Blog and Helpful Articles

What We’re Reading – The Power of Outsourcing in Your Medical Practice

Do you ever feel that there aren’t enough hours in the day to get everything done?  Join the club!  These days, more and more office managers and/or administrators express that despite supposed electronic efficiencies, they are drowning in all the added work being thrown at them.   In addition to juggling the daily demands of running a busy practice, regulatory and other changes – in addition to maintaining patient satisfaction – can frazzle even the most talented leader. Outsourcing may be just the thing to lower your stress level and improve your practice’s performance.

Although the most common service to outsource is your medical billing, services that can now be outsourced range from “patient education counseling to credentialing to legal advice, and even weekend staffing,” reports Shelly Schwartz.  Consider the time and effort that certain activities take and explore if outsourcing makes sense for your practice.  It may not work for every office but after reading this article, you will be in a better position to decide if this could be a good fit for your business.

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Home Health Case Managers Can Save the Day

In the field of home health, the single most important individual just might be the case manager.  Given the increasing pressure for all providers to assure cost-effective, high quality care, a skilled case manager can enhance quality of care and financial stability of the agency.  

Quality of care:  Having one individual reviewing a patient’s care is paramount to ensuring the care is: 

–        Appropriate for the patient’s condition.  In other words, is the care provided still needed?  Case managers can spot changes in the patient’s condition that may warrant  modifications to the plan of care or services.

–        Effective.  Goals are established for all home health patients upon admission.  They can range from achieving independence with performing activities of daily living and self-care to pain control and safely ambulating a certain distance.  Goals are directed to particular outcomes, considering that skilled care in the home should be intermittent, and not an annuity.

–        Sufficient.  Because of their training, case managers are the perfect spotters for gaps in care or areas in which the patient could benefit from additional assistance to meet established goals and maintain independence. 

Financial stability:  The hand of CMS giveth and the hand of CMS taketh away, and lately, there is greater emphasis on the latter.  Recovery audit contractors (RACs) are private companies tasked with the responsibility of identifying improper payments made on behalf of Medicare beneficiaries.  They seem to be working overtime these days, scouring records for Medicare dollars that can be recouped.  It doesn’t hurt that RACs are motivated by a contingency fee for successful recoveries.  However, a strong case manager, wearing a RAC-like hat, can scrutinize the documented (or lack of documented) patient care and assess whether the case meets medical necessity.  He or she can also coach clinical staff on proper documentation to support appropriate care.  It’s no secret that documentation is usually the lynch-pin to any recovery case.

We always say that the key to a deficiency-free survey is a robust quality assurance program and the case manager can be instrumental to that effort.  For some agencies, QA is a rote exercise.  Checking a box on a form is not a true embrace of the purpose of performance improvement, which is to be on the look-out for instances or patterns that could spell trouble and to employ a systematic, objective process for identifying root causes and generating solutions.  When a home health case manager reviews a case, he or she is uniquely positioned to identify potential issues that merit further quality study. 

Case management is an integral part of a citation-free and a RAC recovery-free operation. Further, proper case management benefits the patient’s recovery and supports achievement of goals for a healthier daily life. As the old saying goes, ‘You can spend a little now or a lot later.’ Training, education, emphasis and support of the case management personnel and process are time and money well spent.

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2014 Holds Big Changes for the CMS-HCC Model

The purpose of the CMS-HCC model is to improve the accuracy in predicting the costliness of Medicare Advantage (MA) enrollees’ healthcare costs and to properly fund MA plans for those expenses. It isn’t a perfect model but it surpasses the demographically-based payments of the “old days” that neglected an important characteristic in costliness – the presence of medical conditions – and mitigates selection issues.

In the CMS-HCC model, diagnoses are assigned to hierarchical condition categories (HCCs); the Centers for Medicare and Medicaid Services (CMS) currently uses only 70 of 189 HCCs to pay MA plans.  For each HCC, CMS assigns a coefficient which indicates the marginal cost of treating the conditions in that HCC. The coefficients, in addition to some demographic variables, comprise the enrollee’s risk score.  In a nutshell, the “sicker” the enrollee (based on the number of HCCs represented in the individual’s diagnostic profile), the higher the funding to the MA plan in order to fund the cost of the care. However, the Medicare Payment Advisory Commission (MedPac) acknowledges that the model underpredicts costs for enrollees with five or more conditions and, to a larger degree, for those with eight or more conditions. (MedPac, June 2012)

