Pioneer Accountable Care Organization (ACO) Model Program Frequently Asked Questions

The following questions were published in "Pioneer Accountable Care Organization (ACO) Model Program Frequently Asked Questions" from the Department of Health and Human Services.  For more detail on the these questions, there is a link to the full article at the end of this blog post.

What is an ACO?

• Doctors, hospitals, and other health care providers who voluntarily come together to provide high quality care to Medicare patients.

What is the Pioneer ACO Model?

1. The Pioneer ACO Model shows how particular ACO payment arrangements can best improve care and generate savings for Medicare.
2. It also tests alternative program designs to inform future rule making for the Medicare Shared Savings Program

When does the Pioneer ACO Model:

• Begin?
• January 1, 2012
• When does it end?
• 3 years from January 1, 2012.
• How many ACOs are participating?
• 32 Organizations

How is the Pioneer ACO Model different from the Shared Savings Program?

• To view the list of ways the Pioneer ACO Model differs from the Medicare Shared Savings Program, see the link at the bottom of the blog post.

How is it different from the Advance Payment Model?

• Only available to ACOs participating in the Medicare Shared Savings Program.

Can an ACO Participate in both the Shared Savings Program and the Pioneer ACO Model?

• No

How will payments to the Pioneer ACO work?

• Will follow a shared savings or losses experienced by Medicare for a specific set of beneficiaries.

What are population-based payments?

• Population-based payments are per-beneficiary per month payment amount intended to replace a significant portion of the ACO's fee-for-service (FFS) payments with a prospective payments.

How will beneficiaries be affected by the Pioneer ACO Model?

• Improves partnership between patients and doctors in making health care decisions.

Are beneficiaries required to participate in the Pioneer ACO Model?

• Competitive application review process

How did CMS select the ACOs participating in the Pioneer ACO Model?

• 160 letters of intent, 80 applications

To download the full PDF, please click the following link: Pioneer Accountable Care Organization (ACO) Model Program Frequently Asked Questions (FAQs).

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

Are Medical Scribes Worth The Investment?

Are Medical Scribes Worth The Investment? A study was produced on whether or not scribes are worth the investment.  Two different hospital emergency departments were studied.

Some benefits of scribes:

• Can assist higher acuity emergency departments who struggle with long patient stays.
• Assist in decreasing the amount of patients leaving without being seen (LWBS)
• Assist with challenging EMRs (electronic medical record systems)

What does a scribe do?

• A scribe enters information into an EMR or chart directed by a physician or practitioner.

The study weighed the cost of the scribes' salaries against the return value as well as observed the following factors to see if a scribe was worth the investment:

• Patients per hour
• Relative value unit capture
• Number of billable patients
• Reduction in hours of coverage
• Number of down-coded charts
• Pulse oximetry and rhythm strip capture
• Length of stay for patients
• Door-to-doctor times

• The above factors were observed at two different hospitals. One hospital had an annual volume of 65,000 patients and the other hospital had an annual volume of 68,000 patients. 
• Overall, measuring the two hospitals against the parameters listed above, the hospitals showed improvements with the additional of a scribe.
• The cost for a scribe was about $20 an hour or they can also be measured at 20% productivity of the physician.

To view the full article as well as the percentages of improvements for the parameters, please click the following link: Are Medical Scribes Worth the Investment?

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

Documentation Costs Associated With An ICD-10 Mandate

MGMA produced a fact sheet on: "Documentation Costs Associated With An ICD-10 Mandate".  This fact sheet highlighted documentation costs for small, medium and large practices.

A "Small" Practice:

• Consists of 3 Physicians, 2 administrative staff.
• ICD-10 mandate for a small practice will cost an estimated: $83,290

A "Medium" Practice:

• Consists of 10 Providers, 1 full-time coder, 6 administrative staff
• ICD-10 mandate for a medium practice will cost an estimated: $285,195

A "Large" Practice:

• Consists of 100 Providers, 64 Coding Staff - 10 full-time coders, 54 medical records
• ICD-10 mandate for a large practice will cost more than an estimated: $2.7 million.

6 Key Areas that ICD-10 will impact:

1. Staff Education and Training
2. Business Process Analysis of Health Plan Contracts, Coverage Determinations and Documentation
3. Changes to Superbills
4. IT System Changes
5. Increased Documentation Costs
6. Cash Flow Disruption

To read the full article, please click the following link: Documentation Costs Associated With An ICD-10 Mandate

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

Medicare Billing Rises at Hospitals With Electronic Records

The New York Times published an article: "Medicare Billing Rises at Hospitals With Electronic Records". The article discussed many key points on the impact of Electronic Health Records (or EHRs). The following are some points from the article:

• EHRs may be contributing to billions of dollars in higher costs for Medicare, private insurers & patients making it easier for the physicians to bill more for their services.
• In 2010, hospitals received $1 billion more in Medicare reimbursements than 5 years prior.
• For instance one hospital's reimbursements rose 43% in 2009, the same year they began their EHR.
• Another hospital discussed in the article had an increase in their paid claims by 82%.
• Because of the higher coding, this has prompted the attention of federal & state regulators as well as private insurers - they state that coding of E/M Services is vulnerable to fraud and abuse.
• One individual stated that  EHRs "can improve the quality of care, save lives and save money"

Some negatives of Electronic Health Records - EHRs are as follows:

• Automatically generated patient history
• Cut-and-paste examination findings from multiple patients - called "cloning"
• Boxes that allow doctors to review patients symptoms without a full exam being done.
• One individual was quoted stating: (the use of electronic records): "makes it faster and easier to fraudulent".

To download the full article, please click the following link: "Medicare Billing Rises at Hospitals With Electronic Records"

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

Emergency Room Visits Likely to Increase Under Obamacare

The National Center for Policy Analysis published a short article titled: "Emergency Room Visits Likely to Increase Under Obamacare".

According to the article, the following are two reasons why costs for the Emergency Room will increase:

• Around half of the insured will enroll in Medicaid and these patients typically seek care in the Emergency Room more often than those who are uninsured.
• There will be an increased demand for emergency rooms

Health Insurance Status
The Congressional Budget Office States the following:

• 32 million people who are uninsured will be able to obtain health insurance under the health care reform.
• About half of this 32 million will enroll in Medicaid and the State Children's Health Insurance Program.
• The health insurance exchanges to start in 2014 with implementation to begin in October 2013 will allow more members to obtain health insurance.

Emergency Room Use

• Many people think that the uninsured go to the hospital more than those with insurance and in this article, they state this is not the case.

Predicting Emergency Room Use Based on Change in Health Insurance Status

If the following 4 points are met:

1. Half uninsured obtain insurance
2. Newly insured enroll 50/50 in Medicaid & private plans
3. The newly insured are reflective of the current population
4.  The newly insured behave similar to those like them

• Under 18, the number of insured will climb to 22% from 18%
• Ages 18-44 ER visits will increase to 28% from 21%
• Ages 45-64 ER visits will increase to 28% from 19%

Predicting Emergency Room Use Based on Health Care Rationing

• Uninsured make almost two physician visits per year it is more than 3.5 for privately insured and 7.5 for Medicaid patients.
• It is estimated that the newly insured will attempt 3.6 additional physican visits
• After the above being said - this would be an increase of 39-41 million additional emergency room visits per year.

To download the full article with a chart, please click the following link: Emergency Room Visits Likely to Increase Under Obamacare.

