Blog and Helpful Articles

What We’re Reading – The Forces of Nature and Lost Medical Records

After news of the 125 tornadoes that touched down in the Midwest this weekend, I recalled an article published about Joplin, MO, entitled “Lost medical records complicate Joplin hospital’s tornado recovery.” This article details how tornadoes that ripped through Joplin became an eye-opener on the importance of electronic medical records (EMR).

Besides debris, medical records and x-rays were found as far away as 75 miles from the devastation. Included in paper records are patients’ most important information, such as name, social security number, date of birth and address. Fortunately, the information wasn’t lost since the hospital had back up its paper charts to an EMR just three weeks before the catastrophe. However, the paper records and all the identifying health information were still out there, and the hospital’s only recourse was to ask anyone finding these records to return them.

All healthcare providers face serious financial and legal penalties if the security of their records is breached. The United States Depart of Health and Human Services requires that medical providers protect individually identifiable health information against any reasonable anticipated threat or hazard. When a provider experiences a breach on grounds other than willful neglect, no fines are imposed.

As we continue to experience unexpected weather events and forces of nature, it behooves all providers to be prepared to safeguard their patients’ records.

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The Basics of HIPAA (Part 2)

Monday, we began a discussion about the Health Insurance Portability and Accountability Act (HIPAA) and reviewed two of its early provisions:  Portability and Medicare Program Integrity.  Today, let’s review the most important aspect of HIPAA for the majority of providers.

Administrative Simplification

Did you know that, prior to HIPAA, there were over 400 formats for submitting electronic claims?  The administrative simplification provisions of HIPAA reduced the number of forms and methods of completing claims, and other payment-related documents.  In short, HIPAA standardized the way information is transmitted, making your job a lot less complicated.

By forcing insurance companies to use the same format for their transactions, HIPAA actually saves your practice time and money.  The staff is able to send more information, faster, and spend less time in wasted efforts.

Of the transactions covered under HIPAA, these are the most important for the medical practice environment: eligibility, claims, health claim status, payment and remittance advice, and referral certification & authorization. HIPAA makes it possible for information to flow in one standard format, which makes it easier for computers to “talk” to each other.

One way to do this is to make sure everyone speaks the same “language.”  For computers, language usually means numbers.  That’s why we use ICD-9-CM and CPT-4/HCPCS codes.  These standard codes mean the same things to everyone.  HIPAA made it mandatory for everyone to use the same codes.  Scan you believe that some insurance companies had actually made up their own codes for certain procedures?!  No wonder billing was such a complicated endeavor!

Two other components of HIPAA are the security rule and the national identifiers.  The security provisions protect all electronic health information from improper access or alteration, and against loss of records.  The identifier component of HIPAA creates one unique identifying number for each provider, employer, individual and insurance payor.  This means that, as patients, our health records aren’t identified by our social security number.  For providers, this means simplicity.  Did you know that a single provider may have had more than 30 provider numbers, depending on which insurer you were dealing with?  One standard number simplifies work for you in the office and may also makes it easier for providers to be recredentialed by the various insurance plans.

Next time we meet, we’ll review the basics of who governs HIPAA and who is required to comply with it.  You might learn some surprising information. See you then!

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The Basics of HIPAA (Part 1)

HIPAA is one of the most encompassing legislative changes to happen in the US in the past 20 years. It’s also one that generates a lot of misinformation, myth and sometimes even apathy.  A lot of providers believe that securing patient records is the extent of the compliance requirement.  Accompany us on a five-part journey into the Basics of HIPAA and see if your organization has a good understanding of this law.

Introduction

The Health Insurance Portability and Accountability Act (HIPAA) is a Federal law, enacted in 1996, that was implemented in phases.

It contains the following provisions:

A.  Portability

This component was implemented in 1997 and provides available and renewable health coverage.  It also removes the pre-existing conditions clause, under defined guidelines, for individuals changing employers and health plans.  [The Patient Protection and Affordable Care Act (PPACA) – or the health care reform law enacted in 2010 – goes beyond the pre-existing conditions clause in HIPAA.]

For example, suppose an individual changed jobs and had a waiting period of 90 days in order to be covered under the new employer’s health insurance. Before HIPAA, if that person became ill during those 90 days, s/he may not have been eligible for insurance coverage.  Or, if the individual was covered, the illness may have been considered a pre-existing condition, which would not be covered.

HIPAA made it possible for people to change employers and health coverage without any fear of uninsurability.

B.  Medicare Integrity Program (Fraud & Abuse)

This HIPAA component, implemented in 1998, guarantees that the Center for Medicare and Medicaid Services (CMS) has the funding for integrity activities and to expand its anti-fraud initiatives.

