We hear more and more every day about EHR problems and physician dissatisfaction with performance and usability, and the way the federal government makes them use it. So, who should physicians complain to?
Of course you should complain to the vendor about usability, and complain in groups when possible. I’ve started several user groups in the past and have had success in communicating with vendors to improve their products. The key is keeping the User Group independent from the vendor, which takes committed volunteers.
In addition, you may want to complain to the Office of the National Coordinator (ONC) and hope that other physicians will do the same and there will be traction gained by many voices. The ONC has just launched an online complaint form for this purpose, but note, Coordinator Karen B. DeSalvo, MD only wants to hear about problems with certified EHRs.
The American Medical Association (AMA) is also working on behalf of physicians with a campaign called “Break The Red Tape” which calls upon physicians to write about (or video) their EHR story. Even if you don’t plan to share your EHR story, be sure to click on the link and hear from real people.
Physicians (and their staffs) are overwhelmed with all the mandates. As a consultant, I no longer work with Meaningful Use, PQRS/VBM or PCMH. I refer practices to other consultants for these needs because I would rather work on what I think is meaningful in medical practice today – practice business models and strategies that bring more satisfaction to the physician and the patient.
We introduced readers to HiTech-Doctors several years ago before the telemedicine boom really hit. Today, many physicians are thinking seriously about telemedicine and how adding it to their practices could meet patient demand for convenience and ease overcrowded schedules. We decided to catch up with Philip Gideon, MD, cardiologist and Chief Medical Officer of HiTech-Doctors and see what’s new.
Mary Pat: Describe HiTech-Doctors.
Dr. Gideon: HiTech-Doctors is a web-based heath care portal created to open Internet communications between provider and patient. We seek to create the safest and easiest environment for videoconferencing encounters, electronic messaging, clinical data entry, data transfer, and clinical education. Connected care is the future and is here.
Mary Pat: How can a practice improve patient communication using HiTech-Doctors?
Dr. Gideon: We have a high definition videoconferencing service with quality and utilities not yet seen in this industry.
We have developed an email service that allows safe communication with your patients.
For each encounter a history and physical document is generated. This data can be used in the normal workflow of generating the electronic patient chart.
There is a patient data entry service that allows general clinical data to be populated by the patient.
Interactive encounter scheduling is available to make life easier for the patient and the provider.
Other providers and family members can be invited into the video encounter.
The patients can transmit their health information in to their chart.
Mary Pat: How has HiTech-Doctors evolved?
Dr. Gideon: We wanted to create the next generation of electronic health record. An EHR is needed that allows the provider and patient to communicate and learn through multiple technologies in a safe easy way. We have begun to accomplish this “open chart” with our current system platform.
Additionally, the platform needed to aid providers in meeting Meaningful Use (MU) criteria for participation in government incentive programs. MU2, and particularly MU3 criteria, have some specific technological requirements that cannot at this time be fully met by most available EHR providers. We have been able to meet many of these criteria by:
Demographic recording and record of smoking status
Use of secure electronic messaging to communicate with patients
Allowing immediate ability for patients to view and download their encounter record by both document and video format.
Increasing after hours provider accessibility
Gives ability to provide summary of care record electronically
There are so many useful aspects to the platform. We believe that as MU criteria evolve and the repealed SGR mandates develop, our product will lead in the industry. We believe that, but we know HiTech-Doctors will lead in health care communication.
Mary Pat: What does it cost physicians and patients?
Dr. Gideon: For the provider, it is $300 for lifetime enrollment. No additional charge for individual providers.
The communications platform (secure electronic messaging or emailing) is $300 per month per practice.
For the patient, it is $20 lifetime enrollment for an individual and this includes family.
$10 will be added to the patient bill in all encounters as payment for the service to HiTech-Doctors.
Mary Pat: Does insurance pay for telemedicine?
Dr. Gideon: Provider practices are encouraged to notify private insurance providers of the intent to see their patients by telemedicine. The intent should state that the encounter would be billed at an appropriate level of office visit using a QT modifier. The patient would be billed a set amount which should be considered a copay or as part of the total reimbursement. A description of the service being used (HiTech-Doctors) and the cost of service should be included. Some insurance carriers may need to negotiate the fee schedule, but this is commonplace when a new service is offered in a practice.
