Blog and Helpful Articles

What We’re Reading – Four things doctors actually like about ICD-10

As you may already know, the largest complaint about the ICD-10 is that it is “complex and highly specific” with almost three times the number of codes than ICD-9.  Although the 10th edition was introduced in 1992 and most developed countries use a modified version of it, U.S. hospital administrators and physicians have opposed adopting the 10th revision because of the conversion challenges it presents.  In addition, because there is an ICD-11 revision in the works (if you can even imagine that!), some industry experts have recommended a delay in order to migrate directly to the 11th revision.

Nevertheless, adopting the ICD-10 is inevitable, as the system will be imposed on October 1, 2014, so let’s look on the bright side.  This article’s author explains some of the benefits of adopting the ICD-10, such as:

  1. Specific coding
    • Integrates the reason for a diagnosis, which should result in fewer denials by insurance payers.
  2. Ease in locating a possible diagnosis
    • ICD-10 makes it easier to research unusual diagnoses, which translates into less time spent researching and more time for other tasks.
  3. Improved description of the extent of diagnoses
    • The 10th revision will result in better communication to payers of a patient’s morbidity by the ability to refine and report the complexity of encounter.  This can lead to additional rewards from payers for effectively managing patients.
  4. Ease in assigning codes
    • Coding specificity and reduced ambiguity of codes equals fewer coding errors and fewer unpaid claims.

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Tips on Ordering and/or Referring Providers

UPDATE ON 4/25/13:  CMS announced the delay of PECOS edits that would result in denial of home health claims & Medicare part B claims when the ordering/referring physician is not enrolled in PECOS.  CMS will advise the new implementation date in the near future. In the interim, informational messages will continue to be sent for those claims that would have been denied had the edits been in place.

On May 1st, 2013, CMS will turn on claim edits that will affect all Medicare Part B covered services, Durable Medical Equipment (DME), and Part A HHA (Home Health Agency) claims. The following providers are the only eligible individuals to order and refer the above services:

  • Certified Nurse Midwives
  • Clinical Nurse Specialists
  • Clinical Psychologists
  • Clinical Social Workers
  • Interns, Residents, and Fellows (including those employed by the Department of Veterans Affairs (DVA), the Department of Defense (DoD), or Public Health Service (PHS)).
  • Nurse Practitioners
  • Optometrists: can only order and/or refer for labs and X-Ray services under Medicare Part B and DMEPOS services
  • Physician Assistants

In order to avoid unnecessary denials because of the claims edits:

  • Ordering and/or Referring providers must be enrolled in the Medicare program as either an approved provider or with opt-out status (click here to verify a provider).  The list of providers is updated twice a week by CMS.
    • If an enrollment application for an ordering and/or referring provider is in a pending status, the claim will be denied.
    • If the provider only wants to order and/or refer items or services and not bill Medicare, he or she must send CMS an Opt-Out Affidavit including current info and NPI number.  This affidavit must be resubmitted every two years.
  • If a new provider wants to enroll in Medicare and become an Ordering and/or Referring Provider, he or she must complete a paper CMS-8550 or register online through PECOS.
  • This rule applies to physicians and non-physician practitioners.
  • If the claim is denied after 5/1/13, the provider will need to go through the appeals process to have the claim reprocessed.

Here are some to tips to keep in mind when filing a claim regarding the ordering and/or referring provider (which is box 17 on a paper CMS-1500 claim form):

  • Do not include any middle initials for the provider
  • Leave out any credentials (e.g., M.D., D.O., A.R.N.P., etc.)
  • Only include the First and Last name of the provider
  • Verify the NPI is for the individual provider and not the organization
  • Make sure the spelling of the provider’s name is correct and matches both the Medicare database & NPPES Registry

Any provider not listed above, who bills or refers for Part B, DME or HHA services, will not be paid after May 1st.

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What We’re Reading – GAO recommends ending CMS bonus payment demonstration

From the GAO.gov website and different healthcare news websites.

