Manage My Practice

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

CMS has announced two national calls for attestation.

Tue May 3, 2-3:30pm ET (for Eligible Hospitals)

Thu May 5, 1:30-3pm ET (for Eligible Professionals)

CMS is holding conference calls for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare Electronic Health Record (EHR) Incentive Program to provide information on the attestation process. Mark your calendars for one of the calls below.

What the Calls Will Cover

Instructions on How to Register for a Call
To register for these calls, take the following steps:

Prior to each call, presentation materials will be available in the Upcoming Events section of the Spotlight Page on the CMS EHR website.

Registration closes when all available space has been filled, or 24 hours before each call; no exceptions will be made, so please register early.

How will I attest for the Medicare and Medicaid Incentive Programs?

Medicare eligible professionals, eligible hospitals and critical access hospitals will have to demonstrate meaningful use through CMS’ web-based Registration and Attestation System. In the Medicare & Medicaid EHR Incentive Program Registration and Attestation System, providers will fill in numerators and denominators for the meaningful use objectives and clinical quality measures, indicate if they qualify for exclusions to specific objectives, and legally attest that they have successfully demonstrated meaningful use. A complete EHR system will provide a report of the numerators, denominators and other information. Then you will need to enter that data into our online Attestation System. Providers will qualify for a Medicare EHR incentive payment upon completing a successful online submission through the Attestation Systemimmediately after you submit your results you will see a summary of your attestation, and whether or not it was successful. The Attestation System for the Medicare EHR Incentive Program will open on April 18, 2011.

For the Medicaid EHR Incentive Program, providers will follow a similar process using their state’s Attestation System. Check here to see states’ scheduled launch dates for their Medicaid EHR Incentive Programs.

Do you have questions about the EHR Incentive Programs? Do you want to find out if you are eligible, how much of an incentive payment you can earn, and learn more details about the program and what you need to do to qualify?

• Visit the Path to Payment page for a program overview
• Visit the Meaningful Use page

When can I attest?

To attest for the Medicare EHR Incentive Program in your first year of participation, you will need to have met meaningful use for a consecutive 90-day reporting period. If your initial attestation fails, you can select a different 90-day reporting period that may partially overlap with a previously reported 90-day period. To attest for the Medicare EHR Incentive Program in subsequent years, you will need to have met meaningful use for a full year. Please note the reporting period for eligible professionals must fall within the calendar year, while the reporting period for eligible hospitals and critical access hospitals must fall during the Federal fiscal year.

April 18, 2011, is the earliest an eligible professional, eligible hospital or critical access hospital can attest that they have demonstrated meaningful use of certified EHR technology under the Medicare EHR Incentive Program.

Under the Medicaid EHR Incentive Program, providers can attest that they have adopted, implemented or upgraded certified EHR technology in their first year of participation to receive an incentive payment.Medicaid EHR Incentive Program participants should check with their state to find out when they can begin participation.

What can I do now to prepare for attestation?

Visit the Registration page and get registered for the EHR Incentive Programs right now. If you haven’t previously registered, you can complete the registration and attestation process at the same time.

Also, review the Attestation User Guides, which provide step-by-step instructions for login and completing attestation. You can find separate Attestation User Guides for eligible professionals and eligible hospitals in the Resources section below.

Finally, you can enter your information in our Meaningful Use Attestation Calculator prior to submitting your attestation to see if you would be able to meet all of the necessary measures to successfully demonstrate meaningful use and qualify for an EHR incentive payment.

What will I need to login to the Attestation System?

If you are an eligible professional, you’ll need:

• Your Type 1 National Provider Identifier (NPI)
• The same user ID and password you used to register

If you are working on behalf of an eligible hospital or critical access hospital, you’ll need:

• An active National Provider Identifier (NPI)
• The same user ID and password you used to register
• An EHR Certification Number from Office of the National Coordinator
• If you did not register the facility, you’ll need an Identity and Access Management system (I&A) Web user account (User ID/Password) and be associated to the organization NPI, if you’re a user working on behalf of an eligible hospital or critical access hospital. Create a login in the I&A System if you’re working on behalf of an eligible hospital or Critical Access Hospital and don’t have an I&A web user account.

What is the CMS EHR Certification Number?

During attestation, CMS requires each eligible professional, eligible hospital and critical access hospital to provide a CMS EHR Certification ID or Number that identifies the certified EHR technology being used to demonstrate meaningful use. This unique CMS EHR Certification ID or Number can be obtained by entering the certified EHR technology product information at the Certified Health IT Product List (CHPL) on the ONC website here.

NOTE: The ONC CHPL Product Number issued to your vendor for each certified technology is different than the CMS EHR Certification ID. Only a CMS EHR Certification ID obtained through the CHPL will be accepted at attestation.

Eligible professionals, eligible hospitals and critical access hospitals can obtain a CMS EHR Certification ID or Number by following these steps:

1. Go to the ONC CHPL website.
2. Select your practice type by selecting the Ambulatory or Inpatient buttons.
3. Search for EHR Products by browsing all products, searching by product name or searching by criteria met.
4. Add product(s) to your cart to determine if your product(s) meet 100% of the CMS required criteria.
5. Request a CMS EHR Certification ID for CMS attestation.NOTE: The “Get CMS EHR Certification ID” button will not be activated until the products in your cart meet 100% of the CMS required criteria. If the EHR product(s) do not meet 100% of the CMS required criteria to demonstrate Meaningful Use, a CMS EHR Certification ID will not be issued.
6. The CMS EHR Certification ID contains 15 alphanumeric characters.

I’m an Eligible Professional (EP). Can I designate a third party to register and/or attest on my behalf?

In April 2011, CMS implemented functionality that allows an EP to designate a third party to register and attest on his or her behalf. To do so, users working on behalf of an EP must have an Identity and Access Management System (I&A) web user account (User ID/Password), and be associated to the EP’s NPI. If you are working on behalf of an EP(s), and do not have an I&A web user account, please visit I&A Security Check to create one. States will not necessarily offer the same functionality for attestation in the Medicaid EHR Incentive Program. Check with your State to see what functionality will be offered.