Encounters can alternatively be billed by the provider as cash or fee-for-service. This is specifically true for Medicare and Medicaid patients using the system outside of Medicare/Medicaid telemedicine criteria (cms.gov).
Either means of payment require a credit card transaction prior to starting the encounter.
Mary Pat: How does a practice implement telemedicine?
Dr. Gideon: The Hitech-Doctors team has put together an implementation plan to accommodate any office or medical center.
Setting up computers, tablets and phones to accommodate the best virtual experience.
Modification of patient scheduling workflow to allow a choice of in office or online encounters.
Acquire and categorize patient email contact list.
Email, postal, and in office advertisement of the new online service.
The implementation involves strategic scheduled learning teams early in the initiation. Both in-person and online availability of the HiTech-Doctors team is present as the roll out takes place and after. This combination of staff and provider education, hardware setup, advertisement, and ongoing technical and clinical support offers the best success.
Mary Pat: Is there technical support?
Dr. Gideon: Yes, 24/7 technical and user support are available buy phone at 1-480-588-2512. Try it!
Mary Pat: Since we last talked, the national conversation about telemedicine has changed radically. How has the conversation changed HiTech-Doctors?
Dr. Gideon: HiTech-Doctors has continued to promote the use of telemedicine as another form of patient:provider communication. Many levels of acceptance and regulation of video encounters need to be in place to allow broad use of telemedicine. This is the conversation at present, and it will need to continue. HiTech-Doctors hopes to help keep the momentum in the right direction towards sustaining the patient doctor relationship.
Mary Pat: What do you think about the interstate telehealth licensing compact?
Dr. Gideon: The compact addresses serious questions about healthcare, such as physician shortage in both rural and urban regions and poor access to care. Telemedicine stands to be an efficient tool in the solution.
There are tremendous benefits to having interstate licensure. Electronic visits are already a proven means of healthcare communication that can be gap-filling technology where there is poor access to healthcare. The compact has had progressively more backing by states and congressional leaders. Allowing providers to have interstate license gives the ability to optimize the use of the available technology.
Recently UHC announced it would cover telemedicine services for its subscribers, however, only if the services were procured through specific telemedicine intermediaries. What are your thoughts about this development?
Insurance providers are at a stage where they need to, and can, set the physician fee schedules for telemedicine given no specific value or code has been yet assigned by CMS. Blue Cross Blue Shield of Arizona recently also consented to paying for telemedicine at only 80% of the billed visit. United Healthcare doing business with only specific telemedicine companies is a normal practice of insurance providers in this current time of managed healthcare. HiTech-doctors offers a platform that allows real medical practice to occur. It is far more than triage to keep insurance company clients out of the ER or urgent care. The real winner is the telemedicine service that allows confident and safe communication.
Mary Pat: What is in the future for HiTech-Doctors?
Dr. Gideon: We are excited to move with the growing pains of our healthcare system so that we stay connected to actual need. Technology through HiTech-Doctors will continue to help in producing the best health outcomes at a low cost. The other side of the HiTech-Doctors healthcare portal is better outcomes and living.
More information on HiTech Doctors is available at their website here or by calling 480-588-2512.
For a long time the idea of wearable health tracking devices seemed like an idea out of science fiction, but these days the technology is real and cost effective, and wearables will have a big effect on how your practice operates. Here with more insight on the nascent wearable industry is Guest Author Anne Zieger, CEO of Zieger Healthcare. – Abe
For most doctors in private practice, the astonishing growth of health wearables has all but passed them by.
According to a leading health IT group, the use of health and fitness apps is growing 87% faster than the entire mobile industry. That’s pretty astonishing for a product category most of us hadn’t even heard of five years ago.
But to date, this hasn’t changed medical practice much. While physicians may review readings gathered by consumer-grade measurement devices such as home glucose meters, blood pressure cuffs and pulse oximeters, few are integrating data from wearables into their consult, much less integrating that data into their EMR.
