- Everyone is waiting for the other shoe to drop on Medicare payments.
- Private practices may not have the in-house expertise to implement an EMR and may not be able to afford a consultant (although some states are receiving grants to help practices – check your state’s grant here.)
- There is a lot of confusion on the parts of Meaningful Use that have been clarified and of course, on those that haven’t.
- Administrators are distracted by RAC, PECOS, HIPAA , PQRI, eRx and RCM.
- Some practices have spent years avoiding Medicare and Medicaid patients and now don’t have the patient numbers to participate.
- Everyone and their uncle is selling an EMR – who can tell the long-timers who are about to be bought from the short-timers who might last forever?
- Physicians are worried about the drop in production that (some say) happens when a practice launches an EMR.
- There seems to be as many horror stories as there are success stories with EMRs.
- Practices that are affiliated with a hospital are nervous about tying themselves to the hospital in such a serious way as hopping on their EMR package.
- Because two practices can have absolutely opposite experiences with the same EMR, no one can find consistent recommendations for any single product. (It’s not the product, it’s the implementation!)
- Bonus Reason: lots of people are confused about how to qualify for the ARRA money (read my post about this here.)
Archive for March, 2010
A number of people asked me about the impact of health reform on them as individuals. Here is a great story from the Atlanta Journal-Constitution that takes specific examples of individuals and families and speculates on how the new bill(s) will impact them.
For 2010, the changes are minimal:
- Dependent children may be covered by their parents’ health insurance policies until age 26.
- A high-risk insurance pool will open for people with pre-existing conditions who have been uninsured for six months.
- In 2011 Medicare will pay for an annual checkup, and deductibles and co-payments for many preventive services and screenings will be eliminated. The Medicare prescription drug doughnut hole will gradually narrow every year until it is eliminated in 2020. People in the “doughnut hole” could receive a $250 rebate this year.
I have to say that I’ve been dumbfounded by the fury raised over the passage of the new healthcare legislation. I realize that the bills separate people into winners (uninsured, providers with uncompensated charity care, patients with pre-existing conditions, Medicare patients, providers who see Medicaid patients, families with adult children, etc.) and losers (companies who have to pony up more money for their retired employees, insurance companies, illegal immigrants, high wage earners, etc.), but this story placed the fury into a different perspective for me. It’s a good read.
What does healthcare reform mean for the physician practice? Many are predicting the rise of concierge practices (also called boutique medicine, retainer practices, VIP medicine and cash practices) as physicians find they cannot survive if their patient population is predominantly Medicare, Medicaid and uninsured patients. Concierge practices fall into two categories:
- The first operates on an insurance+ model, which means that the practice accepts and files the insurance for the patient, but also requires an additional out-of-pocket fee of anywhere from $1500 to $1800 per year to be a patient of the practice. The fee is to cover services that Medicare and commercial insurance do not, such as physicals, phone consultations, wellness counseling and patient education.
- The second operates on a strictly cash basis and the practice does not accept or file any insurance for the patient. The patient pays a flat fee per year for care (usually in the $5,000 to $15,000 range) and all primary care is provided for that amount. The patient still needs to carry insurance for prescriptions, hospital services and sub-specialist services. Imagine being a manager in this type of practice – no pre-authorizations, no insurance department, no eligibility checking, no refunds…
Concierge medicine has not been around that long, but it is growing in popularity by leaps and bounds. The first acknowledged concierge practice was formed in 1996 in the Pacific Northwest. In 2002, CMS (Centers for Medicare and Medicaid) published a memo stating that physicians may enter into retainer agreements with their patients as long as these agreements do not violate any Medicare requirements. In 2003, the Department of Health and Human Services ruled that concierge medical practices are not illegal. Today, there are approximately 5,000 physicians using the concierge model in the United States today.
MEDICARE CUTS, MEDICARE CLAIMS AND DON BERWICK
Shortly after all the shouting and voting on healthcare reform was over, Congress recessed for two weeks leaving the controversy over the 21.5% cuts required by the SGR formula still unsettled. CMS has advised the MACs to again hold claims for services provided from April 1 to April 10 to give Congress a chance to get back to work and back to voting for an additional delay (or not) for the cuts. If the cuts are allowed to stand, many physicians will start making their own cuts by minimizing the number of Medicare and Medicaid patients they will see.
Amidst this craziness, a voice of sanity is heard and it is Donald Berwick, MD, current President of the Institute for Healthcare Improvement (IHI) and probable Obama pick for the head of CMS. If you don’t know Don Berwick or the IHI, click here to read an interview with him about the IHI’s “100,000 Lives Campaign” or watch the video below of him speaking about the dimensions of quality. Good stuff!