When will I get paid?

Incentive payments for the Medicare EHR Incentive Program will be made approximately four to six weeks after an eligible professional, eligible hospital or critical access hospital meets the program requirements and successfully attests they have demonstrated meaningful use of certified EHR technology. CMS expects that Medicare incentive payments will begin in May 2011. Payments will be held for eligible professionals until the eligible professional meets the $24,000 threshold in allowed charges.

Eligible hospitals and critical access hospitals attesting in April 2011 could receive their initial payments as early as May 2011. Final payment will be determined at the time of settling the hospital Medicare cost report.

Medicaid incentives will be paid by the states and are expected also to begin in 2011. States are required to issue incentive payments within 45 days of providers successfully attesting to having adopted, implemented or upgraded certified EHR technology during their first year of participation in the Medicaid EHR Incentive Program. Launch date for the Medicaid EHR Incentive Program varies by state, so the earliest date attestation can begin also varies by state. Several states have disbursed incentive payments as early as April 2011.

How will I get paid?

Payments to Medicare providers will be made to the taxpayer identification number (TIN) you selected at the time you registered for the Medicare EHR Incentive Program.

CMS will deposit payment in the first bank account on file. It will appear on your bank statement as “EHR Incentive Payment”

If you receive payments for Medicare services via electronic funds transfer, you will receive Medicare EHR Incentive Program payment the same way. If you currently receive Medicare payments by paper check, you will also receive your first Medicare EHR Incentive Program payment by paper check.

IMPORTANT: Medicare Administrative Contractors (MACs), carriers and fiscal intermediaries will not be making these payments. CMS has contracted with a Payment File Development Contractor to make these payments.

Have questions about your EHR incentive payment?

DON’T: Call your MAC/carrier/fiscal intermediary with questions

DO: Call the EHR Information Center

1-888-734-6433. TTY users should call 1-888-734-6563

Hours of Operation: 7:30 a.m. 6:30 p.m. (Central Time) Monday through Friday, except federal holidays

Why the payment amount may be less than you thought: The Medicare & Medicaid EHR Incentive Program Registration and Attestation System contains a Status tab at the top which will contain the amount of the incentive payment, the amount of tax or nontax offsets applied, and the remittance advice reason code containing the reason for any reduction.

For those receiving paper checks, there will be a tear-off pay stub which identifies offsets made to the incentive payment.

Where you can find more information about the offsets: For more information about tax offsets, call the Internal Revenue Service (IRS) at 1-800-829-3903.

For more information about non tax offsets, call the Department of the Treasury, Financial Management Service (FMS) at 1-800-304-3107.

Will CMS conduct audits?

Any provider attesting to receive an EHR incentive payment for either the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program potentially may be subject to an audit. Here’s what you need to know to make sure you’re prepared:

Overview of the CMS EHR Incentive Programs Audits

• All providers attesting to receive an EHR incentive payment for either Medicare or Medicaid EHR Incentive Programs should retain ALL relevant supporting documentation (in either paper or electronic format used in the completion of the Attestation Module responses). Documentation to support the attestation should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.
• CMS, and its contractors, will perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers.
• States, and their contractors, will perform audits on Medicaid providers.
• CMS and states will also manage appeals processes.

Preparing for an Audit

• To ensure you are prepared for a potential audit, save the supporting electronic or paper documentation that support your attestation. Also save the documentation to support your Clinical Quality Measures (CQMs). Hospitals should also maintain documentation to support their payment calculations.
• Upon audit, the documentation will be used to validate that the provided accurately attested and submitted CQMs, as well as to verify that the incentive payment was accurate.

Details of the Audits

• There are numerous pre-payment edit checks built into the EHR Incentive Programs’ systems to detect inaccuracies in eligibility, reporting and payment.
• Post-payment audits will also be completed during the course of the EHR Incentive Programs.
• If, based on an audit, a provider is found to not be eligible for an EHR incentive payment, the payment will be recouped.
• CMS will be implementing an appeals process for eligible professionals, eligible hospitals and critical access hospitals that participate in the Medicare EHR Incentive Program. More information about this process will be posted to the CMS Web site soon.
• States will implement appeals processes for the Medicaid EHR Incentive Program. For more information about these appeals, please contact your State Medicaid Agency.

Where can I find user guides and other resources?

Below are step-by-step Attestation User Guides to help you attest for the Medicare EHR Incentive Program. You can also use our Attestation Worksheet, Meaningful Use Attestation Calculator, and educational webinar to help you prepare for and complete the attestation process:

• Attestation User Guide for Eligible Hospitals
• Attestation User Guide for Medicare Eligible Professionals
• Meaningful Use Attestation Calculator (version 1)
• Electronic Specifications for clinical quality measures (CQM)

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

1-888-734-6433. TTY users should call 1-888-734-6563.

EHR Information Center Hours of Operation: 7:30 a.m. 6:30 p.m. (Central Time) Monday through Friday, except federal holidays.

I admit to being a great fan of electronic media for healthcare. My fandom, however, does not mean that I believe all paper and ink informational and marketing mediums are dead.

Because most practices have some portion of their patient population depending on paper for information and may also market to that population (whether patients or referrers), my opinion is that the practice brochure remains a viable and important piece of paper. You might want to give yours an update, though, to make it more usable and meaningful to everyone.

Using your brochure for your patients – new, established and future

• ABOUT – a brief sentence or two making it clear what ages, genders and types of problems your practice works with. You might also want to note if you do not see your patients in the hospital. A Mission Statement is a waste here – the reader wants facts. A history of the practice is also a waste here – save this for your website. You don’t even really need to itemize your providers here. Think of someone who knows nothing at all about you. Their first question is “Is this a practice I need and want?”

Your ABOUT could even be on the front of the brochure, so the patient doesn’t have to spend time reading the entire brochure if they are not a fit for your practice. Here’s an About Example: Main Street Urology helps men and women ages 18 and older with problems such as urinary infections, kidney stones and prostate problems. We see patients in our two offices, as well as at XXX and XXX hospitals.

