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Your Practice Management Software Is Only As Good As Your Practice Management

The Robot Practice Manager

 

A colleague of mine has been part of a well-known PM/EMR company’s software support team for 10 years. She often tries to steer people to me when she cannot solve a client’s problems with a software solution. Even though she was once a practice administrator herself, she is a software support person now and the problems she sends to me cannot be solved with software. “Mary Pat,” she asks me, “Why do they think I can solve their practice management issues? All I am empowered to do is to help them use the software.”

Earlier in my career (before EMR) I heard someone call “Practice Management” software “Billing” software and I remember being offended for some reason. I thought “Billing” was such a narrow description of what PM software did – but they were right. That software is meant to deal with everything billing. It all comes down to billing – whether it is the actual billing/claims management itself, running reports to diagnose billing problems, or capturing recalls so patients get reminded to come in for a service and…get billed. Before you unload on me in the comments let me be clear that I am not saying that healthcare is all about billing, I am only saying that Practice Management software was developed to handle the financial side of the house.

Practice Management software cannot “do” practice management. It cannot figure out your workflow so you capture data in the most efficient way, and it cannot analyze your reports and tell you what to change to increase efficiency or decrease overhead. It certainly cannot tell you the best way to schedule, or how much to charge your self-pay patients. It is only a billing tool.

I have worked in healthcare long enough to have helped practices go from manual billing (you typed or hand-wrote claim information on a 1500 form and mailed it in) to their first practice management system. I did a lot of practice management consulting even though that’s not what I was there to do. I had to get them in shape on paper so they could handle the software. I had to get their workflow optimized so the software would make things better – not worse.

An implementation of Practice Management software is not intended to do anything but set-up the system and train you to use it. Sometimes that perfectly rosy future the salesperson paints is nothing like the painful first steps (and cash flow jam) of a new system. An implementation will not fix the issues that are existing in your practice that have nothing to do with the functionality of your billing system.

 

Your Practice Management Software can:

    • Automate your registration process so patients can register and check-in online, or at a kiosk in the practice.

But your Practice Management Software cannot:

    • Train staff to greet patients and make them welcome in the practice.

 

Your Practice Management Software can:

    • Check the patient’s eligibility for active insurance coverage.

But your Practice Management Software cannot:

    • Automatically choose the correct insurance company/payer to attach to each patient account (one of the biggest problems I hear about in the field!)

 

Your Practice Management Software can:

    • Calculate the days since the patient’s last physical, the days left in a global period or visits left in annual cap. 

But your Practice Management Software cannot:

    • Help the patient understand their benefit plans and understand their financial responsibility.

 

Good practice management has a lot to do with attracting, training, coaching and retaining the right staff, as well as providing them with the tools to do the job you hired them to do. Getting the software right is a must, but don’t expect your software trainers to be able to solve any of your staffing, communication, workflow or cultural problems. That’s up to you, the Practice Manager!

(Photo Credit: baboon™ via Compfight cc)

Posted in: A Career in Practice Management, Collections, Billing & Coding, Day-to-Day Operations, Finance

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Medicare to Providers “Tell Us More”

What's In Your Brain?

 

 

Medicare recently started denying an increased number of claims because documentation submitted for diagnostic tests does not include signed test orders or evidence of intent (MD progress notes listing tests needed) and evidence of medical necessity (description of clinical conditions and treatment showing the need for the testing.)

Most of us who have gone through the implementation of a EMR realize that electronic medical records (EMRs) do not always “tell the story” of a visit in the way that paper records used to. Encounters are documented without the glue that allows an auditor to understand what went on during the visit. Here are three ways to make sure that your documentation meets requirement for Medicare and other payers.

 

Establish Medical Necessity: Make sure the test is attached to the right diagnosis

Some providers attach all diagnoses assigned to a visit to any/every test ordered and performed. This is incorrect. All diagnoses can be attached to the Evaluation & Management (E/M) code, since all were addressed during the visit. Don’t list any diagnoses from previous visits that were not addressed at the current visit unless you note their impact on your decisions for care at the current visit.

