Manage My Practice

The CLIA regulations require a facility to be appropriately certified for each test performed. To ensure that the Medicare and Medicaid programs only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA
certificate level.

New test list here (pdf.)

All CLIA waived tests here (pdf.) – updated July 6, 2010

I have been getting lots of questions lately about finding jobs in healthcare management.  The healthcare field is very mobile right now and many managers inside the field and in other fields are looking for advice on the best way to make a move.

In addition to making sure they have the right skills and experience, job seekers also need to be sure that their digital reputations are sterling, and if not, need to make the move to correct them.  In fact, every single person reading this post should check on their digital footprint and see what the web has to say.  You never know when an employment change will suddenly be in your future.

What if you don’t show up on the web radar at all because you’re not on Twitter, Facebook, LinkedIn and Google finds no matches for your name?  That says you’re not in the know, not networking, not sharing and definitely not computer-savvy.  Here’s an excellent SlideShare presentation by Susan P. Joyce of job-hunt.org that gives job seekers (and truly, each one of us in healthcare is a job seeker, whether we admit it to ourselves or not) a gold mine of information about creating or correcting your online presence.

CHIME is the professional organization for chief information officers and other senior healthcare IT leaders.

CHIME has produced a CIO-oriented publication providing details on how organizations should focus their efforts to implement EHR systems that will qualify for stimulus funding payments through the HITECH Act. The 80-page guidebook is available free to the public and can be downloaded here.

Also, the American Hospital Association (AHA) and CHIME have worked collaboratively to create a guidebook for CEOs on the HITECH Act and meaningful use implementation. The handbook entitled, “Health Care Leader Action Guide on Implementation of Electronic Health Records”, provides a readable, actionable, step-by-step guide designed to assist CEOs and other C-suite executives in the EHR implementation process. The 22-page guide is available free to the public and can be downloaded here.

• All available appointments are full.
• All staff showed up for their shifts.
• No one burns toast in the toaster oven and sets off the fire alarm.
• None of the staff show up to work wearing flip-flops or pink underwear beneath their white scrubs.
• All patients have been reminded about their appointments so they all show up.
• Patients calling for same-day appointments are able to be worked-in appropriately.
• No patients give false information at check-in.
• Established patients arrive on time with their insurance information and co-pay.
• New patients arrive on time to complete their paperwork, and give their insurance card, photo ID and co-pay to the receptionist.
• Patients with x-rays or other imaging studies bring the films or a CD.
• Patients with fasting appointments arrive having fasted.
• All patients arrive bringing their bag of medications.
• Patients in wheelchairs and with difficulty ambulating are accompanied by caregivers.
• Patients who do not speak English or are deaf have notified the office prior to the appointment and the appropriate technology or interpreters are available for the appointment.
• Patients with procedure appointments have followed their pre-procedure instructions.
• Patients with procedures have been pre-authorized by their insurance carrier and their personal financial responsibility has been discussed with them and payment arrangements have been made.
• Patient eligibility has been checked and those unable to be authorized have been called before their appointment to gain further information about their payer source.
• If computers go down, there are paper procedures in place to enable staff to continue seeing patients.
• No patients arrive saying “I forgot to tell you, this is Worker’s Comp/ an auto accident/ a liability case and I was told by my lawyer not to pay anything.”
• None of the patients pee on a waiting room chair.
• Neither JCAHO nor any state or federal officers show up.
• The copiers and faxes all work.
• No subpoenas come in the mail.

  

  Image by Smithsonian Institution via Flickr

• It’s not your very first day live on electronic medical records.
• All phone calls are answered before the third ring and no one has to leave a message.
• No patients walk in the door with severe chest pains and say “I knew the doctor would want to see me.”
• Patients remember to call the pharmacy for refills.
• Providers all run on time and seem in particularly good moods.
• Patients get their questions answered with callbacks within two hours.
• Someone delivers sandwiches, drinks and brownies to the practice for lunch.  There is enough for everyone.
• No bounced checks come in the mail.
• Providers spend so much time in the exam room listening to their patients that the patients leave feeling that every question they had (and a few they didn’t know they had) was answered.
• Providers circle the services and write the diagnosis codes numerically on the encounter form, remembering that Medicare doesn’t pay for consults any more.
• Sample medications that providers want to give patients are in the sample closet.
• Records that providers want to reference are in the chart and are highlighted.
• No one calls urgently for old medical records that are in the storage unit across town.
• There are no duplicate medical records.
• Patients checking out never say “But he was only in the room for 5 minutes!”
• The patient restrooms don’t run out of toilet paper.
• No bankruptcy notices come in the mail.
• All phlebotomists get blood on the first stick.
• No kids cry.
• The HVAC system works beautifully, keeping it cool where it needs to be cool, and warm where it needs to be warm.
• Congress announces that the SGR formula has been revoked and a new reasonable model for paying physicians has been discovered.
• Everyone goes home at 5:00 p.m., glad to have a job, glad to be of service, and happy with their paychecks.