The reasons for this are many. For one thing, doctors are creatures of habit, and are unlikely to change their assessment routine unless they are pushed into doing so. What’s more, their EMRs are not set up to gather fitness data in a routine and streamlined data. Then when you consider that physicians aren’t quite sure what to do with the data – short of a shocking data outlier, what does a physician do with a few weeks of exercise data? – it seems even less likely that they’ll leverage wearables data into their clinical routine.
Over the next few years, however, this state of affairs should change dramatically.
Data analytics systems will begin to including wearables data into their calculations about individual and population health. And physicians will be expected to become adept at using wearables to better track the health status of chronically-ill patients. In short, wearables should fundamentally change the way physicians care for patients, especially those at greater risk.
Here’s some examples of how this will play out.
Data analytics
In an effort to improve the health of entire patient populations, organizations such Louisiana-based Ochsner Health System are testing Apple’s HealthKit technology. Through HealthKit, which connects with Ochsner’s Epic Systems EMR, the health system will be able to pull in and integrate a wide range of consumer-generated data, notably input from wearables.
While Ochsner’s first big win came from its test with wireless scales for heart patients—which led to a 40% decrease in admissions—the bigger picture calls for clinicians to use wearables data too, leveraging it to track the health of it entire patient base.
Tracking the chronically ill
Though most wearable health bands are consumer devices, used largely by the already fit to help them stay that way, medical device companies are building a new class of wearable devices designed to help clinicians track serious chronic illnesses in a serious manner.
Phillips, for example, announced a few months ago that it had released a biosensor patch designed to track symptoms of COPD, send the data to a cloud-based central software platform using the patient’s wireless device, then route the results to that patient’s clinician via a pair of related apps. This gives the physician 24-hour access to key indicators of COPD status, including respiratory rate, heart activity and rhythm and physical activity.
Conclusion: Much more to come
The bottom line in all of this is that wireless monitoring of remote patients has already arrived, and that new uses for data from health bands and other fitness devices are likely to become a standard part of patient care over the next few years.
While no one is suggesting that the data and practical observations a doctor gathers during a fact-to-face medical visit are becoming less value, medical practice is likely rely more heavily on monitoring of wearable smart bands, sensors, smart bands, sensor-laden smart clothing and more as time goes by. Now is a good time to prepare for this shift in medical practice, or risk getting left behind.
Zieger Healthcare’s team of veteran marketing communications pros will help you reach out to key healthcare stakeholders and grab their attention. With decades of experience in the industry, we know exactly how to tell healthcare stories that sell.
Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities
Question 1:
When will the ICD-10 Ombudsman be in place?
Answer 1:
The Ombudsman will be in place by October 1, 2015.
Question 2:
Does the Guidance mean there is a delay in ICD-10 implementation?
Answer 2:
No. The CMS/AMA Guidance does not mean there is a delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization. Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code. The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015 or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims.
Question 3:
What is a valid ICD-10 code?
Answer 3:
ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. To be valid, a code must be coded to the full number of characters required for that code, including the 7th character, if applicable. Many people use the term billable codes to mean valid codes. For example, E10 (Type 1 diabetes mellitus), is a category title that includes a number of specific ICD-10-CM codes for type 1 diabetes. Examples of valid codes within category E10 include E10.21 (Type 1 diabetes mellitus with diabetic nephropathy) which contains five characters and code E10.9 (Type 1 diabetes mellitus without complications) which contains four characters.
A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.
Question 4: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a NCD or LCD or other claim edit?
Answer 4:
Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.
Question 5:
What is meant by a family of codes?
Answer 5:
“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.
Question 6:
Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?
Answer 6:
In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations. (See Question 7 for more information about this). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.
In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code.
Question 7:
National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required. Does the recent Guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific codes?
Answer 7:
No. As stated in the CMS’ Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.
As such, the recent Guidance does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10. It is important to note that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9. LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side. The NCDs and LCDs are publicly available and can be found at http://www.cms.gov/medicare-coverage-database/.
Question 8:
Are technical component (TC) only and global claims included in this same CMS/AMA guidance because they are paid under the Part B physician fee schedule?