• NEW & ESTABLISHED PATIENTS – Answer the second most common question next, which is “How do I get services?” Try to make this brochure as applicable to as many people as possible, so do not assume that the person reading the brochure has already signed on as a new patient. Consider the person that knows nothing about you and briefly describe all ways people can contact you to become a patient.
  • Your website – do people complete their registration electronically and you call them to set the appointment or do they request an appointment and you email a response? How is it done?
  • Your phone number – hopefully you are in step with the modern world and know that people don’t always think about establishing or following up on medical care during office hours. Do you have a way besides your website for patients to request appointments that are not urgent? Can they call and leave a message or do they get your answering service asking them to call back during office hours?
  • Stop by the office – largely discouraged by most offices, patients in the rural communities I’ve worked in know that stopping by the office is the quickest way to get service. Do you welcome that “interruption”?
  • Walk-in hours, work-ins, or same-day sick visits – what is appropriate for a same-day visit? When should patients go to the emergency room or call 911?

• PRESCRIPTIONS – The third most-common question is about getting new prescriptions and refills. With most people hoping to get a prescription without an office visit charge (who doesn’t want to save that co-pay?), requests for prescriptions are one of the primary reasons most specialties are struggling to keep the phones answered (read my post on phones here.) If you are not going to prescribe a new medication without an office visit, put it in writing. If all refills are obtained by calling the pharmacy, say so, and state how long it typically takes to get an existing prescription refilled. If you require a visit every 6 months for chronic illness medications, and a visit every month for chronic pain medications, say so. For practices with large numbers of chronic pain patients, spell out your terms including pain medication contracts and periodic laboratory tests.

• PAYMENTS – Now is a good time to state your payment policy. What is due at time of service? What kinds of payments do you accept? Do you require a credit card on file? Do you collect deductibles and co-insurance? Surgery or procedure deposit? Fee for no-shows? Fee for forms completion? Fee for NSF checks? Do you give discounts for self-pay patients? Do you have a sliding scale for financial need patients? Do you send statements? One of my big management philosophies is: Don’t Surprise The Patient. Don’t think it indelicate to discuss money before the visit. It is a business transaction and it is only fair to let the one paying the bill know and understand your policy upfront before the service has been rendered. Read my post on developing your financial policy here.

• COMMUNICATION -This is where most misunderstandings take place. How can you provide as many straightforward means of communication between the practice and the patient as efficiently and productively as possible?
  • Main practice number – should get the patient to a real person during office hours and give an alternative after hours. Malpractice companies will tell you that patients should not be able to leave a message on the main practice number as they may assume it is monitored and your practice may have liability. For routine questions, let your answering service take a message to be passed along on the next business day, or have voice mail box for the answering service to utilize.
  • Automated attendant number – some patients will prefer the automated attendant, especially if your options are published on the website or in the practice brochure and patients can call any time to leave a message.
  • Website – should have detailed information about contacting the practice during and after office hours. If you allow or encourage non-medical emails from patients, let the writer know how and when a response will come. Make clear what types of questions are appropriate in non-encrypted email and use a secure portal or encrypted email for emails with protected health information (PHI.)

More tips for your brochure

• To be as inclusive as possible, do not use medical terminology, abbreviations or jargon and aim for a readability level of 6th grade. Use the active voice and simple, short declarative sentences, a font of 12 or more and use as few multi-syllabic words as possible. If you wonder how your brochure readability stacks up, you can paste your text here for a free analysis. Microsoft Word 2007 and newer has a function you can turn on for a readability score at the conclusion of your spelling and grammar check.
• Use as little text in paragraphs and use as many headings and bullets as possible.
• Don’t cram the brochure with every little detail you can think of – keep it simple with plenty of white space.
• A map is always a good idea.
• Your practice name, website, phone numbers and office hours should appear at least twice – maybe on the inside and the outside. Having the basics on both sides is helpful to patients who place your brochure on their refrigerator or tape it inside the kitchen cupboard for easy reference.
• This article assumes a tri-fold brochure, but your brochure could be bigger or smaller. A tri-fold is not only easy to fold in half and stick in a pocket or a purse, it is also feasible to produce yourself.
• A digital copy should be available on your website for patients to print out, either in the tri-fold style, or on standard 8 1/2″ x 11″.

Using your brochure as a marketing tool

Make your practice brochures do double duty by providing them to:

1. The Welcome Wagon
2. The Chamber of Commerce
3. Real Estate offices
4. Rental Agency offices
5. Hotels
6. Any location with a display of brochures of local events and services
7. Libraries and Museums
8. Hospitals
9. Urgent Cares
10. Campgrounds, RV sites, theme parks
11. Sporting event locations
12. Spas
13. Hairdressers and nail salons
14. Malls and shopping centers
15. Daycares
16. Continuing Care Communities
17. School nurses
18. Gyms and sports clubs
19. Parish Nurses
20. Churches
21. Any place you give a talk or program
22. Correspondence you send welcoming a new business to the area
23. Chiropractors
24. Complementary Care Practitioners (accupuncture, meditation, etc.)
25. Convention Centers
26. The Health Department
27. Employers
28. The State Welcome Center
29. State Rest Stops
30. Service Clubs (Rotary, Kiwanis, Jaycees)
31. Medical office programs in local schools (high schools, technical schools, vocational schools, community colleges)
32. Nursing programs
33. Other medical offices in your building or medical park
34. Medical employment agencies
35. Home Health agencies
36. The Red Cross
37. Durable Medical Equipment and Supply Stores
38. Dentists
39. Community Centers
40. Afterschool programs
41. Pharmacists and Pharmacy Technicians
42. Physical Therapists
43. Massage Therapists
44. Parks and Recreation Centers
45. Airports
46. Train stations
47. Bus stations
48. Rental car agencies
49. Any business or individual you buy goods or services from
50. Radio and television stations

Bonus #51: Give them to your new staff so they understand the fundamentals about your practice very quickly.

