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The Role of Medical Billing in Accountable Care Organizations

Saturday, December 15th, 2012

Accountable Care Organizations (ACOs) represent an innovative delivery model by which different stakeholders in the healthcare system (i.e. providers, hospitals, payers, etc.) will collaborate to provide quality to a population at certain level and share in the savings. Therefore, coordination of billing will be all the more important. Each type of clinical organization currently may have a different billing process. Also, each healthcare entity, whether it is a clinic or hospital, has its own billing software. How are ACO participants going to coordinate with such a set-up? How do vendors that provide billing solutions or third-party billing companies deal with this?

One important strategy is to leverage technology, as much as possible, with the least amount of reliance on paper. Some clinics and hospital systems may be doing their billing still on paper.  The capturing of information digitally will allow ACO members to share and communicate financial and clinical data related to billing with some ease. With the greater adoption of interoperability standards such as HL7 and vehicles to transit information such as health information exchanges, the billing information stored in EMRs (electronic medical records)  and Practice Management  (practice management) systems can be shared among ACO entities regardless of their geographical locations or the information technology applications they are using.

Software vendors that create PM (practice management) software or have it part of their EMR system should be excited because electronic submission of claims is perfect for the limited time frame by which ACO members have to show quality and cost savings. ACO programs usually last only 3 years and data reporting to CMS is expected to start in year 2. Submitting claims on paper results in a much longer response time from payers, especially if the claim is large or complicated. Furthermore, when claims are denied sending remittance advice electronically is a lot quicker and more efficient.

Third party billing companies also have a huge advantage in that they are already experts in compliance which is becoming a larger issue in the wake of healthcare reform and the ACA (Affordable Care Act).  For example, the prediction is that in the years to come RACs (Recovery Audit Contractors) will be visiting clinics and hospitals more often. With the electronic submission of clinics and the ability to group clinical data electronically also, thanks to EMRs, the government will be able to audit easier and more frequently.  A second competitive edge for third party billing companies is that they have already engineered a very efficient way to help the practice or hospital with their revenue cycle. The reason is that most of these companies get paid on a percentage of monthly revenue from their clients. This efficiency is a perfect “culture match” for the ACO.

As ACOs become more popular and healthcare institutions learn how to make them work, we will began to see a greater need for better billing practices that are more coordinated and efficient. The proper technology and software system will enable ACO participants to meet their goals in providing high-quality care while saving costs that ultimately will translate into shared savings. Software vendors and third party billing companies have a lot to gain from initiative, as long as they understand how to leverage strengths.

 

Jitesh Chawla, MD

Patagonia Health CMIO

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The Role of EMRs in Accountable Care Organizations

Wednesday, December 12th, 2012

As the final rule on ACOs ( Accountable Care Organization) has come out, it is apparent that that the value that EMRs (electronic medical records) bring is unprecedented.Under the Medicare Shared Savings Program, ACO participants (which may include medical practices, hospitals and payers) are graded and paid based on 4 domains of care quality: 1) patient experience;2) care coordination and safety;3) preventative health; 4) at-risk populations.The program consists of a 3 year performance period in which the performance of the ACO mapped against thresholds set by CMS. To reap financial benefits from this program, providers must report on 23 of 33 quality measures spanning these 4 domains during the second year and 33 out of 33 in the third. Some of the measures, like # 20, which asks for the percentage of providers that have received Meaningful Use money are easy to satisfy if you have a Certified EMR.

 

ACO participants are incented to work together and efficiently because if they don’t meet the CMS thresholds they must pay money back. Data is key when trying to coordinate care and the exchange of clinical data must be done properly to meet the quality measures set by CMS.

 

Now it must be apparent to medical providers that if they want to join an ACO it is very important that they are comfortable using an EMR. The good news is that there are certain features of the software that allow providers to capture the necessary data for ACO quality measures easily. For example, in the Preventative Health domain there are measures such as Adult weight screening and follow-up and Tobacco Use Assessment. Both of these are Meaningful Use criteria and any certified EMR has screens and buttons to record this information.

 

In another example, the domain of at-risk population contains a diabetes composite measure in which the number of diabetics who BP is less than 140/90 must be recorded. To do this, it may necessary to setup a report in which there are fields to search for a patient’s diabetic status and their blood pressure level concurrently. For instance, in Patagonia Health’s EMR, there is a section called “My Reports” where users can fully customize search criteria for certain disease conditions, procedures and demographic characteristics.

