Blog and Helpful Articles

What We’re Reading – A year after lockdown: 5 ways the world of work has changed for good

It’s doubtful that anyone remains unaffected by the lockdowns that persist a year after the start of the public health emergency.  Every sector and group would argue that the effects have been particularly difficult on its own members, but most concede that Human Resource Management, as a whole, has been hard hit.  This interesting article describes five lasting changes that may not be all bad.  In fact, the author believes that COVID was the “Big Accelerator” to drive the sorely needed changes.

First among them is how we communicate. Every aspect of communication in the workplace has changed and tools are rapidly evolving to facilitate communication and collaboration and better mirror the way people worked in the face-to-face environment. While video-conferencing has kept us (too?) connected, there’s a need for platforms that offer integrated tools like chat, social networking, file storage and distance education, as well as those that support the onboarding process.

Next is how we hire.  We’ve blogged about other talent acquisition and employee retention aspects, but hiring has been turned on its head in the lockdown era.  From interviewing to training, more is being done remotely which changes the ‘vibe’ and interaction.  Add to that equipping workers with the needed skills to move victoriously into this decade, and overhauling the system begins to seem like an understatement.  In fact, companies are relying more on external labor, and HR needs to bridge the gap in certain skills while developing a strategy to prepare the internal workforce for new demands.

The third one is how we learn. Online learning has become the norm and now includes onboarding, which used to be called orientation, but now goes by this much cooler term. The next step in the digitized learning environment, however, is delivering customized experiences focused on a person’s career interests, capabilities and performance; this means your learning platform has to deliver way beyond one-size-fits-all education.  Given the heightened expectation of growth and development by most 21st Century workers, artificial intelligence may be just the thing to tweak learning opportunities into delivering personalized outcomes.

Let’s move onto #4:  how we tend to employee needs. While the vast majority of workers believe their employers provide them with info to keep them healthy and safe, and are happy to have a job, mental health struggles are skyrocketing. Rates of anxiety and depression among US adults have tripled during the pandemic and this issue is now front-and-center for most employers this year.  Companies are investing more time, attention and resources into mental health.

The last issue is where we work. Remote work has exploded in the past year accompanied by other employee flexibilities. Before COVID, one in five employees worked remotely; now 71% work from home most or all the time.  This, however, is not a viable long-term strategy for some businesses, who are now reining in their latitude and reconsidering how to do so in a manner that balances worker and company business concerns.

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Billing No-Nos: Careless Eligibility Checks

Eligibility checking is one of the foundations of proper billing.  This is the process by which the practice verifies the insurance status of the patient before services are rendered; the second aspect of eligibility checks is careful examination of the information received and matching it against the practice’s billing records.  Time and again, we’ve seen eligibility verification results that specifically say the patient is inactive, were unprocessed due to an error or verify eligibility for a different line of business.  Sadly, front desk staff is sometimes rushed or multi-tasking and may not catch these issues, or may see what they expect to see.  In other instances, staff have been poorly trained on what to look for in a verification result or the practice may outsource the eligibility function to people who don’t read the information correctly.

Eligibility checks should be done at every visit and ahead of time.  Some practices rely on the membership roster from the managed care plan to ‘verify’ eligibility rather than performing a specific check just prior to the visit.  In other instances, we’ve encountered offices who check insurance status for the first visit of the month, without considering that plans can retroactively disenroll a member, or that the member may default on the premium payment later in the month and be ineligible for services.

We recently found a few examples where members of a PPO plan were entered into the billing system as having a capitated HMO plan.  Instead of billing fee-for-service claims, the practice submitted encounters, which have no payment.  [Mind you, the eligibility checks and ID cards clearly reflected the members had PPO insurance.] By the time the practice realized the error, intending to correct and resubmit the claims, the filing deadline and dollars were long gone.

Make sure your practice has a precise eligibility verification process for each and every visit, and that billers spot-check results to ensure accuracy.  Given the ability to submit electronic verifications, even in batch form, there’s no excuse for not performing the critical function.

Read the next installment in our Billing No-Nos series: Diagnostic testing global fees.

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Opportunities Abound Despite Medicaid Moratorium

The Centers for Medicare & Medicaid Services (CMS) has extended the temporary moratorium on new home health agency enrollments into the Florida Medicaid program through July 29, 2021. However, there currently are other opportunities to become a Florida Medicaid service provider through various Medicaid Waiver programs.

These programs waive many of the rules which providers and recipients of Medicaid must meet in order to participate. The purpose of the Waiver programs is to expand services to meet the needs of specific groups of people who have certain health and social needs and are unable to pay for services.