In addition, CMS and the Government Accountability Office have concluded that risk scores in MA plans have risen faster than those for fee-for-service (FFS) beneficiaries and so significant adjustments have been made to the 2014 CMS-HCC model to “bring MA risk scores in line with those in FFS Medicare.” Consequently, the Patient Protection and Affordable Care Act (PPACA) requires CMS to reduce MA enrollees’ risk scores by an amount greater than 3.4% each year.  (MedPac, June 2012)

The biggest operational change affecting our clients is the removal of certain frequently –occurring diagnoses from the model because their HCCs have supposedly lost their predictive value.  One might question whether – instead or in addition to – they were removed because of their widespread presence in enrollee diagnostic profiles. Chronic kidney disease (CKD) is one glaring example.  CKD is classified in five stages based on kidney function, and stages 1 through 3 have been removed from the model for 2014, which means that there is no longer a coefficient associated with these conditions.  According to the National Kidney Foundation, of the 26 million American adults with CKD, almost 19 million have stages 1 through 3.  Similarly, the National Institute of Health reports that 60-70% of diabetic patients have some form of neuropathy; unfortunately, that condition has also been removed from the CMS-HCC model for 2014.

Needless to say, these changes have created quite an outcry among our clients, who have redoubled efforts to ensure the most complete and accurate coding and documentation for the balance of 2013. Moreover, CMS is studying plan and provider use of health risk appraisals (HRAs) and annual wellness visits (AWVs). The Centers for Disease Control defines an HRA as “a comprehensive a systematic approach to collecting information from individuals that identifies risk factors, provides individualized feedback, and links the person with at least one intervention to promote health, sustain function and/or prevent disease. A typical HRA instrument obtains information on demographic characteristics (e.g., sex, age), lifestyle (e.g., smoking, exercise, alcohol consumption, diet), personal medical history, and family medical history.”  An HRA form is a comprehensive document that compiles an individual’s history and summarizes the status of all chronic conditions.  CMS is questioning their validity because of a concern about the absence of HRA-identified conditions in subsequent provider encounters.


Source:  Issues for risk adjustment in Medicare Advantage, June 2012, Medicare Payment Advisory Commission, accessed on March 7, 2013

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Is your practice utilizing the Advanced Beneficiary Notice of Noncoverage (ABN) correctly?

The Advanced Beneficiary Notice of Noncoverage, or ABN for short, is a waiver of liability that is provided to all Medicare patients if the provider believes an item/service may not be covered by Medicare or considered medically necessary.  Now that we have established when to use an ABN, the following providers should be giving them out: doctors’ offices, providers (including laboratories), practitioners, suppliers, and skilled nursing facilities (SNF) when services may denied under Part B.   ABNs are not required in an emergency situation.

Not only do providers need to make sure they are providing ABNs appropriately, but they need to use the correct version.  As of January 1, 2012, any ABN forms with a release date of 03/2008 (in the lower left hand corner) are considered invalid with CMS, so if you have any stock piles of these forms, get rid of them.  Make sure that you are using the ABN form with the release date of 03/2011 which became mandatory as of 1/1/12.

Since we have reviewed the basics of the ABN, here are a few tips on the billing process when submitting a claim with an ABN.

  • Modifier GZ is used when providers expect Medicare will deny a service or item and they don’t have an ABN signed by the patient.
  • All claims with modifier of GZ will be denied automatically & not subject to complex medical review.
  • Modifier GA is used when providers expect Medicare will deny a service or item and they do have a signed ABN.
  • Failure to report modifier GA could result in your assuming financial responsibility for denied service or item.

If you have any other questions, need additional information on the ABN process, or want to download the newest version of the form, visit the CMS website or for more info on the modifiers visit the FCSO website.

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Employee Relations: Lay the foundation for a good business!

A good work environment is the foundation of a solid and effective employee-relations program.  Employee relations focuses on communication as it relates to satisfactory productivity, motivation, morale and the prevention and resolution of problems that arise or affect work situations. As a manager, you can choose to treat employees in a respectful manner or not, however disrespectful treatment is a foolproof way of yielding little or no productivity. HR “best practice” shows us that going the “respect” route will yield higher levels of productivity, lower your turnover rates and improve morale. So how do you really respect your employees? Respect is not only about how you speak to someone but it applies to how you, as a manager, get things done in your role as a leader, supporter and developer of your employees.

