issues of in- and out-of-network providers that require patients to either travel all the way to Albuquerque or other towns and cities to receive in-network care or pay out of pocket , which is a cost they cannot bear. Furthermore, with smaller facilities in rural contexts that serve lower income populations that often rely on Medicaid for insurance (and the low reimbursement rates that Medicaid often pays for procedures and care performed), it is financially difficult to stay afloat.
One common theme observed among participants working especially in the behavioral and mental health field is that both prior authorization and formulary requirements not only delay effective and evidence-based patient care, but even obstruct it.
If you or a loved one may have been injured as a result of medical negligence in New Mexico or in another U.S. state, you should promptly find a New Mexico medical malpractice attorney, or a medical malpractice attorney in your state, who may investigate your medical malpractice claim for you and represent you or your loved one in a medical malpractice case, if appropriate.
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