Remember that screening tests and diagnostic tests are two different things. A screening test is ordered when you are looking for something with no provocation. Wikipedia states that a screening test “may be performed to monitor disease prevalence, manage epidemiology, aid in prevention, or strictly for statistical purposes.”

A diagnostic test is ordered when there is a sign or symptom that prompts the provider to look for the cause. Wikipedia defines a diagnostic test as “a procedure performed to confirm, or determine the presence of disease in an individual suspected of having the disease, usually following the report of symptoms, or based on the results of other medical tests.”

According to Medscape, the 5 main reasons for any test are as follows:

      • Screening: Screen for disease in asymptomatic patients. For example, a prostate-specific antigen (PSA) test in men older than 50 years.
      • Screening: A test may be performed to confirm that a person is free from a disease or condition. For example, a pregnancy test to exclude the diagnosis of ectopic pregnancy.
      • Diagnostic: Establish a diagnosis in symptomatic patients. For example, an ECG to diagnose ST-elevation myocardial infarction (STEMI) in patients with chest pain.
      • Diagnostic: Provide prognostic information in patients with established disease. For example, a CD4 count in patients with HIV.
      • Diagnostic: Monitor therapy by either benefits or side effects. For example, measuring the international normalized ratio (INR) in patients taking warfarin.

 

Reveal your decision making in the record

      • Need add’l tests to est. xxxxxx. Plan to…
      • Return in 3 wks and repeat test to establish…
      • DM worsening – will….
      • Consider d/c xxxxxx medication if fatigue persists.
      • Hypothyroidism vs. anemia?
      • Fatigue most likely sec. to HTN meds – r/o electrolyte abn.
      • DM stable, continue current regimen, recheck in 3 months.

 

Don’t forget the signatures!

A signature log can be as simple as entries on a document such as:

Provider Name (printed): ______________________

Full signature (written by provider): ______________

Initials (written by provider): ___________________

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Posted in: Collections, Billing & Coding, Compliance, General, Medical Coding Education, Medicare & Reimbursement, Medicare This Week

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The New Age of Managed Care Contracting: Talking with Maria Todd of The Healthcare Business Institute

Managed Care Contracting

 

 

Dr. Maria Todd has been in healthcare since 1979 and has been the nation’s leading managed care trainer and consultant since 1989. She’s trained more than 70,000 healthcare professionals via more than 2500 road show seminars presented through McGraw Hill Healthcare Education Group, HFMA, MGMA, Heritage Professional Education and Business Network. Her iconic Managed Care Contracting Handbook sold more copies than any other managed care professional handbook in history, and is now in 2nd edition. No other industry professional has contributed more to the art of managed care contracting and managed care professional skills education than Dr. Todd. Manage My Practice recently sat down with her to learn more about “the new age of contracting.”

Mary Pat: Maria, you are teaching attendees at your contracting course what is new about payer contracting. What’s different in the current environment?

Maria: The managed care contracting scene is radically different under healthcare reform and the PPACA. Anyone who hasnt revisited their contracts in the past few years because they conveniently rolled overyear to year may find that they could be shut out of renegotiation, certain networks and other strategic updating that should have been done vigilantly since 2009.

Mary Pat: Do managers still need all the previous skills related to contracting with payers?

Maria: They need even more! For example, they will need to be able to safely configure bundled case rates without overlooking costly inclusions due to vague or ambiguous descriptions and accurately calculate the business opportunities and risks under capitated models.

Mary Pat: Contracting carries a lot of risk. How do you teach people about contract risk?

Maria: By showing them the ambiguities in every day contract language that doesnt look like legalese but can create loopholes for payment bundling, denials, foreclose appeals, and force the physician to refrain from billing.

Mary Pat: Many physicians have told me that there is no real negotiability in payer contracts anymore. I don’t believe that is true – what do you think?