Image by S.C. Asher via Flickr

Revenue cycle management (RCM) is a critical function in any healthcare entity. Managers do not have to know every detail about RCM, but if the RCM is on-site, they must understand:

• RCM reports and how to spot and be proactive about down-trends;
• performance measures for RCM staff and how to coach staff to improved performance; and
• the billing system and relationship with electronic claims, payments and remittance advice.

If the RCM department is outsourced, managers must be able to:

• generate ad hoc reports to assess billing company performance;
• hold the billing company to its performance guarantees; and
• stay abreast of changes in payer regulations and legislation and not rely solely on the billing company’s advice.

No matter what else a manager accomplishes or does well, if the RCM isn’t tight and right, nothing else will count.

What exactly is RCM?

Revenue Cycle Management encompasses all facets of the process of contracting for, accounting for and collecting the practice’s revenue. It includes:

1. Setting fees.
2. Contracting with payers.
3. Identifying patients’ correct payer sources (eligibility) and plans (benefits).
4. Counseling of patients prior to a high-cost procedure or surgery or needing financial assistance.
5. Documenting the services provided and producing charges for the services.
6. Collecting from outpatients at time of service.
7. Entering the services and patient payments into the computer system.
8. Filing primary and secondary payer claims.
9. Posting payments and contractual adjustments from payers.
10. Researching and appealing payer denials and underpayments.
11. Writing off small balance accounts and bad debts.

You notice that I didn’t mention sending statements.

If you’re considering opening your own lab or considering your options for adding a new service line to your lab, you should review the three different ways of procuring equipment and supplies.

Purchasing Equipment

When you purchase equipment outright, you either have the cash on hand to purchase the equipment or you borrow the funds from the bank. A purchase usually carries the lowest interest rate for a loan, but the capital equipment must be depreciated over a period of time (generally five years for laboratory equipment) and appears on the balance sheet as a long-term debt. If assets are liquidated to purchase capital equipment, the interest opportunity for those assets must be factored in against the lower interest rate available for a loan versus a lease.

Leasing Equipment

A lease can be one of two types: Fair Market value (FMv) or capital. In a FMv lease, ownership at the end of the lease is dependent on the lessee paying a fair market value for the commodity, generally 10% – 15% of the retail price of the goods. A capital lease is also sometimes referred to as a dollar buy-out lease because at the end of the term of the lease, the lessee can purchase the commodity for $1.00.

As one would expect, the interest rate on a FMv lease is less than on a capital lease.
Ownership is optional at the end of the lease period, but is generally a given for a capital lease because there would be no reason to opt for a capital lease with the higher interest rate if ownership at the end of the lease was not desired. Capital leases can be deducted for tax purposes like purchases. One of the most attractive options for leasing capital equipment is there is no capital outlay required to acquire the equipment. Another is that service can be added to the lease payment as an interest-free pass through, whereby the leasing agency passes the service payment on to the contracted service provider on a monthly basis, eliminating the large service contract that would otherwise come due annually after the warranty has elapsed. And, unlike a purchase, a lease can be considered a tax-deductible overhead expense.

Reagent Rental

A reagent rental agreement is arranged by the manufacturer or distributor of the equipment being acquired. The cost is usually based on a cost per reportable test (CPR), but sometimes is based on total test count. In a CPR arrangement, calibrations and controls are not counted in the pricing structure, while in a total test count arrangement, all tests are counted and charged. The price paid per test covers the cost of the instrument, service, reagents and consumables for the term of the agreement, but there is no ownership at the end of the agreement. This option, like leasing, offers the use of capital equipment, reagents and consumables without capital outlay. It also eliminates the need to contract for service annually after the warranty has elapsed because the service is covered in the CPR. For labs with very large volumes, highly competitive CPR rates can be negotiated, making this an attractive option for reference labs. However, the CPR is calculated to cover the cost of the equipment and service in addition to reagents and consumables, so at the end of the term of the agreement, the instrument has essentially been paid for but there is no ownership. If the reagent rental agreement is renewed without renegotiating the terms, the equipment could be paid for more than once without ever achieving ownership.

Successful reagent rental arrangements require the lab operator to have an accurate estimate of test volumes over the length of the agreement. Failure to estimate correctly could mean paying for tests that are never run, or losing the lower cost per test advantage that generally accompanies growth. If the managers estimate of tests performed over the term of the agreement is too low, the organization will pay much more than they need to for tests.

However, for small labs with no capital funds available for instrument purchases, this option might allow the lab to do in-house testing that otherwise might not be available.

Making the Right Choice

Is the technology changing rapidly?

If the technology is volatile and rapidly changing, ownership of highly technical equipment can be a burden. If the technology is going to evolve and change to the extent that the equipment is out of date by the end of the term of the loan or lease, ownership is not always desirable, unless the dated equipment could be used as a backup instrument.

What is your financial position?

Is your cash flow sluggish? Choose a reagent rental.

Is your credit tapped out? Choose a lease or reagent rental.

Is it preferable for the equipment to show up on the balance sheet as a long-term debt (buy it) or on the operating statement as an expense (lease it or go the reagent rental route)?

Who has the best deal?

Talk to the rep who sells you your medical supplies.

Talk to your group purchasing organization.

Talk to someone from whom you’ve purchased medical equipment before.

Ask other offices who they’ve purchased from.

Ask a consultant to shop it for you.

Talk to someone from your specialty society to see if any deals are to be had from affiliates.

Finally…

Crunch the numbers, consider your group’s position financially and tax-wise, and make a the best decision based on what you know about your world today, and your best guess about tomorrow.

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.

Laboratory Equipment Image by RahelSharon via Flickr

Yesterday I had the pleasure of speaking to the Fayetteville (NC) Area Medical Group Managers Association (FAMMA) and we had a lively discussion about social media and healthcare. Here’s the link that you can use to download my powerpoint presentation.

Hospital Wage Index Reform Call

Special Open Door Forum: Presentation and Listening Session on Hospital Wage Index Reform

Tuesday, April 12, 2011, 1:30 PM 3:00 PM ET.

