Manage My Practice

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Note: see my latest post on registering and attesting for the EHR Incentive Program here.

Registration opens on January 3, 2011 for the Medicare and Medicaid EHR Incentive Programs

1. Register as soon as possible after January 3, 2011.
2. You can register before you have a certified EHR, but you will have to have an EHR when you attest.
3. You can register even if you do not have an enrollment record in PECOS.
4. A link to the Incentive Registration will be available here when it is published.
5. Not all states will be ready to participate in the Medicaid program on January 3rd. Information by state is here.

What do you have to have to register?

1. A National Provider Identifier (NPI) All eligible professionals, eligible hospitals, and critical access hospitals (CAHs) must have a National Provider Identifier (NPI) to participate in the Medicare and Medicaid EHR Incentive Programs.
2. An enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS) All eligible hospitals and Medicare eligible professionals must have an enrollment record in PECOS to participate in the EHR Incentive Programs. Eligible professionals who are only participating in the Medicaid EHR Incentive Program are not required to be enrolled in PECOS. If you do not have an enrollment record in PECOS, you should still register for the Medicare and Medicaid EHR Incentive Programs.
3. CMS Identity and Access Management (I&A) User ID and Password
   • Eligible Professionals: Eligible professionals can use the same User ID and Password they use for the National Plan and Provider Enumeration System (NPPES). This is also the same User ID and Password that is used to access PECOS. If you do not have an active User ID and Password for NPPES or PECOS, request them here. You will need your type 2 NPI, your Taxpayer Identification Number (TIN), and your address from IRS Form CP-575. You will also need to mail a copy of IRS Form CP-575 as directed.
   • Hospitals/Critical Access Hospitals: Authorized Officials can use the same User ID and Password they use to access PECOS. If you do not have an Authorized Official with access to PECOS, request a User ID and Password here. You will need your type 2 NPI, your Taxpayer Identification Number (TIN), and your address from the IRS Form CP-575. You will need to mail a copy of the IRS Form CP-575 as directed. Additional hospital staff will need to request access to the “EHR Incentive Programs” application here and be approved by the Hospital’s Authorized Official.

What else do you need to know about registration?

Hospitals:

1. Hospitals that are eligible for EHR incentive payments under both Medicare and Medicaid should select “Both Medicare and Medicaid” during the registration process, even if they plan to apply only for a Medicaid EHR incentive payment by adopting, implementing, or upgrading certified EHR technology. Dually-eligible hospitals can then attest through CMS for their Medicare EHR incentive payment at a later date, if they so desire. It is important for a dually-eligible hospital to select “Both Medicare and Medicaid” from the start of registration in order to maintain this option.
2. Hospitals that register only for the Medicaid program (or only the Medicare program) will not be able to manually change their registration (i.e., change to “Both Medicare and Medicaid” or from one program to the other) after a payment is initiated and this may cause significant delays in receiving a Medicare EHR incentive payment.

Eligible Professionals:

1. Eligible professionals eligible for both the Medicare and Medicaid EHR Incentive Programs must choose which incentive program they wish to participate in when they register.
2. Before 2015, an eligible professional may switch programs only once after the first incentive payment is initiated. Most eligible professionals will maximize their incentive payments by participating in the Medicaid EHR Incentive Program.

The Electronic Health Record (EHR) Information Center is open to assist the EHR Provider Community with inquiries.

Hours of operation are:
8:30 a.m. 4:30 p.m. (Central Time) Monday through Friday (except federal holidays)
1-888-734-6433 (primary number) or 888-734-6563 (TTY number)

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Many years ago when I started in healthcare I noticed a certain attitude of the staff toward the patients. It was as if the physicians, nurses and other staff were bestowing an honor upon the patients when they provided them with care.

It was not until later that I realized that exactly the opposite was true. It is we who are privileged to earn the trust and confidence of the patients who allow us to serve them.

Someone once explained it to me this way:

Imagine you are the host and you have invited several guests to your home. You’ve cleaned the house and prepared everything so that your guests will be comfortable. You’ve turned on all the lights and placed a welcome mat outside the front door.