In Florida, the Medicaid Waiver program is administered by the Agency for Health Care Administration and the Agency for Persons with Disabilities, (APD). Each agency provides services to specific types of recipients through the Home and Community-Based Services (HCBS) waiver program. HCBS programs generally fall into two categories: health services and human services. HCBS programs may offer a combination of both types of services and do not necessarily offer all services from either category.

Aside from the traditional medical or medically oriented services, waiver programs also reimburse for services as varied as architects, carpenters, electricians, dietitian services, transportation and plumbers, among many others. However, Medicaid only reimburses for services that are determined to be medically necessary. A medical necessity determination must be made by a qualified professional (such as a registered nurse, board-certified behavior analyst, qualified developmental disabilities professional, or physician) and must be obtained at least annually and periodically upon request to determine that the level of service requested continues to meet the level of the recipient’s need.

General long-term care-oriented business opportunities exist in addition to those currently reimbursed by Medicaid in spite of the moratorium on enrollment of new home health agencies. Whether or not the Medicaid extends the moratorium for home health agency enrollment in 6-month increments, you have many options available to leverage the unique growth on the horizon for the long-term care industry.  Here are some recent blogs on some of your options: general info,  nurse registry, APD, and group homes.

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Billing No-Nos: The Uncredentialed Provider

Welcome to this series on billing errors.  Over the next few weeks, we will bring you common issues we continue to see when working with medical practices large and small.  The first “no-no” to explore is the uncredentialed provider.  We use this term to mean any clinician (physician or non-physician practitioner [NPP] such as a nurse practitioner or physician’s assistant) who has not had his/her credentials verified and approved by a payor and is essentially, not a ‘participating provider.’  All payors require a credentialing and approval process, from Medicare and Medicaid to managed care plans; because these entities are heavily regulated, paying a non-credentialed provider for services can be problematic.

Why do uncredentialed providers get themselves in hot water?  The first reason is they just don’t understand the rules.  Many clinicians rely on the grapevine for their information instead of going to the source and embrace the adage, if everyone’s doing it, it must be right.  Sometimes, though, the medical practice goes through creative gyrations to shoehorn the uncredentialed practitioner’s work into a reimbursable service – intentionally.

Let’s start with the understanding that every payor requires a practice to submit a medical claim/encounter that reflects the provider who actually rendered the service. Just like taking an exam for a friend is unethical, billing a claim under the name of Provider B when Provider A saw the patient is fraudulent.  This can occur when a practice hires a clinician whose credentialing is still being processed, when the provider cannot be credentialed by a payor (for whatever reason), or when there is a financial advantage.

Medicare, for example, pays a lower rate when an NPP renders a service as compared to a physician.  We’ve seen practices routinely bill NPP visits under the name of a physician, even having the physician co-sign the note to make it look legit.  The only instance when this would be acceptable is when the physician collaborated with the NPP in seeing the patient, performed some part of the visit and otherwise actively supervised the encounter. This has nothing to do with the fact that most NPPs need a supervising physician; in that respect, the supervising physician has delineated a scope of practice for the NPP and is available for questions or issues.  But if there was no physician involvement in the encounter, the practice cannot bill the NPP’s visit under the name of the physician.

Remember that especially with electronic medical records, every keystroke is tagged to a user and date/time-stamped.  So, if indeed a physician collaborated on the encounter, he or she should document on the note exactly what was done and authenticate the entry.

The one exception to the above is “incident to” billing for Medicare beneficiaries where CMS will pay at 100% of the physician fee schedule even if an NPP sees the patient.  An incident-to scenario is one where the physician has personally treated the patient for the particular medical problem and has established the diagnosis and treatment plan; in this case, the NPP is carrying out an order from the MD/DO while a physician (not necessarily the one who gave the order) is on the premises during the service.  In addition, the physician who gave the order must still be involved in the patient’s medical care, as evidenced by medical record entries.  In this case, the practice would bill under the physician’s NPI and receive 100% payment.

Read the next installment in our Billing No-Nos series: Careless eligibility checks.

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What We’re Reading – Insurers Must Cover COVID-19 Testing for All

According to the Centers for Medicare and Medicaid Services, Department of Labor and Department of the Treasury, private health plans may not deny coverage of COVID-19 tests for members who are asymptomatic or have no known or suspected exposure to C-19.  The tests must be covered without cost-sharing, prior authorization or other medical management as long as a licensed/authorized provider administers or refers the patient for the test.

In addition, insurers must cover point-of-care C-19 diagnostic tests and those provided at state-administered or locally administered testing sites although they are not required to – but may choose to – provide coverage of testing for reasons of public health surveillance or employment purposes.

This document provides an extensive FAQ on the subject and citations to relevant statutes.