Section 3137(b) of the Affordable Care Act requires CMS to submit to Congress, by December 31, 2011, a report that includes a plan to reform the wage index under the Medicare hospital inpatient prospective payment system (IPPS). CMS acquired the services of Acumen, LLC to assist in its study of the wage index. During the first part of this special open door forum, Acumen will present its concept of an alternative methodology for the wage index. The second part will be a listening session, during which CMS would like to hear from you regarding your opinions about Acumen’s concept, as well as any suggestions on alternative methods for computing the wage index. If you wish to participate via conference call, dial 1-800-837-1935 Conference ID 50101623. Please see the full participation announcement in the Downloads section here.

Electronic Health Record Incentive Program Attestation Begins This Week

Attestation for the Medicare Electronic Health Record (EHR) Incentive Program begins on Monday, April 18, 2011. In order to receive your Medicare EHR incentive payment, you must attest through CMS’s web-based Medicare and Medicaid EHR Incentive Programs Registration and Attestation System.

You can preview selected screenshots of the Attestation System to help you understand what the attestation process will involve. Please note that these screenshots are only examples the final appearance and language may incorporate additional changes. CMS will release additional information about the Medicare attestation process soon, including User Guides that provide step-by-step instructions for completing attestation and educational webinars that describe the attestation process in depth.

You need to understand the required meaningful use criteria to successfully attest. Meaningful use requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare EHR Incentive Program are different:

• EP Meaningful Use Criteria Must report on 15 core measures, 5 of 10 menu measures, and 6 clinical quality measures, consisting of 3 required core measures and 3 additional measures.

• • Visit the Stage 1 EHR Meaningful Use Specification Sheets for EPs for information on core and menu measures for EPs.
  • Visit the Clinical Quality Measures page for information on the required clinical quality measures for EPs.

• Eligible Hospital and CAH Meaningful Use Criteria Must report on 14 core measures, 5 of 10 menu measures, and 15 clinical quality measures.

• • Visit the Stage 1 EHR Meaningful Use Specification Sheets for Eligible Hospitals and CAHs for information on core and menu measures for eligible hospitals and CAHs.
  • Visit the Clinical Quality Measures page for information on the required clinical quality measures for eligible hospitals and CAHs.

You should also make sure that you begin your 90-day reporting period in time to attest and receive a Medicare payment in 2011. The last days to begin 90-day reporting periods for 2011 incentive payments are:

• Sunday, July 3, 2011, for eligible hospitals and CAHs; and
• Saturday, October 1, 2011, for EPs.

Under the Medicaid EHR Incentive Programs, the date when participants can begin attestation for adopting, implementing, upgrading, or demonstrating meaningful use of certified EHR technology varies by state. Visit the Medicaid State EHR Incentive Program web-tool for more information about your state’s participation in the Medicaid EHR Incentive Program.

Want more information about the EHR Incentive Programs? Make sure to visit the CMS EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs; also read the new EHR Incentive Program FAQs from CMS.

Preventive Services, Preventive Physical Examinations and Annual Wellness Visits Quick Reference Charts

The ABCs of Providing the Initial Preventive Physical Examination Quick Reference Chart provides Medicare Fee-For-Service providers a list of the elements of the IPPE, as well as coverage and coding information. View the chart here.

The ABCs of Providing the Annual Wellness Visit Quick Reference Chart provides Medicare Fee-For-Service providers a list of the elements of the AWV, as well as coverage and coding information. View the chart here.

The Medicare Preventive Services Quick Reference Chart provides Medicare Fee-For-Service providers coverage, coding, and payment information on the variety of preventive services covered by Medicare. View the chart here.

A hardcopy booklet containing all three charts, as well as the Quick Reference Information: Medicare Immunization Billing chart, will be available at a later date.

Latest HCPCS Code Set Changes

The Centers for Medicare & Medicaid Services is pleased to announce the scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set. These changes have been posted to the HCPCS web page here. Changes are effective on the date indicated on the update.

Revisions to ASP Pricing Files

The Centers for Medicare and Medicaid Services (CMS) has posted revised October 2010 and January 2011 ASP (average sales price) files, which are available for download here (see left menu for year-specific links).

Physician or NPP Signatures on Lab Requisitions

In the Monday, November 29, 2010, Medicare Physician Fee Schedule final rule, the Centers for Medicare & Medicaid Services (CMS) finalized its proposed policy to require a physicians or qualified non-physician practitioners (NPP) signature on requisitions for clinical diagnostic laboratory tests paid under the clinical laboratory fee schedule effective Saturday, January 1, 2011. (A requisition is the actual paperwork, such as a form, which is provided to a clinical diagnostic laboratory that identifies the test or tests to be performed for a patient.)

On Monday, December 20, 2010, CMS informed its contractors of concerns that some physicians, NPPs, and clinical diagnostic laboratories are not aware of or do not understand this policy. As such, CMS indicated that it will focus in the first quarter of 2011 on developing educational and outreach materials to educate those affected by this policy. CMS indicated that once the first quarter educational campaign is fully underway, it will expect requisitions to be signed.

After further input from community, CMS has decided to focus for the remainder of 2011 on changing the regulation that requires signatures on laboratory requisitions because of concerns that physicians, NPPs, and clinical diagnostic laboratories are having difficulty complying with this policy.

Face-to-Face Encounter Requirements for Home Health and Hospice

Effective April 1, 2011, the Centers for Medicare & Medicaid Services (CMS) expects home health agencies and hospices have fully established internal processes to comply with the face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patients eligibility for Medicare home health services and of recertification for Medicare hospice services.

Section 6407 of the ACA established a face-to-face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner working with the physician, has seen the patient. The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.

Similarly, section 3131(b) of the ACA requires a hospice physician or nurse practitioner to have a face-to-face encounter with a hospice patient prior to the patients 180th-day recertification, and each subsequent recertification. The encounter must occur no more than 30 calendar days prior to the start of the hospice patients third benefit period. The provision applies to recertifications on and after January 1, 2011.

On December 23, 2010, due to concerns that some providers needed additional time to establish operational protocols necessary to comply with face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patients eligibility for Medicare home health services and of recertification for Medicare hospice services, CMS announced that it will expect full compliance with the requirements, beginning with the second quarter of CY2011.