The Cash Flow Statement answers the question: where did the cash and any profit (positive margin) go? It reflects where the money came from and how the business spent it.
The Income Statement reveals a profit or a loss for a specific accounting period. The statement itemizes income, cost of goods, operating expenses and other income/expense data.
A Balance Sheet is a snapshot of the assets, liabilities and net worth of the business on a specific date, indicating the financial health of a company at one point in time.
The CMS (Centers for Medicare and Medicaid Services) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. The CMS annually updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual should be utilized by carriers and FIs as a general reference tool that explains the rationale for NCCI edits.
Carriers implemented NCCI edits within their claim processing systems for dates of service on or after January 1, 1996. More information here.
Version 16.1 of the CCI edit database is scheduled to be effective on April 1, 2010. There are 2,054 new edit pairs effective for this release. 35 of these are effective retroactive to October 1, 2009. This means that if you billed for and were paid on one or more of these retroactive edits, you may be subject to repayment.*142 edit pairs are reported as terminated (no longer effective) for this release. Four are terminated retroactive to December 31, 2005; four are retroactive to December 31, 2006 and 76 are shown as terminated retroactive to December 31, 2007. I guess this means that if you were denied due to a CCI edit pair during these periods, you should be able to resubmit the claim and get paid.*You can expect 1,947 changes with respect to the modifier indicator with 1,892 going from an indicator of 0 (no modifier permitted) to an indicator of 1 (modifier permitted). 55 edit pairs report a change in the modifier indicator from a 1 to a 0.*In total, there are 1,337 duplicate edit pairs in the database. These are records that were made effective at one point, then terminated and then made effective again. There are also currently 5,309 swapped pairs. These are edit pairs that were introduced in one order (i.e., 99350 as column 1 and 96416 as column 2), terminated and then re-activated in the opposite order (i.e., 96416 as column 1 and 99350 as column 2).
The CMS (Centers for Medicare and Medicaid Services) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. The CMS annually updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual should be utilized by carriers and FIs (Fiscal Intermediaries) as a general reference tool that explains the rationale for NCCI edits.
Carriers implemented NCCI edits within their claim processing systems for dates of service on or after January 1, 1996.
More information from CMS here.
As I write this Sunday night I am listening to the US House of Representatives’ discussion/posturing prior to a ‘yes” or “no” vote for the Senate’s healthcare reform bill H. R. 3590. I don’t usually listen to CNN Live, but I want to remember this moment as I think it is the beginning of significant change in healthcare.
I’m not sure what this change will be, but many things that have been status quo for healthcare during my career might change almost beyond recognition by the time I retire. This, I think, is a good thing. I don’t think the current system is bad, but I sure think it could be better. As with any change, there will be good things, bad things, and unintended good and bad things. It should be fascinating.
Discussion has now timed out and the representatives are voting; 216 votes are needed to pass. The vote has just been announced (10:45 p.m.) and it is 219 Yeas to 210 Nays and the bill is passed! The next step is for it to be signed into law by President Obama, which might happen tonight or tomorrow.
Now the representatives are voting on H.R. 4872 – “The Health Care and Education Affordability Reconciliation Act of 2010″ which contains fixes to H.R. 3590 that have been negotiated between the two chambers. The bill has just passed (11:37 p.m.) with 220 Yeas and 211 Nays! 4872 will now go to the Senate for a vote which some are predicting will pass as early as Tuesday.
President Obama spoke from the White House after the votes and said “Tonight we answered the call of history.” The passage of these bills has been compared to the passage of Medicare in 1965 and the passage of Social Security in 1935.
Here are details of both bills.
Details on H.R. 3590 ”˜”˜Patient Protection and Affordable Care Act’’
Cost: $940 billion over ten years.
Deficit: Would reduce the deficit by $143 billion over the first ten years. Would reduce the deficit by $1.2 trillion dollars in the second ten years.
Coverage: Would expand coverage to 32 million Americans who are currently uninsured.
Health Insurance Exchanges:
- The uninsured and self-employed would be able to purchase insurance through state-based exchanges with subsidies available to individuals and families with income between the 133 percent and 400 percent of poverty level.
- Separate exchanges would be created for small businesses to purchase coverage — effective 2014.
- Funding available to states to establish exchanges within one year of enactment and until January 1, 2015.