 

Finally, the exchange of health information between providers and entities requires ability for the system to send and receive data securely and in a format that the receiving end would be able to decipher. Exchange of clinical data is a Meaningful Use criterion and is done through CCR (care of continuity record) which generates a summary of the usually about the patient’s medication, laboratory, immunizations, provider names, vital signs, alerts. Providers simply need to press the CCR button and it generates a file. This file can then be sent in encrypted format through email currently (and through Health Information Exchanges later) to the other provider’s EMR.

 

EMRs have become a powerful tool that has empowered medical providers to collect the necessary data in order to provide medical care with a sense of accountability and level of quality in the form of an ACO. The Meaningful Use Program has further enabled different EMRs to have the standard features important for this data collection.

 

Jitesh Chawla, MD

Patagonia Health CMIO

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Surprise! State Pharmacy Registry is Underutilized

Tuesday, November 27th, 2012

This news item on NPR station caught my attention. North Carolina Attorney General is worried that the doctors and pharmacists are not using the state built controlled substance registry as much as they should. Further, DHHS has commissioned a study to understand the reasons for low adoptions. 

This medical registry was introduced to prevent people from abusing drugs. The news and discussion is about overdose. They are related, but not connected. 

Regardless, there is a simple answer. EHR and SureScripts database. With Meaningful Use guidelines, EHRs must support drug-drug, drug-allergy interactions. With e-prescriptions, most EHRs also perform dose checks and warn doctors about wrong dosage. SureScripts database connects doctors and pharmacists. Doctors can pull up all the medications a patient has been taking, regardless of who prescribed them. So, if the patient was prescribed Oxycontin or Amoxicillin in California, a doctor in Reidsville, NC can still look it up. Since the doctors are already using the EHR, they know this information in the context of their note writing. Then write a new e-prescription for the patient. 

The state registry, while good, requires doctors to log in to a different website. Then search for  the patient using a bunch of parameters. If they find the right patient, they may be able to tell the meds this patient was taking.

Pharmacists are connected to SureScripts, from where they are also able to access the medication history of the patient. There is no need for either the doctor or the pharmacist to connect to the registry and do extra work. 

There are 2 distinct issues here and they are being mixed in the news articles.

1. Drug overdose:

Doctors are performing this step using EHRs. So, patients should not be prescribed more than recommended dose. Pharmacists can additionally check doseage, but I don't know why they need to look into state built registry instead of pharmacy databases. This is a more serious issue that includes patient and care taker education. It cannot be solved by a state registry. 

2. Doctor shopping:

Unfortunately this is common. Patients will go to different doctors to be prescribed pain medications. Doctors using e-prescription have the medication history built-in. I know cases where doctors identified these patients using the EHR. Of course they refused more prescriptions for these patients.

EHRs currently don't track meds that are written on paper and paid in cash. This meds history is sometimes available only in the state registry. Doctors have asked for this to be included in the EHR. But the state application has no interfaces. EHRs or any other automated system cannot pull this data. 

Doctors and pharmacists are already overburdened. Having them log into one more disconnected system is asking for too much. The state registry needs to integrate with applications doctors are already using. State legislators need to talk to the customers (doctors and pharmacists) instead of adding one more study.

 

 

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Tips for Review of Systems in Medical Billing

Monday, September 24th, 2012

Combining History of Present Illness (HPI)  and Review of Systems (ROS) is possible when doing medical billing. Many medical billers think this practice is breaking a rule or impossible. However, documenting an element once to account for HPI and ROS is acceptable medico-legally when done correctly.

CMS states that physicians absolutely do not need to document an element two times just so the person performing medical billing knows it is meant to be used both for review of systems and history of present illness. It is perfectly acceptable to use an element for both.

The only time an element cannot be used in duplication is when you attempt to use it in the same area. For example, the complaint of chest pain cannot be used in ROS for musculoskeletal systems and the cardiovascular system. It can be used only for one location in the medical billing.

A medical biller also cannot use a timing phrase such as "began a couple of days ago" to account for both the HPI duration and timing. Direct medical documentation must be used.

According to Dr. Jitesh Chawla, healthcare expert, the most important thing to accomplish in medical billing is to make the bill match the service that was actually given. When this occurs, payment is made quicker. Medical billing companies can assist medical practices with this task. Outsourcing your medical billing be beneficial for your practice, however, better yet is to use an electronic medical record (EMR) that has an integrated practice management (PM)/ Billing system that can send statements directly to the payer. This takes the worry off correctly coding and billing by manual means and physicians will see reimbursements much quicker! Please stay tuned for more articles on this subject and feel free to share your thoughts in the meantime.