Answer 8:
Yes, all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance.
Question 9:
Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?
Answer 9:
No, the audit and quality program flexibilities only pertain to post payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.
MEDICAID
Question 10:
If a Medicare paid claim is crossed over to Medicaid for a dual-eligible beneficiary, is Medicaid required to pay the claim?
Answer 10:
State Medicaid programs are required to process submitted claims that include ICD-10 codes for services furnished on or after October 1 in a timely manner. Claims processing verifies that the individual is eligible, the claimed service is covered, and that all administrative requirements for a Medicaid claim have been met. If these tests are met, payment can be made, taking into account the amount paid or payable by Medicare. Consistent with those processes, Medicaid can deny claims based on system edits that indicate that a diagnosis code is not valid.
Question 11:
Does this added ICD-10 flexibility regarding audits only apply to Medicare?
Answer 11:
The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. This Guidance does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.
Question 12:
Will CMS permit state Medicaid agencies to issue interim payments to providers unable to submit a claim using valid, billable ICD-10 codes?
Answer 12:
Federal matching funding will not be available for provider payments that are not processed through a compliant MMIS and supported by valid, billable ICD-10 codes.
OTHER PAYERS
Question 13:
Will the commercial payers observe the one-year period of claims payment review leniency for ICD-10 codes that are from the appropriate family of codes?
Answer 13:
The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. Each commercial payer will have to determine whether it will offer similar audit flexibilities.
This continues to be one of our top ranking posts of all time.
This tells me that people continue to struggle with the process of evaluating employee performance.
The point of the “Five Questions” evaluation is not to focus on the fact that the employee is often tardy or doesn’t complete assignments on time – those things should be initially dealt with outside of this process (remember the old adage “No new news at the performance evaluation.”) They can be added to #3 as goals, but the idea is to to dig under those things and see if the employee is dissatisfied, overwhelmed or under-challenged.
I typically use this form at 90 days after hire, then at the one year mark, then every 6 months thereafter.
Yes, evaluating this much is very time-consuming – but it pays BIG dividends.
Invest in your employees by using this form and meeting for at least an hour – you might be surprised that it’s one of the most in-depth evaluations you’ll ever do!
This is a VERY succinct performance evaluation that I’ve used for years. Called “Five Questions”, the employee completes it, submits it to the manager, then together they discuss, evaluate and add to it during the evaluation interview. Here are the questions:
What goals did you accomplish since your last evaluation (or hire)?
What goals were you unable to accomplish and what hindered you from achieving them?
What goals will you set for the next period?
What resources do you need from the organization to achieve these goals?
Based on YOUR personal satisfaction with your job (workload, environment, pay, challenge, etc.) how would you rate your satisfaction from 1 (poor) to 10 (excellent.) 1 2 3 4 5 6 7 8 9 10
You do have to stress that question #5 is not how well they think they’re doing their job, but how satisfied they are with the job.
The great thing about this evaluation is that it is one piece of paper and not too intimidating. Staff can use phrases or sentences and write as little or as much as they like. If it’s hard to get a conversation going with the employee, ask them “What was your thought process when you assigned your job satisfaction a number __.” Usually that opens the floodgates!
If you use a goal-oriented evaluation like this one, you will find that employees will grasp that you are asking for their performance to be beyond the day-to-day tasks, and to focus on learning new skills, teaching others, creative thinking and problem-solving and new solutions for efficiency and productivity.
October 1, 2015 is a date that looms large for everyone involved in the operational and financial functions of any medical practice. At the time of this post’s publishing, practice administrators, managers, billers and coders have less than three months to make sure they have the processes and systems in place to minimize the business disruption from the changeover. As we talked to clients and readers about the challenges they are facing with the ICD-10 upgrade over the past several years, we started looking for tools that could help practices ease the transition.
One tool really stood out more than the others. Swiftaudit Search is a web-based coding conversion and look-up tool for both ICD-9 and ICD-10 code sets that we strongly endorse for its ability to supercharge ICD-10 coding, audits and upgrade preparations. We’ve been using Swiftaudit Search here at Manage My Practice for months now and we are very excited about how it can help our readers and clients.
