Where Did the Idea of Meaningful Use of Electronic Medical Records Come From?
The American Recovery and Reinvestment Act of 2009 was signed by President Obama on February 17, 2009. The Law includes the Health Information Technology for Economic and Clinical Health Act or the HITECH Act. The HITECH Act establishes programs under Medicare and Medicaid to provide incentive payments for the Meaningful Use of Certified Electronic Health Records technology.
The goal of the HITECH legislation is to improve healthcare outcomes, to facilitate access to care and to simplify care. It is believed that the installation of electronic health records in medical practices is only the beginning. The goals of HITECH will be met when the EHR is used in a meaningful way.
What is Meaningful Use (MU)?
There are three identified components of Stage I Meaningful Use. They are:
- Use of a certified EHR in a meaningful manner such as e-prescribing.
- Use of Certified EHR Technology for the exchange of health information (exchange data with other providers of care or business partners such labs or pharmacies)
- Use of Certified EHR Technology to submit clinical quality and other measures.
The first stage of Meaningful Use is capturing and sharing the data. Meaningful Use Stage II is advanced clinical processes and Stage III is starting to look Meaningful Use of an EHR in the context of improved healthcare outcomes.
There are 25 specific criteria for MU Stage I listed in this article in Healthcare IT News:
[1] Objective: Use CPOE (Computerized Physician Order Entry)
Measure: CPOE is used for at least 80 percent of all orders
[2] Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The EP (Eligible Provider) has enabled this functionality
[3] Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data.
[4] Objective: Generate and transmit permissible prescriptions electronically (eRx).
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.
[5] Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data.
[6] Objective: Maintain active medication allergy list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data.
[7] Objective: Record demographics.
Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data
[8] Objective: Record and chart changes in vital signs.
Measure: For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20.
[9] Objective: Record smoking status for patients 13 years old or older
Measure: At least 80 percent of all unique patients 13 years old or older seen by the EP “smoking status” recorded
[10] Objective: Incorporate clinical lab-test results into EHR as structured data.
Measure: At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.
[11] Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
Measure: Generate at least one report listing patients of the EP with a specific condition.
[12] Objective: Report ambulatory quality measures to CMS or the States.
Measure: For 2011, an EP would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an EP would electronically submit the measures are discussed in section II.A.3. of this proposed rule.
[13] Objective: Send reminders to patients per patient preference for preventive/ follow-up care
Measure: Reminder sent to at least 50 percent of all unique patients seen by the EP that are 50 and over
[14] Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II.A.3.
[15] Objective: Check insurance eligibility electronically from public and private payers
Measure: Insurance eligibility checked electronically for at least 80 percent of all unique patients seen by the EP
[16] Objective: Submit claims electronically to public and private payers.
Measure: At least 80 percent of all claims filed electronically by the EP.
[17] Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.
[18] Objective: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)
Measure: At least 10 percent of all unique patients seen by the EP are provided timely electronic access to their health information
[19] Objective: Provide clinical summaries to patients for each office visit.
Measure: Clinical summaries provided to patients for at least 80 percent of all office visits.
[20] Objective: Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
Measure: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information.
[21] Objective: Perform medication reconciliation at relevant encounters and each transition of care.
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.
[22] Objective: Provide summary care record for each transition of care and referral.
Measure: Provide summary of care record for at least 80 percent of transitions of care and referrals.
[23] Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted.
Measure: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries.
[24] Objective: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
Measure: Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically).
[25] Objective: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities.
Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary.
Have the Details of MU been finalized?
The comment period for the NPRM (Notice of Proposed Rule Making) for Meaningful Use is currently open but will close on March 15, 2010. You can read the NPRM here. Many individuals and organizations have expressed concern that the timeline for implementing EHR and meeting MU criteria is too short for the majority of providers. The American Academy of Family Physicians (AAFP) recently sent a 7-page letter to acting CMS Administrator Charlene Frizzera (see story here) that included the following concerns:
- The administrative burden of reporting computerized physician order entry measures “is excessive to the point of being unachievable for most eligible providers.”