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

Detached ER Costs Criticized

The Journal Gazette published an article from Bloomberg News titled: "Detached ER Costs Criticized" highlighting claims that freestanding Emergency Room charges are excessive.

• The article discussed one patient's bill was nearly $2,000 ($700 out-of-pocket and $1,518 "facility fee") - this is about 5x what the patient would have paid to get similar care elsewhere.
• The Benefits of Freestanding Emergency Rooms:
• They offer 24-hour service, short waits along with board certified emergency specialists.
• They also may be helping out the overcrowded and understaffed hospital Emergency Rooms.
• The charges that come along with the free-standing ERs are closely related in amount to what you would pay at a hospital because the services are similar.
• Some states have required free-standing emergency rooms to accept all patients regardless if they can pay or not.  
• One individual quoted in the article said: "Many are glorified urgent-care centers, but they still bill ER charges."
• These unattached ERs as well as urgent-care centers will transfer patients to hospitals if they require more care than they can handle.  
• According to the article, expenses in a stand-alone ER are more than 10 times what the patient would pay if they went to a doctor's office or an urgent-care.

To view and download the full article, please click the following link: Detached ER Costs Criticized

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

ICD-10 Transition to Impact Specialists More Negatively

EHR Intelligence published an article titled: "ICD-10 Transition to Impact Specialists More Negatively".

According to the article:

• Some specialties will be affected more than others
• ICD-10 will increase the number of codes from 14,567 to approximately 68,000 codes.
• Implementation costs range from $83,000 to $2.7 million per practice (according to the AMA)

Easy specialties for transition to ICD-10:

• Hematology
• Oncology

Most challenged specialties for transition to ICD-10:

• Obstetics
• Psychiatry
• Emergency Medicine (Poisoning)

The outcomes for this study were a result of a case study done by the emergency department at Illinois Health Connect.
 

To view the full article, please click the following link: ICD-10 Transition to Impact Specialists More Negatively

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

Wolves at the Door: E/M Coding Now

Advance News Magazine published an article titled: "Wolves at the Door: E/M Coding Now: Documentation is More Important Than Ever".   In this article, they discussed the following:

• OIG Uses Data Analytics
• Coding Trends of Medicare Evaluation and Management Services - 2001-2010 Part B goods and services.
• The OIG stated that E/M coding "has been vulnerable to fraud and abuse".
• Data analysis identify types of E/M services with improper payments for Part B services.
• The OIG identifies specific physicians who bill higher-level E/M codes
• If you're already a target, you should address the following:
• Look at your practice policy and procedures (P & P) manual
• If your coding is outsourced, work with vendors
• You should also perform internal documentation and coding audits
• If you have more than one coder have them do a quality assurance (QA) review of another coder's work.
• Provide the same case to all your coder's and see what the outcomes are and if there are any differences.
• Have an outside consultant perform documentation and coding audits.

To view the full article, please click the following link: Wolves at the Door: E/M Coding Now

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

Hospitals Crack Down on ED Repeat Users

Health Leaders Media published an article titled: "Hospitals Crack Down on ED Repeat Users". Key points from the article were as follows:

• Case Manager Plan
• St. Luke's Hospital implemented a plan to identify those who were "frequent fliers" patients who visited the ER 12 times in 12 months.
• Many of these patients go to the ER for various reasons such as: they don't have a family doctor, they lack finances or they may be unable to make their doctor's hours.
• This hospital has estimated that they have saved about a half million dollars by not having to provide additional care and testing for these so-called "frequent fliers"
• Creating a Direct Relationship
• In Massachusetts, many of their "frequent fliers" or as they called them "MVPs" did have primary care physicians.
• The issues that these patients dealt with were more psychological, social and economic issues.
• Following the Care Plan
• Patients receive a letter if they have gone to the ER for more than 12 times.
• They make sure the patient understands the treatment program from their last Emergency Department discharge.
• Technology and Diabetes
• The article stated that in one study 11% of ED visits at two particular hospitals was for diabetic visits.
• They came to the conclusion that patients were not getting the care they needed.
• Behavioral Care and Insurers
• Lack coordination which results in a negative impact on individuals
• Changing Behavior
• The change for these Emergency Departments has shown good results
• No Cure Yet
• Although, improvements have helped at many hospitals, the problems with frequent fliers in the Emergency Department still has a long ways to go.

To download the full article, please click the following link: Hospitals Crack Down on ED Repeat Users

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

Reducing Emergency Department Overuse

Overuse of the Emergency Department for non-urgent or avoidable visits costs the U.S health care system an estimated $38 billion/ year. A Research Brief was published by New England Healthcare Institute Reducing Emergency Department Overuse. The brief covered the following topics:

• Who overuses the ED?
• What are the root causes of the problem?
• What are the consequences of ED Overuse?
• Solutions
• Redesign primary care services
• Telephone Access to After-Hours Consultation
• Extended Practice Hours
• Open Access Scheduling
• Group Visits or Shared Medical Appointments
• Access to Appropriate Services
• Outreach to Primary Care Providers
• Connecting Vulnerable Patients to Appropriate Services
• Provide Alternative Sites of Primary Care for Non-Urgent Conditions
• Urgent Care Services
• Worksite Clinics
• Telemedicine
• Improve Disease Care and Management
• Provide Patient Education
• Offer Patients Financial Incentives
• Increased Co-payments for Non-Urgent Use
• Healthy Rewards Accounts
• Collect Improved Data on ED Use
• ED Census Reports
• Predictive Modeling
• NEHI Recommends the following: 
• Establish collaborative relationships among EDs, primary care providers and community services
• Understand the Patient Population
• Reform payment for primary care services
• Invest in health information technology
• Increase the primary care workforce
• Redesigning primary care services

To view the full study, please click the following link: "Reducing Emergency Department Overuse"

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

Patient Charges for Top Ten Diagnoses in the Emergency Department

PLOS One published an study titled: "Patient Charges for Top Ten Diagnoses in the Emergency Department".

• The study was conducted to examine charges, variability, payer group for diagnosis & treatment for the 10 most common outpatient conditions in the Emergency Department.
• The study was conducted from a 2006-2008 Medical Expenditure Panel Survey, patients aged 18-64 years of age who had a single discharge diagnosis.
• The study covered 8,303 encounters which represented 76.6 million visits.
• The study concluded that ED charges for common conditions are expensive with high charge variability.
• A few of the top ten diagnoses were the following: Headaches, Sprains and Strains, Upper Respiratory Infection & Back Problems
• The purpose of the study was to allow patients and providers become aware of ED charges that patients may face in the current health care system.

To view the full article with all top ten diagnoses, please click the following link: Patient Charges for Top Ten Diagnoses in the Emergency Department

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

Electronic Medical Records Probed for Over-Billing

The Center for Public Integrity published an article titled: "Electronic Medical Records Probed for Over-Billing" The article discussed the shift from paper medical records to electronic medical records (EMRs) and concerns with doctors and hospitals billing higher fees.

Key takeaways from the article were:

• Electronic Medical Records (EMRs) may be prompting doctors and hospitals to pay higher fees to Medicare.
• Some software from digital records companies that is marketed to may actually be encouraging the use of elevated billing codes.  
• "Cloning" (cutting and pasting prior encounters for a patient) may also be a cause of problems for the size of the patient's bill.
• According to one testimony, the cloning (copy/paste) method may only be limited to the services documented that were "pertinent" to treating the patient's current medical problem.
• Cloning also may have inaccurate information regarding the patient.
• The Obama administration plans to spend $30 billion dollars in order to help doctors and hospitals 
• Overall, the IT industry agrees that EMRs can lead to higher costs, but EMRs are easier for doctors and hospitals to document all the work they do.