The Center for Healthcare Transformation may not be my organization of choice, but they’ve put together an excellent timeline of the PPAC (Patient Protection and Affordable Care Act), also called the ACA or Affordable Care Act.

The timeline shows what’s happening in regards to Medicare, Medicaid, public health, insurance, Indian health, taxes and government programs.  You can slide the timeline forward or backward and jump around in hourly, daily, weekly, monthly, quarterly, yearly, etc. increments.  It gives you a wonderful sense of the Big Picture.  It is also being constantly updated.

And, for a quick look at the ACA changes happening as of September 23, 2010, you can watch a short video that I made for the “? of the Day” tab above.  I thought this tab was getting just a bit boring, so I thought I would post short animations there that readers could share with staff or whomever for infotainment.  I posted the first video under the “? of the Day” tab and also here for your convenience.

GoAnimate.com: Jack Asks About Healthcare Reform by Mary Pat Whaley

I am fortunate to be serving on the North Carolina MGMA Medicare Committee this year.  When we met yesterday, the members were asked why we wanted to be on the committee.  I said I couldn’t believe any practice manager wouldn’t want to be on the Medicare Committee!  I want to be on the front lines, asking questions and trying to understand the massive changes hitting our practices daily.  Don’t you? If you’re not a member of your local or state manager’s group and you’re not volunteering on one or more committees, why not?

Important Information and Reminders About the Upcoming Version 5010 and ICD-10 Transitions

CMS has resources for providers, vendors, and payers to prepare for the transition. Fact sheets available for educating staff and others about the transition include:

The ICD-10 Transition: An Introduction

Talking to Your Vendors About ICD-10 and Version 5010: Tips for Medical Practices

Talking to Your Customers About ICD-10 and Version 5010: Tips for Software Vendors

Compliance timelines, materials from CMS-sponsored calls and conferences, links to resources and sign up for email updates here

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Medicare FFS 5010 Program: Taking EDI to the Next Level- Ninth National Education Call on Medicare Fee-For-Service (FFS) Implementation of HIPAA Version 5010 and D.0 Transactions

August 25, 2010
2:00pm To 3:30pm EST

The Centers for Medicare & Medicaid Services (CMS) will host its ninth national education call regarding Medicare FFS’s implementation of HIPAA Version 5010 and D.0 transaction standards on August 25, 2010.  This session will focus on the 835 Electronic Remittance Advice transaction.  Subject matter experts will review Medicare FFS specific changes as well as general information to help the audience prepare for the transition; the presentation will be followed by a Q&A session.

Registration will close at 2:00 p.m. EST on August 24, 2010, or when available space has been filled.

Target Audience: Vendors, clearinghouses, and providers who will need to make Medicare FFS specific changes in compliance with HIPAA version 5010 requirements.

Subject: Medicare Fee-For-Service (FFS) Implementation of HIPAA Version 5010 835 Electronic Remittance Advice Transaction

Agenda:

* General Overview

* Medicare Specific Changes

* Timelines and Deadlines

* What you need to do to prepare

* Transaction Specific Issues

* Q & A

Conference call details:

Date: August 25, 2010

Conference Title: Ninth National Education Call on Medicare Fee-For-Service (FFS) Implementation of HIPAA Version 5010 and D.0 Transactions

Time: 2:00 p.m. – 3:30 p.m. ET

In order to receive the call-in information, you must register for the call. It is important to note that if you are planning to sit in with a group, only one person needs to register to receive the call-in data.  This registration is solely to reserve a phone line, NOT to allow participation.

Registration will close at 2:00 p.m. ET on August 24, 2010, or when available space has been filled.  No exceptions will be made, so please be sure to register prior to this time.