- The rule could require manually entering results from laboratories that don’t have an interoperable interface with the physician’s electronic health record.
- The term “health information” is used throughout the proposed rule, but is never defined.
- A requirement that a patient’s health information be shared with that patient within 48 hours doesn’t take in account that physicians or their staff may not be able to process the information if that 48-hour period includes weekend days.
- There is no incentive for physicians who meet less than 100% of the proposed requirements, so it is an all-or-nothing approach.
The Medical Group Management Association recently surveyed (see Modern Healthcare story here) 445 physician practice administrators in February 2010 with the following feedback:
- Nearly all are aware of the upcoming incentive programs for meaningful use of electronic health records, but fear the programs will reduce physician productivity.
- 68% of respondents expect physician productivity will decrease if all 25 proposed meaningful use criteria are implemented.
- Nearly one-third believe the decrease in productivity will be greater than 10 percent.
- Almost 25% of practices without an EHR doubt some of their providers will ever attempt to qualify for incentives.
- Among practices with an EHR, nearly 84 percent believe some of their physicians will attempt to qualify for Medicare or Medicaid incentives by the end of 2011.
How Do I Comment on the MU Standard?
You can submit your comments on the NPRM on MU here.
You can read comments already submitted here.
How Do I Know if My EHR is Certified?
No EHRs have been certified for the CMS Incentive Program and the certifying bodies have not yet been announced. It seems reasonable that CCHIT will be one certifying body, but there are expected to be others. If your vendor tells you that his EHR is certified before the rule has been finalized and the certifying bodies have been announced, ask him “For what?”
What Does it Mean to Be Eligible? (description courtesy of Everything HITECH)
This term encompasses three general types of payers to establish eligibility: 1) Medicare Fee For Services (FFS), 2) Medicare Advantage (MA) and 3) Medicaid.
For hospitals to be eligible, they can be acute care (excluding long term care facilities), critical access hospitals, children’s hospitals.
For providers, these include non-hospital-based physicians who receive reimbursement through Medicare FFS program or a contractual relationship with a qualifying MA organization. The Act defines the term “hospital based” eligible professional to mean an EP such as a pathologist, anesthesiologist,or emergency physician, who furnishes substantially all of his or her Medicare covered professional services during the relevant EHR reporting period in a hospital setting (whether inpatient or outpatient) through the use of the facilities and equipment of the hospital, including the hospital’s qualified EHR’s (Fed Reg p. 1905). The determining factor is the site of service as to whether the service is hospital based or not. If the EP provides at least 90 % of their services in a hospital inpatient, hospital outpatient or hospital emergency room setting (Point of Service codes 21, 22, 23), then they are considered a hospital based EP and not eligible for EHR incentive payments (i.e. providing substantially all of his or her Medicare covered professional services).
There is a difference between Medicare and Medicaid when it comes to defining an eligible professional for EHR incentive payment purposes. Medicare defines an eligible professional as (Fed Reg p. 1996):
- doctor of medicine or doctor of osteopathy
- doctor of dental surgery or dental medicine
- doctor of podiatric medicine
- doctor of optometry
- chiropractor
Medicaid, on on the other hand, defines an eligible professional as (Fed Reg p. 2001):
- physician
- dentist
- certified nurse-midwife
- nurse practitioner
- physician assistant practicing in a Federally Qualified Health Center (FQHC) or a Rural Health Clinic, led by a physician assistant.
What are the Guidelines for Providing Patients With Their Medical Records Electronically?
Under HIPAA, patients currently have the ability to access their medical records. Meaningful Use does not change HIPAA in that regard. You may charge patients for the expense related to providing paper or electronic medical records. Each state has its own schedule for charging for medical records (state-by-state schedule here.)
Do Eligible Providers Have to be Participating With Medicare to Receive the Incentive Money?