Subsidies: Individuals and families who make between 100 percent – 400 percent of the Federal Poverty Level (FPL) and want to purchase their own health insurance on an exchange are eligible for subsidies. They cannot be eligible for Medicare, Medicaid and cannot be covered by an employer. Eligible buyers receive premium credits and there is a cap for how much they have to contribute to their premiums on a sliding scale. Federal Poverty Level for family of four is $22,050.
Paying for the Plan:
- Medicare Payroll tax on investment income — Starting in 2012, the Medicare Payroll Tax will be expanded to include unearned income. That will be a 3.8 percent tax on investment income for families making more than $250,000 per year ($200,000 for individuals).
- Excise Tax — Beginning in 2018, insurance companies will pay a 40 percent excise tax on so-called “Cadillac” high-end insurance plans worth over $27,500 for families ($10,200 for individuals). Dental and vision plans are exempt and will not be counted in the total cost of a family’s plan.
- Tanning Tax — 10 percent excise tax on indoor tanning services.
- Closes the Medicare prescription drug “donut hole” by 2020. Seniors who hit the donut hole by 2010 will receive a $250 rebate.
- Beginning in 2011, seniors in the gap will receive a 50 percent discount on brand name drugs. The bill also includes $500 billion in Medicare cuts over the next decade.
Medicaid: Expands Medicaid to include 133 percent of federal poverty level which is $29,327 for a family of four.
- Requires states to expand Medicaid to include childless adults starting in 2014.
- Federal Government pays 100 percent of costs for covering newly eligible individuals through 2016.
- Illegal immigrants are not eligible for Medicaid.
- Six months after enactment, insurance companies can no longer deny children coverage based on a preexisting condition.
- Starting in 2014, insurance companies cannot deny coverage to anyone with preexisting conditions.
- Insurance companies must allow children to stay on their parent’s insurance plans through age 26.
- The bill segregates private insurance premium funds from taxpayer funds. Individuals would have to pay for abortion coverage by making two separate payments, private funds would have to be kept in a separate account from federal and taxpayer funds.
- No health care plan would be required to offer abortion coverage. States could pass legislation choosing to opt out of offering abortion coverage through the exchange.
**Separately, anti-abortion Democrats worked out language with the White House on an executive order that would state that no federal funds can be used to pay for abortions except in the case of rape, incest or health of the mother. (Read more here)
Individual Mandate: In 2014, everyone must purchase health insurance or face a $695 annual fine. There are some exceptions for low-income people.
Employer Mandate: Technically, there is no employer mandate. Employers with more than 50 employees must provide health insurance or pay a fine of $2000 per worker each year if any worker receives federal subsidies to purchase health insurance. Fines applied to entire number of employees minus some allowances.
Immigration: Illegal immigrants will not be allowed to buy health insurance in the exchanges — even if they pay completely with their own money.
Details on H.R. 4872 – “The Health Care and Education Affordability Reconciliation Act of 2010″ (fixes to 3590)
COST: $940 billion over 10 years, according to the Congressional Budget Office.
HOW MANY COVERED: 32 million uninsured. Major coverage expansion begins in 2014. When fully phased in, 95 percent of eligible Americans would have coverage, compared with 83 percent today.
INSURANCE MANDATE: Almost everyone is required to be insured or else pay a fine. There is an exemption for low-income people. Mandate takes effect in 2014.
INSURANCE MARKET REFORMS: Major consumer safeguards take effect in 2014. Insurers prohibited from denying coverage to people with medical problems or charging them more. Higher premiums for women would be banned. Starting this year, insurers would be forbidden from placing lifetime dollar limits on policies, and from denying coverage to children because of pre-existing medical problems. Parents would be able to keep older kids on their policies up to age 26. A new high-risk pool would offer coverage to uninsured people with medical problems until 2014, when the coverage expansion goes into high gear.
MEDICAID: Expands the federal-state Medicaid insurance program for the poor to cover people with incomes up to 133 percent of the federal poverty level, $29,327 a year for a family of four. Childless adults would be covered for the first time, starting in 2014. The federal government would pay 100 percent of the tab for covering newly eligible individuals through 2016. A special deal that would have given Nebraska 100 percent federal financing for newly eligible Medicaid recipients in perpetuity is eliminated. A different, one-time deal negotiated by Democratic Sen. Mary Landrieu for her state, Louisiana, worth as much as $300 million, remains.
