NOTE: The date has been
changed to July 5, 2011 delayed indefinitely.
The following statement was released by CMS on November 26, 2010:
The Centers for Medicare & Medicaid Services (CMS) previously announced that, beginning January 3, 2011, if certain Part B billed items and services require an ordering/referring provider and the ordering/referring provider is not in the claim, is not of a profession that is permitted to order/refer, or does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS), the claim will not be paid. The automated edits will not be turned on effective January 3, 2011. We are working diligently to resolve enrollment backlogs and other system issues and will provide ample advanced notice to the provider and beneficiary communities before we begin any automatic nonpayment actions.
Image by Squash713 via Flickr
NOTE: If you need the basics on RACs, click here for my article.
From our friend Frank Cohen:
Over the past year or so, I have been involved in conducting post RAC (and other) audit analyses to determine whether the RAC (or other auditing agency) was using appropriate statistics and calculations to create their overpayment estimates.
As you can probably imagine, in nearly every case, I have found this not to be true.In fact, as it turns out, the errors I find nearly always are in favor of the auditor, not the healthcare provider.
RAC is able to take advantage of the practice in three areas
The first area has to do with pulling samples for review.If these samples are not random or worse yet, if they are intentionally biased, they can create a misrepresentation of overpayment that unfairly penalizes the provider and because RACs are paid a commission, benefits them.
The second area has to do with the way in which the overpayment point estimate is calculated.This is where they come up with something like the average overpayment per audited unit (i.e., claim, claim line, member event, etc.).
The third has to do with the methodology used to extrapolate the point estimate for the sample to the universe of units for the healthcare provider.An error in any one of these areas can result in a gross exaggeration of the final overpayment demand.
Understanding how to defend yourself from the results of an audit
I have developed a series of three short, free webinars to teach you how to catch potential errors in each of three areas.
Part 1 will be on validating random samples and is scheduled for Monday, December 13 from 1:00 to 2:00 EST.
Part 2 is on how to calculate the overpayment point estimate and is scheduled for Tuesday, December 14 from 1:00 to 2:00 EST.
Part 3 is on verifying extrapolation results and is scheduled for Wednesday, December 15 from 1:00 to 2:00 EST.
Each webinar will probably last around 30 minutes with an additional 30 minutes for questions. I plan to record these and post them later so if you can’t make it, don’t worry. Each session will be available for review after the last one is completed.
For more info or to register, go to www.frankcohen.com and click on the Webinar tab.Also, feel free to forward this on to co-workers or to post wherever you think folks may benefit.
Ever wondered if you are doing things right, or doing the right things when you hire a new employee? Then this series is for you! Human Resource Consultant Susan Hayes will cover the hiring paperwork including posting the job, the job application, the job offer letter, the I-9 form, the W-4, and the personnel file.
Once you have made the decision…
…to fill a new or existing position you will post/advertise the job internally and externally. Larger employers usually post open jobs on a bulletin board that is located where current employees, as well as the public, have access. When there are several hundred employees, possibly in several locations it is hard to get the word out that a job is open. However, smaller employers rarely need to post an available job because the grapevine works very well and word of mouth will spread the news before you have a chance to announce it.
What difference does it make if you post a job?
The main reason you post a job whether you have 10 employees or 200 employees is to be sure you are not inadvertently discriminating against any class of people. A hiring can be defended only if the job was posted and anyone with skills, knowledge and/or background to do the job had a chance to apply. If the job is not posted, there could be a question as to why certain people did not know. Were only males told that the job was open so a female would not get hired?
I’ve had to defend hirings in areas of race, gender, age and disability. If there is no proof that the job was made available for anyone with skills, knowledge and/or background, and there is no documentation of the decision process, you might find it hard to defend why you hired an applicant. Job postings and advertisements should be kept for a minimum of one year in order to be compliant with the Americans with Disabilities Act (ADA), Age Discrimination in Employment Act (ADEA), and Fair Labor Standards Act (FLSA).
What’s the best way to advertise a position?