No, the eligibility requirements only relate to the benchmarks for the percentage of Medicaid patients you have, or amount of allowed Medicare charges you have.
Can Eligible Providers Work at Locations Other Than Hospitals and Private Practices and Receive the Incentive Money?
The location where the provider works is not the issue. The issue is whether or not the provider meets the requirements, either for Medicare or Medicaid, to be considered eligible for the program.
It doesn’t matter where the provider accesses the certified EHR. If they meet the eligibility criteria, and they are using a certified EHR, they can collect on the stimulus money.
What Are Health Provider Shortage Areas?
Physicians practicing in determined “health provider shortage” (detailed info here) areas will be eligible for a 10% bonus payment.
How Does This Incentive Relate to ePrescribing or PQRI?
If the PQRI Program is extended in its current form, practices can participate in both PQRI and an EHR Incentive Plan.
If the EP chooses to participate in the Medicare EHR Incentive Program, they cannot participate in the Medicare eRx Incentive Program simultaneously. If the EP chooses to participate in the Medicaid EHR Incentive Program, they can participate in the Medicare eRx Incentive Program simultaneously.
Also, e-prescribing penalties sunset after 2014, so that no physician will be subject to penalties for failing to both e-prescribe and use an EHR!
How Do EPs Get Paid For Meaningful Use of a Certified EHR?
For the first payment year only, all an EP or hospital has to do is to be a “meaningful user” for a continuous 90-day period during the payment year. Hospitals’ payment year is October 1 to September 30 and EPs’ payment year is the calendar year. You must start and complete the 90-day period within the payment year with no overlapping.
Also, if you can qualify as a Medicaid Eligible Provider (or Hospital), are in the process of adopting, implementing or upgrading your EHR and your Medicaid patient volume is at least 30% (Pediatricians only need 20% minimum and Hospitals need 10% minimum), you can collect your incentive money without meeting Meaningful Use criteria.
Attestation forms and forms of other types are most likely the way that EPs will provide information to apply for the incentive funds, although the details have not yet been released.
What Does it Mean to Transition From One Program (Medicaid or Medicare) to Another?
EPs who meet the eligibility requirements for both the Medicare and Medicaid incentive programs will be able to participate in only one program, and will have to designate which one they would like to participate in. After their initial designation, EPs are allowed to change their program selection only once during payment years 2012 through 2014.
To Recap:
How Do I Get My EHR Stimulus Money?
- Decide whether you are an eligible provider for any of the programs.
- If you are, buy a certified EMR (once certification has been defined.)
- Use your EMR in a way that demonstrates your meaningful use of the product.
- Pass “GO” and collect your money.
ARRA (Stimulus Bill) Acronyms
• A/I/U –Adopt, implement or upgrade
• CAH –Critical Access Hospital
• CCN –CMS Certification Number
• CDS –Clinical Decision Support
• CMS –Centers for Medicare & Medicaid Services
• CY –Calendar Year
• EHR –Electronic Health Record
• EP –Eligible Professional
• eRx –E-Prescribing
• FFS –Fee-for-service
• FY –Federal Fiscal Year
• HHS –U.S. Department of Health and Human Services
• HIT –Health Information Technology
• HITECH Act –Health Information Technology for Electronic and Clinical Health Act
• HITPC –Health Information Technology Policy Committee
• HIPAA –Health Insurance Portability and Accountability Act of 1996
• HPSA –Health Professional Shortage Area
• IFR –Interim Final Rule
• MA –Medicare Advantage
• MCMP –Medicare Care Management Performance Demonstration
• MITA-Medicaid Information Technology Architecture
• MU –Meaningful Use
• NPI –National Provider Identifier
• NPRM –Notice of Proposed Rulemaking
• OMB –Office of Management and Budget
• ONC –Office of the National Coordinator of Health Information Technology
• PQRI –Medicare Physician Quality Reporting Initiative
• Recovery Act –American Reinvestment & Recovery Act of 2009
• TIN –Taxpayer Identification Number
To see the full transcript of the CMS Audio Conference Call from February 23, 2010 which this article drew heavily upon, view the handout, or listen to the audio of the call click here.