We sat down with the creators of Swiftaudit Search, Chicago’s SpringSoft to ask them more about how practices can prepare for the upgrade.
Manage My Practice:Tell us about SpringSoft and how you starting working in the healthcare software market.
SpringSoft: We’ve provided software to the healthcare coding and compliance market since 1995. Our first product was E&M Coder™ for evaluation and management coding and audits. It all started when a few forward thinking doctors told us “the auditors are coming.” Given our background in corporate business systems, our research provided a couple of interesting observations at that time. One – physician offices had few easy to use software applications. Two – from a business point of view, physician offices needed help with coding and compliance. So we tackled a challenging little-understood coding issue in 1994 – the introduction of evaluation and management codes.
Manage My Practice: Your product that is designed for medical coding has gone through several iterations since the ICD-10 mandate was first announced – how did your product evolve?
SpringSoft: We started designing what is now Swiftaudit Pro several years ago. As we designed the coding components, we realized that our ICD-10 Search features would benefit physicians during the transition to ICD-10. Again, we took on a daunting challenge. We knew we had to design an intuitive ICD-10 Search Feature. Once you find a group of codes, the next problem was to be present all of the ICD-10 coding information to describe the patient’s health condition. So now, as Swiftaudit evolves, our goal is to present the ICD-10 coding guidelines in a quick and straightforward way.
Manage My Practice: We‘ve seen a wide variety of encoder-type products designed for hospitals and large organizations, and some designed for billing companies and consultants. What target market is the best fit for your products and why?
SpringSoft: Currently, we see our market as physician offices. Hospital and large organization coding systems have to address ‘packet’ coding, such as DRG (Diagnosis Related Groups) and HCCs (Hierarchical Condition Categories). Hospitals and large organizations will benefit from our auditing platform – SwiftAudit Pro. Providers who need to code ICD-10s will benefit from Swiftaudit Search. They can use our product to learn how code their common ICD-9 diagnosis in ICD-10 language.
Manage My Practice:What do you hear are the biggest challenges faced by practices in making the transition to I-10?
SpringSoft: We hear that immediacy and time are the biggest challenges. Immediacy – it is always easier to learn new methods when you can consistently work in the new method. A baseline understanding helps provide context and what the changes are. We will all learn when everyone starts coding in ICD-10. Time – the change to ICD-10 is not trivial. It impacts the office’s income. Everyone will need to spend a little more time – coding in ICD-10, and time in improving their coding as payers respond to codes submitted. A practice can reduce frustration if they understand and prepare for their learning curve. Like all new methods, it takes practice to perfect.
Manage My Practice:For many practices, their ability to utilize ICD-10 will come down to the support the EHR or Practice Management vendor has built into the software, yet many practices have not even seen how their software will work with ICD-10. What do recommend for practices whose software has not yet been updated to I-10, or whose software makes no useful correlation between I-9 and I-10?
SpringSoft: We agree with many consultants and trainers. Transition your top ICD-9 codes to specific ICD-10 codes. Be cautious of depending on published crosswalks. ICD-9s which describe ‘unspecified’ elements often are crosswalked to ‘unspecified’ ICD-10s. Experts in the industry are cautioning that ‘unspecified’ ICD-10s may not be paid. Ask your EMR vendor, will you handle all of the ICD-10 coding guidelines, such as Code First, Code Also, Use Additional Codes? Will you map to ‘unspecified’ ICD-10 codes or warn me of ‘unspecified’ ICD-10 codes? How will you help me find more specific codes? You can use Swiftaudit Search to build your Favorites Lists. We will provide you the ICD-10 coding guidelines, and provide a communication platform for your expert coders to provide you with coding tips and alerts.
Manage My Practice: What are some of the features in Swiftaudit Search that your product has that others you’ve seen do not?
SpringSoft: We feel that our ease of use and screen design makes us stand out from the crowd. The ICD-10 code set is overwhelming. We’ve worked very hard to provide the information you need at a glance.
Manage My Practice: Swiftaudit Pro (as opposed to Swiftaudit Search) is more for the coding and billing side of the practice. How do you see coders and billers using this product in their practices?
