Note: I am republishing this to my email subscribers because none of the links worked the first time around. I’ve fixed everything now – so sorry for the error – must have been healthcare fatigue!
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I’ve noticed that a lot of people in healthcare seem unusually tired and even, if I dare say so, somewhat cranky. This includes me. I’ve decided we’re all suffering from healthcare fatigue – fatigue from dealing on a daily basis with so much change, uncertainty, and financial stress. Here’s my top ten list of healthcare management stressors accompanied by posts I’ve written that discuss the topic or suggest resources for the challenge.
10. Red Flags Rules – on again, off again, patients don’t want to have their pictures taken or let you copy their driver’s licenses.
- Red Flags Rules (RFR) Delayed for the Fifth Time – This Time Until December 31, 2010
- Red Flags Rule and Identity Theft Prevention: You Don’t Have To, But You Should!
- Image by purpleslog via Flickr
9. HIPAA - don’t be fooled, HIPAA is not something we handled years ago and it’s taken care of; there are new requirements and penalties associated with HIPAA breaches. HIPAA is a biggie and something that now infiltrates almost every facet of healthcare.
8. Employment Uncertainty – both for you and your staff – the aftermath of layoffs can be even more demoralizing to those who didn’t lose their jobs. Also, many healthcare entities are still freezing raises. If I hear one more time “we’ll just have to do more with less” I might just scream.
- My Take on “10 Ways to Keep Employees Happy” in Medical Practices
- Dear Mary Pat: Should Staff Be Allowed to Use The Internet on Their Smart Phones at Work?
- Image by jcoterhals via Flickr
7. Unrealistic Workloads – directly related to #9, most staff and managers have much more work to do than they did just two years ago. Couple that with the ability for managers to be available and work by computer, phone, text message, email or Skype 24/7 and you have fatique that you understand only when you truly, truly stop and wind down for more than three days at a time.
6. Hospitals Buying Practices – this could be a good thing or a bad thing, but as you and I know, change is completely unnerving to most people. Hospitals have very different cultures than private practices and trying to marry the two takes skill, patience and excellent leadership.
- Image via Wikipedia
5. Stimulus Money for Using EMRs – it’s a big decision and many practices are very nervous about purchasing an EMR. Many think that meaningful use components are unrealistic and even more are fearful of the inevitable productivity drop when the EMR is implemented and for months afterwards.
- ARRA Eligible Providers: Who Is Eligible to Receive Stimulus Money and How Much is Available Per Provider?
- FAQ on HITECH, Meaningful Use, Eligible Providers, and the Stimulus Money
- Ten Reasons Why (Some) Physicians Aren’t Rushing to Adopt EMRs
- Electronic Medical Record Guru Rosemarie Nelson Reveals Best EMR Product on the Market Today
4. Unhappy Patients – lots of patients are also trying to do more with less (argghhh!) and are avoiding coming to the doctor whenever possible. The front desk staff and the phone staff in particular are getting a lot more heat when they inform patients they’ll have to make an appointment.
- 50 Customer Service Ideas to Treat Your Patients to Friendly, Easy and Unexpected Service
- How To Be A Billing Advocate for Your Patients
- How to Apologize to a Patient
- A Memo to the Staff: The Preciousness of Patients
3. PECOS – be glad if you don’t know what PECOS stands for, or be very, very afraid.
- Providers Without a PECOS Record Will Receive a Letter From Their Medicare Administrative Contractor (MAC)
- My Notes from the CMS Open Door Forum on May 19, 2010: PECOS, DMEPOS and Blue Ink on Paper Forms
- Is Your Practice Ready for the 60-Day PECOS Countdown?
2. Medicare Reimbursement – this year has been as exhausting as watching a single point of ping pong played for hours – there will be cuts, there won’t be cuts, there will be cuts, there won’t be cuts. Gird your loins as the November 30 deadline looms for the next potential cuts.