If you don’t have the following ten items on a manual checklist or in your EMR, you might want to add them. Any time I hear someone list things that improve quality of life and downstream health, I think to myself “This is future reimbursement criteria.” Actually, several of these are already included as measures in the 2010 PQRI (Physician Quality Reporting Initiative) list.
I came across this list on the physician blog “The Examining Room by Dr. Charles”. Dr. Charles writes:
“These items were chosen by the National Commission on Prevention Priorities, and highlight those preventive services including immunizations, screenings, preventive medications, and counseling that give “the most bang for the buck.”
- Discuss Daily Aspirin Use
- Childhood Immunization
- Smoking Cessation Advice and Help to Quit
- Screening for Alcohol Misuse and Brief Counseling
- Colorectal Cancer Screening
- Hypertension Screening
- Influenza Immunization
- Vision Screening
- Cervical Cancer Screening
- Cholesterol Screening
Get ahead of the curve, and discuss with your providers how you can give your patients more bang for their preventive care buck by making these ten items standard questions in your practice.
Read more on Dr. Charles blog here.
Okay, okay, so I shamelessly lured you into reading this post by telling you Rosemarie Nelson would reveal the “best” EMR product on the market, and she really does, only not in the way you wish she would. Read on to the end of this post for her EMR advice.
It was my pleasure to talk with Rosemarie Nelson after she had given her third presentation (!) at the North Carolina MGM Fall Meeting at Pinehurst this past October. As we visited, I realized I’ve been listening to Rosemarie talk about electronic medical records for at least 10 years. If you don’t know Rosemarie, she’s a running fanatic, an EMR guru, Principal Consultant with Medical Group Management Association (MGMA) and she has 15 years of consulting in operations and technology under her belt.
When I asked her why it’s so hard to implement electronic medical records in a physician’s office she said: “Medical practices are a home-grown industry, really a cottage industry, so every single one is different. There are specialty differences and workflow differences and many EMR vendors don’t know how to address this.”
Rosemarie particularly enjoys helping groups to fix poorly implemented systems and often finds that vendors have not carefully looked at the way the client physicians work before selling them a system. She has experienced the many unique ways that practices operate, and why they operate that way, and has been able to bring EMR success to over 300 practices during her tenure.
Rosemarie recommends that practices take electronic records a bite at a time. She suggests that groups start with one component, maybe ePrescribing, or messaging or electronic test results, and get it working really well. Although vendors might prefer that a group follow its timeline, there is no reason that a practice cannot set its own timeline. Finding out if a vendor will be flexible to a group’s unique needs and timeline is a must-have question when developing a RFP (Request for Proposal.)
The dichotomy of the physician (“make it so”) and the administrator (“take it slow”) is another challenge medical practices face. Many physicians want EMR to happen quickly and painlessly with no interruption of workflow. Rosemarie suggests to these physicians that they should “refer their business to a specialist (her), just as they would refer their patient to a specialist.” Working through the process takes time.
Here are some other observations from Rosemarie:
- “Apply the EMR as a tool to the operations, it is not an end to itself.”
- “Accept the incremental benefits” of the electronic medical record. “All or nothing is a losing propostition.”
- On the Stimulus Money for implementing EMR: “Do it because of the benefits and if you qualify for the stimulus, all the better.”
- On preparing an RFP (Request for Proposal): “Define the deliverables, the timeline and the money and focus on your practice’s absolute needs.”
- On scanning old paper records into the EMR, she says “Only 25% of documents stored are ever used again.”
- On savings using ePrescribing (besides the Medicare bump): “ePrescribing can save each FTE provider $15,000 per year on average.”
