Blog and Helpful Articles

What We’re Reading – Sometimes physician query is imperative

A staff member’s role is one of supporting the clinician.  However, in the area of coding and billing, the perspective is more of collaboration as the employee must appropriately transfer the practitioner’s documentation into correct codes, advise him/her on the coding guidelines, and solicit clarification when information is ambiguous.  After all, certain documented information can be misinterpreted, be confusing or in some cases, be incorrect, and these will affect reimbursement; consequently, proper querying of the physician is critical to accurate reimbursement, especially in the realm of inpatient care when the medical necessity of an admission can be called into question. In addition to affecting reimbursement, this can impact the authorization process by the patient’s insurer. For example, the word ‘acute’ is often misused. This article’s author defines the concept of acute as ‘something has changed in an otherwise stable condition.’  Diagnoses such as pericarditis and appendicitis may imply their acute status, but this does not preclude the need to document correctly.

This article covers several other language issues in greater detail and highlights the need to query the physician in order to select the most correct and specific codes for the encounter.  Using proper codes also affects the integrity of the data which is used worldwide in tackling health concerns and establishing policy.

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The Basics of HIPAA (Part 4)

In this series on The Basics of HIPAA, we review the definition and meaning of the term Protected Health Information, or PHI. At the end of our conversation, you will see that the penalties for violating HIPAA are pretty severe.  However, because most provider organizations understand the sanctions for noncompliance, your practice probably has implemented many of the safeguards we discuss in this series.  If you have any questions about that, be sure to ask your supervisor.

Protected Health Information

The focus of HIPAA’s Privacy Rule is protected health information.  This is individually identifiable information that has to do with the “past, present or future physical or mental health or condition of an individual.”  The key to PHI, as it’s called, is that it must identify or reasonably identify, the person.  For example, how many identifying characteristics can you think of for health information?  Some include:  the patient’s name, address, social security number and other contact information.  What about employer information?  That’s an identifier.  How about date of birth, medical record number or photograph?  Those are means of identifying a person as well. HIPAA has a list of at least 20 identifiers.

The important thing to remember is that a person has the right to expect privacy of his or her health information.  And don’t forget, PHI can be verbal, too, so it’s especially important to watch what we share about a person’s PHI, with whom and the circumstances in which we share information.

The HIPAA law says we can’t use or disclose PHI except in specific circumstances.  It’s crucial to understand that “using” PHI usually refers to what is done with it inside the practice or organization.  The law is very clear about when you can look at someone’s PHI, and basically, it must be in the course of performing your job responsibilities.

We’ll give you an example:  Suppose you answer the phones for a provider and have no need to access PHI as part of doing your job.  In that case, the law says you should not have access to it.  However, what if you happen to come across PHI that you know you shouldn’t have access to?  The law also says that you will not view the PHI since you know you really don’t have a right to do so.  That part is on the “honor system” as long as the provider has taken the steps to limiting your ability to view PHI.  It’s always a good idea to let your supervisor know of this incident so that revisions can be made to the office policies if necessary.

Disclosing PHI has to do with providing information outside the practice or organization.  The law obviously states that you may disclose PHI for the purposes of treating a person.  For example, if a patient was referred to a cardiologist, and this physician needed a test result, it would be permissible for you to fax the information to the cardiologist’s office, as long as you made sure you were faxing to the correct place.  Other permitted disclosures are outlined in the HIPAA law and are probably included in your organization’s HIPAA policies.

Penalties

As with any law, HIPAA has numerous provisions and standards.  Non-compliance with HIPAA, or any violation of this law, can result in fines and even criminal penalties.

When HIPAA was first implemented, the fine to a Covered Entity was $100 per violation up to $25,000 per year for negligent violation of a single standard.  When President Obama signed the Health Information technology for Economic and Clinical Health (HITECH) Act in 2009, the penalties escalated.

Moreover, HIPAA provides for severe criminal penalties for individuals who knowingly disclose protected health information.  Fines start at $50,000 and can reach up to $250,000, with the added possibility of one to ten years in prison.

In short, HIPAA shouldn’t be taken lightly.  Remember, when in doubt, always check with your practice’s Privacy and/or Information Security Official.  If you don’t know who that person is, ask your supervisor or the practitioner.  Next time, we’ll complete our five-part series on the Basics of HIPAA with a look at the Security Rule that governs electronic health information.

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Electronic Prescribing: the Double-Edged Sword

In these days of information overload, it’s easy to overlook things that affect a provider’s bottom line.  One such item is the Electronic Prescribing (eRx) Incentive Program.  Established in 2009, eRx encourages eligible professionals (EPs) who render services to Medicare Part B beneficiaries to participate in this effort aimed at preventing medication errors and reducing adverse drug events.  Another advantage of eRx is the EP’s instant access to drug formulary and coverage information which reduces patient out-of-pocket costs and subsequent calls to the provider for medication changes. Prescriptions for Medicare Advantage members do not count for this program.

