A typical standard operating procedure in many practices when adding a new physician is to phase in his/her schedule  as s/he becomes credentialed by each payer.  Traditionally, new physicians have been able to see Medicare patients immediately due to the Medicare guideline that allowed for a practice to retro-bill for Medicare patients seen before (up to 27 months, actually) the doctor was officially credentialed.

Now all that has changed, and starting April 1, 2009, practices can only retro-bill for Medicare patients seen 30 days prior to the date the credentialing form was filed (if it was ultimately approved.)  What are the implications of this?
continue reading "Attention Medical Practice Staff: Medicare Changes the Rules for Credentialing and Retro-Billing"

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The Medical Home, also called the Patient-Centered Medical Home, and the Personal Medical Home, is a movement to solve the problem of fragmented care (one hand doesn’t know what the other is doing) by having a primary care physician or practitioner act as the center of all care information for the patient.   Fragmented care is dangerous (lack of coordination of care causes mistakes and mistreatments), costly (repetition of diagnostic tests and regimens), and wasteful of healthcare resources.  The Medical Home plan goals are to provide care for all individuals, improve care, and decrease healthcare costs.

“Crossing the Quality Chasm: A New Health System for the 21st Century” was published in 2001 by the Institute of Medicine.  In this landmark book, the patient’s role and responsibility for navigating the healthcare system and acting as the information hub around which the spokes of primary, specialty and tertiary care providers revolve was denounced
continue reading "What is a Medical Home?"

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ARRA: American Recovery and Reinvestment Act of 2009, also called “The Stimulus Package” or “The Stimulus Bill.”  Of the $850B in the bill,  $51B is pegged for the health care industry and $19B of that will be used to incent medical practices to adopt EMRs/EHRs.

CCHIT: the Certification Commission for Health Information Technology is a private organization that certifies EMRs and EHRs based on 475 criteria spanning functionality, interoperability and security.  CCHIT does not evaluate ease of use of products, financial viability of the company offering the software; or the quality of customer support offered by the software vendor.  Whether or not CCHIT will be THE certifying organization to approve “qualified EMRs” will be announced at the end of the year.  (Can be pronounced “SEA-CHIT” or each letter can be pronounced as in “C.C.H.I.T.”)

Comparative Effectiveness: Comparative Effectiveness Research (CER) compares treatments and strategies to improve health.  For CER, HITECH provides $300M for the Agency for Healthcare Research and Quality, $400M for the National Institutes of Health, and $400M for the Office of the Secretary of Health and Human Services.
continue reading "Quick Reference for Acronyms and Buzzwords of ARRA and HITECH"

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By Carla Hannibal, CMM,CPM,CIMBS

Recovery Audit Contractors (RACs) will pursue corrections of Medicare claims by auditing for overpayments and underpayments under Part A or B of the title XVIII of the Social Security Act.  Health care providers will be affected as Medicare has recently contracted with RACs for 2009 and beyond.  RACs will audit every United States and Peurto Rico health care provider who files with Medicare.  The audit and recovery plan is expected to be in place by
continue reading "What Health Care Providers Need To Know About Medicare and the RAC"

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I was intrigued to interview the man behind the upcoming free webinar “Lean Six Sigma for the Medical Practice.”  Frank Cohen, former Physician Assistant, Hospital CEO, and Consultant of 20 years is the Senior Analyst of MIT Solutions, Inc., and the host for this and other webinars that I think many healthcare managers will be interested in.

Cohen specializes in data mining and statistical modeling for medical practices.  His website www.mitsi.org describes their services this way:

MIT Solutions, Inc. has been leading the health care industry in the development of decision support and business intelligence tools for medical practices since 1992. Our sole purpose is to help the practice staff work faster, smarter, make more money and improve compliance. At MIT Solutions, we develop products and services that transform the way you do business.

Cohen is a significant player in the healthcare improvement world for several reasons.  He worked with the AMA in 2008 to introduce the first Payer Report Cards, which focused on how quickly and accurately payers reimburse physicians for medical services.