- On using electronics to make the medical practice more efficient, “A typical primary care practice might get 85-100 patient calls per day. Try to offload 30% of those calls per day to electronics – ePrescribing, patient secure messasging, electronic lab results, appointment requests, etc.”
- On her favorite client story: “A cardiologist who did not want to do ANYTHING differently, saw me two years later and told me that EMR was the best thing that had ever happened in his practice!”
- Her favorite tip: “Add your website address to your appointment reminder calls!”
- And…her most asked question ever – Tell Me Which EMR to Buy, to which she replies, “There really is more than one good product out there. Buy the one that matches your needs and your workflow the best, and it will be the right one for you!”
You can reach Rosemarie Nelson here: RosemarieNelson@alum.syracuse.edu
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
I heard something this morning on National Public Radio (NPR) that really got me excited – a very short snippet from Tim Brown about a project he’d like to work on – his vision of the electronic medical record of the future. I think it’s worth 3 minutes of your time to listen to how his team has been working on health care problems, the key to the creative answers, how to get buy-in and what he would really love to to get his hands around.
I invited readers of MMP, colleagues on LinkedIn, and Tweeps (friends on Twitter) to comment on my post “101 ideas for Increasing Revenue and Decreasing Expenses.” I’ve listed their ideas below and hope you’ll chime in on the comments with even more ideas! Thanks to everyone for contributing.
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Partner at B2B CFO® – Experienced CFO for Rent. Fast, Effective, Affordable.
Consider adding a part-time CFO to the mix. Many medical offices have very weak financial capability or understanding. Assistance can range from better financial reports, capital expenditure analysis, budgeting and exit plans.
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Eastern Region Sales Manager – Billing Tree
1) Build a relationship with the patient before he/she leaves the practice.
2) Make sure they know you are expecting payment on the portion they owe, and when you are expecting that payment.
3) Let them know what your process is for collecting, and when they will go to an outside agency.
4) Enable a web site to take payments 24 hours a day.
5) Set up an IVR system to take phone payments after hours.
6) Communicate your available payment acceptance methods in writing, on the phone and every time you speak with your patients.
7) Send the invoice or statement when you intend to send it.
Re-inforce the payment acceptance methods on the first and any subsequent invoices.
9) Adopt a plan for following up with any patients that don’t pay after 10 days.
10) Get email addresses from all of your patients and their permission to contact them in that manner.
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Sr. Product/Process Trainer and EDI Implementation Consultant
One suggestion would be to integrate the revenue cycle mangement function with your clearinghouse {for electronic billing} with integrated solutions like Coding database and Updates, Industry Broadcast, Performance and Audit reports for Claim Edits, Transmission and Rejects. Also, better training resources for billing staff actively into the practice management system.
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Consultant at Pacific Women’s Medical Group
I would add effective cash management (even if interest rates are so low).
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Medical and Business Consultant at Transworld Systems
Utilize a Flat Fee Collections Agency for Non-responsive Patient Pay concerns.
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Principal Consultant – Culbert Healthcare Solutions
- Do you collect co-payments on the way in rather than on the way out?
- Does your PM/Scheduling system show the patient co-payment and outstanding patient balance in the appointment screen? If not, then can you download a listing for your front desk staff?
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DPT Healthcare Consulting & Training
I’d like to add “acknowledge the patient with eye contact” and offer “polished customer service” and they will WANT to return = return on your $ $
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Managing Partner, Dynamic Grape Companies
One other thought… don’t be afraid to try new technology. For example, one of my clients has developed a kiosk that allows patients to take their own weight and bp and electronically feeds the data into their EMR. The whole set up costs about $3500 and can save a ton of staff time. Tele-health in general should also be considered.
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VP at Operations
If you select a reasonably priced EMR and you implement enhancements then you more than save on staff cost. Keep in mind that my practice rolled out the EMR five years ago, so we have had time to get it right. Here are some of the savings/revenue opportunities:1. We utilize our electronic technology to send text messages and emails to our patients to remind them of their appointments. This function alone saves my practice one FTE. Not only do we save with staff time we improve patient satisfaction, as our Blackberry users loves the email or text that they can directly add to their calendars. The revenue enhancement to this function, we decrease no shows and lag time in our physician’s schedules.
