Blog and Helpful Articles

What We’re Reading – Managing Difficult Change at Your Medical Practice

Medical practices across the country are facing change in order to keep up with the growth in health care.  The author of this article reminds us that change doesn’t have to be a bad thing, when managed effectively.  Ken Hurtz, points out that during times of transition, managers have a tendency to focus on the tangibles (timetables and training classes) rather than office politics, morale, and staff buy-in, that “can sink the Titanic.”

This article outlines six simple steps that will help to make change and transition in your office as smooth as possible:

Be an Open Book

  • Communicate early and often.

Explain Yourself

  • Offer reasons as to why the proposed change is necessary.

Alleviate Fears

  • Reassure your staff that they are an important part of the office team and you will do what needs to be done to accommodate them individually during the transition.

Plan Ahead

  • Stay organized and allow yourself ample amounts of time for planning.

Face Resistance

  • Make sure you have the support you need and be prepared to address the concerns of those who view the change as negative.

Show Commitment

  • Maintain strong leadership and remain positive.

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How to Navigate the Medical Review Projects

Jurisdiction 11 Home Health and Hospice

FAQs: Additional Medical Review Projects and CERT

To help reduce the Comprehensive Error Rate Testing (CERT) program error rates, Palmetto GBA was recently funded by CMS to undertake additional medical review projects that involve medical review of and education for certain E/M coded claims, advanced imaging claims, major procedure claims, inpatient hospital claims and home health claims that contributed to the majority of the J11 MAC CERT payment errors. Providers selected for education and/or medical review are selected based on the frequency of their billings for the services/codes mentioned above.

Palmetto GBA’s educational and review efforts will primarily focused on reducing payment errors from insufficient documentation and improper coding. Providers will receive written results of the project’s findings if being selected for medical review

The following FAQs are developed to help clarify what the additional medical reviews involve and how providers can help in the process. For more information, please refer to the article The ABCs of the Comprehensive Error Rate Testing (CERT) Program and How to Respond to CERT Requests.

1.            Will the reviews be done on claims that have already paid? Claims review is focused on prepayment review at this time; however, post payment review will be initiated if necessary.

2.            Who will be selected for review and/or education for the additional medical review projects? All providers who bill the identified codes may be included in the review projects.

3.            Did I do something wrong to be included in this small sample review? Not necessarily. Providers were selected on the basis of their utilization of certain procedure codes. Being selected for review does not necessarily that a provider has done anything wrong.

4.            How will I know what claims have been selected for review? Providers will receive additional documentation requests (ADR letters) requiring medical records for each claim. The ADR will state the claims were selected as a result of a “special study” or “increased medical review.”

5.            How much time do I have to submit the requested documentation? It is important to provide the requested documentation within 30 days. If no documentation is received by our office within 30 days from the date noted on your ADR letter, the claim determination will be made based on the information present. Failure to respond to the documentation requests may result in further scrutiny by Palmetto GBA.

6.            How do I submit the requested documentation? Submit complete documentation as requested to the fax number or address located on the ADR letter. If you do not have the original ADR letter, please submit your documentation with the applicable fax cover sheet. Documentation for Part A claims should be faxed to (803) 462-2576. Documentation for Part B claims should be faxed to (803) 462-2577. Documentation for HHH claims should be faxed to (803) 462-2578.

7.            If I miss the deadline to submit the requested documentation, can I just resubmit the claim? Claims that were denied due to lack of documentation cannot be resubmitted as a new claim. Resubmitting a denied claim as a new claim is considered fraudulent billing practice. If you miss the deadline for the documentation request and you receive a remittance advice indicating a denial due to missing information (remark code N102), you may submit the requested complete documentation along with a Redetermination and Reopening Request form located on the Palmetto GBA J11 Part A, J11 Part B and J11 Home Health and Hospice website.

8.            What can I do if I disagree with the medical review decision on a claim? If you disagree with a claim decision, you may request a redetermination within 120 days from the date of the remittance advice.

9.               How will I learn of the review results? Providers will receive results in writing once all of their selected claims have been reviewed and results have been calculated.