To view the full article, please click here: Electronic Medical Records Probed for Over-Billing

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

A Guide to Health Insurance Exchanges

Kaiser Health News published: "A Guide to Health Insurance Exchanges".

• Exchanges: Where consumers can comparison shop for health insurance.
• If everything goes well, exchanges could make the buying process easier for health insurance and may lead to lower prices because of increase competition.
• The exchanges must be set by October 1, 2013.  The exchanges will then go into effect January 1, 2013.
• States have the option of:
• Setting up their own exchanges
• Partnering with Federal government to run an exchange
• Or opt out of the exchanges (when they opt out, the federal government runs the exchange for the state)
• Exchanges will be open to:
• Individuals buying their own coverage
• Employees of firms with 100 or fewer workers (some states 50)
• Most people will be able to get subsidies average of $4,600 per person.
• Undocumented immigrants will be banned from the exchanges.
• Exchanges will be available for residents who earn up to 400% of the poverty level (around $44,600)
• Most people will be required to have coverage by 2014.
• Members of congress will be required to buy from exchanges if they want coverage from the federal government.

To view the full article. please click the following link: A Guide to Health Insurance Exchanges

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

Health Insurance Exchanges Implementation

Kaiser Family Foundation published a fact sheet on "Establishing Health Insurance Exchanges: A Overview of State Efforts".  This fact sheet highlighted the state-based health insurance exchanges (& implementation of these exchanges) which are a key component of the Affordable Care Act (ACA).

• 17 States & Washington DC intend to establish a state-based exchange
• Mississippi's application for state-based exchange was rejected
• 7 States are planning on a partnership exchange
• 26 states will default to federal facilitated exchange
• State-based exchanges must provide access to telephone call centers, build a website with information about insurance options and application assistance and create a Navigator program to improve public awareness and enrollment.
• According to the article, $3.5 billion dollars were distributed to all but 4 states to aid in the funding of the IT infrastructure that is necessary to support the exchanges.
• The fact sheet also has a Figure with "Total Federal Grants for Health Insurance Exchanges" and a Table with "Characteristics of State-Based Exchanges" 

To download the full PDF, please click the following link: Establishing Health Insurance Exchanges: A Overview of State Efforts

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

Health Insurance Exchanges

The Washington Post published an article titled: "Arrival of Insurance Exchanges Raise Questions About Health Coverage in 2014" The article addressed man questions and below are some key takeaways from the article:

• The new insurance policies will have to meet certain standards related to coverage and cost.
• Premiums cannot be more than 3 times higher for older people than it is for younger people.
• Many young people will be eligible for subsidized coverage - through exchanges, their parents insurance or Medicaid. 
• Premium subsidies will be available to people who have incomes at 400% of the poverty level. There are limitations to who can get this as well.  
• If you drop coverage altogether (don't purchase on your own, through an employer or through health care exchange), you will be penalized $95 or 1% of your taxable income.

To read the full article, please click the following link: "Arrival of Insurance Exchanges Raise Questions About Health Coverage in 2014"

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

What Does Sequestration Mean to Medicare?

Medicare News Group published an article titled: "What Does Sequestration Mean to Medicare?" Key takeaways from the article are as follows:

• Medicare provider payments will be cut by 2% April 1st, 2013 unless Congress passes an alternate deficit reduction plan before then.
• Cuts will be applied to: 
• Medicare Hospital Insurance (Part A)
• Medicare Medical Insurance (Part B)
• Contractual Payments to Medicare Advantage Plans (Part C)
• Medicare Prescription Drug Plans (Part D)
• 90% of Medicare spending is limited to the 2% in cuts and 8% exemption
• If the sequestration goes into effect, an estimated $11.085 billion in cuts will occur
• From, 2013 to 2021 - the article stated that the Congressional Budget Office estimates that $31 billion will be spent because of the sequestration. 

To view the full article, please click the following link: What Does Sequestration Mean to Medicare?

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

How Social Media Can Improve Your Medical Practice

American Medical News (Amednews.com) published an article on "4 Ways Social Media Can Improve Your Medical Practice"

1. Discover Needed Services
• Gain insight on what patients will do to improve their health
• What obstacles stand in their way to improve their health
• Find out what services interest people
2. Improve Customer Service
• Pay attention to complaints
• Respond to complaints with a public apology & offer to correct the situation 
3. Gather Feedback on Medications
• Monitor buzz on social media sites such as Twitter to see if people are talking about a certain medication
• They can monitor if the treatment works or doesn't work by the social media buzz that it produces.
4. Compare and Improve Quality
• Look at your competitor's social media sites and see what they are doing
• Learn from your competitor's mistakes as to not do that yourself
• Patient privacy is a concern

To read the full article, please click the following link: "4 Ways Social Media Can Improve Your Medical Practice" from American Medical News

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

Services Covered and Summary of Benefits Covered (SBC)

Healthcare.gov published an article on "Services Covered and Summary of Benefits Covered (SBC)" In the article, they highlighted the following bullets:

What services are covered under my insurance?

• Coverage for Preventive Care
• Coverage for Pre-Existing Conditions
• Children's Pre-Existing Conditions
• Pre-Existing Conditions for anyone
• Temporary Exclusions in job-based plans
• Coverage for Pregnancy under Job-Based Plans
• Coverage under Small Employer Policies

How can i find out what is covered in my insurance plan?

• Health Plan Summaries
• Summary plan descriptions
• Questions on job-based insurance?
• More Information on What's Covered

What does my health insurance company or job-based plan have to disclose to me about my health coverage?

• They must give you a SBC (Summary of Benefits and Coverage)

What's in a Summary of Benefits and Coverage (SBC)? 

• Summary of benefits plan covers with cost-sharing associated with coverage.  The article lists the information it all covers.

When can I get an SBC?

• You can get an SBC when you make a request, apply for coverage and more listed in the article

What other information may i need to make a decision about coverage?

• Check the premium what access to doctors and prescription drug plans

Can I get the SBC in languages other than English?

• Yes, if 10% of people speak another language you may request it in the other language.

Additional questions answered in the article were:
Will this SBC change throughout the year?
What if I have more questions?

To download the full article, please click the following link: Services Covered and Summary of Benefits Covered (SBC)

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

FREE Critical Care Webinar - April 24th, 2013

Join us on April 24th, 2013 at 12pm EST, for a FREE Critical Care Webinar

In this webinar, we'll discuss:

• Are you losing money by not billing Critical Care?
• Critical Care Scenarios
• Critical Care Questions and Answers

Space is limited to the first 150 attendees who sign up


To register for the webinar, please click the following link: Critical Care Webinar

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

Research Reveals Reasons Underlying Patient No-Shows

ACP (American College of Physicians) published an article highlighting reasons for patient no-shows for a psychiatric practice. Although this article highlights the reasons for no-shows in a psychiatric practice, these reasons could be similar in other practices as well:

• The no-show rate was between 19% and 22%
• Between $11 million and $19 million was lost.
• The research studied over 11,000 visits and they found that socioeconomic factors do affect whether or not the patient will show up for their appointment
• The time and the type of patient they scheduled determined whether or not they were going to show up for their appointment.
• Patients who lived:
• 5-10 miles away were very likely to show
• 19 and 60 miles were more likely to miss their appointments
• Greater than 60 miles they almost always showed up
• The study found that there were many logistical factors & demographic characteristics (whether the patient was married, what their gender was) played a role in if they were to show up for their appointment.