Throughout the first quarter of 2011, CMS has continued outreach efforts to educate providers, physicians, and other stakeholders affected by these new requirements. CMS has posted guidance materials including a MLN Matters article, questions and answers documents, training slides, and manual instructions which are available via CMS Home Health Agency Center and Hospice webpages. CMS Office of External Affairs and Regional Offices contacted state and local associations for physicians and home health agencies and advocacy groups to ensure awareness about the face-to-face encounter laws, and to distribute the educational materials.

CMS will continue to address industry questions concerning the new requirements, and will update information on the Web site here for home health and here for hospice.

Federally Qualified Health Center Fact Sheet Revised

The revised publication titled Federally Qualified Health Center (revised March 2011) is now available in downloadable format from the Medicare Learning Network here. This fact sheet is designed to provide education about Federally Qualified Health Centers (FQHC), including background; FQHC designation; covered FQHC services; FQHC preventive primary services that are not covered; FQHC Prospective Payment System; FQHC payments; andMedicare Prescription Drug, Improvement, and Modernization Act of 2003 provisions that impact FQHCs.

Avoiding the Adjustment 2012 Medicare Payment Adjustment for Not ePrescribing in 2011

In November 2010, the Centers for Medicare & Medicaid Services announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between Sat Jan 1 and Thu June 30, 2011, may be subject to a payment adjustment on their Medicare Part-B Physician Fee Schedule-covered professional services. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx Incentive Program.

From 2012 through 2014, the payment adjustment will increase each calendar year. In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99% of their Medicare Part-B PFS amount that would otherwise apply to such services. In 2013, an eligible professional or group practice will receive 98.5% of their Medicare Part-B PFS-covered professional services for not being a successful electronic prescriber in 2011 or as defined in a future regulation. In 2014, the payment adjustmentfor not being a successful electronic prescriber is 2%, resulting in an eligible professional or group practice receiving 98% of their Medicare Part-B PFS-covered professional services. (The payment adjustment does not apply if less than 10% of an eligible professionals or group practices allowed charges for the Sat Jan 1, 2011 through Thu June 30, 2011, reporting period are comprised of codes in the denominator of the 2011 eRx measure.) Also 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 eRx Payment Adjustment:

• Eligible professionals An eligible professional can avoid the 2012 eRx Payment adjustment if (s)he:
  • Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of Thu June 30, 2011, based on primary taxonomy code in NPPES;
  • Does not have prescribing privileges. Note that (s)he must report G8644 at least one time on an eligible claim prior to Thu 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.

NOTE: Group Practices For group practices that are 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 75-2500 unique eRx events for patients in the denominator of the measure. For additional information, please visit the Getting Started webpage here or download the Medicares Practical Guide to the Electronic Prescribing (eRx) Incentive Program under Educational Resources on the same website.

Implementation of Errata for Version 5010 of HIPAA Transactions

BTW, errata is a list or lists of errors and their corrections. Errata is plural and the singular is erratum.

CMS does not have a version 4010A1 direct data entry and a separate version 5010 direct data entry. The Priority (Type) of Admission or Visit code is now required on all version 4010A1 institutional claims submitted or corrected via direct data entry, as well as on version 5010 institutional claims, regardless of how they are submitted. Providers that are unsure which code to use are to use code 9 (Information not Available). Additional Priority (Type) of Admission or Visit code values and descriptions are available from the National Uniform Billing Committee or from your servicing MAC. The Priority (Type) of Admission or Visit code is not required on 4010A1 institutional claims submitted or corrected via an 837. More information on Version 5010 here.

IMPORTANT 5010/D.0 IMPLEMENTATION ITEMS

REMINDER 5010/D.0 Errata requirements and testing schedule can be found here

REMINDER Contact your MAC for their testing schedule

READINESS ASSESSMENT Have you done the following to be ready for 5010/D.0?

READINESS ASSESSMENT What do you need to have in place to test with your MAC?

READINESS ASSESSMENT Do you know the implications of not being ready?

New Mental Health Services Booklet

A new publication titled Mental Health Services is now available in downloadable format from the Medicare Learning Network here. This booklet is designed to provide education on mental health services, including covered mental health services, mental health services that are not covered, mental health professionals, outpatient psychiatric hospital services, and inpatient psychiatric hospital services.

Ambulance Fee Schedule Fact Sheet Revised

The revised publication titled Ambulance Fee Schedule (revised March 2011) is now available in downloadable format from the Medicare Learning Network here. This fact sheet is designed to provide education about the Ambulance Fee Schedule including background, ambulance providers and suppliers, ambulance services payments, and how payment rates are set.

Health Professional Shortage Area Fact Sheet Revised

The revisedpublicationtitled Health Professional Shortage Area (revised March 2011) is now available in downloadable format from the Medicare Learning Network here. This fact sheet is designed to provide education on the Health Professional Shortage Area (HPSA) payment system and includes an overview of the program and general requirements.

Medicare Disproportionate Share Hospital Fact Sheet Revised

The revised publication titled Medicare Disproportionate Share Hospital (revised March 2011) is now available in downloadable format here. This fact sheet is designed to provide education on Medicare Disproportionate Share Hospitals (DSH) including background; methods to qualify for the Medicare DSH adjustment; Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and Deficit Reduction Act of 2005 provisions that impact Medicare DSHs; number of beds in hospital determination; and Medicare DSH hospital payment adjustment formulas.

G0431QW is Deleted and G0434QW is Added to CLIA Waived Test Schedule

The Centers for Medicare & Medicaid Services (CMS) is updating the status of two codes on the Clinical Laboratory Fee Schedule (CLFS).

• Effective April 1, 2011, code G0431QW is deleted from the CLFS. Code G0431 describes a high complexity test, and should not be reported with a QW modifier; the QW modifier indicates a CLIA waived test.
• Effective April 1, 2011, code G0434QW is added to the CLFS. Code G0434 can describe a CLIA waived test. The use of the QW modifier to indicate a CLIA waived test is necessary for accurate claims processing.