The Government Accountability Office (GAO), a nonpartisan investigative arm of Congress, recommends that CMS should discontinue its quality bonus program demonstration. The reasons are the budgetary impact, lack of data to assess results, and concerns that it rewards providers of medicare health care, according to a report released by GAO on April 2012.  The report suggested that CMS implement the Medicare Advantage bonus payment system authorized by the Patient Protection and Affordable Care Act (PPACA).

The estimated budgetary impact of the bonus program demonstration would be seven times larger than that of any Medicare demonstration since 1995, because the payments are larger than those mandated by the PPACA.  The PPACA mandates bonuses for health plans that achieve a star rating of 4 or higher instead of the demonstration project’s bonuses for star ratings as low as 3.  The GAO report estimates that under the PPACA bonus system, about one third of MA beneficiaries would be covered by plan sponsors eligible for a bonus payment, whereas under the demonstration system, about 90% of beneficiaries would be covered.

CMS responded that the quality bonus payment demonstration program’s design is consistent with the overall goal of improving quality in the Medicare Advantage program and does not preclude a credible evaluation of the demonstration. Absent this demonstration, CMS believes that many plans would not have the incentive to improve quality of care delivered to MA enrollees.

The concern about lack of data stems from the fact that in 2012 and 2013, bonus payments are based on data collected before the final specifications of the demonstration were released on April 2011. As a result, 2014 would be the only year that CMS could evaluate the results of the demonstration program. This means that bonuses for the demonstration project would be paid without adequate comparison data. Furthermore, the rollout of the demonstration program to all MA plans precludes having a comparison group that could isolate the effects of the demonstration and allow for unbiased evaluation.

CMS conceded the point and will evaluate the demonstration by looking for comparison group outside the MA program, such as plans that contract with Medicare under section 1876, which are cost contracts or those participating in commercial and Medicaid CAHPS and HEDIS programs.

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Personnel Requirements of a Florida Home Health Agency – Part 5

In this last installment of our five-part series on The Personnel Requirements of a Florida Home Health Agency, we will cover the position of home health agency Medical Director.

The first and most important point to keep in mind is that Florida does not require home health agencies to have a medical director. In the past, some unscrupulous agencies used the veil of the medical director position to have an excuse to pay providers who referred patients to them (which is against the law).  Some agencies had several medical directors!  Because of that, the State of Florida developed specific and strict criteria for the medical director position for those agencies who would like to add this position to their organization.

If an agency has a medical director, it must:

  • Have only one. The days of multiple medical directors are over.
  • Have a written contract with the physician that has at least a one-year term, and specify the services that will be provided by the physician.  Some common tasks performed by medical directors include participating in the quality assurance process by attending meetings, reviewing medical charts, assisting with quality studies of clinical patterns or trends observed in the patient population, providing guidance to the agency leaders on clinical issues, etc.
  • Include specific payment that is at fair market value.  We’ve seen payment based on flat fees as well as hourly rates.  Again, the concept of fair market value prevents an agency from remunerating a physician an exorbitant sum for supposedly performing medical director duties, especially if the physician also refers patients to the agency, which is common.   The specified fee also cannot vary.  In other words, the agency cannot pay the physician at $150 per hour in January and at $250 per hour in March unless there is a change in the market value of physician medical director services.
  • Finally, the medical director must submit invoices that detail the work performed, the dates on which that work was performed, and the duration of that work; these invoices must match the payments made to the doctor.

A medical director can be a very valuable team member to the home health agency, providing solid guidance that translates into better patient outcomes and, ideally, lower patient care costs.  Unfortunately, some hucksters’ past behavior has prompted the intense scrutiny by AHCA in this area. However, if an agency is truly utilizing the services of a medical director and follows these simple, sensible guidelines, it should be able to proceed confidently in the interests of quality care.