Depending on the job and your community, you may advertise your position in different ways. Some practices give referral fees to employees who refer people who are hired. Some programs give 1/2 of the referral fee when the new employee passes the 90-day mark and the other half when the new employee reaches one year. Craigslist is one of the most popular places to advertise positions. Depending on the position you may also want to consider:
- Employment Security Commission
- Comm unity Colleges – post jobs and also ask teachers for recommendations
- Local or state medical manager groups or listservs
- Specialty job boards or publications (nurses, technologists, mid-level providers)
- Social media such as Twitter, LinkedIn and Facebook
How should you describe a position in an advertisement?
My favorite way to give potential applicants as much information as possible so they can decide if they are a fit for the job is to place a small ad on craigslist.com, the newspaper or other media directing applicants to call a job line at your practice. You can assign a voice mail box as the job line and instruct those interested to call and listen to a description of the requirements for the job, the responsibilities of the job and the benefits of the job. Asking applicants to then email or mail a resume or complete an online application will ensure that your applicant can follow directions!
Why do I need to use an application?
While there is no law that states a potential employee has to complete an application, if you are an employer that is covered by the Fair Labor Standards Act (FLSA) there is certain information that you must collect.
Who is covered by FLSA?
Any private employer with two employees or more that engages in interstate commerce activities and has an annual business volume of at least $500,000 is covered by FLSA. Also covered are hospitals, educational institutions and state and federal public employers. Individual employees who are engaged in interstate commerce activities even if their employer does not gross $500,000 a year would be covered also. Interstate commerce is the buying and selling of products and services across state borders.
The application is a quick way to get the information in the beginning of the process and have it together in one place if the applicant is hired. The application also helps you to compare information between applicants that has been standardized. Some resumes are crafted to hide shortcomings and those shortcomings will easily appear when an application is completed.
Some people do not have resumes and the application is an easy way to have information about an applicants educational and work background in one place with a signature to verify the information. It can also provide legal information to refer to in the future. For instance, if an employee puts on an application that he/she can work any day of the week and then when asked to work on Sunday, claims that he/she cannot, you can go to the application and find the claim in writing.
Most applications no longer require a full social security number. Because the application may pass through many hands, this is one way to protect the applicant’s number from inadvertent exposure.
Many employers require even top level position candidates to fill out an application so they have documentation of experience and education. Applicants will need to provide details and dates of past employment and education, as well as detailed information on licenses, credentials and certifications. If the application is completed online, this application information may automatically download to a human resources program, saving the employer time and money.
It’s important for the job application to be complete and accurate. The information that you will independently verify is: Name, Address, City, State, Zip Code, Phone Number, Eligibility to Work in US, Felony convictions, and if under age, working paper certificate.
Applications should be kept in a confidential place for one year in order to be in compliance with ADA, Rehabilitation Act, and Title VII of the Civil Rights Act. However ADEA requires that applications for those over 40 years of age must be kept for two years. The dilemma is: how do you know the age of the applicant if you cannot ask it on the application? The answer = keep all applications for two years to be safe.
Read Part 2 in this series here.
ABOUT THE AUTHOR: Susan Hayes’ undergraduate degree in Psychology from NC Wesleyan College prepared her to weigh objectivity with compassion. Her Masters in Public Health from The University of North Carolina at Chapel Hill and her background in benefits administration have given her a comprehensive understanding of the complexities and scrutiny imposed on businesses, particularly healthcare businesses. Twenty years as a human resource specialist in the healthcare field means that Ms. Hayes is well-positioned to help a healthcare entity of any size find solutions for human resource issues. She can be contacted at Susan Hayes, MPH, Hayes Consulting, 910-284-1627, firstname.lastname@example.org.
AMAs toll-free Grassroots Hotline – 1.800.833.6354
AMA website discussing the issues here.
AMA flyer to post in your office here.
Steps to digging under the meaning of EMR certification:
- Click to see the most recent alphabetical list (by product name not company) of all products certified here.
- Find the company or companies you are using or are considering using.
- Check that the exact name of the product is what you have or might purchase.
- Check to find out if a module or part of the product is certified or if the complete product is certified.
- Check to make sure the version of the product is the version you have or will have.
If you have questions about each company’s exact criteria met, you are in luck! On the ONC site here, you can click on each company’s detail (“View Criteria”) on the far right column labeled “Certification Status” to see what they have and don’t have. Compare this to how you are anticipating using your EMR to meet meaningful use. The more check marks a company has, the better-equipped they are (and more flexible) to meet your practice needs and to qualify for the stimulus money.