South Florida, in particular, seems to have more than a fair share of people engaged in defrauding the Medicare and Medicaid programs.  HIPAA has allocated funds for improved fraud detection programs and increased staff to investigate allegations of fraud.  It seems not a week goes by without some news of a fraudulent provider being caught.  In addition, CMS has retained the services of private recovery contract auditors who specialize in combing for inappropriate payments and recouping them for the federal and state governments.

Next time, we’ll discuss the third provision of the HIPAA law, and the one that probably affects provider organizations the most in today’s healthcare environment.

 

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Job Descriptions & Performance Appraisals – Who Needs ‘Em?! (Part 4)

This is Part IV of our four-part series on job descriptions and performance evaluations, two tools that are underestimated in the operation of any department or business. Monday, we discussed that the two are inter-related.  We suggested using the essential functions from the job description to create the performance eval document, and assign a rating scale to each task.  Today, we will wrap up our conversation and show you an example of a performance evaluation.

Any conversation on performance evaluations would be incomplete without mentioning a very important point: don’t wait for the annual review to discuss performance.  Good managers live by the concept that there should be no surprises during the appraisal.  Similarly, when assessing performance, make sure you look at the entire block of time (one year if annual, 90 days if it’s a probationary period eval), and not just the last week or two.

That leads me to a reminder that you should document things all year long.  If an employee receives positive feedback from a patient or customer, let the rest of the staff know. And then print or save the info in his or her personnel file.  Same goes with negative issues.  When you have a disciplinary chat with a worker, jot down a note or two.  Some managers send an email to themselves (especially if there is no HR dept) and save it in an e-file.  Whatever method you choose, do it faithfully and performance appraisals will be the learning tool they were designed to be.

You may have the best intentions to do this all perfectly, but running your department or company will undoubtedly get in the way.  Start small.  Get the job descriptions done.  Think about performance targets.  Soon you will naturally progress to periodic evaluations and the more formal written appraisal.

We hope this four-part series has been useful.  Here is an example of the concept we discussed today.  Try your hand at these documents and be sure to leave us a comment on your progress.

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Job Descriptions & Performance Appraisals – Who Needs ‘Em?! (Part 3)

Last week, we discussed the need for job descriptions for each position in your company.  Smart managers quickly realize that the formality of a job description is paramount to the employee’s understanding of where the job fits in the organization’s structure and the major elements of the position.  As we discussed, job descriptions needn’t be too fancy; as long as you summarize the essential functions and requirements, you’re light years ahead of your peers.  In part III of this four-part series, we’ll consider performance.

If job descriptions are a figment of the imagination in small companies, performance appraisals are virtually non-existent.  The two are very related as we will see in today’s discussion.  Who hates performance evaluations? Raise your hands…..  We can see you!!!  But let me ask you a few questions:

Is every employee performing as well as you expect or desire?

Are they doing their job well and grasping the inter-relatedness of their work in the big picture of your company?

The next logical question is… what have you done about it?  Grin and bear it?  After all, you ‘just can’t hire good help nowadays??’  Not true.  Good help is cultivated and trained.  While you can’t change someone’s personality, you can obtain the performance you want and need from your staff.  You just need to communicate it by various means (oral and written) and then follow through.

Once you’ve invested the time in creating the job description, the performance evaluation is a walk in the park!  Simply use the same essential functions you listed in the job description and create a rating scale.  Some employers use a five-point (excellent, good, average, fair, poor) scale for each task;  others use a number from one to 10, with a specified range of behavior from 1 = does not meet expectations to 10 = consistently exceeds expectations, and varied points in between.  It’s important to give some thought to your expectations about the task or function so that you can convey ahead of time, during the job description chat, how you will rate the individual’s performance. If you tell someone what you expect (especially if it is objectively measurable, such as error rates, denied claims, etc.) and then explain that this will be the basis of the evaluation, you have a better likelihood of seeing the performance you want. And by chance, if you don’t, you have ammunition to refute the employee’s challenge to a low evaluation score.  “Remember when we reviewed your job description and I told you x, y and z?”

Hopefully, our discussion today has convinced you that job descriptions and performance evaluations are a good investment of your time and will help you reap the benefits of a solid, performing team.  Thursday, in part IV of our four-part series, we’ll finish our coverage of performance evaluations and show you an example of how to tie together both documents for better success.

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What We’re Reading – Stress Management Tips for Customer Service Professionals

Customer service can be a rewarding part of your job, but it can also be very frustrating. Sometimes it’s difficult to conduct yourself in a professional manner while experiencing stress from your customer. This article discusses stress relieving ideas to help keep you cool, calm and collected when you find yourself about to lose control.

Most people who have never worked in customer service won’t understand how stressful it is when a customer is in ‘attack mode.’ Trying to rationalize with this customer may seem impossible because he or she is upset and too close to the situation. The first thing to remember is that this is not a personal attack. So don’t take it personally and work on keeping your cool. Keep in mind that there is a nice person inside this very angry customer, and that sometimes her frustration at a recurring issue can send her over the edge.  Just stay calm, reassure her that you will try to resolve the issue, and she’ll most likely show you a softer side.

