Handling Electronic Submission of Medical Documentation

The Department of Health and Human Services and the Centers for Medicare and Medicaid published a manual on the Process for Handling Electronic Submission of Medical Documentation (esMD)

Overview of the Process for Handling Electronic Submission of Medical Documentation is as follows:

• Centers for Medicaid and Medicare Services (CMS) developed a mechanism to electronically receive medical documentation from providers. 
• This project is called Electronic Submission of Medical Documentation (esMD). 
• Medicare Review Contractors have requested an electronic mechanism to receive imaged medical documentation. 
• Electronic mechanism is used submit imaged medical documentation upon request.

The manual also includes the following submission time frames:

• Prepayment Review Time Frames
• Postpayment Review Time Frames

To download the full article, please click the following link: Electronic Submission of Medical Documentation

Implementation of National Recovery Audit Program

Published by the Centers for Medicare and Medicaid Services: "Implementation of Recovery Auditing At The Centers For Medicare & Medicaid Services", discusses the Medicare Fee-For-Schedule Program

The guide includes the following topics:

• National Recovery Auditing Program - 4 Regions in the United States (A, B, C, & D)
• Medicare FFS Claims Processing
• Improper Payments in the Medicare FFS program
• Medicare FFS Recovery Audit Program Contract Awardees
• Implementation of the FFS National Recovery Audit Program
• Status of the Recovery Audit Program for Medicare Advantage, Medicare Prescription Drug, and Medicaid Programs
• FFS Recovery Audit Review Process
• Key Program Components
• FY 2010 Results
• Corrective Actions
• Continuous Improvement

To view and download the full PDF document, please click the following link: Implementation of Recovery Auditing

How to Handle ED Patients Who Do Not Need To Be Admitted

Do you need a solution on how to handle your Emergency Department patients who do not need to be admitted to the hospital, but are not ready for discharge from the ED?

William Beaumont Hospital in Royal Oak, Michigan implemented a solution that they have found to work well in their emergency department. The solution was titled: "Clinical Decision Unit". This solution was suited for those patients who need to still be monitored without using valuable inpatient space by admitting them to the hospital.

• Guidelines for the Clinical Decision Unit were developed based on best practices from hospitals around the country. 
• The support of physicians and hospital leadership was critical to the success of the Clinical Decision Unit.

The reasons they implemented the Clinical Decision Unit were because of the following:

• The hospital was missing myocardial infarctions (MIs) and admitting patients with chest pain who did not have acute coronary syndrome
• Bed availability was an issue, hospital occupancy rates routinely over 90 percent (where they remain today)
• Lack of bed availability triggered ambulance diversion

To view and download the solution for your emergency department, please click the following link: Clinical Decision Unit

Medicare Overpayment Collection Process

Need information on the Medicare Overpayment Collection Process?

A 3-page fact sheet was developed by the Centers for Medicare and Medicaid Services highlighting the following information about the collection of Medicare physician and supplier overpayments:

• Definition of an overpayment and why the overpayment occurs:
• Duplicate submission of the same service or claim
• Payment to the incorrect payee
• Payment for excluded or medically unnecessary services
• A pattern of furnishing and billing for excessive or non-covered services.
• The Overpayment Collection Process
• The recovery process is used when Medicare discovers an overpayment of $10 or more
• Steps in the Overpayment Collection Process include:
• Demand Letters
• Repayment Plans
• Rebuttals
• Appeals
• Additional Medicare Resources and links

To view and download the fact sheet, please go to the following link: Medicare Overpayment Collection Process (PDF)

For additional resources, please click the following link: Medical Reimbursement, Inc. Resources

How to Avoid Ambulance Gridlock

Reducing the amount of gridlock caused by multiple ambulances waiting to transfer patients to hospital care results in a decrease in the amount of treatment wait time and faster turnaround.

An example of a strategy to decrease ambulance gridlock was developed at Valley Hospital Medical Center in Las Vegas, Nevada. The strategy was named "EM Xpress".

Some facts about EM Xpress:

• Simlar to a car racing model comparing the pit crews to the Emergency Department staff
• Reduces the Emergency Department wait time from 19 minutes to under 10 minutes
• Increase of around 75 ambulances a day up from 52 ambulances a day
• Runs from 11am to 11pm

The strategy works in the following way:

1. Bring your patient to Valley Hospital
2. Check-in with the Transfer of Care software
3. Give report to the Charge Nurse or the EM Xpress personnel
4. Offload your patient
5. Done - the Charge Nurse will check you out – drive safely

To download and view the full strategy, please follow this link: How to Avoid Ambulance Gridlock

Other resources are available to assist you at the following link: Medical Reimbursement, Inc. Resources

*We are not affiliated nor endorsed by Valley Hospital Medical Center. The Urgent Matters article is used with permission on our website*

Guide on Medicare Physician Fee Schedule

Need information on the Medicare Physician Fee Schedule?

The Centers for Medicare and Medicaid Services published a short fact sheet on the Medicare Physician Fee Schedule.