Maria: I have always been able to negotiate some changes, perhaps not all that Id like to. The fact of the matter is that if there is nothing to negotiate, the contract is considered adhesiveand unfair and the courts can toss it out. Language can also be construed in interpretation against the drafter, if it is ambiguous. Also, the courts are not there to be paternalistic. If you negotiate some and leave others the courts put the onus on the physician or his/her manager for not finishing the job. You are not entitled to a fair contract unless you negotiate one. The class teaches participants how to spot problems and mitigate them, and provides more insight to defend a reason to say no thanks, Ive had enough!

Mary Pat: You say “Price is not the driver anymore.” What is?

Maria: New trends in contracting level the pricing field. That means that quality and service accountability, as well as adherence to evidence-based care protocols and guidelines will be measured, prescribing habits and patient engagementonly now, they will be contracted performance elements. The whole new ball game of pay for performance is now driven on different metrics. If one doesnt perform at a base level, one will have to find another ball field.

Mary Pat: Do managers and physicians need the help or review of a lawyer before they sign a payer contract?

Maria: Yes.. but for the right reasons. Too many attorneys are asked to assist on operational reviews. For most attorneys, those without practical experience in health administration and operations, (late entrants into law school after a career in healthcare, for example) the doctors and managers you mention are asking the attorneys to work outside their scope. Attorneys should, for the most part, review for enforceability and compliance, not fee schedules, operational practicability, and procedural matters that are purely at the discretion of the contracting parties to agree.

Mary Pat: In your course you discuss contracting with ACOs. Can you talk about what practices will need to learn to be able to contract appropriately with ACOs?

Maria: Which ones to align with, first. Second, how to get out if they make a bad decision, and third, what to look for and watch out for along the way. No one wants to miss the ACO with the successful management and operations and shared savings outcomes, and be left with the ACO that doesnt function well, isnt aligned and doesnt make any shared savings bonus at the end of the year.

Mary Pat: Many managers do not know how to handle ERISA (self-funded insurance plans where the employer acts as its own payer) claims. Do you teach skills to deal with ERISA claims?

Maria: I teach 3 ways to deal effectively with this problem. We know practices hear Were ERISA and we dont have to pay timely or accurately.We teach practices how to get paid faster and more accurately from ERISA payers and teach them exactly what to say to the “ERISA Excuse.”

Mary Pat: Do you talk about out-of-network strategies in your course?

Maria: Yes, because there will be times when the right strategy is to say no. Even them physicians and other healthcare providers may be able to attract market share in other ways, some that may even cost less in overhead and hassle factor – like, cash, for instance.

Mary Pat: What is the single most important thing (without giving away any trade secrets from your course!) that you wish managers and physicians would know about contracting?

Maria: How 150 words and phrases we use in everyday language like shalland other words like appropriate, adequate, reasonable, material, use best efforts, use reasonable commercial efforts, best, other, indemnify and hold harmless, can make life so miserable for physicians and their managers and collections staff because they didnt realize the implications.

Maria K. Todd, PhD

Maria has very graciously agreed to give Manage My Practice readers a 20% discount (code MMP2013) on her 3-day managed care contracting workshop which will be offered on August 14, 15 & 16, in Denver, Colorado. The Healthcare Business Institute, a new non-profit training and professional skills development institute in Denver, Colorado will host this hands-on workshop at the Grand Hyatt Denver Downtown. For more information and registration, call 800-209-7263 or register online here.

(Photo Credit: photos by blperk via Compfight cc)

Posted in: Compliance, Day-to-Day Operations, Finance

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Why Medicare Patients May Be Asked to Pay in Full for Services

Medicare Patient!

 

 

 

 

 

Most Medicare patients believe that Medicare pays for everything they need or want at their physician’s office, but there are services that either:

    • Are only covered by Medicare for a specific medical need (for instance, performing a diagnostic EKG when the patient has no related symptoms)
    • Are only covered by Medicare at specific intervals (for instance, performing a Pap smear more often than every 24 months for low-risk women)
    • Are never covered by Medicare (for instance, an annual physical)

In any of the above cases, because Medicare may not or will not pay, medical practices will give the patient an Advance Beneficiary Notice (ABN) that explains what Medicare may not pay for, why Medicare may not pay for it, and what they (the patient) will be responsible for paying IF they elect to receive the service and sign the ABN stating so.