To read the full article, please click the following link: Research Reveals Reasons Underlying Patient No-Shows

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

Doctors Fear For Medicine's Future

In an article by FrontPage Magazine, results from a survey state that many doctors fear for the future of medicine.

The survey went as follows:

• 36,000 physicians completed the survey
• 90 percent said that the medical system is "on the wrong track"
• 83 percent say they are "thinking about quitting"
• 61 percent said the system "challenges their ethics"
• 70 percent say "reducing government would be the single best fix"

Some key views from those surveyed were:

• 2/3 said the EMR (electronic medical records) compromise medical privacy and confidentiality
• One physician opted out of Medicare and Medicaid over 12 years ago and they stated they have never been busier.
• 2/3 said they are just barely squeaking by or losing money and expect the financial situation to worsen in the next 5 years.
• Increasing regulations have a direct impact om cost of care increasing.

To view the full article, please click the following link: Doctors Fear For Medicine's Future

For additional billing, coding, and reimbursement resources, please click here: Medical Reimbursement Resources Page

How to Bill for Critical Care and Dual Services

Today's Hospitalist published an article on how to bill for critical care and dual services.  The article discussed the codes for ICD-9 that hospitalists should be using to bill for the critical care services.

Teaching Requirements

• According to the CMS both the resident and the attending physician must be present to bill 00291
• The time for critical care does not need to be continuous

Dual Services

Consult vs. Observation Codes

• Outpatient consult codes 99241-99245
• Office or other outpatient codes 99201-99215
• Subsequent observation care codes 99224-99226
• Outpatient consultation codes 99241-99245

Short-Stay Admissions

• Initial hospital care codes 99221-99223
• Admission and discharge on the same date 99234-99236 - must stay a minimum of 8 hours before you can bill that code set.

To read the full article, please click the following link: How to Bill for Critical Care and Dual Services

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

A Consumer's Guide To The Health Law

Kaiser Health News published a consumer guide to the health law. According to the article, here is what is to come by 2014:

• In 2014, if you don't have health insurance you will have to have it or you will have to pay a fine.
• Individual penalty will be $95/year or 1% of their income (whichever is greater) it will rise to 2.5% (or $695) by 2016
• Family penalty will be $2,085/year or 2.5% of their income whichever is greater.
• Requirement may be able to be waived for reasons for example: financial reasons or religious beliefs
• Federal law will override state laws on blocking requirements to have health insurance.
  
• Insurance at work is likely to stay the same
• Plan may change
• May change premiums, deductibles, co-pays and network coverage.
  
• Some parts of the law that are in place now:
• Eligible for preventative services with no out-of-pocket costs
• Health plans can't cancel your coverage if you get sick
• Children with pre-existing conditions cannot be denied coverage
  
• Government will pay for anyone with an income at or lower than 133% of the poverty level
• $14,856 for an individual and $30,656 for a family of 4
  
• If you don't qualify for Medicaid:
• Subsidies will be available for individuals and families between 133% and 400%
• $14,856-$44,680 for individuals $30,656-$92,200 for families
• 
  
• Information on small businesses providing insurance
• No employer is required to provide health insurance
• In 2014, if your business has more than 50 employees the business will have to pay a fee.
  
• If you're over 65, there are changes listed in the article too.

For the full article, please click the following link: After the Election: A  Consumer's Guide To The Health Law

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

Predictive Modeling Analysis of Medicare Claims

Since June 30, 2011, Medicare has implemented a predictive analysis system. The following bullets explains the predictive modeling anaylysis in more detail.

Predictive Modeling Analysis of Medicare Claims

• Predictive Analytics System analyzes Medicare FFS (Fee-for-service) claims in order to detect fraudulent activity.

The modeling technology goes as follows:

• Builds profiles of providers, networks, billing patterns, and beneficiary utilization
• These profiles create risk scores estimating the likelihood of fraud.
• The profiles are automatically prioritized by which has the most alerts and risk score.
• The analysts at CMS then review the cases which were those of high risk score/ high alert.
• Depending on what the analysts find, they take the appropriate action.

What the risk score does to the claims payment:

• Only alert CMS to review the claims activity
• CMS does not deny claims because of predictive model results
• Enables automated cross-checks

To read the full article, please click the following link: Predictive Modeling Analysis of Medicare Claims

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

Affordable Care Act & Grandfathered Health Plans

Healthreform.gov published an article on Affordable Care Act and "Grandfathered" Health Plans. The purpose of the Affordable Care Act is to give families and businesses more control over their health care

Protecting Patients' Rights in All Plans

• Must provide certain benefits to their customers for plan years starting on or after September 23, 2010.

Additional Consumer Protections Apply to Non-Grandfathered Plans

• They can make routine changes
• Grandfathered plans for policies in effect on March 23, 2010
• Cannot:
• cut or reduce benefits
• raise co-insurances
• significantly raise co-payment charges
• significantly raise deductibles
• significantly lower employee contributions
• add or tighten on annual limit on what insurer pays
• change insurance companies

Projected Impact on Consumers and Plans

• Large Employer Plans
• Small Business Plans
• Individual Health Market
• People in Special Types of Health Plans

Projections of Employer Plans Remaining Grandfathered, 2011-2013

• See chart in article
• Choices in 2014 and subsequent years

For the full article, please click the following link: Keeping the Health Plan You Have: The Affordable Care Act and Grandfathered Health Plans

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

What Employers Should Know About Healthcare Changes Ahead

Insurance Journal published an article on "What Employees Should Know About Healthcare Changes Ahead" The article discussed what would happen after Obamacare.  5% of companies are using the approach in which they give their employees a set amount of money to buy their own health insurance.

The article suggested the follow as to what you can do currently:

• This year's tax season matters
• Look at your tax return you may qualify for subsidies
• Income levels will determine premium costs and what is covered by tax credits
• If you and your spouse file separately consider filing jointly
  
• Educate yourself
• Public Exchanges are going to start October 1, 2013 open-enrollment for health insurance begins.
  
• Save money
• If you have a HSA (Health Savings Account) they are unsure if these will carry-on after 2013 so the article suggested to max these out & you will have money later.
• Insurance costs could rise in 2014

For the full article, please click the following link: What Employers Should Know About Healthcare Changes Ahead

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

Coding Changes for 2013

ACP Internist published an article with updates on coding changes for 2013. In the article they discussed the revised ICD-9 update schedule as follows:

• Oct 1, 2011 - ICD-9 & ICD-10 code sets
• Oct 1, 2012 - limited code updates for ICD-10 (no updates to ICD-9)
• Oct 1, 2014 - limited code updates to ICD-10 code set (no updates to ICD-9 since it no longer will be used)
• Oct 1, 2015 - regular updates to ICD-10 will begin.

New Care Management Codes

• Will be introduced in 2013
• Reporting and reimbursement of non-face-to-face care for complex, chronic illnesses & have been discharged from a hospital or facility not described in CPT or HCPCS codes.

Complex Chronic Care Codes - allows physicians & qualified health professionals to report the work & time they spend on a patient's care (including non-face-to-face elements)

• 99487
• 99488
• 99489

Transitional Care Management Codes - codes for follow-up care after the patient has been discharged from a facility setting.