10.            What are some common reasons for claim denials?How can I avoid these denials? Some common reasons claim denials to occur are:

  • Missing or illegible provider signature or use of a signature stamp
  • Missing or unsigned physician’s orders
    • Verify that any necessary orders are legibly signed and submitted with the requested documentation.
  • Illegible documentation
    • Print or clearly write progress notes and all medical documentation if dictation is not used.
    • If you feel documentation may be deemed illegible, you may submit typed or dictated exact copies of any written documentation.  Make sure that any typed or dictated copies include the complete date of service and are signed legibly by the provider.
    • Ensure that documentation is clean and dark enough to be legible when received as a fax transmission.
  • Failure to provide documentation for all dates of service requested.
    • Review the ADR letters closely to ensure that documentation is submitted for all dates of service requested.

Learn More

For additional information regarding redeterminations, please refer to the Appeals section of the J11 Home Health and Hospice website.

For tips on Home Health Billing or more info regarding this article, contact Imark Consulting, Inc. or www.homehealthbilling.com

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Increased Claim Scrutiny!

Palmetto GBA is performing a variety of medical review activities in addition to the reviews discussed in the next article. As part of our normal medical review process, we perform ongoing data analysis and identify services and providers for medical review.

Providers selected for probe reviews would have approximately 20- 40 claims selected for medical review. Providers that have been progressed to complex medical review would have a percentage of their claims selected for medical review that is commensurate to their charge denial rate. For example, a provider with a 40% charge denial rate on a probe review would likely be progressed to complex review with their edit set to suspend 40% of the claims they bill for medical review. 
 
Providers that have questions or issues related to the volume of claims selected for medical review should contact the phone number listed in their notification letter.  Prepayment medical review is also being performed by the ZPICs. If a ZPIC is performing prepayment medical review of a provider, the ADR letters will be on Palmetto GBA letterhead but will identify that the documentation is being requested by and should be returned to the ZPIC.

For tips on Home Health Billing or more info regarding this article, contact Imark Consulting, Inc. or www.homehealthbilling.com

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What We’re Reading – Feeling Better About ICD-10

With all of the negative talk going around about the ICD-10 conversion, the author of this article puts forth reasons why ICD-10 will prove to be a good thing…eventually.

  • Updates technology and specificity.  ICD-9 was developed in 1979 and is now more than 30 years old.
  • Improves public health tracking.  ICD-10 makes it easier for public health officials to track diseases and threats, dangerous settings, and even acts of bio-terrorism.
  • Discourages up-coding and fraud.  More specificity will make it harder for providers to lump patients into a more severe disease or procedural category.
  • Specifies reasons for patient noncompliance.  The current system offers one classification for patients who fail to follow a recommended regimen, while the ICD-10 offers at least eight.
  • Detailed data on injuries and accidents.  ICD-10 offers information about injuries such as where they occur, what part of the body was injured, and what implements were used.
  • Tracking of healthcare-associated conditions.  ICD-10 allows much greater explanation and accountability for adverse events that occur within healthcare institutions.
  • Specifies procedures by degree of difficulty.  ICD-10 allows certain procedures to be subdivided by difficulty.
  • Precision in reporting complications from medical devices.  ICD-10 allows providers to be much more precise in describing the nature of the malfunction.
  • Creates jobs.  Conversion to ICD-10 will create jobs for coders and trainers.
  • Aligns with EHR.  The conversion to ICD-10 will ensure that electronic medical records, value-based purchasing metrics, and meaningful use incentive programs speak the same language.

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What We’re Reading – Sharing Patient Feedback with Your Staff

In this article, Shelly K. Schwartz suggests sharing patient feedback with your staff.  There is nothing like receiving positive feedback to boost in office morale.  On the other hand, negative feedback can be a great motivation to make some changes in areas the areas of the office that could use some improvement.

When It’s Negative

Complaints received about a particular staff member should always be dealt with in private.  When a complaint is more general, it is often beneficial to address it at the next staff meeting.  Your staff needs to know that you are aware of what is going on in the practice even though you may not be there to witness it personally.  In today’s economy, customer service is extremely important and as Mark Huizenga, a medical practice consultant points out, “A 90 percent satisfaction rate is just not good enough anymore.”

Say It Loud

Positive feedback, of any kind, should always be shared with the entire office staff.  Make sure to recognize individuals who receive stellar comments from patients.  Recognition at a meeting and even small rewards are great ways to emphasize to your staff that good customer service is valued at your practice.

Survey Results

Whether you conduct your own customer service surveys or monitor the online rating sites, patient comments, good and bad, should be shared with your staff.  These surveys are great ways of letting your staff know what is important to your patients when they visit your office.

Stay focused on the positive and let patient feedback motivate change in your office.