TAXES: Dramatically scales back a Senate-passed tax on high-cost insurance plans that was opposed by House Democrats and labor unions. The tax would be delayed until 2018, and the thresholds at which it is imposed would be $10,200 for individuals and $27,500 for families. To make up for the lost revenue, the bill applies an increased Medicare payroll tax to investment income as well as wages for individuals making more than $200,000, or married couples above $250,000. The tax on investment income would be 3.8 percent.
PRESCRIPTION DRUGS: Gradually closes the “doughnut hole” coverage gap in the Medicare prescription drug benefit that seniors fall into once they have spent $2,830. Seniors who hit the gap this year will receive a $250 rebate. Beginning in 2011, seniors in the gap receive a discount on brand name drugs, initially 50 percent off. When the gap is completely eliminated in 2020, seniors will still be responsible for 25 percent of the cost of their medications until Medicare’s catastrophic coverage kicks in.
EMPLOYER RESPONSIBILITY: As in the Senate bill, businesses are not required to offer coverage. Instead, employers are hit with a fee if the government subsidizes their workers’ coverage. The $2,000-per-employee fee would be assessed on the company’s entire workforce, minus an allowance. Companies with 50 or fewer workers are exempt from the requirement. Part-time workers are included in the calculations, counting two part-timers as one full-time worker.
SUBSIDIES: The proposal provides more generous tax credits for purchasing insurance than the original Senate bill did. The aid is available on a sliding scale for households making up to four times the federal poverty level, $88,200 for a family of four. Premiums for a family of four making $44,000 would be capped at around 6 percent of income.
HOW YOU CHOOSE YOUR HEALTH INSURANCE: Small businesses, the self-employed and the uninsured could pick a plan offered through new state-based purchasing pools called exchanges, opening for business in 2014. The exchanges would offer the same kind of purchasing power that employees of big companies benefit from. People working for medium-to-large firms would not see major changes. But if they lose their jobs or strike out on their own, they may be eligible for subsidized coverage through the exchange.
GOVERNMENT-RUN PLAN: No government-run insurance plan. People purchasing coverage through the new insurance exchanges would have the option of signing up for national plans overseen by the federal office that manages the health plans available to members of Congress. Those plans would be private, but one would have to be nonprofit.
ABORTION: The proposal keeps the abortion provision in the Senate bill. Abortion opponents disagree on whether restrictions on taxpayer funding go far enough. The bill tries to maintain a strict separation between taxpayer dollars and private premiums that would pay for abortion coverage. No health plan would be required to cover abortion. In plans that do cover abortion, policyholders would have to pay for it separately, and that money would have to be kept in a separate account from taxpayer money. States could ban abortion coverage in plans offered through the exchange. Exceptions would be made for cases of rape, incest and danger to the life of the mother.
STUDENT LOAN OVERHAUL: Requires the government to originate student loans, closing out a role for banks and other private lenders who charge a fee. The savings ”“ projected to be more than $60 billion over a decade ”“ are plowed into higher Pell Grants for needy college students and increased support for historically black colleges.
MEDICARE: Extends Medicare’s solvency by at least nine years and reduces the rate of its growth by 1.4 percent, while closing the doughnut hole for seniors, meaning there will no longer be a gap in coverage of medication.
Here’s a companion piece to my recent list “50 Ways to Attract New Patients to Your Practice.” Once a patient makes an appointment to see your provider, be sure to keep them coming back by wowing them with your customer service.
- Introduce yourself to patients. “Hi, I’m Jane and I am Dr. Smith’s assistant and I’ll be working with you today.”
- Wear a visible and readable name tag with your first name in large letters.
- Smile and speak to all patients, family members, and vendors in the practice. If anyone has a question mark on their face or is hesitating, be sure and ask “May I help you?”
- Always smile while speaking on the phone and always introduce yourself. “Good morning, Dr. Smith’s Practice, this is Jane. How may I help you?”
- Providers should always shake hands with patients and others in the exam room. That first touch is so important!
- New patients should receive a special welcome and should receive special attention, remembering that the patient doesn’t know how the practice works.
- Have a patient information brochure that describes your practice’s services, providers, and policies on medication refills, after-hours services, filing insurance, filling out forms, and making payments.
- Have multiple ways for patients to complete their registration information – forms mailed to them, online completion, completion in the practice at a computer kiosk, completion at the practice with personal help, or pre-registration by phone.
- Ask patients how they would like you to communicate with them about lab/test results – telephone (home, work or cell), email, mail, phone retrieval and let them know (in writing if possible) when they should call if they haven’t heard from you.
- Place tablets and pens in the waiting area so patients can write down questions for their provider while they are waiting.