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What We’re Reading – Deloitte study on Future of Healthcare

The Deloitte Center for Health Solutions conducts a biennial survey to understand how consumers make health care decisions, and published some interesting insights.  They analyzed the responses from surveys administered before and during COVID-19, and broke down responses among demographic groups:  Gen Z (born 1997 or later); Millennials (born 1982-1996); Gen X (born 1965-1981); Baby boomers (born 1946-1964); and Seniors (born 1900-1945).  Some interesting conclusions are summarized below.

  • More than half of seniors (63%) and boomers (57%) are likely to be vocal about disagreeing with their doctor, compared to 50% of Gen X and 46% of millennials & Gen Z. In early 2020, 51% of consumers (no demographics cited) were likely or extremely likely to tell their doctors when they disagreed with them.
  • The use of tools to measure fitness and track health improvements has risen from just 17% of consumers in 2013. In 2020, 42% of consumers measured fitness and health improvement goals like exercise, weight & sleep via tools and 28% monitored health functions, such as blood pressure, blood sugar and mood.
  • Along these lines, Gen Z and millennials are more likely than older consumers to believe that trackers change their behaviors; 87% of Gen Z and 85% of millennials believe their behaviors have changed a great deal or moderate amount compared to 69% of boomers and 47% of seniors.
  • Consumers have increased virtual visits and interactions with health care technology and are more willing to share their personal data; the largest increase was seen among Gen X and baby boomers.
  • Fewer consumers were happy with their virtual visit clinicians and wait times, showing that consumers expect high quality interactions with clinicians who listen and take their time.
  • A Deloitte COVID-19 survey revealed that 66% of respondents believe they need to be physically examined by a clinician and 56% don’t believe they receive from a virtual visit the same value and quality care as from an in-person visit.
  • About a third of consumers are comfortable using at-home diagnostics for various reasons, but close to half of Gen Z and millennials feel this way.

Naturally, this data has big implications for healthcare organizations and other vendors:

  • There is a need for tools to assist people in better managing their health, such as improving medication adherence and patient satisfaction, and the data shows these are likely to be well-received.
  • Interoperability is the new ‘in-thing’ as consumers clamor for more of a one-stop shop for all their medical information.
  • Organizations need to build trust among their patients so they’ll feel comfortable sharing data. This includes clarifying the ownership of the information; 65% of consumers believe they should own their own health data, compared to 30% who believe their doctors should own it.
  • Lastly, the patient experience is paramount, and providers should invest in improving technological capabilities to deliver more satisfying and high-quality care. It’s interesting to note that 85% of physicians across the country believe they could benefit from training to improve virtual visit skills, especially conveying empathy.

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2021 Home Care Outlook is Bright Indeed!

Long term care providers have reason to rejoice based on a survey conducted by Home Health Care News at the end of 2020. Agencies feared the worst last year with the implementation of the Patient Driven Groupings Model (PDGM) and were blindsided by the double whammy which included COVID-19.  As the dust has settled, home care operators see a silver lining in last year’s cloud.

Survey responders predict continued growth in 2021 and beyond; 35% of participants selected skilled care as the area of most anticipated growth, followed by 31% who believe non-skilled services hold the greatest promise.  It’s clear that since the pandemic, families are keener on keeping loved ones at home and bringing help in as opposed to considering assisted living or other placement.

Many agencies seem to be turning to telehealth technology to aid in remote patient monitoring, primarily for chronic disease management and vital signs monitoring.  Right now, these technologies are not reimbursable, but they go a long way to delivering value and outcomes which form the basis for the payments of your referral sources.  Given the tighter payment models for home care, technology can provide vital information for your clinical staff and even avoid an ER visit; check out our blog on this topic.

For years, we’ve advised clients to quantify their achievements with high-cost patients to more favorably position themselves with payors.  Perhaps your agency can demonstrate less exacerbations of a patient’s chronic condition because of your staffing and care protocols.  Tell that story to the people who write the checks or refer patients to your business!  And if you think this applies only to the skilled care world, guess again.  Personal care can show good social outcomes, such as patient satisfaction & engagement, good safety records and delayed institutionalization.

Staffing continues to be an area of challenge as cited by 59% of survey responders, significantly beating changing payment models which concerned only 19%; this is an interesting shift when compared to the 2020 outlook, which showed these two areas neck-and-neck at 43%. The greatest area of expense seems to be staffing (41%) over PPE/infection control (27%)!  A solid staffing plan and re-evaluation of your pay scales are good ideas to position your agency to recruit and retain superior direct care providers.

Overall, home care agencies are poised for a good 2021 and growth much beyond this year.   Referral sources are evenly split among hospitals, physician offices and other community sources, so this is the time to fine-tune that “Referral Relations Plan” to solidify partnerships and highlight your agency’s stellar outcomes.

 

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Supporting a Diagnosis of Angina Pectoris

In a primary care setting, we sometimes encounter patients who have been diagnosed with angina pectoris and are being followed by the primary care practitioner (PCP).  In this blog, we will share some of the most common issues regarding this risk-adjusted condition that causes a great deal of consternation for providers and coders alike.