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What We’re Reading – Study: Special Home-Visit Program Could Promote Prevention

A special Medicare program aimed at keeping patients with chronic diseases out of the hospital may help lower health care costs by focusing on prevention of expensive complications.  A study conducted by XLHealth and America’s Health Insurance Plans found that diabetic patients enrolled in a Chronic Condition Special Needs Plan (SNP) had lower rates of hospitalization than patients enrolled in fee-for-service Medicare programs.

A large part of the Chronic Condition SNP is the HouseCalls program which sends nurse practitioners and physicians to patient’s homes.  Although HouseCalls may seem expensive, researchers believe the cost will be offset by the reduction in hospital admissions.  The research team states that, “preventive care performed as part of the HouseCalls program can include a complete health history and physical; a medication inventory; a social-needs review; foot exams; flu vaccinations; blood-pressure monitoring; urinalysis; depression and pain screening; and assessments of functional, cognitive, and fall-risk status.”  Researchers believe that by adapting methods used by the Chronic Condition Special Needs Plan, the Centers for Medicare and Medicaid Services may be able to improve care and outcomes for patients with chronic diseases.

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What We’re Reading – In Challenging Times, Customer Service Quality Matters Most!

Customer service quality is the currency that keeps our economy moving. When money is tight, many people experience a sense of lower self-esteem. When customers get good service from your business, it helps boost their self-image. And when they feel good about themselves, they feel good about you. And when they feel good about your customer service quality, they buy.

During economic hardships, people are extremely conscious of their hard-earned money and how they spend it. Customers want to be sure they’re getting the maximum value for the money they spend. Basically, customers want firmer guarantees, more attention, more appreciation and more recognition. This article gives eight proven principles you can use to raise customer service quality during challenging times.

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‘Meaningful Use’ for Physician Practices: Is It Worth the Trouble?

The foundation of the Medicare & Medicaid EHR Incentive Program is to improve quality of care.  Facilitating documentation, enhancing provider communication and focusing on indicators that produce better outcomes necessitate an electronic solution for most providers.  To achieve this, CMS has created significant and attractive financial incentives:  a maximum payment of $44,000 per eligible professional (MD, DO, DMD, DDS, DPM, DC, OD) for Medicare, or up to $63,750 per EP for Medicaid.  This means that a group with three EPs, could qualify for three distinct payments which are paid over a five-year period.

The Eligibility Process

Eligibility is straightforward.  The EP must:

  • Select an electronic health record system from the list of Certified EHR Technology.
  • Decide for which incentives to apply.  The Medicaid incentive payment is based on a volume of at least 30% Medicaid patients, while the requirement for the Medicare payment is contained in the volume requirements for the core and other measures.
  • Register with CMS and receive an ID number.
  • Complete an attestation each year.  Keep in mind that a distinct attestation must be completed for each EP based on his/her use of the system.

However, the hand that giveth, also taketh away, so it’s important to understand the requirements that constitute ‘Meaningful Use’ and the attestation process that validates an EP’s eligibility for payment.  This is the point at which some of the clients we’re coaching through the attestation process throw up their hands and say, “Maybe I don’t really need the money.”

The obvious goal of this program is to ensure providers use the system to its maximum capabilities to deliver quality care.  It’s not unusual for a physician to make the investment in an EHR and then fail to devote the time to understand and adapt to the system. The result is a system that fails to deliver the efficiencies promised by the vendor.

The Attestation Process

An attestation is the means by which CMS ensures the system is implemented and used for key processes.  The attestation is also what triggers the payment.  For the first year, the EP is required to demonstrate compliance with 15 core measures during any 90-consecutive-day period.  Some of the criteria are relatively simple, such as recording smoking status and maintaining an active allergy and medication list.  Others can be somewhat taxing, like providing a clinical summary to patients for 50% of all office visits within three business days.  But for the most part, the measures are do-able once the provider overcomes any psychological barriers to the system and realizes that the criteria will result in better care.  These criteria include ordering medications electronically and allowing the system to check for drug interactions.

This process also requires meeting five Meaningful Use measures which include at least one public health criterion. Some examples are the capability to submit electronic immunization and syndromic surveillance data, as well as incorporating clinical lab test results into the system as structured data.  This means that simply scanning in or importing the lab report isn’t sufficient.  Providers need to key the actual values in a numeric or positive/negative format so the data can be analyzed and aggregated.

The burden for subsequent years is demonstrated use of the system for all required measures for the entire year, and not just one quarter.  Obviously, it is expected that once a provider enjoys the benefits of an EHR, he or she will be more apt to continue the trend.