Stay focused on what you can do to resolve the issue. When you remain professional, the customer will be open to listening to you. After all, you know your company’s services, products, policies and procedures better than the customer does, so try to regain control of the situation. This article suggests that you make an agreement with yourself before work that you’ll stay in control of your customers and your mood.

The author also offers some great ideas to keep a healthy work/life balance because stress does affect us physically. That’s why it’s very important to keep away from sugary snacks, turn to high protein snacks and drink plenty of water to keep from getting dehydrated.

So if you’re having one of those days, this article’s useful tips will help you stay calm under the most stressful conditions, on and off the job.

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Job Descriptions & Performance Appraisals – Who Needs ‘Em?! (Part 2)

This is part II of our four-part series on job descriptions and performance appraisals. Monday, we discussed the importance of job descriptions and how to craft them.  Our discussion left off after an in-depth look at the essential functions or tasks for the position.  Today, we’ll look at the other requirements.

Work environment is key to conveying the conditions under which the employee will perform the work.  For example, the phrase “demanding and fast-paced environment” gives the employee a good idea of what to expect. Clarifying physical demands is also paramount to preparing the candidate for the position.  If an essential function of the position entails lifting large boxes, specify the weight.

An important aspect to remember is that employers cannot discriminate against disabled individuals.  So the job description must provide information that is useful for even a disabled person to assess whether he or she can do the job. That’s why the Americans with Disabilities Act (ADA) has many guidelines that must be incorporated into a job description.  In a nutshell, the ADA protects an employee or job applicant who has the prerequisite skills and knowledge and is able to perform the essential functions of the job, with or without the employer making a “reasonable accommodation for that disability.” For that reason, be sure to summarize the position’s supervisory responsibilities, mental and physical demands as well as the work environment.

The important thing to remember is that a job description needs regular review.  Perhaps once a year, you can assess your overall organization, review the positions and their functions, and plan for changes or expansions.  Then it’s a good idea to revise the job description so it is a current representation of each position.  Remember to review the new job description with the employee and obtain a signed acknowledgment of having done so.

Here is an example of the main elements of a job description.

Next week we will discuss performance appraisals to understand how these two concepts tie together to maximize your organization’s success.

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Job Descriptions & Performance Appraisals – Who Needs ‘Em?! (Part 1)

Our experience has shown that sometimes smaller organizations don’t follow established conventions in the human resources arena. One such item is the job description, and its cousin, the performance evaluation.  In this four-part series, we will explore the need for each and share tips to make your work easier, or at least less tedious.

Job descriptions are useful and critical for many reasons.  Keep in mind that employment is an unofficial contract.  You will exchange payment for the performance of certain functions.  After all, you wouldn’t sign on with an insurance company if you didn’t understand the coverage, right?  Similarly, employees need a good understanding of the position, their tasks and accountabilities; and you, as the employer, need to convey the expectations for which you will exchange a salary and benefits. In addition, as a manager, you need to know that all the critical functions in your department or business are covered and have the ability to measure whether they are being met to your satisfaction.

In the most basic terms, a job description is a list of the global tasks performed by the individual, his/her areas of responsibility and the requirements of the position.  But it’s important not to underestimate the importance of having one.  Although the process can seem daunting at first, writing a job description is a very good exercise for the manager or business owner.  First of all, it’s important to understand the tasks that need to be performed by the individual.  Consider what the person will be responsible for doing and list the tasks in order of importance and/or frequency performed.  Be specific enough to cover the functions without dictating the “how” of the work as this may vary over time.  It’s also a good idea to provide any measurable standards if they will be monitored and used to gauge performance.  An example is, “Answer incoming calls by the third ring,” but only if this is a key factor for the business, if it will be tracked and if the individual will be held accountable for meeting this standard.  Be careful not to box yourself in with too many rigid requirements that are ‘nice to have’ but not required for the job and that will be difficult – if not impossible – to enforce.

Another important aspect of the job description is the area for qualifications.  In this section, the manager should list the minimum requirements for the position in terms of skills, education, effort, etc.  Although you may prefer a college-trained person, is that degree of education really needed for someone to do the job? It’s best to consider your minimum standards because you may encounter difficulty in finding enough candidates if your requirements are very narrow.  In addition, many candidates have top-notch skills and become loyal, valued employees but they might be overlooked if your requirements are too stringent and screen them out of consideration.  Of course, if specific training is germane to the position, by all means, require it.  However, in many cases, the minimum standard you set is adequate and you can indicate that the additional training is ‘preferred.’

Thursday, we’ll look at the balance of the requirements for a good job description and provide an example you can use to create your own department or company job descriptions.