Your guests have arrived at the front door and have rung the doorbell.

You open the door, see your guests…and slam the door in their faces!

This essentially is what you do when you open your doors for business, then treat your customers poorly. You have invited them to do business with you, then have not been welcoming and appreciative when they accept your invitation.

If you have staff who don’t understand how important it is to form relationships with your patients beginning with a warm welcome, help them to envision each patient as arriving with an engraved invitation in their hand.

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NOTE April 2011: CMS recently announced that July 5, 2011 will not be the date that claim editing will begin.

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If you read my post on November 29th, you already know that CMS delayed pulling the trigger on January 1, 2011 to require PECOS enrollment for ordering and referring providers and enforcing nonpayment of claims that fail the ordering/referring provider edits.

CMS has just announced a new implementation date (calling it “a placeholder future implementation”) of July 5, 2011 – unknown.

As a refresher, the only providers who can order/refer Medicare beneficiary services are:

doctor of medicine or osteopathy;
dental medicine;
dental surgery;
podiatric medicine;
optometry;
chiropractic medicine;
physician assistant;
certified clinical nurse specialist;
nurse practitioner;
clinical psychologist;
certified nurse midwife;
clinical social worker

Claims that are the result of an order or a referral must contain the National Provider Identifier (NPI) and the name of the ordering/referring provider and the ordering/referring provider must be in PECOS or in the Medicare carriers or Part B MACs claims system with one of the above types/specialties.

The claim editing that will begin on July 5, 2011 date not known will verify the ordering/referring provider on a claim is eligible to order/refer and is enrolled in Medicare.

The process to be used to determine if the ordering/referring provider on the claim matches the provider in the national PECOS file or in the contractors master provider file is as follows:

• MCS (Multi-Carrier System) will verify the National Provider Identifier (NPI) of the ordering/referring provider reported on the claim against the national PECOS file.
• If a match is not found, the MCS will verify the NPI of the ordering/referring provider on the claim against the MCS master provider file.
• If a match is found, the MCS will then compare the first letter of the first name and the first 4 letters of the last name of the matched record.
• If the names match, the ordering/referring provider on the claim is considered verified.

If you’ve not verified that your providers are properly enrolled in PECOS, you have yet another chance to get it figured out.

Here’s the Cheat Sheet:

1. Check to see if your provider is enrolled by reviewing the Ordering and Referring file found in the download section of the OrderingReferringReport tab (click here) on the Medicare Provider and Supplier Web Site. The report is currently more than 15,000 pages but you can view it on the screen.
2. If not enrolled, you can get your provider enrolled by paper or electronically. The Internet-based PECOS application is here.
3. After submitting an enrollment application via Internet-based PECOS, you must:
   • Print, sign and date (blue ink recommend) the Certification Statement(s), and
   • Mail the Certification Statement(s) and applicable supporting documentation to the designated Medicare contractor (no later than 7 days after you complete the online portion.)

   NOTE: The Medicare contractor will not be able to begin to process your enrollment application until it receives a signed and dated Certification Statement.

For more detailed information on PECOS, click on the PECOS category on the right-hand side of this web page.

For flu shot updates for the 2011-2012 influenza season, click here.

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Changes in Flu Shot Codes When Billing On/After January 1, 2011

CMS has created specific HCPCS codes and payment allowances to replace CPT code 90658 for Medicare billing purposes for the 2010-2011 influenza season. Note that these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer be recognized.

1. • Q2035 (locally priced)
     • Afluria vacc, 3 yrs & >, im
     • Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
   • Q2036 ($7.439 national allowable)
     • Flulaval vacc, 3 yrs & >, im
     • Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
   • Q2037 ($13.253 national allowable)
     • Fluvirin vacc, 3 yrs & >,im
     • Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
   • Q2038 ($12.593 national allowable)
     • Fluzone vacc, 3 yrs & >, im
     • Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
   • Q2039 (locally priced)
     • NOS flu vacc, 3 yrs & >, im
     • Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)

     Other information:

     • For dates of service between October 1, 2010 and December 31, 2010, the CPT 90658 and the Q-codes will be valid for billing; however, providers may not bill Medicare for both the CPT 90658 and any of the Q-codes for the same patient for the same date of service. Thus, if a provider vaccinates a beneficiary on any date between October 1, 2010 and December 31, 2010, the provider may either bill Medicare immediately using CPT 90658, or hold the claim and wait until January 1, 2011 to bill Medicare using the most appropriate Q-code. If a claim has already been submitted and processed using CPT 90658, then there is no need to use the Q-code for that same service. For dates of service on or after January 1, 2011, providers may only bill Medicare for one of the HCPCS codes that appropriately describes the specific vaccine product administered.
     • For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.
     • Annual Part B deductible and coinsurance amounts do not apply to these vaccines. All physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.
     • Be aware that Medicare contractors will not search their files to adjust payment on claims paid incorrectly prior to implementing CR7324. However, they will adjust such claims that you bring to their attention.

For additional information on providing the flu shot, see my previous post here.

Non-sufficient funds (NSF) checks cost practices time and money. A NSF check (also called a bad check, a bounced check, or a returned check) is one that a patient gives you, you deposit and the bank returns to you because the account is closed or does not have sufficient funds to cover the check. A written NSF check protocol ensures that staff can process the check and collect the money owed in a businesslike manner, spending a minimum of time and money.

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1. Contact your bank and ask what their NSF check practices are so you can develop your policy appropriately. Find out the bank’s charge to the practice for depositing a bad check, and if the bank attempts to collect the money from the patient’s account more than once before returning it to you. If they try to collect twice, you may choose not to deposit the check again.
2. Post signs in your practice (usually at check-in and/or check-out) to let patients know what your returned check fee is. You may charge exactly what the bank charges you or you may charge an additional fee for the work it takes your staff to collect the NSF check.
3. Note that some collection bureaus or third-party collectors will process NSF checks for you. You and the agency will determine the cost above the bank fee of the NSF check processing and this additional fee will either belong to the agency, or the two of you will split it.
4. You may send the check through a second time after calling the patient’s bank to see if there is money in the account.
5. Post the adjustment to the patient’s account showing the returned check amount and post the returned check fee as a charge.
6. Call the patient to request that they come to the practice and exchange their NSF check for cash or a money order – the total owed will be the amount of the check plus the returned check fee.
7. If you cannot reach the patient by phone, send a certified letter with a copy of the check (see sample verbiage below.) Do not return the bounced check to the patient until they have paid the amount due (for the check and the bank charge) in full. Keep a copy of the letter and check in your bad check file. In the letter, let the patient know if there is any repercussion to them if they do not make the check “whole” and require that they respond with a certain number of days.
8. Once a patient passes a bad check, only accept cash or money orders from the patient going forward. Place a pop-up alert in your computer system to this effect so check-in and check-out staff collect appropriately.
9. If the patient does not satisfy their bad check, you may choose not to see the patient again, however if your practice provides urgent services, do not turn the patient away for urgent services due to an unpaid bill. You can refuse service once you discharge the patient with a 30-day notice, and provide the patient with 30 days of emergency-only care.
10. There are check authorization services that confirm whether or not the check is good at the time you take it. You can also verify checks that come in the mail, and if not good, you can contact the patient immediately and avoid the bank fee. What you decide to charge the patient in this case is up to you, but collecting a standard bad check fee for any NSF check will help defray the costs of the check authorization service.
11. Some practices do not accept checks. The number of people paying by check are dwindling, while more people are opting to pay by credit or debit card. Some practices are keeping credit cards on file for all fees owed by the patient which is not only convenient, but you can process the transaction and tell immediately if money is available to cover the transaction.
12. Check your state law for NSF check laws to confirm the number of days to give the patient to cover the returned check and what other means of collecting the money are available to you.
13. A few related notes: (a) Most practices collecting large sums of money will require patients to pay in cash, by cashier’s check or money order before the service is rendered so as not to risk the possibility of a bounced check. (b) It is not recommended that you accept checks dated for any date except the actual transaction date. (c) Never accept a check where the patient has written “Paid in Full” unless the account is well and truly paid in full. (d) Never let the patient overwrite a check and get change from the practice, or cash a check for a patient.