• CPT 99495
• communication with the patient or caregiver within two business days of discharge
• MDM of at least moderate complexity during the service period
• face-to-face visit within 14 calendar days 
• CPT 99496
• communication with the patient or caregiver within two business days of discharge
• MDM of at least moderate complexity during the service period
• face-to-face visit within 7 calendar days

For the full article, please click the following link: Variety of Coding Changes Loom For 2013.

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

2013 Radiology CPT Code Update

An article published by the American College of Radiology discusses the following codes that have changed in 2013. Below is how the article broke down the Radiology Codes by specialty.

Diagnostic Radiology

• Revised - Cervical Spine Codes
• 72040, 72050, 72052
• Deleted - Bronchography
• 71040, 71060

Interventional Radiology 

• New - Thoracentesis & Pleural Drainage Codes 
• 32554, 32555, 32556, 32557
• Deleted - Pneumocentesis & Thoracentesis
• 32420, 32421, 32422
• New - Cerviccocerebral Artery Studies
• 36221, 36222, 36223, 36224, 36225, 36226, 36227, 36228
• Deleted - Cerviocerebral Angiography Codes
• 75650, 75660, 75662, 75665, 75671, 75676, 75680, 75685
• New - Retrieval of Foreign Body
• 37197
• Deleted - Foreign Body Retrieval Codes
• 37203
• New - Thrombolysis Codes
• 37211, 37212, 37214
• Deleted - Thrombolysis Codes
• 37201, 37209, 75900

Nuclear Medicine

• New - Endocrine and Parathyroid
• 78012, 78013, 78014, 78071, 78072
• Revised - Parathyroid Codes
• 78070
• Deleted - Endocrine Codes
• 78000, 78001, 78003, 78006, 78007, 78010, 78011

Radiation Oncology 

• New - Stereotactic Body Radiation Therapy Code
• 32701

Category III Code Changes

• New - Focused Microwave Ablation Code
• 0301T
• Extended - CAD and HDR Brachytheraphy Codes
• 0174T, 0175T, 0182T

For the full article, please click the following link: 2013 CPT Code Update - Radiology.

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

More Health-Law Changes Coming in 2013

The Wall Street Journal published an article titled: "More Health-Law Changes Coming in 2013". The article listed the following 5 changes that will come about in the year 2013. They are as follows:

1. Higher Premiums
• 13% of companies planning to raise their employees contributions by 5% or more.
• Insurers give rebates to consumers if the insurers spend less that 80% of premiums on medical care.
• In 2012, 13 million consumers got rebates worth $1.1 billion dollars
  
2. Straightforward Summaries
• Easy-to-read descriptions of how the plan works.
• What it covers and doesn't cover - no fine print.
• New glossary of insurance words that you may not understand
  
3. FSA Limits
• $2,500 is the maximum you can put in a flexible spending account.
• FSA are tax free money that you can use to pay qualified out-of-pocket expenses for 
• Examples: copayments for doctor visits or prescriptions
• If you don't use the full amount that you put aside, you will lose that money.
  
4. Dependent Coverage
• Children up to age 26 can stay on their parents' policies
  
5. Higher Spending Cap
• This year (2013), the spending cap is $2 million
• In 2012, the spending cap was $1.25
• In 2014 the spending cap will go away entirely.

To view the full article, please click the following link: More Health-Law Changes Coming in 2013

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

Five Ways Your Health Care Will Change in 2013

On December 26, 2012, The Washington Post published an article on "Five Ways Your Health Care Will Change in 2013".  The basis of these gradual changes rolling out in 2013 are a result of the Affordable Care Act and federal subsidies to purchase health insurance.

1. Health-care cost growth will slow to a new low
• US expected to spend $2.9 trillion on health care in 2013 (3.8% more than estimated $2.8 trillion that was spent in 2012.
• If the 3.8% growth rate happens it will be the slowest growth in decades
  
2. Your Medicare taxes will increase
• 7.65% is taken out of wages to support the elderly and disabled.
• 1.45% goes towards Medicare's hospital bills
• Medicare hospital tax increased by 0.9% in 2013
• Creates a new 3.8% tax on investment income
  
3. Your insurance plan will be explained in plain English
• Easy-to-understand terms
• Health plans with open enrollment after September 23, 2012 are this way.
  
4. Primary care providers in Medicaid will get a 73% raise
• Estimated 7 million new enrollees in 2014.
• Expanding Medicaid program to 133% of the poverty line
  
5. The Obamacare exchanges will be open for business.
• October 1, 2013 is the more significant deadline as health care exchanges open that day
• Health care exchanges will allow Americans to go online, compare plans and purchase health insurances

To view the full article, please click the following link: Five Ways Your Health Care Will Change in 2013

For additional billing, coding and reimbursement resources listed by specialty, please click the following link: Medical Reimbursement, Inc. Resources Page.

Coding and Documentation

In need of coding help?

AAPC's Coding Edge Magazine published an article on  documentation and offered the following tips:

• Reports Don't Need to Be Lengthy to Be Complete
• Minimum requirements that need to be in the medical record are the following:
• 1. History of present illness (HPI)
• 2. Examination
• 3. Medical Decision Making (MDM) components
• If you are documenting radiology, you must document the technique as well as the findings of the study
• Documentation Must Be Relevant
• Extraneous documentation can do more harm than good
• Stick to what's relevant and be thorough
• Documentation Must Support Specific Coding
• Select the code that accurately identifies the service or procedure performed
• Documentation my support the code you select
• Document Same-Day Procedure, E/M with Special Care
• Procedures provided on the same day as an E/M service may cause red flags
• When you report an additional study your documentation must pass the "highlighter test" - supports the initial service

• * Important to remember the "golden rule" - "If it isn't documented, it wasn't done"*

To download the full article, please click here: Let Documentation Drive Your Coding

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

Long Waits at the Doctor's Office Disrespect Patients

KevinMD.com blog posted an article on "Long Waits at the Doctor's Office Disrespect Patients" in the article they explained various reasons why you are kept waiting and different ideas as to what you could do about your wait issues.

The article stated:

• The average time patients spend waiting in 24 minutes
• The average wait times for specialists are longer than general practitioners.

Possible reasons why you are kept waiting:

• The office overbooks & schedules multiple appointments at the same time
• The doctor could have to go to a different office and be running late
• The doctor could be late

What the practice could do for you:

• Call or email if they are running late
• Give you a paging device (similar to restaurants)
• Inform you about the situation at check-in

What you can do:

• Book the first appointment of the day
• Call ahead and ask how the day is going before your scheduled appointment time
• Ask the office staff how long the wait will be
• Explain your frustration to the office staff/doctor
• Find a new doctor

For the full article, please click the following link: Long Waits at the Doctor's Office Disrespect Patients

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources Page

How High Deductible Plans Lead to Low Healthcare Spending

An article published from Forbes titled “How High Deductible Plans Lead to Low Healthcare Spending” shed some light on the impact that high-deductible health plans are having on consumer's healthcare spending. Highlights from the article are as follows:

• There was a 3.8% increase in health costs in 2009 &  a 3.9% increase in health costs in 2010 this equates to the slowest growth rate in 50 years
• There was a 14% increase from the 2010 total individuals enrolled in consumer-directed health coverage
• Health Savings Accounts (HSA) allow people to save their pre-taxed income to spend it on their health care needs
• A study from RAND Corporation concluded that someone who switches from a traditional health plan to a consumer-directed health plan uses 14% less medical services
• More consumers using directed plans would reduce national health spending
• Also according to the study from the RAND Corporation stated that expanding employers with plans such as 50% would reduce health costs by $57 billion per year.

