In Episode #4 of The Manager’s Minute Video Series, Mary Pat explains the difference between insurance “eligibility” and insurance “benefits” and why a successful practice should check them both for every patient, at every visit.
At a press conference last Thursday, Secretary of Health and Human Services Kathleen Sebelius and Attorney General Eric Holder announced the creation of a “Public-Private Partnership” to prevent healthcare fraud. The voluntary partnership between federal and state agencies, private healthcare insurers and fraud prevention groups is designed to share information among all groups proactively to go after common healthcare fraud schemes. Sharing informationlike best practices, front line observations on emerging threats as well as “scrubbed” patient population data will allow coordinated efforts between payers and law enforcement to stop fraud before it happens.
“Previously, neither the government nor insurers chased the money until it was ‘out the door’ in what has been called a pay-and-chase model. Now, we’re taking away crooks’ head start” – Secretary of Health and Human Services Kathleen Sebelius
Building on new legislative tools passed as part of the Affordable Care Act, as well as initiatives like the Healthcare Fraud Prevention and Enforcement Action Team (or HEAT for short), the new public-private partnership is designed to share intelligence with all stakeholders in fraud prevention so more fraud can be prevented as opposed to prosecuted.
For fraudulent providers and billers, the effects of the new partnership should be pretty obvious – more and better ways for you to get caught. But for the the compliant majority, data sharing partnerships like this one provide insight into how payers law enforcement will be working together in the future. As more health data is standardized, easily blinded and shareable, information partnerships between all parts of the healthcare ecosystem will become more common, and software vendors will find more ways to slice and dice the “big data” to detect fraudulent billing.
The proposed, but not finalized, deadline for ICD-10 is October 2014. Most coding experts recommend training staff 6 months before the deadline. What’s a practice to do with the other 18 months?
Who chooses the ICD-9s in your practice today?
There are many methods physicians/providers use to choose a diagnosis code:
- Encounter forms (AKA superbills, fee slips, routing slips, etc.) are used in many practices, even those with EMRs, for the physician/provider to choose the service and the corresponding diagnosis. Some encounter forms have the most common diagnoses printed on the back and the physician/provider is required to choose one or more diagnoses and “map” them to the service provided. In some practices, medical assistants or nurses may complete the encounter form with the physician’s instructions.
- Physicians/providers may write out their diagnoses and leave staff to translate it into a code.
- Surgical practices may have encounter forms for non-office surgeries, or they may use other means to communicate to the biller what actually was done in the OR. Surgeons may use smartphone or iPad charge capture, dictation or surgery cards or duplicate-form tear sheets. Coders may abstract the codes from the dictation the physician completed in the hospital.
- Electronic Medical Record packages may offer physicians choices of diagnoses based on those most-used in the practice, and/or related to the documentation entered and those CPTs and ICD-9s, once chosen, are interfaced to the billing system.
- Some physicians may use both an EMR and an encounter form.
- Coders may abstract the diagnosis straight from the documentation without any intervention on the physician/provider’s part.
Regardless of who chooses the ICD-9 today, realize that much more specific descriptions of the diagnoses will be required to document the correct diagnosis in ICD-10. If the physician/provider is doing the choosing (always my recommendation for non-surgical services), the documentation must support the diagnosis code just the same as if a coder is abstracting the code.
Physicians could, but probably won’t, start improving their diagnosis documentation now. Closer to the October 2014 deadline, your practice may want to have an audit of your diagnosis documentation to see how you would fare in ICD-10 world, and to assist physicians in improving their documentation skills.
Take this opportunity to make your current system better.
A host of changes can potentially use ICD-10 as a scapegoat! For groups using EMR and relying on encounter forms “because it’s comfortable”, the move to ICD-10 is an excellent reason to get rid of the encounter forms. Pushing the code straight from the EMR to the practice management or billing system is the most efficient method overall.
For groups using paper charts, there are a number of free and pay ICD-9 smartphone apps for all brands of phones. You know there will be apps that crosswalk ICD-9 to ICD-10, so get started now getting comfortable with searching for and bookmarking your most used diagnoses on your phone or iPad.
Physicians, does your EMR do this?
Some EMRs already have ICD-10 information in place and available for use now. If it does, start looking at the ICD-10 information provided and begin compiling your new list now. Start your own internal crosswalk to help train your brain for the future.
Think about the life of an ICD-9 code in your practice today.
Make a list of every place and every process an ICD-9 touches. Think beyond attaching a diagnosis to the patient visit, and consider other ways you use ICD-9s. Referrals, test ordering, registries, research…
Consider who in your practice might become the ICD-10 specialist.
It could be a physician, a nurse, a coder or a biller. Someone in your practice should attend webinars or classes to understand the structure of ICD-10 and take on the mentor role for the practice. It may be your coder, or if your coder doesn’t have formal anatomy & physiology training, it might be someone else in the practice. Who should it be?