The ONC site with the Certified Health IT Product List (CHPL) is Version 1.0. Version 2.0 is now being developed and will provide the Clinical Quality Measures each product was tested on, and the capability to query and sort the data for viewing. The next version will also provide the reporting number that will be accepted by CMS for purposes of attestation under the EHR (“meaningful use”) incentives programs.
You can tell ONC what you think would be helpful in the new version by emailing your ideas to ONC.email@example.com, with “CHPL” in the subject line.
If you’d like a list of just outpatient/medical practice EMR products or just inpatient / hospital products, I’ve split the big list into two smaller printable lists here:
Tips On Buying An EMR
Remember that meeting meaningful use does not tell the whole story – if you are shopping for an EMR be prepared to go beyond a product’s certification status to consider:
- Flexibility – does it make the practice conform to it or can it conform to the practice? How?
- Templates and best practices – are you starting from scratch in developing protocols, templates and cheat sheets for your practice, or does it have a storehouse of examples to choose from or tweak?
- Built for the physician, or the billing office, or the nurses, but doesn’t really meet the needs of all three? Make sure the functionality is not too skewed to one user group, but if it is, it should be somewhat skewed to the provider.
- Interface and integration with your practice management system. Does the information flow both ways? Do you ever have to re-enter information because one side doesn’t speak to the other?
- Interface with other inside and outside systems: Labs, imaging, hospital systems, ambulatory surgical center systems?
- Built-in Resources: annual upgrade of HCPCS and ICD codes, drug compendium (Epocrates), comparative effectiveness prompting?
- Mobile applications - EMR on your providers’ phones?
- Data entry systems - laptops, notebooks, tablets, iPads, smartphones, voice recognition?
- Hosting – in your office? at the hospital? at the vendor’s data center? in the cloud of your choice?
- What’s the plan for ICD-10? Will they provide practice support and education for the change or will they just change the number of characters in the diagnosis code field?
- Price, including annual maintenance and additional costs for training, implementation, on-site support during go-live, and additional licenses for providers or staff.
Click here for the 2012 Medicare Part A and Part B Premiums and Deductibles.
Medicare Premiums for 2011:
Part A: (Hospital Insurance) Premium
Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.
The Part A premium is$248.00 per month for people having 30-39 quarters of Medicare-covered employment.
The Part A premium is $450.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.
Part B: (Medical Insurance) Premium
Most beneficiaries will continue to pay the same $96.40 or $110.50 premium amount in 2011. Beneficiaries who currently have the Social Security Administration (SSA) withhold their Part B premium and have incomes of $85,000 or less (or $170,000 or less for joint filers) will not have an increase in their Part B premium in 2011. For additional details, see the FAQ titled:
For all others, the standard Medicare Part B monthly premium will be $115.40 in 2011, which is a 4.4% increase over the 2010 premium. The Medicare Part B premium is increasing in 2011 due to possible increases in Part B costs. If their income is above $85,000 (single) or $170,000 (married couple), then the Medicare Part B premium may be higher than $115.40 per month.
Medicare Deductible and Coinsurance Amounts for 2011:
Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2011 = $1,132) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.
For each benefit period you pay:
A total of $1,132 for a hospital stay of 1-60 days.
$283 per day for days 61-90 of a hospital stay.
$566 per day for days 91-150 of a hospital stay (Lifetime Reserve Days).
All costs for each day beyond 150 days
Skilled Nursing Facility Coinsurance
$141.50 per day for days 21 through 100 each benefit period.
Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)
$162.00 deductible for 2011. Patients pay 20% of the Medicare-approved amount for services after meetingthe the $162.00 deductible.
Check out the new services that Medicare will cover as of January 1, 2011 here.
Adrian told me “I am on my fifth career” and that “the arch of my life makes sense.” What a wonderful thing – to have one’s life make sense.
He has been an academic, a physicist, an IT consultant, a conference developer, and now, a consultant to others searching for ways to make conferences work. His book “Conferences That Work” was published last year and is now gaining the recognition it deserves. Among others, he has been consulting with MGMA on the new “EDGE” program they are unveiling for 800 people in March 2011.