SpringSoft: Our background is in coding and compliance. Managers and auditors can use Swiftaudit Pro to improve their coding accuracy and educate their providers. We built Swiftaudit Pro to be a communication platform to aid discovery and process improvement between a practice’s providers and expert coders.
Readers who would like more information or would like to try Swiftaudit Search for free for 30-days can click here.
NOTE: We’ve heard of so many practices that have not started preparations for ICD-10 that that we made the 20-minute webinar “ICD-10 CM: Getting Started Today.” The video addresses strategies for the first step – crosswalking your most used ICD-9 codes into ICD-10.
UPDATED INFO: These recorded webinars are now available here.
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On July 9, 2015 the Centers for Medicare & Medicaid Services (CMS) announced the Comprehensive Care for Joint Replacement (CCJR) model, a proposed payment, quality, and care improvement initiative for hip and knee replacements.
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) will host two offerings of a webinar to describe the proposed rule and respond to questions. The dates and registration links for these webinars are as follows:
Additional information on this Model can be accessed through the CCJR Model web page.
The proposed rule will undergo a 60-day comment period during which time CMS welcomes the input of stakeholders and the public. You can read the proposed rule in the Federal Register.
Can I go without any income from a new practice for 3-6 months?
Do I have another income stream or can I continue to work part-time at the hospital or at an urgent care while I’m building my practice?
Can I envision starting my practice by myself (no receptionist or medical assistant)?
Do I have an existing patient base which will be interested in joining my practice?
Is the community in which I want to work underserved or overserved in my specialty?
Do I have a cash component to my practice that can help defray expenses while I’m building my practice?
Will I be able to count on unpaid help from my spouse, family or friends to get things started?
Will I be satisfied to start my practice by leasing space from another practice, or at a less-prestigious location that might not be my forever-location?
Am I willing to shop for gently used and refurbished furniture and equipment for my medical practice?
Will I be satisfied to use one of the free EHRs, even if it doesn’t have all the bells and whistles?
Bonus Question: Do I have saved or can I borrow $20K to cover my expenses for the first 3-6 months?
Starting a new medical practice is not easy. No one should tell you that it is.
But, if you want to put in the work, make the decisions, and ultimately, practice the way you want to, then a solo practice may be a fit for you.
You may have to call your friends and family together to help you, you may have to work someplace else while you’re building your practice, but the good news is, you are the boss of you.
First, the game-changing announcement below means that a sigh of relief is in order. Some of the anxiety surrounding potential financial disaster should be abated. CMS announced:
“Medicare review contractors [MACs and RACs] will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.” (see FAQ2 below)
Second, we think it means that the sword rattling coming from the AMA and other individuals should subside. The fact that the CMS changes are based on recommendations from the AMA, which has been adamantly opposed to the ICD-10 mandate for years, is no less unexpected than the lion laying down with the lamb.
Regardless of the changes, the AMA’s previous assertion that ICD-10 “will create significant burdens on the practice of medicine with no direct benefit to individual patients’ care” still stands. The transition is inevitable, in my mind, but the changes will lessen the burden on physicians.
In the announcement from CMS, the clarification was made that
“In accordance with the coming transition, the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes.”
Third, CMS will name a CMS ICD-10 Ombudsman to triage and answer questions about the submission of claims. The ICD-10 Ombudsman will be located at CMS’s ICD-10 Coordination Center.
Also, mark your calendars! CMS will have a provider call on August 27th to discuss these changes.
See the answers below provided by CMS in their new FAQs published this week.
Q1. What if I run into a problem with the transition to ICD-10 on or after October 1st 2015?
A1. CMS understands that moving to ICD-10 is bringing significant changes to the provider community. CMS will set up a communication and collaboration center for monitoring the implementation of ICD-10. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10. As part of the center, CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns. As we get closer to the October 1, 2015, compliance date, CMS will issue guidance about how to submit issues to the Ombudsman.
Q2. What happens if I use the wrong ICD-10 code, will my claim be denied?