The report card compared Medicare and seven national commercial health insurers on the timeliness and accuracy of claims processing and was based on a random sample drawn from 3 million claims.  According to the AMA report, UHC ranked lowest in contract compliance with a rate of 62% of claims correctly paid per contract.  Aetna ranked higher with 71% correctly paid and 98% of Medicare claims were correctly paid.  You can review the payer report card here.  Knowing how hard it can be to ensure that claims are paid correctly in the typical medical practice makes the feat of collating and analyzing the data on this scale impressive.

Cohen also developed CMPA, or Comprehensive Medical Practice Analysis, which includes analyses of Procedure Code Compliance, Provider Productivity, Modifier Analysis, E & M Code Utilization Review, Correct Code Initiative (CCI) Compliance, Fee Analysis, EOB-Based Reimbursement Analysis, Procedural Cost-Accounting/Break-Even Analysis, Managed Care Contract Analysis, Relative Value Scale Studies, and Statistical Modeling by Location by Physician.

Cohen’s website hosts an array of valuable downloads available for managers to use.  Here are some examples:

• Comparison of GPCI values by Location – CY2009 vs. CY 2008
• Comparison of RVU values by procedure code – CY 2009 vs. CY 2008
• Physician Compensation Model Using Work RVUs
• RBRVS Calculation Template – 4th Quarter, 2009

Like most of us, Cohen has an interest in how medical practices can continue to meet the burden of increasing costs and shrinking reimbursements.  He looked to the dual programs of Six Sigma and Lean to reveal ways for practices to eliminate wasted time, energy and resources and promote efficiencies in the practice.  Cohen writes:

…I obtained my Six Sigma Black Belt certification and more recently, certification as a Lean Six Sigma (LSS) instructor. Over the past few years, I have struggled with developing a process improvement model that is specific to medical practices only, vetting a host of different tools to eliminate those that have little or no application in our vertical market and customize others to work specifically within a physician’s office. I started applying these to some projects in the past couple of years and am very excited about this model and encouraged that this is one of the best ways to optimize profitability for physicians.

Cohen is providing an introduction to his Lean Six Sigma for medical practices through a free webinar on Tuesday, February 24, 2009 from 11:00 a.m. to 12:00 p.m. Eastern.  Webinars are a wonderful way to spend a little time and no money to learn something.  You need a phone for the audio and a computer for the video and chat functions.  I’ve signed up and I hope to “see” you there.

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FrontPageMag.com’s article “Health Care’s New Entrepreneurs” by writer Paul Howard gives a sucinct yet detail-filled overview of what docs are doing to overcome the obstacles primary care docs and patients face.  Paul Howard is the director of the Manhattan Institute’s Center for Medical Progress and the managing editor of its web-based journal, Medical Progress Today.

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From today’s US News & World Report:

This is the fourth year that U.S. News and the National Committee for Quality Assurance, managed care’s major accrediting and standards-setting body, have teamed up to rank healthcare plans. We release the rankings during open-enrollment season, when millions of Americans prepare to select their healthcare coverage for the next year. Go here to view the top 50 commercial plans, top 25 Medicare plans, and top 25 Medicaid plans.

How were plans rated?

The rankings … show how well plans do at preventing and treating illness and providing consumer services to members.

How is consumer service defined?

(Measures) …included members’ opinions about the ease of making appointments and getting care, doctors’ ability to communicate effectively, and satisfaction with claims handling.

I find these measures particularly interesting as only “satisfaction with claims handling” is a measure of the plan.  “Making appointments” and “doctors’ ability to communicate effectively” are services provided by the participating physician, unless the physicians are employed by the plan.  I would like to see measurements of plans be more along the lines of:

• clarity of plan details communicated to subscribers and physicians;
• ability of plan agents to communicate with consumers and physician offices about routine issues and priority issues;
• ability of the plan to provide the physician office (preferably electronically) with pre-authorizations and pre-notifications for services, procedures, surgeries, and implants in a timely and efficient manner.  These functions, which are very critical to getting patients needed services in a timely and efficient manner, are not usually considered to be a part of the claims handling process.
• ability of the physician offices to obtain (electronic) information on individual plan benefits by subscriber or beneficiary OR electronic adjudication of the patient’s visit that day;
• ability of the payer to provide the physician office with info for giving patients real quotes on tests, therapies, procedures and surgeries so that patients can make informed decisions about the cost of their care prior to having a service.