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Insurance Billing Tips: How to use the Front Staff

Tuesday, September 18th, 2012

Getting a claim paid really starts at the front desk. Make sure you get good information. Get copies of insurance cards, driver’s license or ID. Have your staff verify the patient filled out your patient registration form completely. Verify insurance and coverage.

Entering Demographic Information

I strongly suggest that the front desk NOT enter the demographic information into the computer system.

Why? Distractions are always there. They are so busy answering phones, checking-in /checking-out patients, and helping patients and physicians, that causes mistakes to happen easily. Just have them enter enough demographic info to make an appointment. Accurate information from the onset makes the claim process go smoothly and quickly.

Additionally, have a good financial agreement for the patient to sign. Most agreements I have seen are only a couple of sentences and are quite inadequate. Include in your agreement collection fees, interest, attorney and court cost. This way if you have to go after the patient for payment they are responsible for the additional costs of collecting what they owe. You may also want to include that they agree to pay for after-hours telephone advice, no-show fees, form fees, prescription refills, and walk-in fees, returned check fees and a billing fee if a patient does not pay their copay at time of service. A good financial agreement gives you the tools you need to collect patient balances.

Charge Posting of Encounter Forms

Along with your front desk not entering demographics and insurance info, they should also not post charges for the same reason, distractions. Charge entry should be done in a quiet location. A claim with the smallest amount of inaccurate data will hold up your payment. Also your nurses or medical assistants provide logs of labwork, sonograms, EKGs or other procedures so that your poster can cross reference the logs to the fee tickets to insure nothing is missed.

Teach your staff good practices from day one. The front staff is essentially in receiving the clinical and financial information that needs to be passed onto billing staff. If a certain protocol is established with best practices is established it will save you a lot of hassle in the long run. The next series of articles will focus on how to train/advise your clinical staff so that your claims get accepted and billing to insurance becomes a bit easier.

 

 

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The unique EMR needs of a Public Health Agency

Monday, September 17th, 2012

With the passage of the HITECH Act there is been an ever increasing push towards the use of electronic medical records (EMR). However, public health agencies have generally been slower to adopt for a variety of reasons. Certain meaningful use rules, such as conducting syndromic surveillance and reporting to immunization registries, ask providers to communicate with public health agencies. Consequently, public health departments are under pressure to re-structure their technology platforms.

Public health has unique workflows which can have major implications for EMR vendors. To understand this it is important to explore how public health is different from medical care in doctors' offices or in hospitals.

  1. There is greater emphasis on population screening and treatment, resulting in separate clinics focusing on specific aspects of care provision – providing immunizations, conducting STD screenings, etc. Also, there may be many more staff involved, some of which play roles that are not present in outpatient practice.
  2. As part of their mission these organizations normally perform a community assessment at regular intervals. This helps to identify the rates of certain diseases in the community and can guide the deployment of conditions that are more prevalent. As a result the type of visits and demographic make-up of the patient panels can vary greatly over time.
  3. The type of data that needs to be tracked is such that epidemiological studies can be readily done on it (ie. incidence, prevalence, etc.).  
  4. There are certain forms that mandatory to use. One example is the use of Healthy Futures Pediatrics for pediatric physicals.
  5. There are unique situations where patients are seen in settings that are not typical for a doctor’s office. For example, a patient that has tuberculosis will be placed on home quarantine. The nurse will go there and obtain sputum samples and treat the patient with none of the interaction taking place in the clinic.
  6. Finally, there are specific reporting requirements by the State and Federal Government. This has implications on the type of and amount of data that needs to be collected. Also, there

As a result, the EMR vendor has to

  1. Understand various different workflows, each specific to a particular clinic.
  2. Be able to work with a large number of users, some of which play unorthodox roles
  3. Incorporate data fields and a format to capture information that can be used for population reporting. The databases that are used should be able to store a large number of data points.
  4. Provide access to the EMR through a variety of mobile portals – phones, tablets, etc.
  5. Incorporation of or access to certain specific forms.
  6. Design reporting engines that can produce reports in a pre-defined format acceptable to the State and Federal Government requirements
  7. Ensure their product is highly interoperable and can regularly pass data back and forth from providers and to State Registries and between other organizations.

The EMRs that can successfully support public health needs have an architecture that allows need new programming code to be inserted readily without having to create a new. New features can be added through widgets that make it easier for the user to locate and utilize them.

The revolutionizing of Public Health IT infrastructure is a long-awaited milestone that is soon to pass and will improve the management of population health.  The Meaningful Use initiative has really started the ball rolling. The key is use the right electronic medical record to record the data.