Sample Returned Check Letter

Date: _____________________

To:

Dear _______________:

Your check number ______ in the amount of $_________________, dated ___________________, has been returned by the bank. We have verified with your bank that there are insufficient funds to pay the check.

Please replace this check with cash or a money order and pay the bank charge for a total of _______ within ___ days to avoid further collection action.

If you have questions about this, please contact _________ at ________ between the hours of _________.

Sincerely,

Practice Name

Two milestone Acts were approved by Congress this week and both will be presented to President Obama for his signature shortly.

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What he will be signing:

1. The “Medicare and Medicaid Extenders Act of 2010″ This legislation freezes Medicare physician payments at current rates through the end of 2011. The Act also includes funds for Medicare contractors to pay claims for physician services affected by provisions of the Patient Protection and Affordable Care Act passed last spring. The bill, estimated to cost $19.3 billion over 10 years, will be paid for by changing a provision of the health reform act that provides tax credits for people who buy coverage. President Obama released a statement saying: Its time for a permanent solution that seniors and their doctors can depend on and I look forward to working with Congress to address this matter once and for all in the coming year.
2. “Red Flag Program Clarification Act of 2010“ changes the Red Flags Rule’s definition of “creditor” and relieves doctors from complying with the Federal Trade Commission’s identity theft prevention law.

Most managers know that an I-9 must be completed for each new employee, but how many know WHY the I-9 is a necessary part of bringing a new staffer on board?

The I-9 was first required by the Immigration Reform and Control Act (IRCA) of 1986 (now the Department of Homeland Security – U.S. Citizenship and Immigration Services.) This form verifies the eligibility of an employee to work legally in the United States. You, the employer, are required to verify the employment eligibility for every employee hired.

The DHS can audit the I-9s in a company at any time for no reason.

There have not been routine audits, however, the DHS has hired more auditors recently to help with the audits. Fines of up to $200,000 per I-9 verification that is not completed and maintained can be levied. Regardless of how many or how few employees you have, you must have a completed I-9 for every full-time or part-time employee. The only exception to completing an I-9 is in the case of an independent contractor or someone who was hired before November 6, 1986.

U.S. Citizenship and Immigration Services (USCIS) has revised the list of documents acceptable to complete the I-9 beginning April 3, 2009. The new form must be used for all new hires, and to reverify any employee who may have eligibility documentation on the original form I-9 that has or will be expiring. The revised form will improve the security of the employment authorization verification process. The biggest difference in the form is that all documents have to be unexpired.

An Employment Eligibility Verification form (I-9 Form) must be completed within 3 days of hire. This form should be kept in a separate file from the employees file. The forms should be kept for 3 years or for one year after the end of employment.

Each employee must present original documents, not photocopies.

The only exception is an employee may present a certified copy of a birth certificate.

On the form, the employer must verify the employment eligibility and identity documents presented by the employee and record the document information on the I-9 form.

Employees are required to present either one of the documents from List A, or one document from each List B and List C.

List A (Documents that establish both identity and employment eligibility)

• Current United States Passport
• Permanent Resident Card or Alien Registration Receipt Card (I-551)
• Temporary Resident Card (I-688)
• Employment Authorization Document (I-766, I-688B, or I-688A)
• Foreign Passport with temporary I-551 stamp
• For aliens authorized to work only for a specific employer, foreign passport with Form I-94 authorizing employment with this employer

List B (Documents that establish identity only)

• Driver’s license issued by a state or outlying possession
• ID card issued by a state or outlying possession
• Native American tribal document
• Canadian driver’s license or ID card with a photograph (for Canadian aliens authorized to work only for a specific employer)
• School ID card with a photography
• Voter’s registration card
• U.S. Military card or draft record
• Military dependent’s ID Card

List C (Documents that establish employment eligibility only)

• Social Security account number card without employment restrictions
• Original or certified copy of a birth certificate with an official seal issued by a state or local government agency
• Certification of Birth Abroad
• US Citizen ID Card
• Native American tribal document
• Form I-94 authorizing employment with this employer (for aliens authorized to work only for a specific employer)

No I-9 Documentation?