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What We’re Reading – 5 Ways to Build Customer Loyalty

For almost all businesses, customer service is crucial in solidifying customer loyalty is one key to a successful business. Loyal customers will do anything they can to help your business grow and become successful by turning first to your company for their business needs or by creating word of mouth for potential customers. Because it’s not always easy to create a dedicated customer base, this article explores five ways to build customer loyalty.

Start by getting to know your customers. Ask them what will make them happy and what would completely turn them off. Listening to what they want will help you provide them with the highest value. Your business should also have a ‘go-to person’ who has the right attitude as well as the power to ensure that customer issues are resolved to their satisfaction.

There are various types of communication, so avoid being repetitive with your clients. The author emphasizes dealing with customers as individuals. Communication is a two-way street, so listen to your customer’s needs and discuss the best way to meet them individually. This type of communication will build a special rapport with you customer and deliver their loyalty.

Another idea to consider is rewarding your loyal customers. Everyone likes to be appreciated, so think about a customer-only event or other loyalty discount. An informal event, like a customer appreciation cocktail party, gives your clients another reason to stick around.

Finally, know your market. Today’s customers hail from different ethnicities and backgrounds. Having a bilingual employee could go a long way in making your foreign-language-speaking customers feel comfortable.

The sky’s the limit on the ideas you can use and the dividends this creativity can pay to your business. This article gives a few great and inexpensive ways to build your business and keep your loyal customers.

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Latest ADR Update as of 02/22/2012 – Jurisdiction 11- Home Health and Hospice

Palmetto GBA conducts probe reviews on services provided by Medicare providers within Jurisdiction 11. These reviews are in an effort to prevent inappropriate payments. Data analysis is performed at regular intervals to determine the types of services or providers that will be subject to review. Based on the results of the data analysis, edits are set up in the system to select claims for a probe review, which is either service-specific or provider-specific.

For service-specific probe reviews, a sample of 100 claims will be selected. Based on the results of the data analysis, more than one service-specific review may be conducted at the same time. The total number of claims selected for provider-specific reviews is between 20 and 40 for each provider identified for review. Providers selected for the probe review will receive a letter from Palmetto GBA explaining the reason for the review, why the provider was selected, and the type of review being conducted.

The number of claims selected on a daily basis for each provider is based on the number of claims received from the provider in a given day. Palmetto GBA will randomly select a sample of claims meeting the review criteria each day for each provider until the total number of claims needed to satisfy the probe sampling has been reached. However, providers are cautioned not to alter their billing practices to reduce the number of claims selected for Additional Documentation Request (ADR). If this is identified, it may result in additional medical review, referral to other review entities and or extrapolated overpayments.

When a claim is selected for review, an ADR letter is sent to the provider. It is possible that providers may receive an ADR prior to receiving their probe notification letter if they were selected for a provider-specific probe review. Providers should also note that in the past, medical ADRs were mailed in yellow envelopes. ADRs are now mailed in white Palmetto GBA envelopes, so providers should ensure that internal office processes are set up to identify these requests.

Part A and home health and hospice providers may also use the Direct Data Entry (DDE) system to monitor which claim(s) are in the ADR status/location S B6001. To view claims in DDE that were selected for ADR:

  • Select menu option 01 ‘inquiries’. Press enter and select 12 for ‘Claims’ at the sub-menu.
  • Press enter. Tab to the S/LOC field and type SB6001.
  • All claims in this S/LOC will be reflected in the ‘Claim Summary Inquiry’ screen

Providers may also print their ADR letters from DDE rather than waiting for the hard copy to arrive in the mail. To print a copy of the letter after accessing the list of claims following the above instructions:

  • Tab to a specific claim and type an ‘S’ in the ‘SEL’ field;
  • Once in the claim, press page forward – the ADR will appear after the claim on page 6

In accordance with Medicare regulations, providers have 30 days to respond to an ADR. Providers may fax the records to the number listed in the ADR or mail the records to the address provided in the letter. If no response to the ADR is received within the specified timeframe, payment on the claim will be denied. Palmetto GBA has up to 60 days from the date the documentation is received to complete a review and make a determination on the claim. Once a determination is made, the processing of the claim will be finalized.

Every effort will be made to move providers through the ADR process as quickly as possible. Providers that need to contact the Medical Review (MR) department related to the review of their medical records can call (803) 763-7491. Before calling the MR department regarding significant financial hardships, providers should have responded to some of their ADRs in order for the MR department to provide feedback.

The Medical Review telephone line is a voice messaging system. Providers should ensure that they leave a contact name and telephone number, their provider number, NPI and a brief message to explain the reason for the call. The MR Department will return calls within two business days of receipt in the order the calls are received. Making repeated calls to the MR department is not necessary.

For info or tips on Homecare Billing, contact Imark Consulting, Inc. at 888-370-3339 or visit us at www.homehealthbilling.com

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