 

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Stage 2 Final Rules: Implications for Providers

Tuesday, August 28th, 2012

Finally, on August 23rd, CMS released Meaningful Use Final Rules for Stage 2 of the EHR Incentive Program. For those of you that are knowledgeable about Meaningful Use and saw the proposed Stage 2 Rules there are major changes that were made based on feedback from the medical community.

Nevertheless, since the final version is now out, it is important for medical providers and hospitals to understand what is expected of them and how the criteria differ from Stage 1. This article is a quick overview of the additions and changes in Stage 2 Rules and will present some tips to how clinicians can be ready. We will not cover hospital requirements here.

 Stage 2 Requirements

Stage 2 represents “Advanced Care Processes” according to the Meaningful Use stages plan as explained by ONC. A central theme is “connectivity” where different EMRs or EHRs can exchange data with each other. Also, the first stage allowed providers to get a certified EHR and  learn how to use it to collect some meaningful data. Now the goal is to have them use more advanced functions of the EHR and collect some of the same data for a larger pool of patients.

Some of these measures are new and others represent higher thresholds from Stage 1 (latter marked by *). Examples of few of these measures are highlighted below.

  • At least 5% of patients must access have access to their online health information
  • Providers must engage in secure messaging with at least 5 % of their patients

 

To be sensitive to practices in rural areas CMS is granting exclusion to providers without access to broadband internet. Both measures will require internet connectivity to communicate to patients regardless of whether the EHR is web-based or not.

 

  • Summary of care record for more than 50% of transitions of care and referrals*
  • Transmit summary of care for more than 10% of transitions and referrals to provider even if they have vendor or organizational affiliation*. However, the 2 providers that conduct the exchange must be using EHRs from different vendors
  • Eligible providers must select and  report on 9 out of 64 total clinical quality measures (CQMs)*
  • Tobacco screening for patients 13 or older is required for 80% or more of patients

In addition, all providers must select Clinical Quality Measures (CQMs) from at least 3 of the 6 key health care policy domains from the Department of Health and Human Services’ National Quality Strategy:

  • Population and Public Health
  • Efficient Use of Healthcare Resources
  • Clinical Processes/Effectiveness
  • Patient and Family Engagement
  • Patient Safety
  • Care Coordination

Compared to Stage 1, EPs (eligible providers) must satisfy 20 measures 17 core and 3 / 6 for menu. Reporting will be allowed such so that batches of EPs in the same group can attest together in 1 file. For a full report of Stage 2 measures and requirements visit the CMS website.

Getting Ready

  1. The patient portal is likely the medium by which patients will access online information and use email (secure messaging) to communicate with their providers. Make sure to check with your vendor if the patient portal is set-up to support all these features. PP is included as part of all certified EMRs.
  2. Ensure policies, procedures and workflow allows collection of data in at least 3 of the 6 domains part of the National Quality Strategy. There should be a logical approach to choosing the 3. Health departments may include Population/Public Health, behavioral health practices include care coordination and practices recognized for Patient Centered Medical Home may include Clinical Processes and Effectiveness. In all 3 examples, the CQM topic represents an area that practice or clinic may focused on as part of their daily operations and so the data is being collected anyways.
  3. Adopt the practice of motivational interviewing as patient engagement is bigger theme in this stage of meaningful use.
  4. Keep track of the Health Information Exchanges (HIEs) in your area and make sure your HER connects with them. The good part is that Stage 1, required you to test the CCD/CCR function a which is medium by which patient information is summarized and can be submitted in exchange through a standardized format.

Concluding thoughts

The step-wise government push towards the adoption and use of EHRs is not to advocate the use of technology, help vendors with EHR sales or to create some hurdles to jump though just to get free money. But, providers and practices that streamline their work processes, capture the right patient data consistently, strive for increased quality and safety will find that EHRs are actually enablers for those goals and achieving Meaningful Use, though time consuming, is just a little more than a formality.

 

By Dr. Jitesh Chawla

Patagonia Health, CMIO

 

 

 

 

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Can I Un-sign a Signed Encounter Note and other Ethical Questions?

Monday, July 23rd, 2012

Some the questions Doctors and Nurses ask us

  1. Can I un-sign the note to make changes? I made a mistake, which I want to correct. 
  2. Can I back date my signature on the note?
  3. Can you change the dates on the progress note, so the note is not late per payer standards?
  4. Can I use generic user names (Nurse 1, Front Desk 1) for all my users?
  5. Can the users share the same password? 
  6. Can you let the nurse log in as a doctor to send prescriptions?

In all the cases, the answer is always NO. The database tracks all reads and writes at a granular level. Even changing these dates only superficially affects the data. The database knows the exact trail and someone will be able to find out what happened.