The fact sheet covers the following topics:

• Physician services
• 7,400 uniquely covered services
• Therapy services
• Medicare Part B pays for the services of physical therapists, occupational therapists, and speech-language pathologists based on the Medicare PFS.
• Medicare PFS payment rates
• The Medicare PFS is based on the following three components: 
  • 1) Relative Value Units (RVU)
  • 2) Conversion Factor (CF)
  • 3) Geographic Practice Cost Indices (GPCI).
• The Medicare PFS rates formula
• [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x CF
• Additional Resources

To view and download the fact sheet, please click the following link: Medicare Physician Fee Schedule

For additional resources, please click the following link: Medical Reimbursement, Inc. Resources

How to Streamline Cardiac Care for Heart Attack Patients

A solution created at Memorial Regional Hospital was called "Code Heart" streamlining the cardiac care for heart attack patients in the Emergency Department who required PCI. Some takeaways from the article were the following:

• The purpose of this solution was to: "Eliminate redundancy in treating heart attack patients so patients receive care as quickly and efficiently as possible."
• "Code Heart" eliminated the redundancy in treating heart attack patients with ST-elevation myocardial infarction (STEMI) and the patients now receive care as quickly and efficiently as possible.
• The goal of Code Heart was to ensure that door-to-balloon time in 90 minutes or less.
• With the most current and available data, Memorial met the 90-minute door-to-balloon goal an average of 85 percent of the time.

To view the full article along with the changes that were implemented in the Emergency Department, please visit the following link: Code Heart

*We are not affiliated nor endorsed by Memorial Regional Hospital. The Urgent Matters article is used with permission on our website*

How to Simplify Your Claims and Appeals Process

The American Medical Association (AMA) published a helpful guide titled: "Appeal that Claim - Be informed. Be approved. " on how to simplify your claims and appeals process by assuring proper payment to streamline your claims revenue cycle and streamlining your claims audit and appeals procedures

The guide was divided into the following sections:

• Step 1: Determine who will be responsible for auditing health insurer payments
• Step 2: Collect recommended health insurer auditing resources
• Step 3: Run monthly collection reports
• Step 4: Review the health insurer basis for the denied, delayed, or partially paid claim
• Step 5: Gather supporting documentation to corroborate reversal of the health insurer's determination through the claims appeals process
• Step 6: Develop a claim appeal letter and resubmit the claims to the health insurer
• Step 7: Maintain a health insurer follow-up log
• Step 8: Hold claims processing and review meetings
• Step 9: Continue to appeal partially denied, delayed or partially paid claims

Also contained in the guide are checklists and sample documents to assist you in the claims appeals process.

To download and view the guide, please go to the following link: Appeal that Claim - Be informed. Be approved. 

How to Improve Emergency Department Patient Flow

Looking for a solution on how to improve patient flow?

A case study done at William Beaumont Hospital in Royal Oak, Michigan discusses their new strategy that improves patient flow by decreasing the amount of time they spend in the waiting room.

Their strategy is called a "straight back triage policy", under this system the patient is sent to one of three different treatment areas:

1. Adult and Pediatric Emergent Care
2. Adult and Pediatric Urgent Care
3. Adult and Pediatric Non-Urgent or Prompt Care

Implementing this solution resulting in the following in the Emergency Department:

• Prioritized patient care needs according to severity of illness.
• Assured a prompt initial primary survey of all patients by a health care professional.
• Promoted patient safety.
• Facilitated expeditious care.
• Improved public relations and promote effective communication with patients/significant others.

To view the full solution as well as other solutions to help your Emergency Department, please go to the following link: Improving Emergency Department Patient Flow

*We are not affiliated nor endorsed by William Beaumont Hospital. The Urgent Matters article is used with permission on our website.  

How to Reduce Patient No-Shows

The Medical Group Management Association's (MGMA) In Practice Blog developed a helpful post on how to reduce patient no-shows consisting of 30 tips - some of these tips were common and some were not so common.

A sampling of the tips included:

• Develop a call list of patients who are able to come in for short-notice appointments
• Track the reasons each patient gives for a no-show
• Provide the option to send your patients an e-mail appointment reminder
• Hold a gift card drawing for all patients who show up on time in a given month
• Develop strong relationships with patients to increase their commitment to your practice. Suggestions include sending birthday or holiday cards and assigning nurses to specific patients to work and follow up with.

To view the full blog post with all 30 tips, please click here: 30 Ways to Reduce Patient No-Shows

Practices for Better Health Care

The Agency for Healthcare Research and Quality (AHRQ) published a fact sheet on "30 Safe Practices for Better Health Care" to assist in preventing medical errors which cause harm to patients.

These 30 safe practices that have been endorsed by the National Quality Forum.

According to the article, this National Quality Forum consists of 215 representatives from a variety of the United States' health care providers, purchasers, and consumer organizations.