To download the full article, please click here: How High Deductible Plans Lead To Low Healthcare Spending

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

Emergency Room Patients Across Country Paying Upfront For Non-Urgent Care

More and more individuals are going to the emergency room.  Some of these visits may be from people who do not truly have an emergency.  Citizensvoice.com published an article titled: "Emergency Room Patients Across Country Paying Upfront For Non-Urgent Care" some key takeaways from the article included:

• The number of emergency room visits has risen by 11% in he past five years.
• The number of emergency departments (based from article for the state of Pennsylvania) has shrunk by 10%.
• An estimated 8% of emergency room visits across the country are for problems that could be handled at a walk-in clinic or primary care facility (statistic based on the U.S. Centers for Disease Control & Prevention).
• A growing number of visits to the emergency room are from problems such as sprained ankles, coughs & colds.
• The EMTALA (The Emergency Medical Treatment and Active Labor Act) passed in 1986 states that hospitals are required to administer medical screening examination to any patient to comes to the emergency room.
• Many hospitals collect a fee or co-pay for services provided for non-emergency care in the emergency room.
• Some hospitals may even have an on-site urgent care clinic that they can send the emergency room patients who do not need care in the emergency room - upon doing this they can free up space in the emergency room and treat sicker patients faster.

For the  full article, please click the following link: Emergency Room Patients Across Country Paying Upfront For Non-Urgent Care

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

Emergency Rooms vs. Urgent Care: Differences in Services and Costs

Debt.org published an article on the differences in services and cost on Emergency Rooms and Urgent Cares. Highlights of the article are located in the bullets below:

Emergency Rooms

• Have 5 Levels of Care
• Level 1 is Minor Problems and Level 5: More Severe Problems
• Required to provide care to all patients
• $18 billion could be saved if patients with non-urgent medical problems go to a primary or preventive care center.

Emergency Room Costs

• ER Costs correspond with the severity of the patients illness or injury
• Physician's Fees are typically about 20-25% of the total charges
• Costs vary in different parts of the country
• Average visits in 2009 were $1,318
• Average in-network visit in 2011 was $933
• Average visit in 2009 for common illnesses - (middle ear infection, pharyngitis and UTI) was $570 

Urgent Care Centers

• Free-standing, walk-in medical facilities that provide care with no-appointments.
• They are open extended hours as well as nights and weekends.
• Serve those with non-life threatening medical situations.
• Take in $13 billion dollars in revenue annually.

Urgent Care Center Costs

• Less significant costs than the Emergency Room
• Urgent care estimates say that the visit can cost anywhere from $71 to $125

Paying For Emergency Room Visits

• Private insurance: 54%
• Medicare: 38%
• Medicaid: 33%
• Uninsured Patients: 35%

Paying For Urgent Care Visits

• Fee-for-service basis
• Usually accept most private insurance plans
• Co-pays are around $25-$50 per visit for those who have health insurance
• Discounts are usually offered for those without insurance.

For the full article, please click the following link: Emergency Rooms vs. Urgent Care: Differences in Services and Costs.

For additional billing and coding resources  please click the following link: Medical Reimbursement Billing and Coding Resources Page.

Patient Perceptions on No-Shows

According to a study published by Annals of Family Medicine, there are many reasons why people do not show up to their scheduled appointments. The study stated on average that 42% of appointments were no shows. The study then went on to state the following as potential reasons why the patient didn't show:

• Trouble getting off work
• No child care
• Lack of transportation
• Too costly
• Patients who scheduled their appointments in advance and then felt better also failed to show up to their appointment.  
• Patients also felt "too unwell" to show up to their appointments
• Some people felt "emotional barriers" and the negative emotions that go along with going to the doctor and feel that people could go to the doctor for one thing and then they could have other underlying issues that the doctor may find.

For the full article, please click here: Why We Don't Come: Patient Perceptions on No-Shows

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

Co-Pay Collection Best Practices

TransforMED published an article on co-pay collection best practices. Some key points from the article are as follows below:

• Establish Co-Pay Collection Policies and Procedures

• The article suggests that the best time to collect co-pays is when the patient is in your office.
• Once the patient leaves the office it is more difficult (and expensive) to collect their payment
• Develop a policy that states that co-pays will be required before the patient's appointment

• Who Collects?

• Determine an individual who is responsible for collecting the co-payments - usually this is the front office staff at the reception desk.
• Ensure that your collection process is monitored

• A Team Effort

• Make sure to confirm the patients insurance and co-payments when they schedule their appointment.
• The patient should also be reminded that they will need to bring their insurance card as well as their co-pay when they come for their visit.
  
• "How will you be paying today?" Some ideas for collecting co-payments are below:
• Use a credit/debit card machine (although this will come with a cost of usually 2-3% for the transaction cost and around $.25 per transaction)
• Install ATMs in the lobby

• Train and Reward Your Staff

• Use lines such as: "How will you be paying for your services today, cash, check or credit?" by saying this you are giving them more than one option to pay.
• If the patient knows they need to make the co-payment ahead of time, they should not be shocked when you ask for the payment.

• Communicate with Patients: if this is a new policy for you, you need to be sure to communicate with the patient about this. The following are a few of the ways introduced in the article:

• Place signs in your office
• Mail out letters introducing the new policy to your patients
• Have the patients sign a form at check-in with an overview of your new policies and procedures on collecting co-payments.

For the full article, please click the following link: Co-Pay Collection Best Practices

For additional billing and coding resources, please click here: Medical Reimbursement Coding and Billing Resources.

Health Care Exchanges Under the Affordable Care Act

The New York Daily News published an article on the future of health insurance and what you can expect from health care exchanges.  These changes will start in fall of 2013. Some key takeaways from the article are listed in the bullets below:

• The goal is quality coverage for millions of Americans who do not have health insurance.
• Individuals and Families will have a choice of private health plans 
• The government will help many middle class households pay their premiums
• Open enrollment will start on October 1st, 2013. Enrollment will be online, storefront operations as well as help at call centers.
• Coverage will take place on January 1, 2014 and everyone will be required by law to have health insurance.
• There will be penalties for some individuals:
• For example, as cited in the article: smokers will face a financial penalty and younger "well-to-do" people may not be eligible for income-based assistance.
• There is some concern that the people who need (and will benefit) from the help the most are unaware that these changes are coming and won't benefit when it is first available.

For the full article, please click the following link: The Future of Health Insurance: What to Expect From Health Care Exchanges Under the Affordable Care Act

For additional billing and coding resources, please click here: Medical Reimbursement Billing and Coding Resources.

High-Deductible Health Plans

Rand Corporation completed an assessment on high-deductible health plans and 800,000 families were studied across the United States. Some key highlights of the study were as follows:

• Spending dropped 14% when they had a higher deductible
• Spending was lower when the individual had a high-deductible plan.
• When the individual had employer contributions contributing to more than half their deductible, savings decreased.
•  Costs went down dramatically the first year people had a high-deductible plan 
• High-deductible and consumer-directed plans help control health care costs
• Patients in the study also reduced their preventive care visits (to reduce their spending) but down the road this could be costly as they could have worsening health problems
• Under the Federal Patient Protection Affordable Care Act (ACA) health plan deductibles must be waived when there is preventative treatments. 
• In the short run high-deductible plans are working but they discourage people from getting preventative care.  