2. The robust reporting within the EMR allows the organization to assemble important quality measures that we use in contract negotiations. Without the EMR this would be a labor intensive task.
3. We are able to push a secure message to our patients regarding their pathology results saving staff time on the telephone and increasing patient satisfaction by eliminating a visit just to obtain a normal result.
4. No more chasing charts for a phone message. My call center takes ALL clinical messages. This is attached to the patient’s electronic chart and routed to either a nurse to respond or a physician. This process greatly reduces staff time, decreases the time it takes to respond to the patient’s issue and provides a legal record of the telephone call which is often missed in a paper environment.
5. We receive a discount on our mal-practice insurance because in an electronic environment it is guarantee that your notes are legible.
6. The formulary function built into most EMR’s provides the physician will a real time snapshot if a prescription that he/she is about to write is covered by the patient’s health plan and provides alternatives if available.
I have just highlighted only a couple examples of the administrative benefits. There are many more. It is tough to imagine going back to a paper chart.
I have done the math and we could cover our current EMR with the incentives offered through the government initiative.
I will comment that physicians need to be trained on how to use the EMR. You can lose site of the patient and focus the entire visit on the computer versus the patient, however, we teach our physicians that the patient first and then chart completion. We conduct patient satisfaction surveys and I rarely receive a complaint regarding the physician’s time at the computer. I do however, receive praises from patients regarding the ePrescribe as it decreases their wait times when the arrive at the pharmacy, the prescription is ready.
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Okay Readers, it’s your turn – what’s your secret weapon for increasing revenue or decreasing expenses?
Mary Pat
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.
VistA, (Veterans Health Information Systems and Technology Architecture) which was originally developed in the 1970’s by the Veterans Administration, is an open-source (meaning that the code is available for others to collaborate upon and improve) clinical documentation system that is used by all the 160-plus VA hospitals in the United States, plus all of their outpatient ambulatory clinics. Providing care to over 4 million veterans, employing 180,000 medical personnel and operating 163 hospitals, over 800 clinics and 135 nursing homes , about a quarter of the nation’s population is potentially eligible for VA benefits and services because they are veterans, family members or survivors of veterans. The VistA system has been in use by the Veterans Administration for more than 20 years, and as such is one of the most mature electronic medical records in existence.
As the Veterans Administration does not bill third-party payers, VistA is not a billing system. VistA was released to the public through the Freedom of Information Act by the Veterans Administration and today is publicly available on CDs for a nominal fee. Althought the software is free, there is a cost to install, implement and maintain it.
WorldVistA was formed to extend and collaboratively improve the VistA electronic health record and health information system for use outside of its original setting. The system was originally developed by the U.S. Department of Veterans Affairs (VA) for use in its veterans hospitals, outpatient clinics, and nursing homes. WorldVistA has a number of development efforts aimed at adding new software modules such as pediatrics, obstetrics, and other functions not used in the veterans’ healthcare setting.
WorldVistA seeks to help those who choose to adopt the VistA system to successfully master, install, and maintain the software for their own use. WorldVistA will strive to guide VistA adopters and programmers towards developing a community based on principles of open, collaborative, peer review software development and dissemination.
For more information on VistA, click here for the Wikipedia entry.
Voice recognition (VR), sometimes called speech recognition (SR), is a technology that translates the spoken word into the written/electronic word. In healthcare it is most commonly used for physician notes in the medical record. The physician dictates the information and either edits the information himself/herself, or a staff member edits the information. The physiican note can be printed for inclusion in the paper chart, or can be imported into the electronic chart. Some electronic medical record (EMR) software products have speech recognition built-in, and some have the ability to integrate with speech recognition software.
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…)