Is there a possibility ICD-10 will be further delayed or even go away?
Absolutely! Anything is possible. Personally, I don’t think it will and I would rather hedge my bets by spending some time between now and October 2014 preparing for it, then be taken by surprise and try to ramp up in a very short amount of time.
If you start thinking about it now, you’ll have about 2 years to budget and train for the conversion. You can make ICD-10 a standing item in your board and staff meetings. You can start your “life of an ICD-9 code” list. And you can start evaluating physicians, providers, clinical staff and administrative staff (maybe it’s you!) for a starring role in the Big Change.
Start the walk, the crosswalk, that is.
Some ICD-9 codes will have one ICD-10 code only. The rest will have more than one possible ICD-10 . Start by running a report from your billing system or EMR on your top twenty ICD-9s and check to see which of your top twenty ICD-9s have more than one possible ICD-10.
Resources from CMS – Implementation Guides
CMS has developed implementation handbooks to assist with the transition from ICD-9 to ICD-10 codes. Each guide provides detailed information for planning and executing the ICD-10 transition. Use the guides as a reference whether you’re in the midst of the transition or just beginning.
The appendix of each handbook has templates that are available for download in both Excel and PDF files. The templates are customizable and have been created to help entities clarify staff roles, set internal deadlines/responsibilities and assess vendor readiness.
View the tailored step-by-step plans and relevant templates for each of the following audiences impacted by the transition:
There has been a lot of talk about why our emergency departments are often overloaded with patients seeking primary care, not emergency care. This video explains EMTALA, the law surrounding access to emergency treatment in hospitals.
With the baseball season in full swing we get to see the importance of talent as related to results. Those teams that lack talent or lose talent due to injury find themselves trailing their competition. In business, maintaining talent is also a competitive advantage.
In the book “Now, Discover Your Strengths,” authors Buckingham and Clifton define talent as naturally recurring patterns of thought, feeling or behavior that can be productively applied. Usually, talents come so easily to us that we don’t recognize them as talents. We assume everyone can do the same things.
The great insight about talent is the fact that it comes naturally. Not everyone is capable of being a great baseball player, or a great accountant, sales professional, lawyer, teacher, or nurse. We can develop talent by providing additional knowledge and skills, but each of us are unique individuals with special areas of talent.
As a leader you need to be a talent scout. You need to understand the success factors for every position and seek individuals who bring this talent to the team. You must not make the mistake of hiring someone who doesn’t seem to possess the talent, and hope to train them for success. For example, if you are hiring a sales professional – how effective are they in selling themselves? How effective are they in influencing others? How effective are they in describing the sales process with specific examples?
Assuming you do a good job in attracting talent to your team, how do you retain this most important asset? The following are a few suggestions to maintain talent:
1) Never Take Talent for Granted – Many leaders make the big mistake of a common mind set – “everyone is replaceable.” On the one hand, we all realize that a business does not stop because 1 or 2 people leave. However, it’s not easy to replace talent, and why would you want to? Would the Miami Heat have won the basketball championship without Lebron James? What happens if your best sales rep goes to your competition? What about a top surgeon? What about an excellent receptionist?
2) Engage Your Talent – Talented employees want to be involved in the business. Ask for their opinion, listen carefully, and always show respect. Allow staff to become involved in setting goals and objectives.
3) Turn Talents into Strengths – Provide employees with the opportunity to further develop their talents. This may include additional on the job responsibilities with you serving as mentor, or additional education to build on their talent.
4) Allow for Mistakes & Focus on Strengths – Assist others to learn from their mistakes. Your job is to continue to build on the employee’s talents. For example, if you have a supervisor who is excellent at all aspects of the job with one exception – they are not strong at budgeting. Regardless of the amount of coaching or training you provide budgeting is just not their thing. Don’t make the mistake of spending a tremendous amount of time on budgeting. Continue to use this individual’s talents to move the business forward. It may mean that you assign someone from accounting to work closely with this supervisor to help them get through the budgeting process. Don’t dwell on weaknesses – build on strengths.
5) Model Positive Values & Behaviors – You must model values and behaviors such as integrity, compassion and respect. Talented employees want to work in environments where trust and open communications exist. They want to know what is going on and how they contribute to the success of the organization.
I am often asked my opinion of an acceptable turnover percentage. My answer is always – it depends on who is leaving and why? If a talented employee is leaving for the wrong reason (for example – being taken for granted, a boss who is a micro-manager, lack of trust, etc.) then it’s the organization’s fault. If the individual is leaving for a better opportunity – it still may be the organization’s fault. I believe that it’s the responsibility of leaders to really understand and appreciate the talent throughout their organization. If these individuals know that you recognize their talent, and will not take it for granted, you enhance the probability that they will stay on the team.