Codes G0431 and G0434 will remain on the CLFS.

CMS Launches a Dedicated Web Page for the Medicare Shared Savings Program/Requirements for ACOs

On March 31, 2011, The Centers for Medicare & Medicaid Services (CMS) published in the Federal Register proposed rule CMS-1345-P, Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations that implements the Medicare Shared Savings Program (Shared Savings Program) and establishes the requirements for Accountable Care Organizations. CMS has launched a dedicated web page here for Medicare FFS providers and other providers of services and suppliers. Bookmark the web page and check back often, as CMS continues to add information on the program.

Program for Evaluating Payment Patterns Electronic Report (PEPPER) for CAHs

Beginning in April 2011, the Centers for Medicare & Medicaid Services (CMS) will make available free hospital-specific comparative data reports for critical access hospitals (CAHs) nationwide. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) provides hospital-specific data statistics for Medicare discharges at risk for improper payments. Hospitals can use the data to support internal auditing and monitoring activities. PEPPER is the only free report comparing a CAHs Medicare billing practices with other CAHs by state, Medicare Administrative Contractor (MAC) or Fiscal Intermediary (FI) jurisdiction and the nation. CMS has contracted with TMF Health Quality Institute to develop and distribute the reports.

PEPPER will be distributed electronically to CAH QualityNet Administrators and those who have basic user accounts with the PEPPER Recipient role on or about Monday, April 25, via a My QualityNet secure file exchange. In preparation for receiving and downloading PEPPER from My QualityNet, these individuals should verify that their computer systems are equipped with the software and configuration required to use My QualityNet by following the steps at www.qualitynet.org (see Getting Started With QualityNet and Test Your System.) Additional information about downloading PEPPER from My QualityNet can be found here (includes System Setup and Test Guide, Troubleshooting Tips and a guide for Configuration Changes for Compatibility with QualityNet).

CAHs may work with their Quality Improvement Organization (QIO) to obtain a QualityNet administrator account by visiting www.qualitynet.org and clicking on the Hospitals – Inpatient link. Obtaining a My QualityNet account may take several weeks; CAHs should plan accordingly.

TMF will conduct a web-based training session for CAH staff providing information on PEPPER and how to use it on Thursday, April 28, at 1 p.m. central time. To register for the training, CAH staff should visit https://tmfevents.webex.com. The training will be recorded and posted on http://www.pepperresources.org.

For more information, including the PEPPER distribution schedule, a sample PEPPER for CAHs and information about QualityNet accounts, visit the PEPPER website. CAH staff are encouraged to join the e-mail list on this website to receive important notifications about upcoming PEPPER distribution and training opportunities.

Image by The Library of Congress via Flickr

Fiduciary: a duty (from Latin fiduciarius, meaning “(holding) in trust”; from fides, meaning “faith”, and fiducia, meaning “trust”) is a legal or ethical relationship of confidence or trust regarding the management of money.

Over the past few months the prominence of the word fiduciary in the news has drawn attention to the definition of responsibilities of employers for retirement plans. The United States Department of Labor (USDOL) has been the driving force behind this increase in awareness. Yet the word remains largely misunderstood by most plan sponsors (i.e. employers.)

The most common question I get asked by practice administrators is Am I a fiduciary on our retirement plan, and if so, what does that mean? Unfortunately, there is no simple answer to this question.

The key to answering the fiduciary question is to identify if you exercise discretion or control over the plan. If you, as a practice administrator, exercise control over the plan itself or the assets then the USDOL has identified you as a fiduciary for your firms retirement plan. As such, you get to enjoy all the increased liability and perks that come with that role.

The problem that encumbers most practice administrators is defining what constitutes discretion or control over the plan. Welcome to one of many gray areas in the retirement plan industry. Most plan sponsors feel confident that they have hired a professional who handles the plan and by default they are exempt from fiduciary duty. However, the DOL clearly states that those who hired the service provider also have fiduciary responsibility.

To try and clarify the confusion the DOL has stated business decisions are not a fiduciary action. An example would be the decision to start a plan. This is simply a business decision aimed at rewarding or attracting employees. However, the steps to implement or maintain the plan are taken on behalf of the plan and may trigger fiduciary.

Now that we have established how to identify fiduciary decisions we should define what it means to be a fiduciary. Fiduciaries act on behalf of the participants of a plan and their beneficiaries. As such they are responsible to:

• Act solely in the interest of plan participants and their beneficiaries and with the exclusive purpose of providing benefits to them;
• Carry out their duties prudently;
• Follow the plan documents (unless inconsistent with ERISA);
• Diversify plan investments; and
• Pay only reasonable plan expenses.

Acting prudently under ERISA requires expertise in several different areas, such as investing. In order to fulfill their duty a fiduciary will want to hire someone with professional knowledge to carry out the investment function. Additionally, acting with prudence would suggest that a process was used to make fiduciary decisions and this process should be documented.

Being a fiduciary for a plan carries a lot of responsibility, and potential liability. Fiduciaries may be personally liable to restore losses to the plan or subject to fines for failure to carry out their duties in a manner consistent with basic standards of care.

The good news is that there are ways to reduce any potential liabilities. Providing participants control over the investments decisions in their accounts is one common way to reduce potential liability.

However, by now you know that this is not as simple as it seems. In order to reduce liability participants must be given a broad range of investment options that allows them to diversify the risk. Additionally, participants must be given adequate information that enables them to make an informed decision about the different investment options offered. Even further, participants must be allowed to give investment instructions at least once a quarter, and perhaps more, depending on the volatility of the investment option. Finally, any relief granted to the fiduciary for allowing participants to direct their own investments does not extend to the fiduciarys responsibility to prudently select and monitor the investment alternatives in the plan.

A second option often used by plan fiduciaries is to hire service providers to handle fiduciary functions. This requires setting up an agreement that assigns liability for those functions selected to the hired party. Again, as always, this helps reduce liability but it does not relieve the plan sponsor from the duty to prudently hire select and monitor the service provider. This includes determining if the service provider is following the guidelines established for their specific role.