1. To register for the call participants click here.

2. Fill in all required data.

3. Verify your time zone is displayed correctly the drop down box.

4. Click “Register”.

5. You will be taken to the “Thank you for registering” page and will receive a confirmation email shortly thereafter.   Note: Please print and save this page, in the event that your server blocks the confirmation emails.  If you do not receive the confirmation email, please check your spam/junk mail filter as it may have been directed there.

6. If assistance for hearing impaired services is needed the request must be sent to medicare.ttt@palmettogba.com no later than 3 business day before the event.

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Social Media

Editor’s Note: DataPlus is MMP’s very first sponsor and I want to thank Frank and his crew for their support!  If you would like to sponsor this blog and have over 5,000 readers a month see your flash ad, contact me via email at marypatwhaley@gmail.com.

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The old saying “If you can’t measure it, you can’t improve it” certainly holds true in medical practices today. With falling payer reimbursement it is more important than ever to collect every single dollar your practice is due.

Most practices have sought additional income streams by adding ancillary services. Paying close attention to data can improve decision-making for such services and can dramatically improve revenue without adding any providers or even new patients!

Having ready access to the elusive data within practice management systems can be difficult, but most systems can report the basics.  It is imperative that data is trended over a period of time so that trends can be spotted, benchmarks compared, and improvement plans developed.  Measuring data and comparing it to the MGMA Cost Survey (find it at mgma.com) is one of the best places to start.

1. Collection Rates/Ratios: Two collection rates are measured in medical practices. One is gross collections and the other is net collections, the latter being the most important.

A gross collection rate is payments divided by charges and will depend on an artificial number – how high the charges are set above negotiated allowables – making it not particularly meaningful.

A net collection rate, however, provides a means to benchmark the health of collection efforts. Net collections, simply stated, demonstrate what percentage of collectible dollars (after negotiated contract write-offs)  a practice is actually collecting.   A net collection rate above 95 percent –when calculated correctly – denotes a healthy practice.

2.   Denials: Denials are a significant portion of the cost of running a practice in that services that are provided but not paid for reduce the profitably of those that are. Accurately identifying denials and the reasons for them can help prevent them in the future, thus increasing productivity and lowering expenses. Identifying denial trends by specific payer or payer group, by CPT code, and by origin – whether at the front desk, with coding errors, or in credentialing – is equally important.

3.    Evaluation & Management (E & M) Bell Curve: “Overcoding” and “undercoding” are commonly used terms, but how are they measured? Bell curve trending of E&M data can quickly identify areas where providers may be under coding, resulting in lower revenues, or over coding, resulting in the potential for audits. The difference between a Level 2 and a Level 3 E&M code can mean thousands of dollars in losses per provider per year. Documentation is critical to demonstrating the level of care provided to each patient.

The traditional primary care bell curve below demonstrates that level 3 visits typically comprise about 50% of your established patient encounters, level 2 and 4 visits together about 20% each, and level 1 and 5 visits together about 10%.  When plotted on a graph and drawing a line between each, the shape resembles a bell.

4.    Bad Debt: Bad debt is defined as dollars that could have been collected, but were not.  Break this category into controllable factors and non-controllable factors.  Issues that you should have been able to control are timely filing write-offs, credentialing errors, lack of follow-up, and incorrect information provided by the patient.  Non-controllable issues are bankruptcy,  patient failure to pay, and payers retroactively denying coverage due to unpaid premiums.

Reducing bad debt by just two percent can mean tens of thousands of dollars to the bottom line of a practice. The ability to quickly identify bad debt trends facilitates the development of an improvement plan.

5.    AR Days: AR (accounts receivable) days are a measurement of the average time a dollar stays in an accounts receivable before being collected. The ability to measure, benchmark, and lower AR days provides a means to a significant increase in revenue.  Some best practices that reduce AR days are filing insurance daily, sending statements daily, collecting appropriately at check-in and check-out, working denials quickly, discounting self-insured for time of service payment in full, and using an eligibility tool to check every single patient’s insurance.

6.   Encounters: Accurately reporting and separating encounters for most practices is an arduous task of counting fee tickets or using tick sheets. Few practice management systems accurately provide this information. An encounter is much more than a service code. Being able to segregate office encounters from surgical cases, and reporting by payer, time, and location can help identify opportunities for improvement.

7.   Referral Sources: It is fundamentally prudent for specialty practices to know the origin of patient referrals. This data is rarely reliable or easily created in most practice management systems. Practices need to know not only the source of patient referrals, but also what type of patients (by insurance, by procedure, etc.) are being sent by those sources, and if the referrals from a particular source have increased or decreased over time.