Additional Rules:

    • The ABN must be supplied before the service is rendered, or the practice may not bill the patient.
    • The practice cannot give out “blanket” ABNs that state “whatever Medicare won’t cover.”
    • Once the patient signs the ABN and agrees to pay for the service, the practice must give a copy to the patient, keep the original on file and use a modifier on the claim to indicate that a signed ABN is on file and available for inspection.

The signed ABN is a requirement for charging and collecting from a patient for any services the patient asks for but Medicare may/will not cover. For the same circumstances for non-Medicare patients, a non-Medicare ABN may be used.

More About Using the ABN

On Thursday July 18th, from 3-4pm EST Manage My Practice is presenting a brand new webinar – “Learn How to Use the Medicare ABN and the Non-Medicare ABN to Your Practice’s Advantage.” This is an expanded webinar with 75 minutes of content and 15 minutes of Q & A with the attendees. This 90-minute program is $99.00 per attendee. See more details below. Click here to register for “Learn How to Use the Medicare ABN and Non-Medicare ABN to Your Practice’s Advantage.”

What will I learn by attending the ABN webinar?

    • Six benefits of using an ABN.
    • How to evaluate losses due to use or non-use of the ABN.
    • What is medical necessity and how does it relate to the ABN?
    • When is an ABN required by Medicare and is it used for Medicare Replacement Plans?
    • How to complete the ABN form.
    • Using the ABN functionality in your EMR.
    • Workflow options for introducing the ABN to the patient.
    • What to do about patients who refuse to sign the ABN.
    • How to use the correct claim codes for the Medicare ABN.
    • Collecting for ABN services.
    • Using an ABN for commercial payers.

What does the program Action Pack include?

    • Current Medicare ABN
    • Non-Medicare ABN
    • Workflow charts for the ABN process
    • Sample protocol and policy for using an ABN

 Click here today to register for the ABN Webinar.

Photo Credit: babymellowdee via Compfight cc

Posted in: Collections, Billing & Coding, Compliance, Day-to-Day Operations, Medicare & Reimbursement

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MOOC For Healthcare: What Can You Do (for Free) to Improve Your Management Skills?

Managers can Go Back to School with MOOCsOur clients and readers are constantly asking “What do I need to do to be ready for all of this change in healthcare?” There is so much to digest, plan for and keep track of that our industry is constantly seeking new skills to confront new challenges. Professional development is a critical part of career plans in most industries – but the speed at which healthcare administration is changing is pressing the issue even further. But when can already-swamped managers find the time (let alone the money!) to stay sharp and expand their skill sets?

In the past five years a solution has emerged from the Internet. The MOOC, or “Massive Open Online Course” is a model that has the potential to revolutionize how we educate people on a large scale – not to mention give busy managers a chance to get high-quality education at little or no cost on a flexible schedule. After several universities put free, open-coursework courses online to great success, several sites developed to expand the scale of the model. Now sites like Udacity, Coursera and edX offer free courses with video lectures, materials, and examinations to anyone who can access their site. The New York Times dubbed 2012 “The Year of the MOOC”, but it might be 2013.

If you are a manger looking to stay sharp, check out some of the Coursera offerings for summer and fall of 2013 below!

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Posted in: A Career in Practice Management, Headlines, Leadership

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New 1500 Claim Form Approved to Accommodate ICD-9 or ICD-10 Diagnosis Codes

NUCC Announces Approval of New 2/12 1500 Form for ICD-9 and ICD-10 Accommodation

On June 17, 2013, the National Uniform Claim Committee (NUCC ) announced the approval of Version 02/12 1500 Health Insurance Claim Form (1500 Claim Form) that accommodates reporting needs for ICD-10. The Office of Management and Budget (OMB) has approved the 1500 Claim Form under OMB Number 0938-1197.

During its work, the NUCC was made aware by the health care industry of two priorities that were included in the revisionsto the 1500 Claim Form. The first was the addition of an indicator in Item Number 21 to identify the version of the diagnosis code set being report, i.e., ICD-9 or ICD-10.