Some notable organizations in the National Quality Forum include: The American Medical Association, The American Hospital Association, and the General Motors to name a few.

The article is broken down by the following categories:

• Creating a Culture of Safety
• Matching Health Care Needs with Service Delivery Capability
• Facilitating Information Transfer and Clear Communication
• In Specific Settings or Processes of Care
• Increasing Safe Medication Use

Each of these categories has at least one "safe practice" under it.  For the full PDF and all of the safe practices, please go to the following link: 30 Safe Practices for Better Health Care (PDF)

Items and Services That Are Not Covered Under the Medicare Program

The Department of Health and Human Services - Centers for Medicare and Medicaid published a guide on Items and Services not covered under the Medicare program

The guide is broken down into the following 4 sections:

• Services and supplies that are not medically reasonable and necessary
• Excluded items and services:
• Items and Services Furnished Outside the U.S. (with exceptions)
• Custodial Care (with exceptions)
• Cosmetic Surgery (with exceptions)
• Dental Services
• Certain Foot Care Services and Supportive Devices for the Feet (with exceptions)
• Services Related to and Required as a Result of Services That Are Not Covered (with exceptions)
• Examples of services and supplies that have been denied as bundled or included in the basic allowance of another service include:
• Physician standby services
• Prolonged care
• Examples of items and services reimbursable by other organizations or furnished without charge:
• Items and Services Authorized or Paid For by a Government Entity
• Defective Equipment or Medical Devices Covered Under Warranty

To download the full guide with more examples, please click the following link: Items and Services That Are Not Covered Under the Medicare Program

Changes in Pain Management Coding for 2012

Published by the AAPC's Coding Edge, the article Complete, Current Pain Management discusses the changes to pain management coding that were made in CPT® 2012.

Implant Pump Refill and Reprogramming

• According to the article, the codes for pump refill and analysis/reprogramming are often reported together, as often as 75% of the time
• The revised codes are:
• Pump Analysis Only
• Pump Analysis and Reprogramming Only
• Pump Refill and Reprogramming
• Pump Refill and Reprogramming by a Physician

Determination of Simple vs. Complex Neurostimulator Programming Changes

• Revised instructions for application of the neurostimulator codes
• The revised codes are:
• Neurostimulator Analysis Only
• Simple Neurostimulator Programming
• Spinal Cord or Peripheral Complex Neurostimulator Programming
• Cranial Nerve Complex Neurostimulator Programming

The article also has instructions on how to apply these pain management coding changes as well as guidelines.

Interested in downloading the full article? Please go to the following link: Complete, Current Pain Management to receive the CPT® 2012 Pain Management coding changes. 

AMA 2011 National Health Insurer Report Card

Published by the AMA (The American Medical Association), the 2011 National Health Insurer Report Card is provided as a source for health insurance claims processing timeliness, accuracy, and transparency.

The report card  is broken down for the following health insurance companies (Aetna, Anthem, CIGNA, HCSC, Humana, Regence, UHC, and Medicare) in these categories:

• Payment Timeliness
• Payer claim received date, first Remittance response time
• Cash Flow
• Cash flow analysis, % of claim lines paid $0, EFT adoption rate, EFTs still receiving checks
• Accuracy
• Allowed amount, Contracted fee schedule match rate - major CPT code categories - match rate by state, First ERA accuracy
• Prior Authorization
• Prior authorization frequency
• Claim Edit Sources and Frequency
• Source of payer, Total number of claim edits
• % of total claim lines reduced to 0 (disclosed claim edits, undisclosed claim edits, disclosed and undisclosed claim edits)
• % of edited claim lines reduced to 0 (undisclosed claim edits)
  
• Denials
• % denied, Reason codes, Remark codes, % of reason codes reported with remark code
• Improvement of Claims Cycle Workflow
• CORE certification, Prior authorization, Claim acknowledgement.

To view and download the 2011 National Health Insurer Report Card, please click this link: 2011 National Health Insurer Report Card

Choosing Emergency Room Care vs. Urgent Care Centers

Do you know all the facts when it comes to choosing whether to go to the Emergency Room or an Urgent Care Center?

An article published on fairhealthconsumer.org highlighted important information that you should know.

The article discussed the following:
Emergency Room Care

• You many encounter: ER co-payments, co-insurance or deductibles
• You many encounter: Additional ER out-of-network charges
• Deals with potentially life-threatening emergencies & is open 24 hours a day
• Many plans cover a portion of emergency care
• Most health plans will not pay for ER visits if the visit is not considered an emergency
• To determine this they follow the “Prudent Layperson Standard” under PPACA to determine what is a true emergency.

Urgent Care Centers:

• Most health plans include urgent care centers in their networks
• Have extended hours (primarily when your primary care doctor is not available)
• Provides treatment for less serious emergencies
• Not equipped to deal with major medical traumas or emergencies

The article also went into the cost of the Urgent Care vs. the cost of the Emergency Room.

To view the full article, please go to the following link: Emergency Room Care vs. Urgent Care