Leaders must show their employees that they see them as unique individuals with unique and valuable talents. The security guard who demonstrates excellent customer service skills is critical to your success. The secretary who has great analytical and problem solving skills is invaluable.
Please reflect on the following questions. Can you identify the talents of all of your employees? If not, why not? How easy would it really be to replace your talented staff? What are you going to do to ensure you keep your talented staff?
Great leaders never take their employees for granted. They recruit and develop talented employees, allowing individuals to build their talents until they become strengths. They truly care about their employees and demonstrate their respect for everyone on an ongoing basis.
Establishing a great strategy is critical to long term organizational success. Having the talent on your team inspired to achieve your goals is the competitive advantage.
RL Cooper Associates assists clients to identify talents and turn these talents into strengths. For a listing of our services, including our books “Huddle Up,” “Leadership Tips That Enhance Staff Satisfaction and Retention,” and “Heart and Soul in the Boardroom” please visit us at www.rlcooperassoc.com
Is a medication shortage causing you to use single dose vials for more than one patient?
On July 13, the Centers for Disease Control and Prevention (CDC) released a report detailing two life-threatening outbreaks that occurred when healthcare providers used medication from single-dose/single-use vials for multiple patients undergoing treatment for pain.At least 10 patients contracted severe staph or MRSA (methicillin-resistant S. aureus) infections and had to be hospitalized.An additional patient died, and although MRSA was not listed as the cause of death, it could not be ruled out.
Repackaging is the way to go.
According to Charles Duhigg in his newly released book, The Power of Habit, Rhode Island Hospital was one of the nation’s leading medical institutions. It was the teaching hospital for Brown University and the only Level I trauma center in southeastern New England. Rhode Island Hospital also had a reputation as “a place riven by internal tensions”. In one surgery for instance, a neurosurgeon was preparing an emergency surgery for an elderly gentleman with a critical subdural hematoma. Just before the surgery a surgical nurse noticed that the medical chart and other paper work did not indicate the location of the hematoma. The nurse cautioned that the surgeon should wait until the needed paper work was seen. The surgeon yelled at her that he had seen the cranial scan and said he knew where to operate. He didn’t. He opened the skull on the wrong side. Although he corrected his mistake quickly, the patient died soon thereafter. Such errors are not foreign to most hospitals but the number of errors at this hospital due to poor communication, especially between nurses and physicians who overpowered them with their authority, eventually created a culture of high tension and anxiety.
You wouldn’t think that a simple thing like the place of service would have the potential to cause a $9.5M overpayment by Medicare. But that is the figure the OIG (Office of the Inspector General) says it estimates that Medicare contractors overpaid physicians for place of service errors in 2009.
The OIG conducted the 2009 audit to determine whether physicians correctly coded non-facility place- of-service on selected part B claims submitted to and paid by Medicare contractors. The audit report, titled Review of Place-of-Service Coding for Physician Services Processed by Medicare Part B Contractors During Calendar Year 2009 is available at http://oig.hhs.gov/oas/reports/region10/11000516.pdf on the OIG website.
Physicians correctly coded the claims for 17 of the 100 services that the OIG sampled. However, physicians incorrectly coded the claims for 83 sampled services by using non-facility place-of-service codes for services that were actually performed in hospital outpatient departments or ASCs. Based on the sample results, OIG estimated that nationally, Medicare contractors overpaid physicians $9.5 million for incorrectly coded services provided during calendar year 2009. – (MLN MattersNumber: SE1226)
It’s not surprising that physicians might use the wrong place of service. Because of the verbiage used to identify when the physician is providing the space, equipment and overhead versus when he is not, many of us in the field have been confused.
Here’s how CMS describes it:
The most exciting thing for me about being in healthcare today is the contrast between steep challenges the industry faces on so many fronts – and the vast potential offered by biological and information technology. We do have some dragons to slay, but we also have amazing tools: genetic research, stem cell therapies and nanotechnology, alongside the potential for insight gleaned from mountains of big data. It’s an exciting time, to be certain, and with so much change happening on so many fronts our work is in the spotlight more than it has been in a long time.
Some of the highlights of the semi-annual report:
- Code 90653 – has been ACCEPTED for inclusion in the 2013 codebook production cycle
“Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use”
- Code 90739 – has been ACCEPTED for inclusion in the 2013 codebook production cycle
“Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use”
- Code 90672 – has been ACCEPTED for inclusion in the 2013 codebook production cycle
“Influenza virus vaccine, quadrivalent, live, for intranasal use”
- Codes 90685, 90686, 90687, 90688 were ACCEPTED for inclusion in the 2014 codebook production cycle
- Codes 90655, 90656, 90657, 90658, and 90660 will include the term trivalent, meaning “conferring immunity to three different pathogenic strains or species”
You can learn more about the changes for July 2012 at the AMA’s Category I Vaccine Code Page