 

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What We’re Reading – CMS Creates New Tip Sheet to Help Specialists Meet Meaningful Use

Navigating through all the information and requirements to meet meaningful use, and to successfully complete the necessary attestation, can be confusing and – at times – complicated for many providers.

This tip sheet gives a full introduction of the EHR Incentive Program for both Medicare and Medicaid eligible professionals, and addresses all the areas of meeting meaningful use, including core measures, menu measures and clinical quality measures. It also covers applicable exceptions and provides: a simple and concise stage 1 specification sheet; a meaningful use calculator, which is an excellent template to assess a provider’s ability to successfully attest; and a stage 2 specification sheet.

Many times, all the meaningful use measures do not apply to every provider and this tip sheet definitely covers the relevant areas for understanding and successfully navigating through the program.

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Personnel Requirements of a Florida Home Health Agency – Part 4

So far in our series on the Personnel Requirements of a Florida Home Health Agency, we’ve reviewed the positions of Administrator, Director of Nursing and Supervisory nurse.  This week, we will discuss the requirements of the Financial Officer.

Another requirement for home health agencies in Florida is the Financial Officer, the individual who is responsible for the financial operations of the agency.  However, no specific requirements exist for this individual’s training, experience or responsibilities.  In most cases, the role of Financial Officer is assumed by the agency owner, and less frequently the Administrator.

On occasion, agency clients have delegated the responsibilities to their accountant or other financially minded individual.  If one considers the role of a financial officer, it makes sense to enlist the assistance and oversight of a trusted individual to help the agency remain in solid financial shape and viable.  Some responsibilities of the financial officer can include: creating the annual budget and monitoring its compliance;  maintaining the agency’s financial records and “books” or  – at least – reviewing their status; overseeing the agency’s billing activities (including collection status); and making recommendations for capital investment projects.

The financial officer is a position listed on the State of Florida application for home health agency licensure and requires a Level 2 background screening.

Next week, we’ll finish this five-part series on the leadership requirements of home health agencies by discussing the position of Medical Director.

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What We’re Reading – Physician Meetups Connect with Community, Attract New Patients

Do you want to save time, interact with the community and simultaneously bring new patients to your practice?  This article provides creative create “meetups” either in-person or online and how you can implement this in your office today.  Meetups are informal social gatherings organized – in this case – by patients, for patients.   The author suggests some interesting themes for meetups or you can come up with one on your own.  Here’s a start:

  • Healthy Cooking Demonstrations – team up with a local chef in the community so you both can benefit
  • Insurance Question and Answer Segments
  • Ask a Doctor Hour – answer any medical or health questions
  • Fun Community Nights – throw some kind of event at your office for the community and possibly have a raffle or prizes to give away
  • Run a Weight Loss Camp – require the patients to get a physical performed by you first and then offer weekly weigh ins
  • Topic-focused webinars – focus on a topic about which your patients usually have questions or something they may want to learn more about.  One example for pregnant women is any issue related to pregnancy or childbirth.
  • Wellness Education – offer a variety of topics on how to stay health and/or appropriate issues such as flu season, etc.

Meetups are a great way to provide the community with useful information and introduce you to them in a fun environment.

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Personnel Requirements of a Florida Home Health Agency – Part 3

In this third installment of our series about the Personnel Requirements of a Florida Home Health Agency, we will review the requirements for the supervising nurse.

Home health agencies that do not provide nursing services, such as those agencies that provide only home health aide & homemaker companion services, or only therapy services, are not required to have a Director of Nursing. A home health agency that provides home health aides but no nursing care is required to have a registered nurse (RN) available upon the request of a patient and also to provide supervision to the home health aides (HHAs) and certified nursing assistants (CNAs).  The nurse is not required to have any experience in the field or even supervisory experience. Obviously, the individual must be properly license by the State of Florida. Further, the RN must clear a Level 2 background screening.

This includes the assignment of non-skilled personnel as well as the supervision of all aspects of the services provided. When only physical, speech, or occupational therapy is furnished, in addition to HHA or CNA services, the supervision can be supplied by the licensed therapist, who must be directly employed by the agency or by an independently contracted individual.