8.    Payer Mix: It is not uncommon for practices to drop payors due to perception, and not because of actual data or trends. Emotions sometimes come into play and can result in a provider demanding that a payer be dropped because their rates have changed (or other perceptions). This simply does not make sense. Being able to accurately produce and graph data on major payers without hours and hours of work is of high strategic value to a well-planned business decision. It can answer questions about the impact on a practice if a particular payer is dropped, or how those patient slots would be filled.  Remember to keep adding payers to the practice when feasible; the loss of your largest payer can be minimized if many smaller ones are on board.

9.    Under Payments: One of the more significant ways to improve a practice’s revenue is the swift and accurate identification of carrier underpayments. Identification of underpayments is not simply comparing the payment to an allowable fee schedule.  Practice management systems that have any type of payment audit functionality commonly do not take into account circumstances such as modifiers, or multiple surgical procedures that payers routinely inaccurately apply, causing underpayments.  Having a system to automatically and systematically apply these rules is essential. MGMA states that providers are underpaid an average of six percent of revenue. What does that mean to a practice? The numbers can be astounding to a surgical group, and the identification and collection of those underpayments can be insurmountable.

10.    Fee Schedule Comparison: It can be difficult to determine what payers are reimbursing by contract for specific codes or ranges of CPT codes. The ability to have immediate and accurate access to this data is crucial in payer negotiations. It is important to remember that the payer already has this information and is betting that the practice does not!

It is now more important than ever for practice managers to have access to the critical information outlined above. It is also important to note that not just any one of the above Key Practice Indicators should be used to determine the financial health of your practice, but all, or a combination of them.

The buzzword among practices today is “Dashboards.” The ability to have these Key Practice Indicators in one simple report is proven to increase efficiency, as well as provide a meaningful way to present information to providers. One example of a dashboard is below.

About the author: Frank Trew is the Founder and CEO of DataPlus and  has over 25 years of practice management experience and has served in executive positions in large and small practices. In 1999, as the COO of a large orthopaedic group in Nashville, he was frustrated by an inadequate access to data that limited his ability to measure and improve the bottom line. The development of a data warehouse was the solution.

In 2000, after hearing how this data was a key practice management tool, many of Frank’s peers also wanted to use it improve their practices. DataPlus was formed as a result and has been providing MegaWest, HealthPort, and Centricity users with this unique tool ever since.

Employing a simple to use “point and click, drag and drop” reporting tool, along with an advanced Contract Management and Revenue Recovery System, DataPlus provides key management data across all specialties and throughout the United States.

Frank invites readers to visit the DataPlus website at www.mydataplus.com. Frank may be contacted via email at ftrew@mydataplus.com or by telephone at (888) 688-3282.

State laws generally govern how long medical records are to be retained.

However, the Health Insurance Portability and Accountability Act (HIPAA) of 1996  administrative simplification rules require a covered entity, such as a physician billing Medicare, to retain required documentation for six years from the date of its creation or the date when it last was in effect, whichever is later. HIPAA requirements preempt State laws if they require shorter periods. Your State may require a longer retention period.

While the HIPAA Privacy Rule does not include medical record retention requirements, it does require that covered entities apply appropriate administrative, technical, and physical safeguards to protect the privacy of medical records and other protected health information (PHI) for whatever period such information is maintained by a covered entity, including through disposal.

The Centers for Medicare & Medicaid Services (CMS) requires records of providers submitting cost reports to be retained in their original or legally reproduced form for a period of at least 5 years after the closure of the cost report.

CMS requires Medicare managed care program providers to retain records for 10 years.

Additional information:

1. Providers/suppliers should maintain a medical record for each Medicare beneficiary that is their patient.
2. Medical records must be accurately written, promptly completed, accessible, properly filed and retained.
3. Using a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries is a good practice.
4. The Medicare program does not have requirements for the media formats for medical records. However, the medical record needs to be in its original form or in a legally reproduced form, which may be electronic, so that medical records may be reviewed and audited by authorized entities.
5. Providers must have a medical record system that ensures that the record may be accessed and retrieved promptly.
6. Providers may want to obtain legal advice concerning record retention after CMS-required time periods.

If the topic caught your eye it’s likely because medical practice managers are practical people.  Our job is to get things done and we do it with a passion for being efficient as well as effective.  So you are on the lookout for tips and advice to help you do your job, and (admit it) to confirm that your skills match those of recognized high performers.

