Health Maintenance Organizations (HMOs)

According to the resource posted on Michigan.gov, Department of Licensing and Regualtory Affairs:

Health Maintenance Organizations (HMOs) provide preventive care and other services that are basic to good health. It is a health care system that joins together the financing and delivery of health care services to covered individuals by arrangement with selected providers who furnish a broad set of health care services

The HMO resource includes the following topics:

• The HMO Difference, Advantages & Disadvantages
• Primary Care Physician
• HMO Provider Network, HMO Service Area, HMO Eligibility
• Individuals Open Enrollment FOR HMOs
• HMO Coverage for Pre-Existing Conditions
• HMO Underwriting, Basic Health Services and Mandatory Coverage
• Services Not Covered By HMOs
• Emergency Services From an HMO
• HMO Prescription Drug Coverage
• HMO Deductibles, Copayments And Coinsurance
• HMO Claim Handling
• HMO Coverage for Family Members and Coordination of Benefits
• HMO Complaints and Grievances
• Medicaid HMO Clean Claims

To view the full resource, please go to the following link: Health Maintenance Organizations (HMOs)

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

Making An Appointment for the ER, A Growing Trend

More and more hospital Emergency Room departments are allowing patients to make appointments to come to the Emergency Room according to an article published by the Los Angeles Times

The article described a system called InQuickER

• Patients schedule appointments online and are seen within 15 minutes of their scheduled time.
• Used at 15 different hospitals across the country
• Pros
• Doctors say patient satisfaction is higher
• Lower time spent in Emergency Room
• Patients wait in other area than the waiting room
• Cons
• Downside could be encouragement for people to use the Emergency Room who don't really need it Emergency Care

To view the full article, please go to the following link: Emergency Room Appointments

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

HIPAA in the Emergency Room

Posted on strategiesfornursemanagers.com, the article "HIPAA in the Emergency Room" discussed various topics in which those who work in the Emergency Room should consider when dealing with patients and HIPAA.

The article discusses the following topics:

• Why the ER is different
• Chaotic Setting
• Many Patients 
• Provisions for ER compliance
• Clinician can use their judgement
• Typical trouble areas
• Communication outside the ER
• Law enforcement officers’ access in ER
• Training tips for the ER staff
• Employee fears violation of HIPAA

To view the full article, please click the following link: HIPAA in the Emergency Room

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

Cost of Canceled Outpatient Surgeries Can Climb Into Millions

In an article published by Outpatient Surgery Magazine, "Cost of Canceled Outpatient Surgeries Can Climb Into Millions.

• A study was done at Tulane University highlighting the cost of cancelled outpatient surgeries.
• The study found that 327 (6.7%) of the facility's 4,876 scheduled elective outpatient surgeries were canceled in 2009, which cost the hospital nearly $1 million in revenue over that 12-month span.

According to the article, the following were reasons why patients canceled their surgeries:

• No-shows were a common cause of cancellations
• Patient Transportation issues
• Uncertainty regarding the date of the procedure
• Forgetting about the appointment
• Lack of available beds or equipment

The study also found that: 

• The cancellations varied by specialty
• Improving equipment and resources and increasing efficiency help reduce the likelihood of having to cancel surgeries

To download the article, please go to the following link: Cost of Canceled Outpatient Surgeries
For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Medicare Physician Assistant Rules

In an article published by the Society of Emergency Medicine Physician Assistants (SEMPA) describes Medicare requirements and how they relate to Physician Assistants.