Supervision in the home of the HHA and CNA by an RN must occur with the patient’s approval and agreement to pay any charge for the visits. In essence, if the patient does not authorize the supervisory visits, they cannot occur.  It is important to clarify that accredited agencies must meet their accrediting organization’s standards for personnel requirements and supervisory visits which may differ from the State of Florida’s guidelines in this blog series.

Next week, we will continue our coverage of home health agency leaders by discussing the requirements and responsibilities for the Financial Officer.  We hope you will join us.

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What We’re Reading – CMS overpaid Medicare Advantage (MA) by as much as $5.1 billion, according to the Government Accountability Office (GAO)

A report issued by GAO the week of March 7, indicates that CMS overpaid the MA program run by private companies by between $3.2 and $5.1 billion for the years 2010-2012. The overpayments were the results of CMS inadequately adjusting for health status of members enrolled in Medicare. The GAO discovered that coding differences between MA enrollees and those enrolled in traditional fee for service Medicare lead to inappropriately high risk scores and reimbursements.

CMS adjustments to risk scores to account for diagnostic coding differences were too low, resulting in the overpayment. This report comes in the midst of CMS’ announcement of a proposed decrease in MA payments of 2.3% for 2014. America’s Health Insurance Plans (AHIP) is opposed to this proposed cut, saying that it will negatively affect Medicare enrollees. But the cut has a lot of support from congress, which insists it is a necessary cut to ensure that the program is not overspending for care and services.

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Personnel Requirements of a Florida Home Health Agency – Part 2

Welcome back to our series about the Personnel Requirements of a Florida Home Health Agency.  In the last installment, we discussed the requirements of the Administrator and Alternate Administrator.  This week, we will review the qualifications and responsibilities of the Director of Nursing.

Every home health agency licensed by the State of Florida that provides skilled nursing and other therapy services must have a person who acts as the Director of Nursing (DON). Medicare Conditions of Participation requirements mandate supervision of the agency by a physician or a registered nurse (RN). The State of Florida also has specific qualifications and responsibilities for the DON to meet.

The primary, and most obvious, qualification to serve as the DON is an active RN license; the DON must be a graduate of an “approved school of nursing” and have at least one year of supervisory experience as an RN. In addition to the requirement of being a direct employee of the home health agency, the DON is responsible for overseeing the delivery of professional nursing and therapy care, as well as the non-skilled services provided by the agency.

If the administrator of the home health agency is not a physician or RN, the DON is required to:

1. Establish service policies and procedures regarding biomedical waste, occupational safety and health, and universal precautions and infection control procedures;
2. Employ and evaluate nursing personnel;
3. Coordinate patient care services; and
4. Set or adopt policies for, and keep records of criteria for admission to service, case assignments and case management.

Even though the Administrator is responsible for the daily and ongoing operations of the home health agency, the DON is required to establish and conduct an ongoing quality assurance (QA) program. This QA program must assure that:

1. Case assignment and management are appropriate, adequate, and consistent with the plan of care, medical regimen and patient needs;
2. Nursing and other services provided to the patient are coordinated, appropriate, adequate, and consistent with plans of care;
3. All services and outcomes are completely and legibly documented, dated and signed in the clinical service record;
4. Confidentiality of patient data is maintained; and
5. Findings of the quality assurance program are used to improve services.

Incidentally, an agency with less than 10 full time equivalent employees and contracted personnel may employ the DON as the administrator.

Finally, significant changes to the Florida Administrative Code are being proposed through the rule making process by the Agency for Health Care Administration. They include modifications to the duties and responsibilities of the DON and fairly significant changes to the QA responsibilities of the DON. We will revise this article when those changes are finalized, which we hope will happen within the year.

Join us next week for Part 3 of our series on Personnel Requirements of a Florida Home Health Agency where we will discuss the Supervising Nurse.

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