To read the full article, please click the following link: High-Deductible Health Plans Finds Substantial Cost Savings, but Less Preventative Care

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

Getting Started with an EHR

HIMSS (Healthcare Information and Management Systems Society) issued a fact sheet with the following tips on how to implement an EHR system:

1. Getting Started
• Start by forming an EHR project team
• Write a mission statement
• The EHR project can speed up patient flow and add capacity
• The EHR can also reduce overtime by spending less time filling out paper form and charts.
  
2. Examine Workflow
• Examine how implementing the EHR will change your business. For instance the EHR may speed things up but change how you run your business
  
3. Select the Right Vendor
• Make a list of requirements that you need in an EHR
• Ask people you know what kind of EHR that they use and what their experiences have been with them
• Look on the institute of Medicine and their list for a "key capabilities" for an EHR
  
4. Negotiate a Good Contract
• Negotiate a contract that meets your needs for your EHR
• Ask for references from the vendor
• View the product at a company that uses the vendor already
  
5. Plan Carefully for a Successful Implementation
• Plan how to transfer existing paper based information and how the new documents transfer into the new EHR system.
• Train one "super-user" for every 25 people that will be using the EHR system in your company.

For the full article, please click the following link: Getting Started with an EHR

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

Reducing Patient Wait Times

Health Leaders Media published an article on "How Physicians Can Reduce Patient Wait Times"  The basis of the article was a survey that was administered by Merritt Hawkins & Associates on patient wait times.  The survey studied the wait times for the following specialties: Family Practice, Cardiology, Dermatology, and Orthopedic Surgery.

Family Practice:
Longest Wait Time: 99.6 Days, Shortest Wait Time: 2.47 Days, Average Wait Time: 20.3 Days

Cardiology:
Longest Wait Time: 104.4 Days, Shortest Wait Time: 3.4 Days, Average Wait Time: 22.1 Days

Dermatology:
Longest Wait Time: 98.7 Days, Shortest Wait Time: 2.5 Days, Average Wait Time: 27.5 Days

Orthopedic Surgery:
Longest Wait Time: 59.9 Days, Shortest Wait Time: 2.9 Days, Average Wait Time: 16.8 Days

The article suggested that the following take place to address the wait times:

• Adopt modern tools (for example: EHR)
• Use creative and innovative scheduling models
• Have office hours that better accommodate patient's needs
• Look at quality measurements (such as patient demographics)

Some other solutions the article suggested were: 

• e-messaging, e-visits and groups clinics
• pilot programs - have one physician go around and teach the others to use new protocols.

To download the full article, please click here: How Physicians Can Reduce Patient Wait Times

For additional resources by specialty, please click the following link: Medical Reimbursement Resources Page

Denying Payment for Unnecessary Emergency Room Visits

KevinMD.com published an article on "Denying Payment for Unnecessary Emergency Room Visits".  This blog post highlighted Washington Medicaid Initiative which would deny Medicaid payments for unnecessary Emergency Room visits.

Some takeaways from the article were:

• Washington State is committed to pay for medically necessary care - but many patients go to the ER when they could just go to a primary care physician. 
• There is tremendous overuse and abuse of emergency rooms - at least $21 million dollars a year
• ER Physicians and Hospitals have had the state pay for non-medically necessary services in the Emergency Room.
• Everyone must be seen regardless of their ability to pay according to the EMTALA (Emergency Medical Treatment and Active Labor Act) of 1989.
• One idea that the state of Oregon did was assign a social worker to each of those patients who repeatedly go to the emergency room.  The intent of this is to divert patients away from the Emergency Room who they think are going for a "social problem". The time spent with the social worker costs less than what they would have to pay for the Emergency Room visit.

To view the full blog post, click here: Denying Payment for Unnecessary Emergency Room Visits

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

Referrals to Physicians

The New York Times published an article on patient referrals. Some key takeways from the article about referrals are the following:

• Studies suggested that physicians receive up to 45% of new patients by referrals
  
• Referral rates are so high because of the following reasons:
• Increased specialization
• Lack of time for the doctor to review complex cases
• Fear of lawsuits for not consulting an expert
  
• Specialists are paid better than primary care physicians but depend on other doctors for referrals
  
• One individual had a suggestion to implement bundled payments similar to what hospitals, nursing homes and dialysis centers do.

To view the full article, please click the following link: Referral System Turns Patients Into Commodities

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

Patient Safety and Quality of Emergency Care

The American College of Emergency Physicians published an article on "Patient Safety and Quality of Emergency Care" which lists improvements on patient safety and quality of care.

Some key takeaways addressing the problem of holding (or "boarding") the patients who have been admitted in the emergency room suggested the following solutions:

• Move admitted patients out of the emergency department to inpatient areas
• Coordinate the discharge of hospital patients before noon
• Coordinate the scheduling of elective patients and surgical cases

Takeaways from a survey that was administered on emergency physicians' concerns were:

• Seven out of ten physicians expressed concerns about the proposed physician measures for example - overcrowding.
• Two out of three said that the measures may increase the burden on the emergency department (who are at capacity).
• More than half said cost reductions could harm the quality of care

To read the full article from ACEP, please click here: Patient Safety and Quality of Emergency Care

For additional billing and coding resources, please click here: Medical Reimbursement Billing and Coding Resources

Guidelines for Office-Based Anesthesia

Interested in starting your own practice of ambulatory anesthesia (office based anesthesia), below are a few of the issues that the ASA suggested to follow in their guideline:

Administration and Facility

1. Quality of Care

• Should have a Medical Director
• Valid licenses/certificates for each individual to perform their duties
• All OR personnel should have appropriate education, training and experience
• Anesthesiologist should ensure they are up to date with quality improvement and risk management

2.  Facility and Safety

• Facilities should  comply with all federal, state & local laws, codes & regulations pertaining to the building construction.
• Policies and procedures should comply with laws and regulations

Clinical Care

1. Patient and Procedure Selection

• Patient's procedure should allow them to recover and be discharged from the facility
• Those with pre-existing medical conditions with risk of complications should be referred to appropriate facility

2. Perioperative Care

• Anesthesiologist should be present during and until immediately after the patient is discharged from anesthesia care
• Discharge is the physicians responsibility 

3. Monitoring and Equipment

• All equipment should be maintained, tested, and inspected
• Back-up power should be sufficient

4. Emergencies and Transfers

• The facility should have medications, equipment and written protocol for treating hypothermia
• Written protocols for internal and external disasters

To download the full article with additional guidelines, please click the following link: Guidelines for Office-Based Anesthesia

For additional resources on assisting your practice, please click here: Medical Reimbursement Resources Page

Bringing PAs and NPs on board

Have you considered hiring Nurse Practitioners or Physician Assistants? An article published by American Medical News offers some tips on what to consider:

• They suggest the first step to determine if the new hire (the NP or the PA) would indeed help your practice. You can also look into State regulations to make your decision.
• For example: nurse practitioners can prescribe in 50 states, but only 47 states for controlled substances
• Nurse practitioners can practice independently in 16 states.
• Some states require a physician to audit a percentage of the charts.
• Nurse Practitioners are regulated by the state board of nursing and physician assistants are regulated by their state's medical board.
• Physician assistants are usually hired if you want them to do "technical procedures"
• Nurse practitioners are usually hired if you want them to deal with more of the "evaluation and management" aspect.
• You will need to set up credentialing for the practitioner (which can take months)
• Background checks are important as well as a license check with the state board before you hire them
• Use the proper title for the person you are hiring - in the interview process as well as after they get hired - if you don't use their proper title it can confuse patients as to who they are seeing.