The article highlights the following:

• Physician Supervision
• Supervision between the Physician and the Physician Assistant
• Enrollment
• Must meet requirements to be a Medicare Provider
• NPIs
• "Incident To" Billing
• Must meet various criteria for services performed by a PA in an office or clinic setting
• Medicaid
• Billing for services varies by state
• Billing When Physician & PA Care for Same Patient

To view the full article, please click the following link: Medicare Physician Assistant Rules

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

Hospitals Demand Payment Upfront From ER Patients With Routine Problems

Kaiser Health News published an article on payments upfront in the Emergency Room. The was article titled: "Hospitals Demand Payment Upfront From ER Patients With Routine Problems"

Article Overview:

• Growing number of hospitals have implemented the pay-first policy this was to reduce the number of individuals with routine illnesses from the ER.
• Federally required screening is done
• Half of all hospitals in the United States now charge upfront ER fees
• Emergency-room doctors and patient advocates blast the policy as potentially harmful to patients
• Hospitals turn away uninsured patients who often fail to pay their bills and are a drag on profits
• Dr. David Seaberg, president of the American College of Emergency Physicians, who estimated that 2 to 7 percent of patients screened in ERs and found not to have serious problems are admitted to hospitals within 24 hours.
• A 2010 Health Affairs study found that 27 percent of those visiting ERs could be treated more cost-effectively at doctors' offices or clinics.

Outcome of Payments Upfront:

• Decline in wait times since it implemented upfront payments.
• One hospital implemented a 24-hour on-call nurse triage system to assist the patient whether to go to the ER or a nearby clinic
• 75 percent of patients with non-emergencies left the facility instead of paying the upfront fee.

To view the full article, please go to the following link: Hospitals Demand Payment Upfront From ER Patients With Routine Problems

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

More Medicaid Patients Going to the ER, Study Finds

According to an article published by USA Today, increasing numbers of Americans (especially those who are on Medicaid) are using emergency rooms for their health care.

The article titled: "More Medicaid patients going to ER, study finds" used data from 1997 to 2007 to analyze Emergency Room visits.

• ERs are increasingly serving as "safety nets" (by law they must treat all patients regardless of insurance or their ability to pay)
• A "safety net" facility is described as the following:
• More than 30% of all visitors were on Medicaid
• More than 30% of visits were by people without health insurance
• More than 40% of visits were by Medicaid and uninsured patients
• Conditions could have been managed in a primary care clinic
• Treatment time increased from 22 to 33 minutes during the study since the volume was higher

To view the full article, please go to the following link: More Medicaid patients going to ER, study finds (USA Today)

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

Health Law Guarantees Protection For Emergency Room Visits

Kaiser Health News published an article on a health law that went into effect on September 23, 2010 (six months after the law was enacted). This health law guarantees protection for ER visits.

According to the article titled: "Health Law Guarantees Protections For Emergency Room Visits"  the following occurs:

• Insurance companies must extend several new protections to patients who receive emergency care.
• Patients who need emergency treatment will have their costs covered at the same rate, regardless of whether they are treated at "in-network" or "out-of-network" hospitals. 
• The law also bars health plans from requiring prior authorization for emergency services. And it mandates that plans follow the "prudent layperson" rule. 
• For example, if a person goes to the ER with chest pain, but ends up being diagnosed with indigestion, the claim has to be covered because going to the hospital under those circumstances made sense.
• For years, insurance plans have been denying ER claims for a variety of reasons. 

• There is little data on the overall scope of the problem, a 2004 RAND Corp. study found that at least one out of every six claims for emergency department care was denied by two large HMOs in California. 

To view the full article, please go to the following link: Health Law Guarantees Protections For Emergency Room Visits

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

Why More Primary Care Doctors Are Referring Patients to Specialists

KevinMD.com, published an article on "Why more primary care doctors are referring patients to specialists" more patients than ever are being referred to specialists.

The following are facts from the article on why more patients are being referred to specialists:

• Specialists are more expensive
• More advanced tests are done by specialists
• Primary care doctors see “failure to refer” as one of the leading reasons why they get sued

• From 1999-2009, the rate of referrals doubled

To read the full article, please click the following link:  Why More Primary Care Doctors Are Referring Patients to Specialists

For additional billing and coding resources as well as referrals to specialists, please click the following link: Medical Reimbursement, Inc. Resources

Increase in Health Care Advertisement Spending

According to the article in The New York Times, Health Care Ad Spending Rises, there has been a significant increase in the amount of spending hospitals are using towards advertising.

