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