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PPACA Patients, Providers, and Employers
By: Benjamin Mooney, MT

PPACA Patients, Providers, and Employers
Schools are back in session with people buzzing about their need to increase their training to keep up with increased schedule demands and students who desire to increase training for sports. The greatest demand right now however, regards the sum of the 70% of our United States citizens that desperately need to rehabilitate themselves from a critical disease called Obesity. Obesity plagues the greater majority of the American population and in some geographical locations (specifically but not limited to metropolitan areas where “Corporate America” is the primary employer) the obesity rate is as high as 85%. The Patient Protection and Affordable Care Act (2010) classifies Obesity as a disease that requires exponential measures in preventative care be executed immediately to reduce hospital admissions, readmissions, and to imperatively reduce America's morbidity rate.

Preventative care (alternately preventive medicine or prophylaxis) consists of measures taken for disease prevention, as opposed to disease treatment. Preventative care practices include professions of behavioral therapy, occupational therapy, physical therapy, physical fitness, nutrition, nutrition education, including all disciplines of wellness practitioners. Today the Patient Protection and Affordable Care Act (PPACA) designates these programs be administered by healthcare providers that implement a Value Based Insurance Design (VBID). This design requires that the healthcare provider first complete and report a needs analysis of each individual patient’s treatment program prior to the program being initiated. The PPACA also designates that the delivery of these preventative healthcare solutions, comply to a capitation method of fiscal accounting.

With all of the changes in healthcare that the PPACA implement, one regulation has not changed. Legislation still requires that all employers (including but not limited to government agencies, public organization, and fortune 500 corporations) secure preventative care programs, comprehensive in nature, for all employees on a non-cost sharing basis. This policy continues to urge both employers and employees to engage in health programs that greatly reduce potential disease and injury in the working environment.

“The Fall of Failure”
As a consequence of major health insurance companies failing to due diligence in working with providers in finding solutions that rehabilitate crippling diseases like obesity, as they were responsible to with the inauguration of the PPACA, health insurance companies are vastly reducing coverages throughout the country strictly to the areas (counties) where their “healthcare plans may possibly comply to PPACA legislation”. It is still not clear if they will be compliant by January 1, 2017 to provide coverages in the fiscal year 2017. Major insurers/networks/payors that will be cutting access to programs and/or closing permanently in all sources of operations include United Health Care, AETNA, Blue Cross Blue Shield, Cigna, and Humana. Historically these were the top companies in the country that assist providers in processing claims and ensuring payment from employers that have purchased healthcare plans.

Preventative Practitioners make up 60% of the Medical Field
For the last few decades the preventative health field has been growing consistently at rates in the double digits. Today there are substantially more wellness clinics, nutrition centers, and fitness facilities across the country than there are hospitals. It is very easy to realize that the demand for preventative care is far more significant. Preventative healthcare professionals make up over 60% of the professional medical field.

With the primary urgency emphasized in patient care today being the resolution of Obesity, a disease that impairs all aspects of the body including organ function, psyche, and physical mobility, all providers agree that a comprehensive knowledge and proficiency of anatomy, physics, biomechanics, biology, chemistry, and many other sciences is required. Meaning, preventative healthcare providers, nurses, and doctors all require the same or similar education and studies. Providers agree that the key difference between a “major” medical provider and a preventative practitioner is simply the method of their prescribed treatment. “Major” medical providers apply surgery when an incident has occurred. Preventative care providers implement practices that prevent those incidents from happening often saving patients tens of thousands of dollars.

The core of patient care in America is in the preventative sector. Preventative healthcare providers are required to carry-out far more patient care procedures than the “major” medical provider’s. “Major” medical providers and preventative healthcare providers are both required to commit hourly, daily, weekly, monthly, quarterly, and annual reporting of treatment procedures both prior to and concluding every treatment. The difference is that “major” medical providers (doctors) may only see each patient once per year. The relationship between the patient and their preventative healthcare provider is most often considerably more involved consisting of cooperation and numerous conversations week over week throughout the entire year. Of course preventative healthcare providers must abide regulatory policies like H.I.P.A.A. and Standard Operating Procedures (SOP) within the industry but these education and certification programs are in place available in every county across the country just as CPR/AED certifications featuring updated curriculums as regulations are updated.

What does this mean for today’s healthcare provider?
With the transition of qualified healthcare plans evolving from a “group criteria” basis that generally only encompasses “major” medical coverage in the event of an incident (service for fee), to an individualized approach that emphasizes prevention of any hospital admissions what so ever, the provider’s compensation schedule has respectively transformed. The entire medical field has been reset to a performance based compensation schedule. Meaning all providers regardless of their specialty, field of practice, or years in service get paid for the health problems they resolve; like a commission based sales person. Surgeons, doctors, physicians, nurses, nutritionists, physical fitness trainers, behavioral, occupational, and physical therapists are now all compensated on the same premises based on the quality of care and the services and products they provide. There are no more cushy salaries or fringe benefits being granted to “favored” providers.

In year’s prior the income of a preventative healthcare provider has only been a fraction of what a “major” medical provider earns. There’s no question that most surgeons earn an income superseding six figures (+$100,000). Meanwhile the average preventative healthcare provider earns a modest income of approximately $30,000-$40,000 per year. Preventative healthcare providers are now charged with the implementation of comprehensive treatment solutions that are compliant to the current legislation of the Patient Protection and Affordable Care Act. In doing so, preventative healthcare providers can now earn an annual income exceeding six figures (+$100,000) as their rival “major” medical providers have. In some situation’s preventative healthcare providers are additionally able to establish a passive income in their practice.

For Out of Network Providers
Current legislation cited in the Patient Protection and Affordable Care Act (PPACA) enacted in 2010, requires all employers provide “Coverage of Preventative Health Services” (SEC. 2713). Respectfully the PPACA also requires that all preventative care providers “Ensure the Quality of Care” including “Reporting Requirements” in these same “Wellness and Prevention Programs” (SEC. 2717). There is currently only one organization in North America that delivers the practical modules, education, and resources that meet all PPACA standards allowing providers to serve patients in compliant real time practical methodologies. 365|Health & Fitness of North Texas specializes in assisting preventative healthcare providers to become qualified and contracted in-network providers with all major health insurance networks. They also provide support services for claims processing and other PPACA compliance products, services, and resources via on-line, in-home, on-site, and telephonic.

How do I ensure that I am a qualified In-network Provider?
Becoming an in-network provider is easier than it has ever been. To find out exactly how 365|Health & Fitness (MCO) is exploding with provider solutions that deliver compliant patient care for everyone across the country and overseas, or to find out how to get your patients and clientele enrolled in these qualified wellness, nutrition, health, and fitness services paid for by their health insurance network, providers may contact Provider Acquisitions during office hours of 9am to 4pm CST. For an on-line In-network Provider Application visit http://www.iiivivfitness.com/Provider_License.gov.pdf. Email completed applications, including all contact information (provider name, primary contact, phone number, email, and specialty) to providers@iiivivfitness.com.