Adrian and I covered a range of topics and we discussed my dwindling interest in attending conferences for the past several years. He, too, had been disappointed in conferences – even those he organized – and was determined to find why traditional conference aren’t making the grade any more.
His book outlines four assumptions that traditional conference planners make:
Assumption #1. Conference session topics must be chosen and
scheduled in advance.
Assumption #2. Conference sessions are primarily for
transmitting pre-planned content.
Assumption #3. Supporting meaningful connections with other
attendees is not the conference organizers job; its something
that happens in the breaks between sessions.
Assumption #4. Conferences are best ended with some event that will hopefully convince attendees to stay to the end.
Adrian’s starting point was the current conference model of passive learning – letting others choose the topics and speakers and offering attendees limited opportunities for anything besides pre-determined content. He moved from the model of passive learning to peer learning – leveraging the power and knowledge of the attendees to harness the hot topics of THAT MOMENT, not the moment that the conference committee met to determine the educational content 12 months or even 6 months ago. He noted that the best conference committees are able to guess less than 50% of what attendees really want from a conference.
Adrian uses the example of social media to illustrate the difference between broadcasting information (old) and partnering to share information (new), and notes that the goal of Conferences That Work is to “bring the resources of all attendees to each attendee.” I’ve been to a one-day meeting that accomplished that goal and I left the “camp” feeling energized, overrun with ideas and already connected through Twitter with almost everyone at the well-attended program. It was amazing.
If you are developing meetings or conferences for your church, your charity, your local or state managers group or for any other type of group, or if you want to see the future of conferences, you owe it to yourself to read “Conferences That Work” by Adrian Segar. He’s on a mission and he’s going to design and rock a conference that you, if you’re lucky, will attend some day soon.
Excerpts from his book are available here.
Free downloads to assist in making conferences that work are here.
His blog is excellent and can be found here.
I have finally completed my analysis of the 2009/2010 P/SPS (Physician/Supplier Procedure Summary) Master File. This file contains 100% of all claims submitted to Medicare during a given calendar year, along with a mid-year 5% update.For this analysis, I used around 2.5 billion claim lines that represent nearly every physician in every specialty in the US.For this run, I analyzed the charges submitted to the database and created a file that reports the national average charge for over 10,500 procedure codes. Each procedure code (and modifier, when applicable), report the weighted average charge, the variation (standard deviation) and the sample error.The latter two will allow you to determine the value of the point estimate.
From the Report:
Level 1 Office/outpatient visit, est 38.11
Level 2 Office/outpatient visit, est 65.04
Level 3 Office/outpatient visit, est 92.54
Level 4 Office/outpatient visit, est 140.74
Level 5 Office/outpatient visit, est 198.77
Remember, even though the data come from the Medicare database, our studies show that nearly 95% of all providers submit their retail (or usual) charge so that this is an excellent source for a fee schedule analysis.
To get this file (at no charge),
go to www.frankcohengroup.com and click on the Download tab.When you get to the download page, it will be the second link down.
Also, I am going to be the keynote speaker
(as well as conducting some break-out sessions) for the 2011 Physicians RAC Summit to be held in Orlando, FL the second week of January.I am going to be talking about two major issues; how to assess your risk for an audit and then how to determine whether the post-audit overpayment estimates are calculated properly.So far, in nearly every analysis I have conducted, the overpayment estimate was wrong and, not surprisingly, biased towards the RAC, not the provider.To get more information, go to my website at www.frankcohengroup.com and click on the RAC Summit link.
Frank Cohen, MPA, MBB
I am amazed and thrilled to have have been named one of FierceHealthcare’s “10 Bloggers We Are Thankful For.”
I am in delightful company as the other nine bloggers are writers I read and admire. 33Charts is one of my very favorite blogs, both because of the focus on social media in healthcare and because I just really like Dr. V’s writing.
There aren’t many practice management-related blogs on the web today, but some I recommend arepediatricinc.com (Brandon Betancourt) for insights from a pediatric manager married to a pediatrician, and practicemanagersolutions.com (Rebecca Morehead) for great motivational commentary and practical advice.
Don’t forget to stop by www.fiercehealthcare.com and visit their sites on healthcare IT, practice management and finance.
What blogs do you read and recommend to the readers of MMP?