I know that to measure this, the plans would have to collect data from the physician offices (and some do), and publish this (none do that I know of.)  Kudos to any plans doing this (and write to me and tell me if they/you are) because it acknowledges that the physicians are stakeholders and are a critical part in satisfying consumers.

Medical Group Management Association (MGMA) recently sponsored a survey ..”to assess group practice professionals’ attitudes concerning payers in all 50 states.”  Members who participated will receive a copy of the survey for responses from their state.

More on NCQA:

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I’ve always wanted to go on a cruise and recently I did when I found a great price on the internet.  A cruise has always seemed to me to be the ultimate escape – no cell phone, no computer, no deadlines! I was amazed that I could get a wonderful trip (5 days, 4 nights) for an extremely reasonable price.  But, as my mama always told me, you get what you pay for.

The cruise was not the ultimate escape.  But it was a lesson.  A lesson in marketing.  And I’ve been thinking that I can apply the techniques I saw used on the cruise to reinvent healthcare and bolster the finances of my orthopedic practice.  Here are my ideas (based on the cruise economy):

• At every visit, patients will automatically have their pictures taken and will have their choice of backgrounds such as goal posts (athletic injuries) and ski slopes (vacation injuries) as well as seasonal specials (appropriate for Christmas cards, Valentine’s gifts, etc.)  When the patient is released, a photo counselor will be available to show the patient all the pictures of the health episode and photo packages will be available for as little as $29.99.
• Roving baristas will offer trays of the “health drink of the day” available for $7.50 each, or $4.50 without the souvenir glass.
• To make the time go faster while in the waiting room, BINGO will be played, and BINGO cards will be available at a special of “buy 4, get 1 free.”  There will be a guaranteed jackpot every single day!
• Exam rooms will have exclusive towels with a monogrammed practice logo, available for purchase at the check-out desk ($22.00 for one or $40.00 for two.)
• Exam rooms are stocked with soft drinks ($1.95) and bottled water(4.95) for the patient and family member’s convenience.
• Comfortable spa robes are provided for patients moving from the exam room to the x-ray suite.  Robes that are worn are automatically purchased and charged to patient accounts according to infection control guidelines.
• If patients happen to be in the practice during the breakfast, lunch or dinner hour, a menu will be available and meals will be delivered  at prices from $5.99 to $15.99 plus tax plus 15% gratuity.
• Commemorative x-rays are available in standard ($19.99), framed ($59.99) and autographed by the surgeon ($119.99.)
• All patients will be automatically charged tips for the staff at every visit: $1.00 for the front desk, $2.00 for the x-ray technician, and $3.50 for the medical assistant.

Okay, okay, you get the point.

Don’t you?

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With the Centers for Medicare and Medicaid Services (CMS) revealing yesterday what the Medicare premiums and deductibles will be for 2009, it seems like a good time to brush up on Medicare and what choices providers have in enrolling and participating in Medicare.

Medicare is a health insurance program created in 1965 for:

• people age 65 or older,
• people under age 65 with certain disabilities, and
• people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

TRADITIONAL/ORIGINAL FEE-FOR-SERVICE MEDICARE

Medicare Part A - 99% of patients don’t pay a premium for Part A (hospital insurance) because they or a spouse already paid for it through their payroll taxes while working. The $1,068 deductible for 2009, paid by the beneficiary when admitted as a hospital inpatient, is an increase of $44 from $1024 in 2008.   Part A helps cover:

• inpatient care in hospitals
• including critical access hospitals
• skilled nursing facilities (not custodial or long-term care)
• some hospice care
• some home health care

Medicare Part B – Part B (outpatient/doctor insurance) base premium for 2009: $96.40/month (no change from 2008.)  Premiums are higher for single people over 65 making more than $85K per year and for couples making over $170K.  Part B premiums cover approximately one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over.  The remaining Part B costs are financed by Federal general revenues.  In 2009, the Part B deductible will be $135, the same as it was in 2008.  Part B helps cover:

• doctors’ services and outpatient care
• some services of physical and occupational therapists
• some home health care

Medicare Part D -  Starting January 1, 2006, Medicare prescription drug coverage became available to everyone with Medicare.  In 2008, the deductible is $275, in 2009 it will be $295.