This article from Australia confirms this fact. 12,000 EHR records were manipulated to improve publicly reported performance statistics. EHRs make this possible and make it easy. In paper world, modifying 12,000 paper records would be an enormous task. With EHR this requires a few database queries. 

Though, it is equally simple for someone to query audit trails and recognize what happened. 

Going down this path violates trust and completely erases credibility. You will not look at EHR records the same way again. There will always be suspicion when you see perfect performance benchmarks. 

Besides, the staff now knows you are willing to compromise on ethics. You may find it difficult to refuse more such "harmless" requests! 

Lesson: 

Never, ever manipulate your EHR data in order to accommodate errors or mistakes. Document that error and have an explanation ready for it.  

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E&M Coding and EHRs

Saturday, July 14th, 2012

Another interesting article Fear of EHRs being wrong, doctos code E&M manually.

The report found that 57% of Medicare physicians use an EHR, and 90% of them use their systems to document E&M services. But most physicians still assign those codes manually, which could mean they are undercoding services that could qualify for a higher pay rate.

The article does not clarify why the distrust exists. Though the following statement hints that the EHR may force upcoding? 

Fenton said physicians don’t have enough trust in EHR systems to use the features that assign codes. She said HHS and the Dept. of Justice need to do some kind of certification of the coding capabilities and get them to agree that if something was coded incorrectly and physicians can prove they didn’t alter the software, doctors won’t be held responsible.

 

If fraudulent upcoding is detected, HHS and the Justice Dept. do not go after the software company, they go after the physician, she said.

Regardless, the recommendation from AMA is to have EHRs be certified in coding standards, along with Meaningful Use. 

This raises a few questions

  1. The physicians coded E&M manually before EHRs came along ( or billing manager or billing service did that). Those skills still exist. So, if a physician does not trust the EHR, by all means they should code manually.
  2. EHR's E&M code is a suggestion. It is based on a pure calculation. It is possible the documentation supports lower or higher coding. Physician is ultimately responsible for choosing the correct code. 
  3. Some EHR + PM systems will actually analyze E&M codes for the physician and public Medicare data. A bell curve will let the physician know if the code entered is appropriate. For example, if too many level 4 visits have been performed, EHR may suggest coding at level 3. This is to avoid audits.
  4. EHRs actually help in upcoding. It is easy to mark the required levels of HPI, ROS and PE. 

A physician I know, intentionally codes all visits at level 3, inspite spending 20-30 minutes with the patient. He is very proud of the fact that he has never been audited. 

Other physicians routinely upcode with EHR help. 

Shouldn't AMA focus on the root cause? E&M coding is a game. CMS should put a better system in place that does not require complex calculations. CMS auditors should have a medical background that understand the visit and the work done. Auditors cannot simply count the number of elements in HPI to make a determination. 

Along with the rest of the reform, making billing process simpler will make physician's life so much simpler! 

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ICD10 – How bad is it?

Friday, March 2nd, 2012

How bad can it get? Every one is talking about ICD 10. Some oppose it's introduction in Oct 2013, some want it today. 

When Squawk Box on CNBC talks about it, you know this is crazy. Watch this video at 6:38, Joe Kernen, says ICD 10, you know what it is, ICD 9 has 18,000 rules. Under Obama care, ICD 10 will hve 140,000 rules. Then he goes on to give the usual weird ICD 10 example, 9 separate rules if you are injured by a parrot! He rants speaks about it for a few more seconds. Larry Bossidy (former CEO of GE) clearly has no idea what is the topic and quickly switches the conversation. That was hillarious :)  

Now ICD 10 is also being used as a political tool! This is ridiculous when the decision is data driven. There talks about how high the conversion costs are, but hardly anyone talks about how practices can get more reimbusrsement with proper coding. 

As far as I can tell, ICD-10 was being planned way before Obama took office. HHS submitted this final rule in Jan 2009. 

Regardless, MGMA is strongly opposed to introducing ICD-10 in Oct 2013. They either want it postponed or want a phased introduction. 

Healthcare CIOs think delaying ICD 10 is not such a good idea. This Edifecs survey (done at HIMSS 2012) claims delay would be catastrophic

With 18 months to go, if the industry cannot be ready to implement this change, I think we are in serious trouble. We at least need to start a gradual phase in, instead of complete postponement. 

Legacy EHR vendors have had over 4 years to get their software updated. 

As a cloud based EHR, Patagonia Health is ready to move to ICD-10 today. The Health IT industry seriously needs to get moving quickly on issues like these and focus on more important issues about patient outcomes and reducing health costs for the country. 

A quick FAQ on ICD-10

 

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