The need to identify which version of the code set is being reported will be important during the implementation period of ICD-10.

The second priority was to expand the number of diagnosis codes that can be reported in Item Number 21, which was increased from 4 to 12. Additional revisions will improve the accuracy of the data reported, such as being able to identify the role of the provider reported in Item Number 17 and the specific dates reported in Item Number 14.

Frequently Asked Questions (as of 6/17/13)

1. Why was the 1500 Claim Form changed?

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Posted in: Collections, Billing & Coding, ICD-10, Medicare & Reimbursement

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Master the Vacation Balancing Act

This article was originally published on LinkedIn as a part of their Influencer series.

Vacation Balancing ActSummer is traditionally the slow time of the year for healthcare. Summer in medical settings means vacations and staff coverage, new physicians fresh from residency, and more chances for the local kids to get creatively injured with school out. Even though summer might not have the intense volume of cold and flu season, or the intense number-crunching of the end of/beginning of the year, as a manager there’s always something demanding your attention. So when you need a vacation, you Need A Vacation. How do you achieve the balance of taking time off with being able to step in and manage if the need arises?

Access is the name of the game in achieving balance. I want to be able to go away knowing that I can easily get to things I need without a lot of fuss. That’s why I am such a fan of mobile technology that lets me stay informed or in touch when I’m away – whether at a conference, on vacation, or fitting in family or personal time.

The key to access is using your phone or tablet to enhance and protect your out-of-the-office time, not invade it. Access equals peace of mind and allows the total unwinding that is so critical to rebuilding your energy for the next round. While I’m taking time off this summer, these are the apps I’m using to stay in touch and give me the confidence to let go!

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Posted in: A Career in Practice Management, Day-to-Day Operations, Quality

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Health Insurance Premiums Are Refunded to 8.5 Million Enrollees

Insurance Premium Rebates from Obamacare reach Consumers

The Department of Health and Human Services (HHS) announced recently that nationwide, 77.8 million consumers saved $3.4 billion up front on their premiums as insurance companies operated more efficiently.  Additionally, consumers nationwide will save $500 million in rebates, with 8.5 million enrollees due to receive an average rebate of around $100 per family.

This report includes the 2012 health insurer data required under the Affordable Care Act’s Medical Loss Ratio, or “80/20 rule.”  The report shows that, compared to 2011, more insurers are meeting this standard and spending more of their premium dollars directly toward patient care and quality, and not red tape and bonuses.

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Posted in: Headlines

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The Interview Question That Stumped Me

The Interview Question That Stumped Me

I’ve had many interviews over the course of my career, but one is particularly memorable because of the interview question that completely stumped me.

I was in the third and final phase of an interview, having already met with a team of potential peers and the person I would report to. The last interview was with the team that would report directly to me. I always think being interviewed by potential direct reports is the most difficult of all interviews, probably because while you think you know what peers and the boss are looking for, you have no idea what the staff is looking for.

Everything was rolling along well, and as that final hour was ending I could feel the relief of a runner being able to see the finish line. Then came the stumper: (more…)

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Three Big HIPAA Myths

Waiting Room

 

 

As a healthcare consultant, it is not unusual to be asked about HIPAA regulations on a weekly basis. Three questions come up regularly and seem to cause the most confusion when discussing HIPAA. I call them the Three Big HIPAA Myths – you can’t place medical charts on exam room doors, you can’t use sign-in sheets, and you can’t leave messages on patients’ voice mail or answering machines.

Here, then are the answers, straight from the Office for Civil Rights, which enforces:

  • the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information;
  • the HIPAA Security Rule, which sets national standards for the security of electronic protected health information;
  • the HIPAA Breach Notification Rule, which requires covered entities and business associates to provide notification following a breach of unsecured protected health information;
  • and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety.

#1 Question:  A clinic customarily places patient charts in the plastic box outside an exam room. It does not want the record left unattended with the patient, and physicians want the record close by for fast review right before they walk into the exam room. Does the HIPAA Privacy Rule allow the clinic to continue this practice? 

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Posted in: General

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