We’re not quite ready to roll out my new web, social media and cloud solutions company, but I am extending a special offer through the end of April for the Manage My Practice readers who want to know what this cloud business is all about.

Read my post here on 76 ways to use the cloud in your medical practice.

Here’s how it works.

1. Contact us during the month of April and we’ll get you set up on a free Box.net account – no credit card required!

2. We’ll do a phone assessment of your pain points and tell you how a cloud can help.

3. We’ll teach you how to use Box.net and how to organize your practice or yourself on the cloud (but you’ll have to do all the heavy lifting!)

That’s it.

If you are interested, contact Abraham Whaley here.

Ohio University: Degree offered: Master in Health Administration

Sampling of classes offered: This two-year graduate degree is structured in eight modules, where a module is made up of two or so classes that cover a certain topic, likefinancial dimensions of healthcare leadership or healthcare law and ethics. Each module takes 10 weeks to finish.

Why its a cut above the rest: While Ohio University is an accredited, notable brick and mortar college, the program still offers the flexibility that online degrees are known for; students can apply and enter the program at four different points during the year. The program is also very affordable: total tuition is around $24,000 for the degree, for both in state and out of state students.

Northeastern University: Degree offered: Bachelor of Science in Health Management

Sampling of classes offered: Students in this online bachelors program take the general courses that come with any foundational degree, like English and mathematics, along with their healthcare coursework. The specialized major courses cover subjects like healthcare delivery systems, health regulations, and public health.

Why its a cut above the rest: There arent many bachelors degrees in health administration offered completely online by an accredited college, and thus, Northeasterns degree stands out; the school has regional accreditation from the New England Association of Schools and Colleges, a recognized accrediting body. Students who already have an associates degree have the option of transferring and finishing this bachelors in only 18 months. If you need to complete the entire four-year degree, its incredibly cost-effective, at just under $51,000 for the entire tuition.

Des Moines University: Degree Offered:Master of Health Care Administration

Sampling of classes offered: This degree is arranged into four blocks, with each block containing a series of related courses. Students learn an overview of the U.S. healthcare system, financial management in healthcare, healthcare decision making, and more.

Why its a cut above the rest: The Des Moines program is completely online, and students dont have to worry about traveling for days or weeks of seminars during the year, like in some hybrid programs. All students must complete an administration internship in their local community, meaning youll leave your degree program with valuable, hands-on experience that can help you land a job.

Central Michigan University: Degree offered: Doctor of Health Administration

Sampling of classes offered: Students entering this doctoral program must already possess a masters degree in a topic relevant to healthcare administration; the degree is aimed at upper-level health professionals, and takes 3-5 years to complete. The degree is module based, with eight modules covering 15 courses, in topics like quantitative analysis in healthcare and healthcare economics. Students are also required to attend six 2 day seminars throughout the program, that are offered at locations around the country. Like any doctoral degree, students must complete a dissertation and oral defense, based on their own novel research.

Why its a cut above the rest: You wont have to worry that youll be earning a doctoral degree thats somehow less rigorous because its online, since applicants must have a masters or professional degree and 5 years of health-related work experience to be accepted. And get this: students may choose to take travel seminars in place of their regular seminars, to destinations like Switzerland, Czech Republic, and Belize.

University of Minnesota: Degree offered: Executive Master of Healthcare Administration

Sampling of classes offered: U of Minnesotas degree program takes two years to complete, and combines short in-person seminars with mostly online learning. Every August and May students spend a few days in face-to-face classroom settings, covering topics like healthcare delivery and managing healthcare organizations. Online classes cover topics geared at current health professionals, like legal considerations in health services and healthcare strategies in competitive markets.

Why its a cut above the rest: The curriculum in this degree is based on the criteria for competent healthcare administration, as defined by the non-profit National Center for Healthcare Leadership, ensuring that youre learning the most important concepts in the field. And, Minnesotas MHA has been ranked #2 in the nation by U.S. News and World Report, meaning youll be earning a recognized degree that can really open doors for your career.

Should I consider ePrescribing in 2011 if I’m not ready to install an EMR? 

• In 2012 eligible professionals who are not successful eprescribers, based on claims submitted between January 1, 2011 June 30, 2011, may be subject to a “payment adjustment” (read payment cut) in their Medicare Part B Physician Fee Schedule (PFS) for covered professional services.
• Those that dont eprescribe as a part of 10 Medicare patient encounters by June 30, 2011 will only receive 99% of their Medicare payment for all encounters in 2012.
• Those that don’t ePrescribe as a part of 25 encounters by December 31, 2011, will only receive 98.5% of their Medicare payments for all encounters in 2013 and only 98% of their Medicare payments for encounters during 2014 and going forward.
• The payment adjustment does not apply if <10% of an eligible professionals (or group practices) allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of codes in the denominator of the 2011 eRx measure.