In summary, the Medicare and Medicaid EHR Incentive Program removes some of the obstacles to implementing this important technology by defraying a portion of the costs and by creating measurable goals that enhance patient wellness and facilitate practice efficiency.  And if you haven’t started the ‘Meaningful Use’ process, the ship has not yet sailed on the incentive program.  EPs have the balance of 2012 to secure an EHR and begin using it to qualify for the maximum payment.  The Medicare incentive payments for 2013 and 2014 are $39,000 and $24,000, respectively.

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CMS Provides Guidance on 5010 Discretionary Enforcement Period for Medicare Fee for Service

Medicare Fee-for-Service (FFS) issued an announcement on December 14th regarding its plan for the 90 Day Discretionary Enforcement Period for non-compliant HIPAA covered entities.  According to that announcement, CMS provided a 90 day discretionary period for compliance with planned January 1, 2012 5010 transaction set requirements. However, it was unclear in that announcement whether CMS would continue to accept claims in the 4010 format during the discretionary period. In response to inquiries, CMS provided the following Q&A’s to spell out requirements that must be met in order to qualify for continued submission of 4010 claims between January 1st and March 31st.

 Medicare Fee for Service

1. Q: Will submitters who have not tested 5010 be able to continue to submit 4010 claims after January 1st while their transition plan is being reviewed by the MAC and if the plan is approved how much grace time will they be granted?

    A: Submitters who have not tested will need to submit their transition plan within 30 calendar days of the date of the notice from the MAC. Those who submit a transition plan by the deadline will have until April 1, 2012 to complete their transition to the 5010 formats.

 

2. Q: What will happen if submitters don’t submit a test plan? Will their 4010 claims be rejected as of the 31st day?

    A: If no transition plan is submitted Medicare FFS may direct the Medicare Administrative Contractors (MACs) to reject 4010 claims. The MACs have not been directed to reject 4010 claims at this time.

 

3. Q: Is Medicare going to release information about exactly what a compliance plan will look like?

    A: Medicare will not specify the format of the transition plan. Submitters should outline the steps they have taken and the steps they still need to take to successfully achieve compliance.

 

4. Q: Are the 30 day deadlines stated in the Medicare FFS announcement working or calendar days and does the 30 day clock start with notification or on January 1?

    A: The thirty day deadlines are calendar days and the 30 day clock starts with the date of the notification from the MAC.

 

5. Q: Will the MACs be able to accept a mix of 5010 and 4010 claims during the grace period?

    A: Yes, MACs will be able to accept a mix of 5010 and 4010 claims during the 90 day non-enforcement period.

 

6. Q: Who notifies providers that submit directly? What is the difference between a submitter and a provider?

    A: The MACs notify providers that submit directly. A submitter is a clearinghouse, vendor or biller that submits to Medicare on behalf of one or more providers. The Medicare 90 Day Discretionary Enforcement announcement requires submitters to test with their MACs, submitters to take action in regards to this plan and submitters to send it their transition plans. Medicare has developed the incremental steps in this plan to support the provider’s efforts in working with their submitters.

 Note: Although Medicare Fee-for-Service will accept 4010 claims during the 90 day discretionary period if the transition plans are submitted, other payers have announced plans to accept 5010 only and to reject all 4010 transactions. 

 

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What We’re Reading – Seven Tips to Keep Your Clients Coming Back for More

Are you looking for creative ways to keep your repeat client business? This article gives you 7 ways to do just this!

The first tip is to offer packages for recurring work. The author used the example of a website designer who generally would contact most of his clients maybe once a year. If, however, the same web designer also offered business cards, email template designs and headers for special landing pages, this would bring recurring business.

Another tip from this article is to give your clients special treatment. Ask yourself, who are your best clients? The answer is probably those who accounted for the greatest revenue to your company.  But great clients are also those who’ve referred other clients to you. Special treatment to these happy customers could take the form of discounted rates or other token of your appreciation for the referral.  Also, if you haven’t heard from your clients in some time, it’s a good idea to send an email or snail mail to update them on your work – and consider including a discount coupon.

Treating customers as if they’re special reinforces their value to your business.  One final example the author suggested is to keep track of important dates for your clients. Send your customers a birthday card or gift. Or find a way to recognize the anniversary of when you first started working together.

Some of these tips will take a little hard work and organization, but the author assures us they will pay off. Not only will you convey genuine appreciation for your clients, but more importantly, you’ll keep ‘em coming back for more!

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