🔒Navigating Medicare billing — and creating rural Maine jobs

Dr. Dan Mingle knew he was onto something when he founded Mingle Analytics in 2011. Health care costs were spiraling up, and national reimbursers like Medicare were starting to look at the quality of care they were getting for their money.

Mingle's timing for his new company couldn't have been better. After closing his Oxford Hills-area physician practice in 1998 and then moving into information technology jobs, including as director of clinical informatics at MaineGeneral Medical Center, he founded Mingle Analytics in South Paris to help health care providers complete complicated Medicare reimbursement submission forms. The company offers fee-based consulting and software services. The forms, in turn, determine how much Medicare will reimburse the provider, with deductions made for incorrect or lacking information.

Mingle, who is president and CEO, says his revenue has already topped $5 million. In the first half of this year alone, the company raised close to $1.75 million via investors and Maine Technology Institute loans to adapt its current software to changes Medicare is making to hone its reimbursement system. Medicare will add incentives for good health care outcomes by health care providers.

With the new Medicare Merit-based Incentive Payment System, or MIPS, requirements going into effect Jan. 1, 2017, Mingle figures there will be big demand for his services. He expects revenues to grow 10-fold within five years and current employee ranks of 56 to triple or quadruple.

The Medicare submission is like a tax return but it gives Medicare Part B health care quality information, Mingle says. Part B applies to medical practitioner services. Those who don't submit the form or who submit it incorrectly get a lower reimbursement, so there's an incentive for practitioners to adhere to Medicare's requirements, which is where Mingle's company comes in.

There are about 300 different practice management systems and about 600 different medical records systems from which the information to submit to Medicare is pulled. Mingle Analytics' software assures that information from those systems conforms to Medicare's requirements. A simple example that could cause a hiccup, he says, is having an extra space between a patient's first and last name. Another example is referring to the same medical test in different ways, for example, a hemoglobin analysis test instead of an A1C test for diabetics.

Constraint or growth?

Only three years ago, Mingle had entered the Top Gun program at the Maine Center for Entrepreneurial Development to figure out whether to go forward with constrained growth or to take on outside investors to meet the quickly growing demand for his services. With a national market in mind, he decided on the outside money, while still maintaining control of the company.

“We expected to have to relocate to Portland within our first two years, and then move farther south,” Mingle says. “But we decided why not let people work from home?” About three-quarters of his employees work in Maine, one-quarter in the South Paris headquarters, one-quarter within commuting distance, another quarter working remotely in the rest of Maine and the others in 11 other states, he says.

One of his investors, Maine Venture Fund, lauds the distributed employee model, especially for a high-tech, rural Maine company.

“They have great growth potential, and I like the fact that they have successfully deployed a distributed employee model. That's great for rural Maine,” says John Burns, managing director of the Maine Venture Fund. “He's got big visions and big plans for this company. There's always going to be a significant consulting and significant technology development piece around the business, so it's great for economic development [in the state].”

Burns consulted with Mingle about taking outside investment money to grow. He says Mingle had his eye on going national from the get-go.

“Mingle sought a lot of counsel on the question of outside money, including me. He saw this is a rapidly evolving space, and if he wanted to be a major national player he needed to raise money,” says Burns. “He always viewed this as a national business.”

He adds that Mingle already is one of the largest such service providers in the country, competing with big companies like CECity of Homestead, Pa.

While Mingle Analytics pulled in 5,000 provider clients in its second year of business, it is now up to 32,000.

The majority of physicians in Maine have to deal with Medicare, Mingle notes, because of the percentage of the state's population using the insurance and the fast-aging population.

According to the Kaiser Family Foundation, Maine had 306,420 of the total 55,504,005 Medicare beneficiaries in the United States in 2015. That's 23% of the state's total population, the highest of any U.S. state — tied with West Virginia. There's been a steady rise in Medicare users in the state from 271,626 (20% of the population) in 2011.

How it works

Mingle says there are a large number of items to focus on in health care delivery that make a difference in quality of care. In the case of Medicare Part B, that includes giving anyone over six months old a flu shot, prescribing an aspirin a day for someone with heart disease or the standard A1C hemoglobin test for a diabetic, he says.

“Every potential intervention has a set of criteria that describes who qualifies for a medication and then who got the medication,” Mingle says. “The Medicare system measures a provider's quality of health care, not the patient's compliance with it.”

Medicare has the largest, most aggressive program for measuring such medical interventions, he says. It was introduced in 2007. It arose partly because the World Health Organization found the cost of health care per person in the United States was almost double per person annually compared to elsewhere in the world, yet the quality of care fell close to the bottom compared to other countries.

“Since the 1960s and 1970s health care inflation has exceeded all other inflation,” Mingle says. “So the primary goal [with Medicare] isn't the measurement. The primary goal is to adjust the incentive. It had been fee-for service, quantity. Medicare is attempting to move us to a value-based purchasing system by paying better for high-quality, low-cost care.”

The first step was the Physician Quality Reporting Initiative in 2007, then the Physician Quality Reporting System in 2012, encouraging providers to send in data. In 2013 Medicare imposed a 1% penalty on allowable charges for those who didn't send in data, and that's now 6%.

Medicare publishes 200-300 measures from which practitioners could choose up to nine interventions, so they can make the most of the quality for the needs of each patient, Mingle says.

“A lot of doctor's practices are not generating data that Medicare wants or in the form Medicare wants,” says Maine Venture Fund's Burns. “Mingle can help with what metrics the doctors should report on, which are the best to use.”

The new MIPS rule will be finalized in November. It will take effect Jan. 1, 2017, and the first reporting under it will take effect March 31, 2018, giving providers a chance to update their systems. It's within that updating that Mingle sees opportunity both in consulting with the providers about their own systems and subsequently using its own software to prepare their Medicare submissions.

Adds Burns, “I like the macrothesis [for investment]. Health care reform in the United States will continue for the rest of our lifetime. Good reporting from medical providers is a key part of that.”

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