Incentive Payment

The program has two parts:  one is an incentive for participation. For medications prescribed in 2012 using eRx, EPs will receive an incentive payment equal to 0.5% (down from 1% in 2011) of their total Medicare Part B payments for the year.  This incentive will be reflected in the payments received by the EP from January 1 through December 31 of 2013.  Please note that EPs participating in the Medicare EHR incentive program are not eligible for the eRx incentive.

The target for the 2012 payment is at least 25 unique prescribing events when providing a billable Medicare Part B service during 2012.  Electronically generated refills do not count, and faxed prescriptions are not considered electronic submissions. The incentive payment is triggered by the addition of the G8553 code to the service codes submitted on the claim. Finally, it’s advisable for EPs to check their EOBs to ensure the G-code is reflected in the National Claims History (NCH) database.  If CMS does not indicate acceptance of 25 eRx codes, the incentive will not be paid.

Penalties

Some EPs believe that forgoing the incentive ends the eRx conversation for the calendar year.  This is a huge mistake because the second half of this program involves a penalty for non-submission.  For 2012, EPs must submit no less than 10 electronic prescriptions during the first six months of 2012 to avoid a penalty of 1.5% (up from 1% in 2011) to be reflected in all the payments for Medicare Part B services the EP receives from January 1 through December 31 of 2013.   This reduction is reflected on the Medicare allowable amount and will impact co-insurance payments as well.

Once again, checking EOBs is crucial to ensure the G-code is properly captured and reflected in the NCH database.   The deadline to make any changes or resubmissions to correct missing or faulty codes is July 27, 2012.

Some exemptions to the penalty exist for providers who prescribe less than 100 prescriptions in the first six months of the year; rural practices without high-speed internet access; and providers whose state laws prohibit electronic prescriptions or for whom a significant hardship precludes their participation.  The EP will need to submit a hardship exemption to avoid the penalty.

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The Basics of HIPAA (Part 3)

In this third part of our five-part series on HIPAA, we will review the agencies overseeing HIPAA and also who is required to comply with this law.

Who governs HIPAA?

The Department of Health & Human Services (DHHS) has delegated to the Center for Medicare and Medicaid Services (CMS) the responsibility of overseeing the electronic transaction portion of HIPAA.

DHHS’s Office of Civil Rights (OCR) is responsible for the privacy rules.

Who must comply with HIPAA?

HIPAA affects health plans, clearinghouses and providers, which are referred to as Covered Entities.  For our intentions here, let’s focus on providers.  HIPAA defines a provider as anyone who provides medical or health services and any other person or organization who “furnishes, bills or is paid for health care services or supplies in the normal course of business.”

The list of entities that are considered providers includes: physicians and physician group practices (which also encompasses physician assistants and nurse practitioners), hospitals, skilled nursing facilities, diagnostic centers, outpatient physical or occupational therapy centers, clinical psychologists and social workers, registered dieticians, and certified nurse midwives.  Keep in mind that there are other provider classifications, such as home health agencies and durable medical equipment companies.  The list is very comprehensive.

However, HIPAA also applies to Business Associates.  A Business Associate (BA) is a person or entity who performs a service or function on behalf of a covered entity and who uses protected health information in the process of performing its function.

Some good examples to clarify this concept include:

  • A transcription service.  A transcription service receives information about patients’ health in the course of performing a function or service (transcription) on behalf of the covered entity (the provider).
  • A billing agency.  Billing agencies receive health information about patients so they can perform a service (billing) on behalf of a covered entity (a provider).

Since BAs have access to protected health information, they must also uphold the standards of HIPAA and as a Covered Entity, the provider has the responsibility for contractually requiring this.  BAs are expected to follow all of the HIPAA regulations; this is usually outlined in a separate Business Associate agreement between the Covered Entity and the BA or with language in the two parties’ agreement which includes the same stipulations.

While all states have healthcare privacy laws, HIPAA specifically applies to Covered Entities and their Business Associates as described above.  This means that – for example – if a provider organization is still in the stone-age, with paper records and submitting paper claims, HIPAA compliance is not required.  Bet that surprises you, right??  However, many of the HIPAA guidelines make great sense and increase a patient’s sense of privacy so even if a provider doesn’t meet the Covered Entity definition, these rules are still good to follow.

So what exactly is covered under HIPAA?  Tune in on Thursday when we will explain the concept of Protected Health Information and what that means.

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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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