The number of NPs and PAs has increased over the years. Since 1996-2009 the number of nurse practitioners went up from 70,993 to 158,348 and physicians assistants went up from 29,161 to 73,893.

To view the full article, please click here: Bringing PAs and NPs on board

For additional billing and coding resources, please click here: Medical Reimbursement Billing and Coding Resources Page

ER Doctors Face Quandary on Painkillers

Many times Emergency Room doctors are faced with patients who come complaining of a toothache. There are many issues when this occurs. An article was published by the New York Times on Emergency Room doctors and dental patients.  The article discussed issues when patients come to the Emergency Room with a toothache.

Some issues may occur such as:

• They patient may simply going to the Emergency Room to receive narcotics
• How does the doctor really know if the patient is in pain or is telling the truth about their dental pain?
• The ED may lack the tools to properly diagnose the tooth pain.  
• They do not have a dental x-ray machine which would validate if they tooth pain is in fact an infected nerve and whether or not they should prescribe painkillers
• Most hospitals have patient satisfaction surveys and if a person is truly in pain this might have a negative impact one their responses.

Some solutions mentioned in the article are as follows:

• Have a drug-monitoring database which will tell you if the patient has had any painkillers filled recently
• 40 States have some sort of drug monitoring program
• One hospital in the article offers "dental blocks" yet many doctors do not want to do this.

To view the full article, please click here: ER Doctors Face Quandary on Painkillers

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

Fewer Emergency Rooms Available as Need Rises

The New York Times published an article on the growing number of Emergency Departments closing.  The article was based off of a study published in the Journal of American Medical Association focusing on hospitals in the New York City area whom closed their Emergency Departments. The purpose of the study was to see why hospitals were closing their Emergency Department.

Some statistics on Emergency Room closing rates:

• Urban and Suburban area closing was at a rate of 25%
• Nationally there has been a decrease by 35% of Emergency Rooms

Some of the reasons why hospitals closed were:

• They served large numbers of the poor
• Were at commercially operated hospitals
• Were at hospitals with "skimpy profit margins"
• They operated in highly competitive markets

Even if an Emergency Room in your area isn't closing, it could have an impact on your Emergency Room since the people will have to find another ER to go to.  This could lead to longer wait times and the quality of care could decrease.

To view the full article, please click here: Few Emergency Rooms Available as Need Rises

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

Maximizing Patient Flow in Your Practice

How you manage your patient flow should be ongoing in order to ensure your practice is running as smoothly as possible. An article published by American Medical News (amednews.com) discussed a variety of suggestions in order to improve your patient flow.  Some of the solutions are common but may be looked over when the practice is running their day-to-day operations:

1. Have a variety of different solutions for patient flow
2. Increasing you revenue and patient satisfaction are key
3. Assess how the patients move through the practice
• One idea was to time patients as they move from arrival to departure and all the steps in between
• Another idea was streamlining all the processes
4. Changing how you schedule patients was also an idea
• One example shown was a hospital who had multiple new patients on the same day. Scheduling these new patients (who take longer) on separate days during the week could improve patient flow.
5. At the end of the appointment, make sure the patient knows what do next. (follow-up appointments or other procedures, etc)

To view the full article, please click the following link: "How to Maximize Patient Flow Through the Office"

For additional billing and coding resources, please click here: Medical Reimbursement Billing and Coding Resources

Handling HIPAA in the Emergency Room

Strategies for Nurse Managers published an article on HIPAA in the Emergency Room.  Since the Emergency Room is chaotic and stressful, following guidelines HIPAA may be harder to do. There are many ways the Emergency Room is different.  The following were some of the topics addressed addressed in the article:

• The main priority is obviously to save the person's life in the Emergency Room. Sometimes, the patient's condition prevents them with speaking to the patient and they have to release the information to the family or responsible party
• HIPAA also allows the doctor who is taking care of the patient to use their best judgement for the patient if the responsible party is not available at the time
• HIPAA considers communication in the Emergency Room as "incidental communication" which they don't consider a violation. 
• Trouble areas in the Emergency Room

In addition to the differences listed above, they also offered some "training tips" on how to handle HIPAA requirements while working in a chaotic setting such as the Emergency Room.

To view the full article, please click the following link: HIPAA in the ER: Exceptions, Suggestions for Compliance in a Chaotic Clinical Setting

For additional Medical billing and coding resources, please click here: Medical Reimbursement Billing and Coding Resources

Anesthesia Payment Policies

Washington State Department of Labor and Industries published a fact sheet on Anesthesia Services - Anesthesia Payment Policies. The fact sheet outlines the following:

Noncovered and Bundled Services

• Anesthesia Assistant Services
• Noncovered Procedures
• Patient Acuity

Payment for Anesthesia

• Certified Registered Nurse Anesthetists (CRNA)
• Medical Direction of Anesthesia Team Care
• Requirements for Medical Direction of Anesthesia
• Documentation Requirements for Team Care
• Billing for Team Care
• Payment for Team Care
• Anesthesia Teaching Physicians

Anesthesia Services Paid With Base and Time Units

• Anesthesia Base Units
• Anesthesia Time
• Anesthesia Modifiers
• CPT
• HCPCS
• Anesthesia Payment Calculation
• Anesthesia Add-on Codes
• Anesthesia for Burn Excisions or Debridement
• Anesthesia Services Paid By the RBRVS Method
• Modifiers
• Maximum Payment
• E/M Services Payable with Pain Management Procedures
• Injection Code Treatment Limits

To view the full document, please click the following link: Anesthesia Payment Policies

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

Costs of Emergency Care

According to an article published by ACEP, emergency rooms are cost-effective.

Some statistics on Emergency Care:

• Emergency Care represents 2% of $2.1 trillion in health care expenditures in the United States
• The Emergency Room has multiple resources in same area including: 
• diagnostic testing
• laboratory testing
• pharmaceuticals
• access to other medical specialists
• 20-25% of the fee for the Emergency Room visit is for the physician
• Half of emergency services go uncompensated according to the CMS
• In 2006, more than 60% of emergency patients had some kind of government health insurance
• Those who are unable to afford regular medical care often go to emergency rooms for care
• Emergency Departments serve as a portal for 3/4 of the unisured patients who are admitted to US Hospitals.

To view the full article, please click the following link: Costs of Emergency Care

For additional medical billing and coding resources, please click the following link: Medical Billing and Coding Resources

Stemming Losses in Copays, Deductibles at Your Practice's Front Desk

Physician's Practice published an article titled: "Stemming Losses in Copays, Deductibles at Your Practice's Front Desk"  with advice on how to stop "lost" copayments and deductibles at the time of service:

1. When the Patient Calls to Schedule an Appointment:
• Get the patient's health plan
• Ask if they've paid their deductible for the year
2. Reminder Calls for Appointments:
• Remind 2 days before the appointment and if there is a copayment or a deductible
3. When the Patient Checks in at the Front Desk:
• Collect at the time of check-in (if you know their copayment amount)
• Collect after their visit (if you do not know the percentage they owe at check-in)

To view the full article, please visit the following link: Stemming Losses in Copays, Deductibles at Your Practice's Front Desk

For additional billing and coding resources, please visit the following link: Medical Reimbursement Billing and Coding Resources