One of the first steps is to ensure that all employees have current and realistic job objectives and a clear understanding of their job responsibilities. Once this is in place, then your multiple roles as manager kick into gear. A pivotal part of leadership is being both a good coach and a good counselor and being able to use the appropriate skills depending on the situation.  As a rule of thumb, coaching should always precede counseling.

As a coach, you identify your employee’s need for instruction and direction related to his or her performance or career goals. Coaching then becomes a shared effort between yourself and the employee and relies on mutual goal setting, personal feedback and an ongoing supportive relationship. Most managers coach because it helps to retain employees, which is a positive outcome because we all know how disruptive our work flow becomes when we constantly have staffing turnovers. So managers should always be ready to coach when a problem occurs. Here are two situations where coaching can pay dividends: A new procedure is introduced that can change the work flow and the employee’s responsibilities; this is a good coaching opportunity because job performance sometimes can slip because of resistance to change.  Sometimes, you might recognize that the employee lacks a skill to perform a job; in that situation, the manager-coach may offer training in order to develop that employee.

Suppose you identify a problem that interferes with an employee’s work performance or a behavior that clearly violates the company standards and rules. In that situation you now have to change hats from Coach to Counselor. By means of the counseling process, you define for the employee exactly what behavior needs to change in order to correct and resolve the problem.  Being firm yet respectful, and maintaining a company policy for handling these situations, lays a good foundation to fostering a positive employee-relations environment within your organization. As employees understand company policies and as management ensures a clear and open line of communication, while consistently and fairly adhering to those policies, the organization will see positive results.

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What We’re Reading – Bilateral procedures and MUEs

Are you stumped on when to use modifier 50 instead of modifiers LT and/or RT for Medicare? Modifier 50 is defined as a bilateral procedure which is performed on both sides of the body in the same operative session or on the same day.  If, however, the description of the CPT (Current Procedural Terminology) code specifies that the code is for a unilateral and/or bilateral procedure, modifier 50 would not be appropriate. Unilateral injections are performed on one side of the joint, while bilateral injections are performed on the right and left side of the joint. For example, for CPT code 64479, you would use modifier LT or RT if the procedure was only performed on one side.  If injection was on both sides of the joint, you would use modifier 50.

The First Coast Service Options website provides a great resource to help you determine if modifier 50 should be used: the Medicare Physician Fee Schedule (MPFS) look-up tool under the indicator “bilateral surgery.” To find out more details refer back to First Coast Service Options billing news.  Remember also that not all payors use Medicare’s guidelines so check with each one to understand its billing rules for these modifiers.

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What We’re Reading – Manual update regarding the repayment of overpayments

If your business has ever received a demand letter from Medicare regarding overpayments, your first thought has probably been, “How am I going to pay this back while keeping my business afloat?”  There is good news!  Effective September 3, 2013, an update to chapter 4 of the CMS manual Medicare Financial Management may ease some of your worries.  A provider has the option of submitting an Extended Repayment Schedule (ERS) request, formerly named Extended Repayment Plan (ERP), if repayment within a 30 day period would represent a “hardship.”  If the request is approved, it can result in anywhere from a six- to a 36- month extension to the Medicare contractor and/or up to 60 months with the Centers for Medicare & Medicaid (CMS).  Between the shaky economy and redoubled scrutiny of Recovery Audit Contractors, this may be a lifesaver for providers and give them some breathing room if they’re targeted for overpayments.  To find out more details refer back to First Coast Service Options billing news.

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Professional Association involvement: It’s not just for “newbies”

Students and early careerists often ask about the most important contributor to career success.  The answer never lends itself to just one factor, but usually to a list of the top three, which includes professional organization involvement.  In addition, this involvement can be generalized to an individual of any professional level and at any career stage.  One’s definition of success hardly matters either, as professional organizations can be instrumental to a host of “success markers,” such as income, influence, and personal enrichment.

Selecting the right professional association is a key step; I am partial to the American College of Healthcare Executives (ACHE) for its strength and breadth within the healthcare realm.  In addition to that, involvement in organizations that focus on specific niches within the profession is a good idea; among the most well-known are the Healthcare Financial Management Association (HFMA), Medical Group Management Association (MGMA) and the Health Information Management and Systems Society (HIMSS).  These are national in scope but local chapters serve as community hubs for membership development.