- Image by longhorndave via Flickr
- Deja Vu All Over Again: The Medicare Fee Cut is Pushed Back to November 30, 2010
- Attention Medical Practice Staff: Medicare Changes the Rules for Credentialing and Retro-Billing
- 91 Physician Organizations Sign Statement Naming Congress in “Mismanagement of the Medicare Program” and Imploring it to “Honor its Obligation”
1. The Bottom Line – we have RAC audits, more pre-certification and pre-authorization and pre-notification requirements, more denials, high deductible plans, formularies and 50 other things that are making it difficult to know which hoop to jump through to get paid. Expenses continue to go up, reimbursement continues to go down, and the healthcare world spins faster and harder, making us all wonder when it will, or if it ever will slow down.
- There is No Such Thing as a 10-Minute Office Visit
- The ABN: The Most Misunderstood and Underutilized Document in Healthcare
- 101 Ideas for Increasing Revenue and Decreasing Expenses in Your Medical Practice
- How to Develop a New Financial Policy For Your Practice: A Short Course
Medicare Definition of Eligible Provider (EP)
For Medicare, physicians and some hospitals are eligible providers. “Physicians” includes doctors of medicine (MD) or osteopathy (DO), dentists or dental surgeons (DDS or DMD), podiatric medicine (DPM), and optometry (OD) and chiropractors (DC).
For providers, their annual payment will be equal to 75 percent of Medicare allowable charges for covered services in a year, not to exceed the incentives in the table below. Payments will be made as additions to claims payments.
Hospitals include quick-care hospitals (subsection-d) and critical access hospitals and only includes hospitals in the 50 States or the District of Columbia.
Medicaid Definition of Eligible Provider (EP)
Medicaid takes the Medicare definition of eligible providers (physicians) and adds nurse practitioners, certified nurse midwives and physician assistants, however, physician assistants are only eligible when they are employed at a federally qualified health center (FQHC) or rural health clinic (RHC) that is led by a Physician Assistant. Eligible hospitals include quick care hospitals and children’s hospitals.
At minimum, 30 percent of an EP’s patient encounters must be attributable to Medicaid over any continuous 90-day period within the most recent calendar year. For pediatricians, however, this threshold is lowered to 20 percent.
The first year of payment the Medicaid provider must demonstrate that he is engaged in efforts to adopt, implement, or upgrade certified EHR technology. For years of payment after year 1, the Medicaid provider must demonstrate meaningful use of certified EHR technology.
Change 1:
The definition of “hospital-based physician” was recently clarified to include physicians working in hospital outpatient clinics (employed physicians) as opposed to the inpatient units, surgery suites or emergency departments. This still excludes pathologists, anesthesiologists, ER physicians, hospitalists and others who see most of their patients in the ER as outpatients or as hospital inpatients.
Possible Change 2:
The Health Information Technology Extension for Behavioral Health Services Act of 2010 (HR 5040) is a bill in the US Congress originating in the House of Representatives that would amend the Public Health Service Act and the Social Security Act to extend health information technology assistance eligibility to behavioral health, mental health, and substance abuse professionals and facilities, and for other purposes. You can track the bill here.
For more information on stimulus money for meaningful use of an EMR, read my post here.
With so much going on in healthcare, it would not surprise me if a lot of practices missed the February 2010 deadline for three expanded HIPAA rules. This expansion was dictated by the Health Information Technology for Economic and Clinical Health (HITECH) Act passed by Congress in February 2009.
If you haven’t already, get started now with the new requirements.
- New obligations for business associates (BA) – February 17, 2010 Remember that a BA is a person or organization outside of your entity with whom you share protected health information (PHI) so they may provide services to you. Good examples are your billing service, collection agency, attorney, consultant, computer vendors, attorneys and providers of documentation abstracting or coding services. Under HITECH, BA have the same responsibilities for breaches as the healthcare entity does, but it is the healthcare organization’s responsibility to have an updated, signed BA agreement in place that describes this new responsibility. Here is an excellent example of a BA agreement (first link under Publications) that you can download and tweak for your practice.