A1. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. However, a valid ICD-10 code will be required on all claims starting on October 1, 2015. It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code and the claim would continue to be reviewed for these reasons. This policy will be adopted by the Medicare Administrative Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.
Q3. What happens if I use the wrong ICD-10 code for quality reporting? Will Medicare deny an informal review request?
A3. For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes. Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes. CMS will not deny any informal review request based on 2015 quality measures if it is found that the EP submitted the requisite number/type of measures and appropriate domains on the specified number/percentage of patients, and the EP’s only error(s) is/are related to the specificity of the ICD-10 diagnosis code (as long as the physician/EP used a code from the correct family of codes). CMS will continue to monitor the implementation and adjust the timeframe if needed.
Q4. What is advanced payment and how can I access this if needed?
A4. When the Part B Medicare Contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available. An advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 421.214 are met. To apply for an advance payment, the Medicare physician/supplier is required to submit the request to their appropriate Medicare Administrative Contractor (MAC). Should there be Medicare systems issues that interfere with claims processing, CMS and the MACs will post information on how to access advance payments. CMS does not have the authority to make advance payments in the case where a physician is unable to submit a valid claim for services rendered.
NOTE: Watch for upcoming posts on ICD-10 websites and apps that I am rating for their usefulness. We will also be producing free webinars on translating the diagnoses on your superbills, picklists and cheat sheets for ICD-10 – stay tuned!
In addition, NPs may make more or less depending on their duties, how much physician oversight they require, what the benefit package is, and if the NP will siphon off part of the existing providers’ practices, and therefore, income. Market rates are always important to review so an offer can be made that is somewhat comparable to other NP positions in the community, unless the work is less or more hours, less or more responsibility, etc.
Consider the following before making your offer:
Job Responsibilities
How many hours per week, on average, is the NP expected to work?
Will the NP take call?
Will the NP have his/her own patient panel?
Will the NP be expected to round on nursing home patients or hospital patients or admit or discharge patients (if allowed in your local hospitals)?
Will the NP staff a location without onsite physician support?
Will the NP be managing other staff or other mid-levels?
Support Required by the Physician
How much experience does the NP have overall, and how much in your specialty?
Will a physician be required to review some or all of the NP’s notes for sign-off for a defined period, or indefinitely?
Will the NP be able to write prescriptions for no drugs, some drugs or all drugs?
Will the NP see Medicare patients and thereby be limited to “incident-to” scheduling (the physician must see the patient initially and develop a care plan, then must see the patient every third visit for the initial problem, or every time a new problem is discussed.)
Associated Costs with Hiring an NP
Wages: Base salary, any associated productivity bonuses
Benefits: paid time off, health insurance, life insurance, retirement matching (after one year), expense reimbursement (mileage, etc.)
Malpractice: many NPs and PAs may also want you to guarantee to pay for a malpractice “tail” when they leave your employment. They will need a tail only if your policy is claims made, which means they must pay for their own liability insurance after they leave you for acts when they worked with you. If you have an occurrence policy, it will pay if they were covered under the claim when the act happened, not when the suit was filed, so no tail is needed.
Licenses: Any software licenses for a new provider – some vendors equate NPs and PAs with a 1.0 FTE provider (full license fee) and other vendor equate them to a .5 FTE provider (1/2 license fee.)
Continuing Education: registration, travel, lodging, food, online CME, and do they get paid to take CME, or is CME paid for, but on their own time?
Electronics: Computer, laptop, tablet, iPad, smartphone, smartphone apps and add-ons
Medical Assistant: depending on your specialty the NP may need a FT medical assistant so they can be as productive as possible, or you may already have a medical assistant in-house that can be shared with the new NP. For some specialties, the NP may not need a medical assistant.
General Overhead: this is the biggest thing that practices overlook when they do not assign overhead costs to mid-level providers. All providers require a place to practice, staff assistants – clinical and/or administrative, equipment, medical consumables, etc. A percentage of the overhead should be considered an expense of employing the NP and should be accounted for before considering the NP to have made a profit for you during the year.