An employee who fails to produce the required document, or a receipt for a replacement document (in the case of of lost, stolen or destroyed documents), within three business days of the date employment begins, can be terminated. An employee who shows a receipt has ninety days to present the original documents.

Click here to read “New Employee Paperwork Explained – Part 1: The Application”

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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, hayesconsulting@embarqmail.com.

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Ownership

Private practices are organized in a corporate model where the physicians are shareholders, or where one or more physicians own the practice and employ other physicians or providers. Private practices are almost exclusively for-profit. Physician practices are organized into corporations for the tax benefits as well as protecting the owners from liability judgments.

Hospitals can be for-profit, not-for-profit or government-owned. For-profit hospitals make up less than 20% of the total hospitals in the United States.

Financial Models

Private practice owners take a salary draw, split any receipts after all expenses are paid, and generally distribute receipts monthly or quarterly. This leaves very little at year end to be taxed through the corporation.

Hospitals that employ physicians typically guarantee a salary and offer an incentive plan where the physicians earn more for seeing more patients and/or being more productive based on work Relative Value Units (wRVUs). Hospitals may or may not use a practice expense and revenue model to measure the margin.

Benefits of Managing a Private Practice

1. You get to do everything, so if you like or want to learn about HR, marketing, finance, IT, contract negotiation, revenue cycle management, facility management, and lots of other stuff, you’ll get to do it in a private practice.
2. You are the top position in the practice, so you get to put your imprint on the practice. You can often be more creative.
3. Physicians can be very laid-back and practices can maintain a more relaxed, family-like atmosphere.
4. Decision-making can be straightforward and swift, so you can help your practice to be nimble in response to news events, trends and new ideas. If your practice decides to become a concierge practice or stop or start taking a particular payer, so be it!
5. You may find it easier to get a foot in the door and start your management career in a private practice as physicians don’t always hire managers using traditional means. A recommendation from another manager, a consultant or a physician may be enough to get you started.

Drawbacks of Managing a Private Practice

1. You report to the physicians who may not have business expertise and may fight you on your well-founded recommendations.
2. There is no internal career path – you’re at the top in the practice.
3. Physicians will make less money every time a new non-revenue generating position is added or any time equipment needs to be replaced – expect them to be generally slow to respond to capital expenditure needs, especially if they cannot see that any new revenue will come from the expense.
4. When physicians “eat what they kill”, taking home the dollars they personally earn less their expenses, they can be pitted against each other and have conflicting priorities.
5. Your practice could be purchased by a hospital and you could find yourself out of a job, or your job radically changed.

Benefits of Managing a Hospital-Owned Practice

1. You report to a management professional who should understand the business and be supportive of your well-founded recommendations.
2. You will receive support from other hospital departments: the Human Resources department will screen, orient and provide benefit support to your staff; the Information Systems department will provide and maintain your practice management system, EMR system and other hardware and software; and the Accounting department will pay the bills and write the payroll.
3. You may be able to climb the career ladder and manage multiple practices, or become the Vice President of Physician Practices, or the COO, CFO or CEO of the hospital.
4. You will get to interact with managers of other departments and broaden your hospital knowledge and understanding of the care continuum.
5. You can learn a lot from the process of preparing for and living through a JCAHO (a.k.a. “The Joint Commission”) visit.

Drawbacks of Managing a Hospital-Owned Practice

1. Hospitals use different terminology for charges, adjustments and receipts and work on the accrual system instead of the cash system, which most private practices use. It takes time to understand and distinguishes the terminology and process differences.
2. The entire system will be in a tizzy on a regular basis getting ready for a JCAHO (a.k.a. “The Joint Commission”) visit.
3. You can expect to have much less autonomy in a hospital system and there may be more red tape involved in getting even simple requests filled.
4. Hospital administration may find it difficult to relate to the perspective of the hourly staff and it could be frustrating to balance the needs of the staff and the needs of the organization.
5. Because the hospital is the big-dollar earner, the needs of the clinics may be second, third or fourth down the line in importance.

What do you see as the benefits or drawbacks of your private practice or hospital practice job?