- New disclosure agreement provision – February 18, 2010 This is a big one! Patients now may waive their right to have you file their medical insurance, pay for your services themselves and request that their medical information NOT be disclosed to their insurance plan or any other entity. In other words, patients may elect to become “self-insured”. I recommend that you create a new financial class for these patients so they neither fall into the standard self-pay/financial assistance class or into their actual insurance class. These patients, if you have any, will need to be identified according to their wishes, which could mean that they want you to file insurance for some services and not for others. This means their record must be tagged for what records can be released and what records cannot. There could be an argument made either way for whether or not these patients should receive self-pay discounts that you have in place for your non-insured patients. I would be interested to know how different groups have decided to handle this. There are sample forms for PHI disclosure accounting and for patients to request an accounting of PHI disclosures in the Manage My Practice Library under Operations.
- Information breach notification – February 22, 2010
We’ve heard a lot about this one as the media (along with HHS) must now be notified if a PHI breach involves 500 people or more. Breaches are being reported weekly as non-encrypted laptops are stolen or repurposed, and as copier hard drives (story here) go unnoticed as a security risk. If a breach involves 500 people or less, each individual must receive written notice with details of the breach, the information disclosed, and the steps being taken by the practice or entity to avoid any future breaches, as well as explaining the rights of the patient(s) in protecting their private healthcare information. Several of my employees have received notification letters from health plans and they have been horrified that this could happen. Note that entities that secure health information through encryption or destruction don’t have to provide notification in the event of a breach!
Enforcement is also beefed up.
Criminal penalties will apply to covered entities that violate privacy rules AND to those organizations’ individual employees (can you track who accesses whose records when?) Civil penalties have been increased and harmed individuals may share in the booty. Probably most importantly, HITECH gives state attorneys general the power to enforce HIPAA rules.
Other resources:
- Everyone is waiting for the other shoe to drop on Medicare payments.
- Private practices may not have the in-house expertise to implement an EMR and may not be able to afford a consultant (although some states are receiving grants to help practices – check your state’s grant here.)
- There is a lot of confusion on the parts of Meaningful Use that have been clarified and of course, on those that haven’t.
- Administrators are distracted by RAC, PECOS, HIPAA , PQRI, eRx and RCM.
- Some practices have spent years avoiding Medicare and Medicaid patients and now don’t have the patient numbers to participate.
- Everyone and their uncle is selling an EMR – who can tell the long-timers who are about to be bought from the short-timers who might last forever?
- Physicians are worried about the drop in production that (some say) happens when a practice launches an EMR.
- There seems to be as many horror stories as there are success stories with EMRs.
- Practices that are affiliated with a hospital are nervous about tying themselves to the hospital in such a serious way as hopping on their EMR package.
- Because two practices can have absolutely opposite experiences with the same EMR, no one can find consistent recommendations for any single product. (It’s not the product, it’s the implementation!)
- Bonus Reason: lots of people are confused about how to qualify for the ARRA money (read my post about this here.)
Dear Readers: Here’s an email I got today asking me to publicize this poll to my readers. I thought it was interesting, so here it is. I look forward to the results.
Hi Mary Pat,
Here at Software Advice, we’ve been getting a lot of questions about the HITECH Act and how practices can get a piece of the Stimulus pie. This got us thinking about EMR adoption rates. Has the stimulus influenced practices to buy? Or has it just reinvigorated research?
We may get some insight this Friday. Recovery.gov is supposed to post their report on stimulus spending. This will include information on any grants awarded between February 17th (the signing of the bill) and September 30th.
In the meantime, we’d like to know your anecdotes. Are more doctors buying because of Stimulus incentives? Take our survey at: Obama’s EMR/EHR Stimulus of 2009 – Creating Buyers or Tire Kickers? Be sure to come back Friday to see the results!
Thanks again for your help.
Best,
Houston
________________________
Houston Neal
Software Advice
www.softwareadvice.com
Office: (512) 364-0117
Fax: (360) 838-7866
Skype: hjneal
Email: houston@softwareadvice.com
BUILD ON WHAT YOU’RE CURRENTLY DOING:
1. Add physician hours – add evening or weekend hours; start your office hours earlier and end hours later.
2. Reduce physician time off – decrease vacation or change weekly days off to 1/2 days off.
3. Set a minimum number of providers to be in the office seeing patients at all times the office is open.
4. Have each provider add one new patient visit to his/her schedule weekly.
5. Add ePrescribing to recoup additional Medicare revenue and streamline prescribing (there are free ePrescribing software packages available, but evaluate them carefully so they don’t add more complexity to the system instead of less.)