The first benefit of professional organizations is the vital link to relevant continuing education, something we all need to excel in our careers and ensure we can lead our organizations successfully into the future.  The rapidly changing nature of our profession, coupled with its prominence in the national spotlight, makes current information about trends paramount to serving the needs of all constituents.  Journal reading can certainly keep us current but if you’re like me, a few publications sit on your desk, still wrapped in plastic.

Aside from the obvious educational advantages are the personal ones, and here is where the right mindset is crucial to professional organization involvement.  Over the years, I’ve observed a few common types of professionals:

  • Those who are only visible when they need something (e.g., a job, or specific contact in order to get a job): these professionals seek only to use their contacts when it suits them, a fact that isn’t lost on their network.  Once they’ve obtained what they need, they vanish.
  • People who are “too busy” to become involved, or believe they’re “all set,” career-wise, and thus don’t need the professional involvement: they rob themselves of being known by others and of the gratification of benefiting an early careerist or a professional in transition.  It’s safe to say that none of us arrived at success without encouragement or assistance from others.  “Paying it forward” is one way we honor those who helped along the way and extend their influence to others.
  • Individuals who realize the immense benefit of cultivating contacts for the value of the relationships themselves: they get to know others in the profession for the enjoyment of it.  Often these relationships are beneficial to our careers, but that’s a bonus to connections that are intrinsically satisfying.  When faced with an individual who is in professional limbo, these people don’t feel pressured to “find someone a job;” they can encourage, advise, and/or offer other assistance which may include introductions to people in their own networks.

The pace of business these days seduces us to restrict our circles.  Work, after-hours meetings, children’s soccer games, friends, neighbors and aging parents can form an endless list of demands that seems to preclude professional involvement.  My suggestion is to pick one organization and start with quarterly attendance at professional events.  Consider inviting a colleague to attend with you.  Schedule events ahead of time and block the time in your calendar so that only a true emergency forces you to cancel.

If the prospect of speaking to “strangers” gives you pause, re-frame the thought and dub them “friends in waiting.”  Look for someone to encourage.  Before you know it,  you’ll have enjoyed learning about a current topic, and begun planting a network of seeds you can water in the coming months.

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What We’re Reading – Preventing duplicate claim denials

Are you experiencing more claims denials as duplicates recently?  Make sure that your billing staff and/or billing company are aware that effective July 1, 2013, The Centers for Medicare & Medicaid Services (CMS) instituted new claim edits.  All claims received are now reviewed against any and all “paid, finalized, pending and same claim details,” looking for any duplication submitted without the appropriate modifiers.

This article gives a few examples of those modifiers and when to use them.  Save yourself time and money in the long run by reviewing your claims to make sure they’re not being denied for this reason.

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Differences & Similarities between Home Health Agencies and Nurse Registries – Part 3

Welcome to the third part of our series about the differences between home health agencies and nurse registries. In this installment, we’ll review the last criterion from our list:  one qualifying service by direct employee.

Medicare requires that a home health agency provide skilled nursing services and at least one other therapeutic service (physical, speech or occupational therapy; medical social services; or home health aide services) by direct employee. For example, if the agency selects physical therapy services as the “direct employee service”, all physical therapy care delivered by the agency must be by an employee and not by an independent contractor or anyone outside organization. Conversely, that would require that the agency has no physical therapists who are independent contractors with the agency. After satisfying that Medicare Condition of Participation, (MCOP), a home health agency may engage independent contractors to provide all other services.

Regarding independent contractors, one should be aware of the very fine line between the factors which determine whether an individual is, in fact, an independent contractor.   The Department of Labor and IRS have regulations regarding the classification of individuals, and a quick internet search will provide the Medicare Certified home health agency with an often used “20 Factor Checklist” of issues to help determine whether one would be classified as an independent contractor or an employee.

The MCOP has strict requirements of home health agencies regarding supervision and responsibility for care provided by persons under contract. Accrediting organizations require even more in-depth involvement with supervision of contractors. The State of Florida does not require the extent of supervision of contractors as the MCOP and accrediting organizations do.

Nurse registries, on the other hand, must provide all direct patient care services through independent contractors and are prohibited from providing direct patient care services by employee in accordance with Florida law.  They may provide only skilled nursing, home health aide services, (by home health aides or certified nursing assistants), or homemaker and companion services. Nurse registries are not licensed to provide therapy services.

This concludes our three-part series on the differences between home health agencies and nurse registries. As you may know, there are many other distinctions, but we’ve presented our “top three.”

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