• For example, in the first six months of 2011, health care spending rose 20.4% (or to $717.2 million, from $595.5 million) from the same time period in 2010
• Popular Ad Topics:
• Patient Success Stories
• Catchy Headlines
• Patient Testimonials
• Accessibility of the Hospital
• Ads also may focus on the benefit of the hospital (we help you live longer) vs. the features that they have (great technology, world class physicians) according to Paul Amelchenko, the creative director at BFW Advertising.

To view the article, please click the following link: Health Care Ad Spending Rises

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

Reimbursement and Coding Updates for 2012

According to ACEP's article, Reimbursement and Coding Updates for 2012, the following reimbursement and coding changes have occurred in 2012:

• 2012 Conversion Factor 
• Emergency Department RVUs 
• Telehealth Expansion (includes Emergency Department Services)
• Regulatory Update
• Physician Quality Reporting System (PQRS) 
• CPT Coding Changes for 2012 
• Changes to Observation Codes 
• Time Not a Factor in ED Code Selection
•  ICD-9 code changes for 2012  (effective October 1, 2011 - relevant to Emergency Medicine)
• Chart with the following:
• ICD-9 codes detail influenza with other specific respiratory manifestations
• ICD-9 codes detail causes of anaphylactic shock and other reactions
• V codes expand the list of factors influencing health status and contact with health services that could help explain the reason for an ED visit
• Additional Resources

To view the full article, please go to the following link: Reimbursement and Coding Updates for 2012

For additional billing and coding resources as well as referrals to specialists, please click the following link: Medical Reimbursement, Inc. Resources

Improving Patient Satisfaction Rates by Posting Wait Times

According to the solution titled: "Improving Patient Satisfaction by Posting Wait Times", 50% of the hospitals’ revenue begins with the ED. That being said, the following three hospitals implemented a solution in order to improve patient satisfaction rates:

• Middlesex Hospital in Middletown, Connecticut
• Middlesex Hospital Marlborough Medical Center in Marlborough, Connecticut
• Middlesex Hospital Shoreline Medical Center in Essex, Connecticut

The Goal and Results of the Solution were as follows:

• To determine if different factors influence what Emergency Room patients went to as well as make patient volume more manageable in the process
• The Hospital utilized a simple way to posting wait times from the ER every 5 minutes on their website
• Results of the solution led to:
• Better patient quality
• Left-without-being-seen rates decreased
• Higher satisfaction scores on the Press Ganey scale
• Middlesex Hospital Marlborough Emergency Department was ranked #1 in the state
• Middlesex Hospital Shoreline Emergency Departmentt was ranked #2 in the state

To download the full solution, please click the following link: Improving Patient Satisfaction By Posting Wait Times

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

Patient Safety and Quality of Emergency Care

Since Emergency physicians are dedicated to providing the highest quality of emergency care it is important to stay-up-to-date on various issues that affect patient safety and the quality of  Emergency care.

In an article published by ACEP (American College of Emergency Physicians) the following points are addressed regarding patient safety and the quality of Emergency Care:

• Overcrowding
• The on-call specialist shortage
• Use of technology to improve patient safety
• Pay-for-Performance measures is to improve quality of care
• Mandatory reporting of medical errors

To view the full article, please go to the following link: Patient Safety and Quality of Emergency Care

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

Implementing a Bedside Registration Process

Looking to improve your Emergency Department's triage process and reduce the time patients spend waiting for treatment?
Described below are the problems before implementation and what the hospital achieved after implementing a bedside registration process.

• The solution, Bedside Registration, was created at Cape Canaveral Hospital in Cape Canaveral, Florida and has an ED volume of approximately 33,000 visits annually. 
• Before implementing this solution, the hospital incurred long wait times and had difficulty increasing patient volume, bottlenecks, overcrowding as well as patient, staff, and physician dissatisfaction.

Results:

• After the solution was implemented, there was an 85% reduction in wait times (from triage to treatment rooms) would equate to an 11 minute wait.
• The wait times decreased as the patient volume had increased to 15%.

To download the full solution as well as view other solutions for your Emergency Department, please click the following link: Implementing a Bedside Registration Process

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