Marketing: how will you introduce the NP to the community and to your existing patients? Will you do a focused marketing campaign to encourage a target demographic to try the NP? Will you have an open house to introduce the NP to potential referrers in the community? Will you make contact with and provide flyers to assisted living facilities (Medicare) or daycares (pediatrics) or gyms (wellness, sports medicine, orthopedics) or other venues that match your target patient?
Miscellaneous Requests: signing bonus, office furniture, any special equipment based on personal characteristics or personal preferences (e.g. very short NPs may need a stool in each exam room or may request a hydraulic exam table), a computer at home for use when on call, relocation support, etc.
School Payback: There are programs available for school loan payback for mid-levels working in primary care and/or in underserved areas. This is a huge draw for many mid-level providers – take a minute and find out if these paybacks are available in your area. A new NP may be willing to take a little less in compensation if they are also eligible for loan forgiveness.
Things to Consider
What is the reason for adding an NP? To reduce other providers’ workload? To replace a retiring physician with a non-physician? To add a needed element to the practice (e.g. a female NP in an all-male practice or vice versa)? Improve the quality of life for existing providers (call, nursing home visits, discharges, etc.) Will an NP allow the group to bill for services previously billed outside the practice, such as first assist at surgery?
Will the NP make the market share pie bigger or take a piece of the existing market share pie? Has a projection been done to show the other physicians what their potential reduction in income will be if the NP takes part of the current market share? If the practice is going after new market share, how will this be achieved – general practice exposure vs niche marketing for a new service or something the NP brings to the table?
How much money will the practice have to expense before it sees a return on investment? How long will it take for the NP to cover his/her own expenses? How long will it take for the NP to cover expenses and bring additional income to the practice? Will additional formal or informal training be required? Will additional equipment for new services be required?
Reimbursement: What payers will pay the full allowable amount (billed under a physician) versus the allowable minus 15%?
“Overall compensation for full-time nurse practitioners is on the rise, according to the American Association of Nurse Practitioners (AANP), which today released data from its 2015 National Nurse Practitioner Compensation Survey. The findings demonstrate that nurse practitioners who work 35 hours or more per week have seen average base salaries increase 6.3%, rising from $91,310 in 2011 to $97,083 in 2015, with total annual income increasing 10.0%, rising from $98,760 to $108,643. More than 2,200 nurse practitioners participated in the 2015 survey.”
The survey, which can be purchased for $50, shows the breakout of compensation based on education, experience, region, setting and specialty.
NOTE: If your practice needs helps running the numbers to see how adding an NP or PA will affect expenses and revenue, Manage My Practice has a Pro Forma Service which helps you to make a job offer knowing what your costs will be, how many patients need to be seen to cover costs and how soon after the hire the practice can potentially see a return on their investment. Contact us here or call Mary Pat at (919) 370.0504.
According to a leading health IT group, the use of health and fitness apps is growing 87% faster than the entire mobile industry. That’s pretty astonishing for a product category most of us hadn’t even heard of five years ago.
July 15-16 CMS Webinars: New Payment Model for Joint Replacements
Posted by Mary Pat Whaley on July 14, 2015UPDATED INFO: These recorded webinars are now available here.
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On July 9, 2015 the Centers for Medicare & Medicaid Services (CMS) announced the Comprehensive Care for Joint Replacement (CCJR) model, a proposed payment, quality, and care improvement initiative for hip and knee replacements.
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) will host two offerings of a webinar to describe the proposed rule and respond to questions. The dates and registration links for these webinars are as follows:
Additional information on this Model can be accessed through the CCJR Model web page.
The proposed rule will undergo a 60-day comment period during which time CMS welcomes the input of stakeholders and the public. You can read the proposed rule in the Federal Register.
We encourage all interested parties to submit comments to the rule electronically through the CMS e-Regulation website at http://www.cms.gov/
*Large audiences are anticipated. Plan on joining a few minutes early.
Photo Credit: redegalegadebiomateriais via Compfight cc
Tags: CCJR, Center for Medicare & Medicaid Innovation, CMS, comment period for joint replacement payment model, Comprehensive Care for Joint Replacement, hip replacements, knee replacements, recorded CMA webinars
Posted in: Medicare & Reimbursement, Medicare This Week
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