It’s not uncommon for patients with CAD to experience anginal symptoms (described as squeezing, suffocating or a burning feeling in the middle of chest) but the key, as all clinicians know, is to differentiate between cardiac and noncardiac causes.  The medical literature informs that assessing atypical chest pain begins with careful examination of the chest wall by means of an EKG to start, and noting any abnormal heart sounds.  Atypical chest pain has its own diagnosis code (R07.89), which should be used during the investigational period.

In outpatient medicine, diagnoses are coded once confirmed and in the scenario above, until an individualized plan of testing is carried out in stages and its results evaluated by the clinician, we code based on we (absolutely) know.  In the inpatient setting, providers are permitted by coding guidelines to code “rule out” or differential diagnoses, and PCPs should be mindful of this convention when reviewing inpatient records.

Once a diagnosis of angina is confirmed, the PCP should document the path to the diagnosis and the treatment plan.  If the patient is prescribed a nitrate medication, it should be linked to the diagnosis in the provider’s charting.  In addition, if the patient undergoes a successful intervention and is no longer experiencing angina or being treated for it despite treatment for coronary artery disease (CAD), the angina portion of the diagnosis should be retired.

One of the biggest errors of “support” we see in auditing charts is a reference that the patient had angina in 2015 and PRN Nitro is on the medication list – no signs or symptoms, no episodes, just a medication that is refilled in perpetuity.  This is highly suspect, especially if the patient has had a procedure.  In these cases, it’s important for the PCP’s documentation to describe the patient’s anginal symptoms since the last visit and episodes when he or she last took the medication.  Absent documented anginal episodes or medication specifically for treating angina and not CAD or hypertension, the condition is not supported.

Chart auditors look for contradictory information, such as a recent cardiologist’s note that disputes the PCP’s diagnosis or a negative stress test.  Unless the PCP has charted recent episodes, angina would be queried and flagged for possible removal.

In a nutshell, remember that each note needs to stand alone.  At every visit that you assess this condition, be sure to document:

  • Any signs and symptoms (s/s) the patient has recently experienced or is experiencing.
  • Last time patient had those s/s and/or took angina medication.
  • Linkages among all the medications for angina in the assessment or treatment plan.
  • How the condition is progressing and how the patient is responding to your treatment plan.

There is sometimes a big difference between the clinical and coding perspectives.  Some providers believe that once a patient has angina, this clinical diagnosis never goes away. But in all reality, if there are no current signs of it and there is no documented treatment for this condition right now, just Nitro as needed (and it hasn’t been needed), it’s considered resolved from a coding standpoint.

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What We’re Reading – The SEC’s disclosure rules are changing HR forever. Are you ready?

A big transformation is brewing in HR, mostly affecting publicly traded companies.  The issues, however, are worthy of attention to small business as well, even if it’s not entirely feasible to make these changes.  First, a little history:  investors research companies to assess the long-term health of the business and decide whether to invest in it.  In the past, 83% of a company’s value centered around the org’s physical assets, and the only human capital metric was number of employees, which wasn’t that important to investment decisions.  The SEC, however, has changed its disclosure rules and is now requiring that companies disclose a great deal more about their human capital.  It seems that, according to this article, in 2015, the valuation perspective changed and now 84% of a publicly-traded company’s value has been mapped to human capital.  The prevailing opinion is, after all, it’s the people who make business work.

This means that HR gurus need to not only measure their performance on different metrics and benchmark against other orgs, but use these figures to make organizational changes that move the needle. As the author states, keep in mind that “billions of dollars will be traded on the metrics you report.”

The SEC is now asking public companies to report metrics on employee attraction, development and retention.  Because this generation of workers values growth, learning and experience, businesses need a talent development plan that provides meaningful opportunities for employee growth. One way to improve the employee experience is through mentoring. When employees feel there are “constant opportunities available to them,” you will recruit and retain good workers, or so the story goes.  Quite the tall order!

The article also suggested using artificial intelligence to make a few changes. For example, if your company needs to address diversity, certain AI methods can help you perform blind hiring to remove any bias in the selection process.  AI can also help you identify untapped and valuable skills among your workforce, for example, by analyzing their LinkedIn profiles and other social networking footprints.

Many of us are focused on the more “low-hanging fruit” of HR to attract and retain workers: compensation, benefits, etc.  However, data indicates that workers consider these a given and are focused on other factors when they decide to accept a job offer or stay in your organization.  While this is necessary for public companies, the lessons are not lost on smaller concerns that compete for talent with the ‘big guys.’ HR will need to move quickly to assess where their companies are on the continuum and develop/implement strategies to move them where they need to go.

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