MEDICARE HEALTH PLANS (MEDICARE ADVANTAGE)

Medicare Part C – Medicare now offers beneficiaries the option to have care paid for through private insurance plans.  These private insurance options are part of Medicare Part C, which was previously known as Medicare+Choice, and is now called Medicare Advantage. Medicare Advantage expands options for receiving Medicare coverage through a variety of private insurance plans, including private fee-for-service (PFFS) plans, health maintenance organizations (HMOs) and preferred provider organizations (PPOs), and through new mechanisms such as medical savings accounts (MSAs), as well as adding payment for additional services not covered under Part A or B.

 

COMPARISON OF MEDICARE PLANS

Original Medicare Plan

WHAT? The traditional pay-per-visit (also called fee-for-service) arrangement available nationwide.

HOW? Providers can choose to participate (”par”) or not participate (”non-par”.)  Participating providers accept the Medicare allowable and collect co-insurance (20% of the allowable.) Reimbursement comes to the providers.  Non-participating providers may charge 15% more (called the “limiting” charge) than the Medicare allowable schedule, but the patient will receive the check, which is why some non-par practices require payment at time of service for Medicare patients. To charge patients for non-covered services, patients must sign an ABN before the service is provided.

Original Medicare Plan With Supplemental Medigap Policy

WHAT? The Original Medicare Plan plus one of up to ten standardized Medicare supplemental insurance policies (also called Medigap insurance) available through private companies.

HOW? Medigap plans may cover Medicare deductibles and co-insurance, but typically will not cover anything Medicare will not.  Medicare primary claims will “cross-over” to many Medigap secondary claims so the practice does not have to file the secondary Medigap claim.  Patients may still have a small balance that is cost-prohibitive to bill for.

Medicare Coordinated Care Plan

WHAT? A Medicare approved network of doctors, hospitals, and other health care providers that agrees to give care in return for a set monthly payment from Medicare. A coordinated care plan may be any of the following: a Health Maintenance Organization (HMO), Provider Sponsored Organization (PSO), local or regional Preferred Provider Organ. (PPO), or a Health Maintenance Organization with a Point of Service Option (POS).

HOW? You have to have signed a contract or be grandfathered in (called an “all-products” clause) under an existing contract to see patients and get paid. Primary care providers may have to provide referrals and/or authorization for specialty services and providers. A PPO or a POS plan usually provides out of network benefits for patients for an extra out-of pocket cost.

Private Fee-For-Service Plan (PFFS)

WHAT? A Medicare-approved private insurance plan. Medicare pays the plan a premium for Medicare-covered services. A PFFS Plan provides all Medicare benefits. Note: This is not the same as Medigap.

HOW? Most PFFS plans allow patients to be seen by any provider who will see them. PFFS plans do not have to pay providers according to the Medicare fee schedules or pay in 15 days for clean claims.  Providers may bill patients more than the plan pays, up to a limit. It would be a good thing to notify patients if your practice intends to bill above the plan payment.

Need more?  Try CMS or Medicare.

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Here are two of the newest healthcare games on the market. First up, Rite Aid:

They’re giving $30 gas debit cards with the transfer of a prescription to their store. If the Rx stays with Rite Aid, consumer’s name stays in play to win the gas lottery — a $2,600 gas card.

And next, Aetna:

Aetna is sponsoring a study to see if a lottery can enhance patients’ adherence to prescribed drugs. The Aetna Foundation funded a Universtiy of Pennsylvania team to use prizes of $10 and $100 to reward consumers to take drugs as prescribed. An electronic monitor (the Med-E-Monitor) will track whether 100 participants are taking their warfarin. 50 patients will be enrolled in the lottery with a 1 in 10 chance of winning $10 a day, and 1 in 100 chance of winning $100. A text message will be sent each day to tell the patient whether he/she won the lottery, or if the dose wasn’t taken, whether they would have won the money. 50 people in the control group will be using the electronic monitor but won’t be incentivized with the lottery game.

Both these games are reported by Jane Sarasohn-Kahn at Health Populi. Read the full post here.

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