- Have computers in the waiting area for patients to use. Have Wifi for patients to use their own computers while waiting. Have instructions available for using the Internet to look up medical information and provide a written list of medical websites that your providers recommend. Place this information on your website.
- Prior to touching a patient in the exam room, assistants and providers should wash or sanitize their hands and be sure the patient can see them doing it. Additionally, it’s good to say to the patient “Let me wash/sanitize my hands before I examine you.” so the patient knows you are practicing good infection control.
- Provide staff with patient questions and preferred answers so everyone can answer most questions and no one tells patients “That’s our policy.”
- Have a water fountain with cups in the reception area.
- If you have a television in the reception area, make sure patients can change the channel or the volume.
- Invite patients to become a friend of the practice on Facebook and communicate regularly with your patients keeping them up-to-date on practice news, health news and local events.
- Pretend that every patient is a mystery shopper (and they are!) and treat them like a VIP.
- Give patients a way to reach a real person on the phone, and a way to go through the automated attendant. Remember that not every patient wants or needs the same thing.
- Have an annual open house or patient appreciation day and do blood pressure checks or home safety checklists. Serve healthy snacks and visit with your patients.
- Call 2 days before the patient’s appointment and remind them of the date and time of the appointment. Ask them to press “1″ if they plan to keep the appointment and “2″ if they would like to cancel the appointment.
- When the patient is checking out, ask “Were all your questions answered today?”
- If you give out wrapped candies, make sure to supply sugar-free candies as well as regular.
- Have multiple ways for patients to complete their registration information – forms mailed to them, online completion, completion in the practice at a computer kiosk, completion at the practice with personal help, or pre-registration by phone.
- If your parking lot is shared with other businesses, make sure there are parking spaces marked specifically for your patients.
- Use wayfinding systems to help patients navigate around your practice. Many patients will not read signs, but will identify symbols or pictures if you explain the system. Use themes for providers or services to help patients find their way when coming out of the bathroom or lab. Carpet or tile designs and art pieces can also be used creatively to direct patients in and out.
- If you have a choice, front-load your practice space with patient rooms and leave the furthest rooms for non-patient activities such as offices and staff rooms.
- Give patients their medication list and problem list on a wallet-sized card.
- Bring services to the patient exam room instead of having your patients move around the practice.
- Offer numerous payment options including financial assistance, Medicaid enrollment, medical loans, checking account drafts through debit cards and credit card drafts.
- Offer a “chat with the insurance lady” feature on your secure portal.
- Have new patient pre-appointments for patients to meet with staff to take baseline vitals, log medications and prep chart prior to their first visit.
- Have maps available for patients for any place you might be referring them to, whether in town or out of town.
- Give patients a sheet to take with them that lists medication changes, future appointments, referrals and has a place for them to write down questions between appointments.
- Give patients a customized sheet that shows the name of their medication, what the medication looks like and how to take the medication.
- Send patients emails or letters and post on your website any information relating to hot topics in the news – vaccines, radiation exposure, etc.
- Make your website a one-stop destination for practice information, health information, practice forms and secure messaging with the practice.
- If a patient has a particularly unhappy experience in your practice: a long wait, a mixed-up appointment, give them a gift card with a sincere apology.
- Hand-write an apology to a patient who has had an bad experience with a staff member.
- Validate parking for patients if they have to pay to park to come to your practice.
- Ask patients to rate your service – have forms in the exam rooms and in the waiting room and in new patient packets and on your website.
- If your practice is near a shopping or eating area, give patients a pager to buzz or ring when it is time to see the provider.
- Use your EMR or voice recognition to complete the patient’s medical record and print them a copy of it to take with them when they leave the exam room.
- Have a blanket warmer to give patients who are sick, or have come in on a gurney a warm blanket.
- Go through the daily obituaries to know when patients have passed and send condolences to the family.
- Have an option on your phone system to speak to the manager and take complaints personally. Answer all complaints and call any patients back who leave messages, and any patients that employees tell you had a problem at the practice.
- Call new patients the day after their appointment to see if they had any questions after their first visit.
- Call particularly sick patients the day after an appointment to see if they are improving. (Thanks to Kristen Baird.)
- Give patients who call a benchmark for when they will hear back from you (2 hours for same-day visits, 6 hours for questions, etc.) and exceed your own benchmarks.
- Have a mystery shopper come to your practice and tell you what you don’t know about your practice.
- Send your patients a birthday card.
What do you do in your practice that is Friendly, Easy for patients or Unexpected?