6. Report PQRI measures to recoup additional Medicare revenue.
7. Charge patients an out-of-pocket fee for completing patient forms – disability forms, etc. and reserve office visits for treating patients.
8. Choose an EMR that qualifies your practice for the ARRA money (although it has been widely promoted that in a larger practice, an EMR and its associated work will cost more than you will get from the government.)
9. If you are in an underserved or rural area, check to see if there might be grants or funds available locally, in the state or federally, for adding a service to your practice.
10. If your practice does Independent Medical Exams (IMEs), reviews records or depositions, make sure that your fee schedule for such services is current and that the fees are collected before the physician provides the service.
ADD TO YOUR CURRENT SERVICES:
11. Allergy testing & treatment
12. Dispensing pharmaceuticals
13. Dispensing nutriceuticals
14. Dispensing Durable Medical Equipment
15. Group patient visits
16. Coumadin Clinic
17. Heart Failure Clinic
18. Diabetes Education Classes
19. Add primary care to specialty care practices
20. Add specialty care to primary care practices
21. Research
22. Joint Ventures with other practices or hospital
23. Lease space to other entities
24. eVisits (virtual visits or email visits)
25. Elective procedures or services
26. Mid-level providers
27. Walk-in clinic
28. Occupational medicine: drug screens, employment physicals, etc.
29. Hospitalists
30. Medical Director of local nursing homes
31. Complementary & alternative medicine (CAM)
32. Aging in Place services
33. Social worker
34. Concierge practice
35. School team physician
EVALUATE YOUR REVENUE CYCLE MANAGEMENT:
36. Are you renegotiating payer contracts regularly?
37. Do your scheduling staff know how to educate patients about what payers you have contracts with and are in network with and what the patient’s financial responsibility will be?
38. Do staff know what typical new patient charges are to tell the patient?
39. Do you check every patient’s eligibility for insurance benefits immediately prior to every service?
40. Do you have patients sign a financial policy to acknowledge what they are responsible for based on their payer type?
41. Do you copy the patient’s insurance cards at every visit, or at least compare their current card to the card you have on file? Are you able to scan patient insurance cards and driver’s licenses into your practice management (PM) system?
42. Is your PM system able to download the information from the scan into the patient registration screen? If not, do you have a way to confirm that demographic and insurance information has been entered correctly from the cards?
43. Are your charges being posted daily?
44. Does the person who provides the service, or a documentation coding specialist, choose the CPT and ICD9 code?
45. Is the documentation for the charges being completed within 24 hours of the service?
46. Is your encounter form up-to-date with current CPT and ICD9 codes; do you order smaller batches of them so you can change the codes as new services are added in the practice?
47. Do you check the CPT and ICDD9 matching to make sure the codes are valid for the year, the codes adhere to NCCI and LCD edits before you finalize the charges?
48. Do you regularly audit medical records for coding and documentation and give providers feedback on where coding could be improved?
49. Are you using ABNs for Medicare patients who want services that Medicare might not pay for?
50. Do you file claims daily?
51. Do you correct claims daily when they are rejected at the practice management, claims clearinghouse or payer level?
52. Do you correct claims daily when they are rejected at the claim level and are not paid for for reasons that can be corrected?
53. Do you have your contract allowables in your PM system so you know when you are not being paid correctly by contract?
54. Do you appeal unpaid or underpaid claims?
55. Do you check recoupments or requests for refunds from payers and make sure they truly should be refunded?
56. Do you send insurance and patient payments to a lockbox to be scanned and stored digitally for your staff to post from?
57. Do you make payment arrangements in the office for balances after insurance has paid, or payment plans by drafting credit or debit cards?
58. Do you have a policy of not sending statements?
59. Do you collect the patient’s portion of the service at the time of service?
60. Do you collect fees for elective services prior to providing these services?
61. Can your patients make payments online through your website?
62. Do you file a claim with a patient’s estate if they have died?
63. Do you accept cash only from patients who have passed bad checks?
64. Do you accept cash only from patients who have filed bankruptcy with your practice?
65. Do you inadvertently see patients who have been dismissed from your practice?
66. When adding a physician to the practice, do you timeline the credentialing appropriately so the physician can see patients with insurance as well as those without?