The DENOMINATOR is the visit code that is eligible for an eprescribing code (see list below.)

Patient visit during the reporting period (CPT or HCPCS): 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109

The NUMERATOR is a prescription generated and transmitted via a qualified eRx system and reported using a quality data code.

G8553: At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system (reported via claims, a registry, or an EHR.)

Please note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.

How to Avoid the 2012 Payment Adjustment

An eligible professional can avoid losing 1% in 2012 if (s)he:

• Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of June 30, 2011 based on primary taxonomy code in NPPES,
• Does not have prescribing privileges. (S)he must report (G8644) at least one time on an eligible claim prior to June 30, 2011;
• Does not have at least 100 cases containing an encounter code in the measure denominator;
• Becomes a successful e-prescriber; and
• Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.

Exemptions from the Medicare Payment Adjustment in 2012

• An (EP) eligible professional or selected group practice may request an exemption from the eRx Incentive Program and from the payment adjustment based upon a significant hardship.
• The qualifying circumstances are based upon two hardship codes that need reported on at least one claim prior to June 30, 2011 should one of the following situations apply:

G8642 - The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act.

G8643 - The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under
section 1848(a)(5)(A) of the Social Security Act

To Recap:

1. Each Physician or practice that does not currently ePrescribe should consider whether or not ePrescribing is worthwhile. (Note: For group practices participating in eRx GPRO I or GPRO II during 2011, the group practice MUST become a successful e-prescriber. Depending on the groups size, the group practice must report the eRx measure for 75-2,500 unique eRx events for patients in the denominator of the measure. Check out the Group Practice Reporting Option here.)
2. In estimating the value of ePrescribing, the practice manager must consider on one hand the expense (which there is, even for free standalone eRx systems) surrounding the implementation of ePrescribing, and the potential income from the ePrescribing Incentive.
3. The practice must also determine if an EMR is in their future, and if so, if the installation will take place soon enough to report the 10 encounters with Medicare patients.
4. Individual eligible professionals (EPs) may choose to participate in either the PQRI, eRx, or both. PQRI and eRx are separate incentive programs.
5. If an eligible professional (EP) earns an incentive under the Medicare EHR Incentive Program, he or she cannot receive an incentive payment under the eRx Incentive Program in the same program year, and vice versa. However, if an EP earns an incentive under the Medicaid EHR Incentive Program, he or she can receive an incentive payment under the eRx Incentive Program in the same program year.
6. Eligible professionals must have adopted a “qualified” eRx system. There are two types of systems: a system for eRx only (stand-alone) or an electronic health record (EHR system) with eRx functionality. Regardless of the type of system used, to be considered “qualified” it must be based on ALL of the following capabilities:
   • Generating a complete active medication list incorporating electronic data received from applicable pharmacies and benefit managers (PBMs) if available.
   • Providing information related to lower cost, therapeutically appropriate alternatives (if any). Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all alerts.
   • Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan, if available.

For a list of qualified registries and qualified EHR vendors and products, click here.

An excellent article, Choosing the Right E-prescribing Application: Should you buy a standalone app or an EHR-integrated module? was published in January 2011 by Physicians Practice here.

Image courtesy of Wikipedia

Publications For Your Medicare Beneficiaries
New! The Medicare Learning Network (MLN) has released a new product titled Publications For Your Medicare Beneficiaries. This factsheet lists a variety of beneficiary-related publications available to assist providers in responding to patients questions related to Medicare, all of which can be printed and provided to patients. This product is available in downloadable format here. Check it out – links to more than 70 different publications!

The 2007 Physician Quality Reporting Initiative
New! Anew Medicare Learning Network publication titled The 2007 Physician Quality Reporting Initiative (PQRI) (November 2010) is now available in downloadable format here. This booklet is a compilation of CMSs various educational resources relevant to the 2007 Physician Quality Reporting Initiative.

Guidelines for Teaching Physicians, Interns, and Residents
The Guidelines for Teaching Physicians, Interns, and Residents (revised December 2010) is now available in downloadable format here. This factsheet provides information about payment for physician services in teaching settings, general documentation guidelines, and evaluation and management documentation guidelines.

HIPAA EDI Standards Web-Based Training
The Medicare Learning Network is now offering therevised HIPAA EDI Standards web-based training (revised January 2011) for CE credit. The goal of this activity is to provide information to physicians, suppliers, and healthcare professionals regarding electronic billing and other healthcare electronic transactions such as the Administrative Simplification provisions of HIPAA, electronic transaction standards and code sets required by HIPAA, and an overview of the steps involved in the Medicare electronic data interchange process. To take this training, go here and click on Web-Based Training Modules under Related Links Inside CMS. There are 15 other web-based training classes available on the same site.

Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers and Billers
The publication titled Understanding the Remittance Advice: A Guide forMedicare Providers, Physicians, Suppliers and Billers (revised October 2010) is designed to educate institutional and professional providers who bill Medicare with general remittance advice (RA) information. It includes instructions to help you interpret the RA received from Medicare and reconcile it against submitted claims and provides guidance on how to read Electronic Remittance Advices (ERAs) and Standard Paper Remittance Advices (SPRs), as well as information on balancing an RA. This publication may be downloaded here. If you are training an employee to be a biller or post payments, or if you want to understand more about your billing yourself, this is an excellent resource.

Evaluation and Management Services Guide
The publicationtitled Evaluation and Management Services Guide(revisedDecember 2010) is now available in downloadable format from the Medicare Learning Network here. This guideis designed to provide education on medical record documentation and evaluation and management billing and coding considerations. The 1995 Documentation Guidelines for Evaluation and Management Services and the 1997 Documentation Guidelines for Evaluation and Management Services are included in this publication. This is another great resource that you can use to train staff, physicians, and other providers, or to get up to speed yourself if E & M codes are not part of your education or experience.

Image Credits:

Dancing Seniors: Image by StevenM_61 via Flickr

Money Rainbow: Image by TW Collins via Flickr

Here’s a fascinating video on how the Internet is transforming healthcare. Susannah Fox from the Pew Internet and American Life Project spoke in September 2010 at Mayo Transform 2010 : Thinking Differently About Health Care. The transcript of her talk is here. If you have an interest in where healthcare is going and where your medical group needs to be, take 15 minutes and listen to Susannah Fox.

Patients want to know why they can’t get a return call from their doctor’s office – here are six reasons why the calls have increased and physician offices are having trouble meeting the needs of their patients.

1. Medication questions and requests for a prescriptions change. The average number of retail prescriptions per capita increased from 10.1 in 1999 to 12.6 in 2009. (Kaiser Family Foundation calculations using data from IMS Health, http://www.imshealth.com.) Because it is not easy to access prescription cost by payer in the exam room, medical practices get lots of callbacks from patients asking to change their prescriptions once they arrive at the pharmacy and find out how much the prescription costs. Related issue: Many national-chain pharmacies have electronic systems that automatically request a new prescription when the patient is out of refills. Also related: Patients calling to ask for additional medication samples.
2. Patients are delaying coming to the physician’s office by calling the practice with questions. Patients want to forestall paying their co-pay or their high-deductible by getting their care questions answered without coming to the doctor’s office.
3. Patients call back with questions about what they heard or didn’t hear in the exam room. They may not remember what the physician told them, they may not have understood the medical jargon, or they may have a hearing problem and were not comfortable asking the physician to repeat something.
4. Impatience: we live in an instant gratification world and patient expectations are not aligned with what physician offices can realistically provide.
5. Some patients will not leave voice mail messages and will call back multiple times until they get a live human being or will punch in options until they find someone to answer the phone.
6. Physician offices are often understaffed. Physicians find it untenable to add more staff to do more tasks for less money or no money at all.

And here are some possible solutions:

1. Have formularies for all major health plans on hand in the exam room. These could be paper lists, or electronic lists for the tablet or smartphone. (Note: Epocrates currently has a deal with Walgreen’s to support their discount program on the smartphone.) Don’t underestimate the patient satisfaction and reduction in callbacks for sending the patient out of the exam room with the right prescription. Automatic refills are not an appropriate function of pharmacies. Physicians should provide samples (check the formulary!) and a prescription to get filled if the samples do the job. If a patient can’t afford the brand name prescription, a prescription assistance program is the next step.
2. Patients need to be advised appropriately when they need to see the physician and when they don’t. Good triage nurses can be worth their weight in gold, but you can hold the costs down by hiring a triage nurse or several to work from their homes taking calls from your patients. The nurse will need to have access to your practice management system to schedule appointments and to document the conversation if the patient is given advice.
3. Provide patients with different modes of assimilating health information. Some patients are recording office visits via voice or video and one of the goals of meaningful use is providing patients with an office visit summary when they exit the practice. Websites should be loaded with educational information that physicians can “prescribe” to their patients. Some physicians help to cut down on return calls and improve understanding by asking the patient how they’ll describe the visit to a family member.
4. Give patients (on the web, in the practice, on your on-hold messages) realistic timelines for callbacks and make it so.
5. Yes, some patients will game the system to get their needs met ahead of others. Ask them to adhere to the practice guidelines. There will always be some cheaters, but most patients will respect you if you respond to them when you said you would.
6. The only answer to understaffing is technology. Use a patient portal to allow patients to request refills, schedule appointments and chat with billing staff or nurses. Replace paper charts with EMR. Use efaxing to eliminate paper faxes. Use the cloud to store information and collaborate.