But my goal today is to help you value certain skills you already have but may not appreciate their value to you.  These are my concepts of valuable skills.  I’m going to miss someone’s favorite, so when I do, send a comment, list your skill and share your knowledge.

The first skill is thievery; the honest kind.

The best managers I know are quick to recognize an idea and steal it to use in their own practice.  We expect to do this at the organized idea swaps we call conferences.  But I’ve watched managers scribble notes at a dinner table or at a sidewalk conversation when another manager offers an idea.  Good managers know that a manager-tested idea is worth twice that of a concept proposed in a research article.  I’m not denigrating research.  I love research; I read journal articles for fun.  (My son says that proves only that I am a nerd.)  But nothing beats a peer tested concept.  So listen carefully to your peers, subscribe to your state and national MGMA listservs and steal those ideas.   … and then pass them along to the rest of us.  And ALWAYS give credit to the person whose idea you stole.

The next skill is impatience.

While good managers analyze, research and cogitate looking for a solution, they don’t wait for the perfect one.  High performing managers instinctively use the try and adjust method, formalized in operational improvement programs as PDCA (Plan, Do, Check or Correct, Act) or  PDSA (Plan, Do, Study, Act.)  They try the best solution at hand, check to see if it is working, adjust it, refine it and then implement it.  Then they check it later to see if it is still working.  Good managers don’t wait for the perfect plan.  They go with a good plan and have the courage to improve it on the fly.

High performing managers are patient.

I know what I just told about being impatient, but good managers are patient.  They dig deep enough into a problem to know the real causes.  They ask why enough to get past the obvious.  In Operational Improvement the technique is called The Five Whys.  High performing managers use this without even knowing it has a name.  It requires patience.  It pays big dividends – fewer wrong moves and less stuff to redo.  Those without patience act on the first cause they find, and then have to undo the solution and start over.  You may have heard this described as: “There’s never time to do it right.  There’s always time to do it over.”

High performing managers share recognition and accept blame.

This can be tough, especially in a highly competitive profession.  Advancement as a healthcare executive often comes when a colleague is replaced.  Even if you work in a large organization with clear advancement tracks, you have to compete for the opportunity.  The result  is a temptation to avoid blame and to hoard recognition.  But the best managers share recognition with their team.  They are in touch with their own leaders and keep those leaders aware of their efforts.  That is prudent and fair.  But no one succeeds without the help of those around them.  Good managers recognize that and share credit.  As for the blame – it was your team.  If they failed, then you failed as the leader.  Accept it, correct it, learn from it and move on.  My first mentor reminded me that if I was right one time in three and I was playing baseball, I would have a .333 batting average and be my team’s MVP every year.

High performing managers are curious.

The best are curious about everything.  The Greek poet Pindar said “There is no knowledge without profit.”  Good managers consume information.  This serves to keep them aware of possibilities that others will miss.  It improves their luck factor.  It gives them the ability to be first with the great ideas that advance their practices.
High performing managers love to teach.  Having knowledge is not nearly as much fun as sharing it.  Good managers help their teams improve.  They share their knowledge.  They are enthusiastic when they do it.  They are excited when others gain new skills.  It’s not totally altruistic either.  Skilled teams take on more work, are more efficient and more effective.  This creates additional time for the manager to do things beyond extinguishing fires.  That’s a great thing.

And  last, high performing managers are realistic.

They know there are limits to what they can accomplish alone.  They know that life is not all work.  The very best find ways to be involved with their community.  They make time for their families and friends.  They participate in the world around them.  They are refreshed by their non-work life, so they can enjoy the work day.
What have I missed?  What have you admired in others or found in yourself that are important skills in your success?

Please welcome my long-time colleague and friend Lee Barbieri.  I am hoping Lee will be a regular contributor as he has a lot of interesting ideas and experience to share with MMP readers.

Lee Barbieri is a Medical Practice Management Executive with over 25 years experience, and is a graduate of Va Tech, a medical laboratory technologist, MT(ASCP), and an avid reader.  Lee has worked in both private practice and in hospital networks, in healthcare IT and has also worked in a university hospital, managing diagnostic laboratory services.  Lee says “I am a native of Virginia but I have been a happy North Carolinian for 30 plus years.  My wife and I have two sons and four grandchildren.  I support my alma mater and still find time to be a Duke Blue Devil fan.”