67. If your new physician is only partially credentialed with payers, do you have him/her see the patients with payers they are credentialed with and add payers to their schedule load as the credentialing comes through?
68. Do you meet with representatives from your largest payers monthly to establish relationships and bring problems to their attention? (the squeeky wheel theory of payer relations)
69. Are you pre-certing everything that needs pre-certification or pre-authorization or pre-notification to be sure the service will be paid?
70. Are you receiving payments via electronic funds transfer (EFT)?
71. Are you receiving explanation of benefits (EOBs) or remittance advice (RA) electronically?
72. Are you posting your RA electronically?
73. Are you protecting your practice from embezzlement? (see my post on this here.)
74. Is someone in the practice responsible for staying current on changing coding requirements for Medicare, Medicaid, Tricare and commercial payers?
DECREASE EXPENSES:
75. Eliminate overtime. Evaluate the need for additional staff (part-time?) vs. overtime.
76. Send some staff home (sometimes called “low census”) when there are no patients to be seen.
77. Use volunteers. Tap into the local hospital volunteers, or recruit and train your own.
78. Hire an after-school student employee to do routine jobs.
79. Discontinue paying staff for inclement weather closings when the practice is not open.
80. Shop everything. Negotiate existing service contracts. Do not assume anything is non-negotiable. Negotiate the rent.
81. Get rid of yellow pages advertising. It rarely brings you new patients and is primarily a place to look up phone numbers. You will still get your white pages listing free with your phone service.
82. Utilize pre-employment testing to make sure job applicants have the skills you need.
83. Shop postage machines or look into stamps.com.
84. Join a group purchasing entity (hospital, professional association, etc.)
85. Improve your accounting cycle. Invoices and statements are matched up with packing slips and negotiated prices. Use purchase order numbers.
86. Get the payment discount by paying on time or early – ask vendors for an on-time or early payment discount.
87. Make sure office supplies are not going home with the employees. Make sure office supplies that are ordered are “really need” and not “sure would be nice.”
88. Remind patients of their appointments to decrease no-shows. Call patients who no-show and attempt to reschedule (unless they feel better!) Track no-shows and evaluate the reasons for them.
89. Consider charging for no-shows or dismissing patients for no-shows.
90. Have a good recall system in place. If patients leave without scheduling a needed follow-up, make sure that they are called if they have not scheduled within a certain amount of time. Keep track of annual wellness visits and remind patients to schedule them.
91. Take advantage of any discounts offered by your malpractice carrier by completing risk management surveys and having speakers give annual updates on decreasing malpractice claims. Some carriers give discounts for managers who are members of MGMA or Fellows in the ACMPE.
92. Evaluate any discounts on services or products offered by your physicians’ professional associations and societies.
93. Evaluate your leases - are those big old copiers and faxes worth paying for a service contract?
94. Consider speech recognition/voice recognition and eliminate transcription.
95. Review your computer maintenance contracts. Are you paying for maintenance on equipment or software that is no longer being used?
96. Take advantage of online CME for physicians, midlevel providers, clinical staff and managers.
97. Make plans to attend face-to-face seminars well in advance to take advantage of early enrollment discounts and good flight deals.
98. Evaluate outsourcing. Think about outsourcing transcription, coding, billing, pre-authorizations, credentialing, switchboard, payroll, accounting and medical records copying.
99. Replace your answering service with an answering machine educating patients on the limited reasons for calling after hours and giving the number of the physician on call.
100. Destroy archived financial and medical records that you are paying to store, once you have ascertained that they exceed the required time limit.
101. Hold a brainstorming session with the staff and ask for their ideas for increasing revenue and reducing expenses. The people on the front lines will have excellent ideas. In return, do not nickle and dime the staff to death by charging for coffee, reducing parking stipends or eliminating uniform allowances. Keep in mind that for your rank and file staff, having to pay for their own uniforms or paying more for parking might be a deal-breaker that causes them to search for work elsewhere. Try to focus on the bigger items for savings and make sure the staff know you are trying to keep their small benefits in place in appreciation for their work.
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. (more…)