Image via Wikipedia

CLIA (Clinical Laboratory Improvement Amendments of 88) is the basic set of regulations governing all laboratories that test human specimens (with rare exceptions). It is the minimum standard for labs.
CLIA has given deemed status to several other agencies allowing them to accredit labs and inspect the labs in CLIAs stead. COLA is one of these agencies (as are CAP and The Joint Commission). All accrediting agencies must be at least as strict as CLIA, or to phrase it a different way, all accrediting agencies must have the same regulations as CLIA does, and then may add additional regulations on top of the CLIA regulations if they wish.

There is little difference between CLIA and COLA from a regulatory viewpoint. COLA enforces a few more requirements than CLIA does, but the differences are relatively minor. One example is that COLA requires correlation studies be done when a new instrument is installed to compare the new instrument to an old instrument or a reference lab method and CLIA does not. Another is that CLIA requires an overlap of old control lot numbers to new control lot numbers but doesnt specify a number of times they must be run together; COLA requires overlapping old and new 5 times. So there are differences, but it is pretty easy to see that the differences in regulations are not extreme. CLIA publishes their Interpretive Guidelines on the Internet for all to read so you have ready access to the information as to how a regulation is going to be applied; COLA does not and will not share their Interpretive Guidelines (they consider it proprietary information), so understanding how a questionable regulation will be applied is left to a guess or a phone call to COLA headquarters in Maryland.

From a personnel standpoint, there is no difference between CLIA and COLA. COLA follows the CLIA requirements for personnel qualifications and responsibilities, both for moderately complex labs and for highly complex labs.

From an inspection standpoint, there can be notable differences, depending on the state in which the lab is located. CLIA is a federal program but is administered at the state level in each state. While the regulations they enforce are the same, the quality of the CLIA departments from one state to another varies widely. COLA is a nationwide program and the inspectors move freely between states as needed to inspect labs. Both agencies train their inspectors, so in a perfect world all inspections would be the same within an agency. Unfortunately, however, that is not the real life situation. The quality of the inspectors and the inspections they perform can vary widely in each agency. In many states, CLIA is short-staffed so delays are common. On the whole, COLA is probably a little more uniform throughout the country than CLIA is, but CLIA is usually more dependable with post-inspection routine and follow-up than COLA.

The costs associated with CLIA and COLA are pretty much the same. Both base their costs on the number of non-waived tests performed in a years time. All labs pay CLIA a Certificate Feethe cost of renewing the CLIA identification number. And all non-waived labs pay a Compliance Fee to cover the cost of their inspection, but the Compliance Fee is billed by the inspecting agency, so if youre inspected by CLIA the Compliance Fee will be billed by CLIA and if you are accredited by COLA, the COLA fee covers the cost of the inspection.

Several states have state lab regulations on top of CLIA regulations that are enforced. Pennsylvania, New York, Massachusetts, Maryland, Illinois, and California are several examples. Whenever there is state licensure of labs in addition to CLIA licensure, the fees will usually be higher because there will be both a CLIA and a state fee. If your lab is located in a state with additional state regulations, be sure and find out how the state regulations differ from CLIA and/or COLA (depending on which you choose for compliance). And be aware that when CLIA amends a regulation to make it less strict, COLA and/or the state may not follow suit. Also be aware that if your lab fails to maintain accreditation with one of the agencies other than CLIA, they will lose their CLIA Certificate as well unless they can pass a CLIA inspection. The accrediting agencies carry just as much weight as does CLIA.

Whenever I am asked which agency I recommend for a new lab, my answer is it depends In some states, CLIA is absolutely the best choice (North Carolina is one of those states) because the department is very well run and the inspectors are very well trained and highly accessible when assistance is needed. In other states, CLIA is a disaster and COLA is absolutely the best choice (California and Louisiana being two examples). In the great majority of states, it really doesnt matter which agency is chosen because overall they both do excellent jobs.

Consultant Elizabeth Knollmeyer, B.S., MT (ASCP) has over 40 years experience in the laboratory industry. She specializes in financial, operational management and compliance issues for both hospital and physician office laboratories. Libby has a wide variety of experience with her areas of special expertise including financial review and management, Quality Management protocols, Outreach development, compliance and regulatory assistance, lab design and up fitting, lab remodeling, and market research for IVD manufacturers. She works independently and with large consulting groups to provide interim management for hospitals, and serves as adviser to lab equipment and supply distributors. She can be reached at (336) 288-5823 or at eknollmeyer@triad.rr.com.