Deciding who is a fiduciary and what exactly that means is not an easy task. The most efficient way to reduce your liability is to make sure you document the rationale behind your decisions.

Finally, it may not be clear whether you are a fiduciary or not. The most effective way to reduce any potential liability is to behave as a fiduciary regardless of your actual status. This simply means to perform due diligence as a prudent person would and document the reasons for decisions. Most importantly, please remember that executing the will of the physicians does not necessarily relieve you of your fiduciary duty.

Definitions:

Plan Sponsor: the medical practice or employer

Plan Administrator or Third Party Administrator (TPA): ensures that moneyis beingcontributed into the fund, the proper asset allocation decisions are made and that payouts are promptly distributed among all qualified plan participants or beneficiaries.

Recordkeeper: Recordkeepers are responsible for the tasks associated with tracking participant accounts. Some of these tasks include providing daily, weekly, or monthly valuation; processing investment transactions and handling participant requests for loans. NOTE: Duties of Plan Administrator/TPA and Recordkeeper may be offered by a single entity.

Plan Provider: The Plan Provider is the investment company that manages your plan. A plan provider may be a brokerage, insurance company, mutual fund, or any other investment company.

Plan Advisor: Retirement plan advisors provide a wide variety of services, including investment policy statements, money manager reviews, participant education and enrollment and investment monitoring & reporting.

Resources
Plan Fees Disclosure Form
Understanding Plan Fees and Expenses

Duff Meyer, Institutional Advisor at Carolina Wealth Management

Duff Meyer is the Institutional Advisor at Carolina Wealth Management. A frequent retirement plan speaker, he is dedicated to helping plan sponsors understand and improve their benefit. Duff continually writes articles and informative guides for plan sponsors that are featured in numerous publications and on the web. His entire financial career has been dedicated to helping plan sponsors find a better 401k. He is an advocate for plan sponsor, not the plan provider. He can be reached here.

The definition for marketing that I like is “the process of establishing and maintaining mutually beneficial relationships with stakeholders to facilitate exchanges.”

To expand that definition, consider:

• Mutually beneficial relationships are created when the healthcare entity has a service to provide and consumers of healthcare seek out the service and (ideally) are a payer source.
• Stakeholders can be the healthcare consumer, but can also be the employer who purchases insurance for consumers or directly purchases the services, the federal or state government who reimburses the healthcare entity, the insurance company itself, other healthcare providers including hospitals and physicians, or other companies such as banks providing funding, liability companies providing malpractice insurance, and Independent Review Boards (IRBs) and other third-parties that pay for services. An argument can be made that everyone the practice comes in contact with who has a part in enabling the healthcare entity to be reimbursed for services is a stakeholder.
• A exchange is facilitated when the payer source wants the service, understands the service, and an agreement is made for the terms of the exchange.

How To Develop a Marketing Plan Part 1: Evaluation Process

1. Determine the services you want to provide. Basic services may be straightforward to market to a community as many locations have need for more healthcare services, but new or specialized service lines or ancillaries will need a marketing plan. For instance, a family practice medical group may provide primary care to children and adults, but may also want to develop a diabetes clinic to provide more intensive education and care to a larger diabetic population. An internal medicine or cardiology group may develop an anti-coagulation (coumadin) clinic and a general surgery group may want to establish a wound care clinic. If the new service is developed for existing consumers only, then marketing is largely an internal issue. If your service will be available to new consumers, an external campaign is crucial.
2. Determine your geographic market. Do you plan to market to the immediate/local consumer, to the regional consumer, statewide, through multiple adjacent states, or state blocks such as the East Coast, the Mid-Atlantic, New England, etc.? Do you plan to market your service to consumers in other countries?
3. Identify any consumers in your chosen demographic market who have already purchased services from you to evaluate the potential for consumers to drive the distance to purchase your services.
4. Determine what is currently being provided in the geographic market you’ve chosen and evaluate what potential exists for competitors to provide the same service in the same area. Some places to gather information without cost are:
   1. ZipSkinny (demographics by zip code)
   2. City-Data (includes info on neighborhoods and has a forum)
   3. ZipWho (advanced search capabilities)
   4. State Health Facts (Kaiser Family Foundation)
5. Other methods to assess the need for your service are:
   1. Focus Groups
   2. Telephone Surveys
   3. Mail Surveys
   4. Mall Surveys
   5. Referring Source Surveys (hospitals, physicians, agencies)
6. Now that you have all this data, make an informed decision about going forward with your new service, and marketing it.

How To Develop a Marketing Plan Part 2: The Strategy

Once you’ve determined that a need exists for services you want to provide and you’ve identified the target service area, you must develop a strategy for cultivating a desire for the service and encouraging consumers to come to you for the service.

1. Wrap your brand around the new service, or if the new service will be branded separately, develop that new brand. A brand is a name, term, symbol, special design or some combination of these that is intended to identify the service and differentiate it from the services of competitors.
2. Determine your target market. Are you targeting consumers directly, or are you targeting care providers, employers, businesses, or payers?
3. If your marketing budget was not established as part of the pro forma, establish it now.
4. Select your marketing methods based on your target:
   • Direct to consumer methods include free meet and greet appointments, lectures, personal appearances, direct mail, print advertising, radio, TV, billboards, theatre pre-movie ads and online methods including Facebook, interactive websites, blogs, Twitter, texting, Google advertising, Google Places (not yellow pages), Groupon, Social Living and Facebook advertising.
   • Direct to other service purchasers include online and print press releases, direct mail, invitations to events, personal visits, service brochures and referral sources.
5. Put together your timeline leading up to the launch of your service.

How To Develop a Marketing Plan Part 3: Execute and Monitor

1. Prepare a table or spreadsheet of your strategy and timeline, assigning responsibility for each phase of your plan.
2. Be prepared to collect data both in person and online to analyze which marketing mediums produced conversions (consumers buying your service). Ask every single person who uses the new service “How did you hear about us?” and log it. Use analytics programs to assess online activity surrounding your brand and service.
3. Evaluate your results from different marketing mediums and eliminate those producing poor results and focus on those producing conversions.

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