Blog and Helpful Articles

Do I Really Need Billing Policies?

Call us nerds but we’re fans of having policies & procedures.  They’re not a magic bullet by any means, but they do provide a framework for operating that accomplishes two things:  P&P force practice leaders to consider and document business standards and processes and they guide and remind employees about those workplace standards and processes.  So, although they can be the bane of a manager’s work existence, P&Ps are our friends.  The billing department is one place where we believe you really need robust P&P.  Why?  Because it’s the heart of the office. 

We can’t tell you how many billing assessments we’ve done only to find out that Sally does things this way and on these days, and Henry does them that way and on a different timetable. These differences can impact the financial wellbeing of the practice because so many billing tasks are time-based.  For those of you who tremble at the thought of writing stuff, P&P don’t need to be fancy.  They just need to put forth the steps and guidelines of a process.  Here’s a list of subjects you can cover in your policies:

  • The steps in the billing process for your practice – No need to get too nitty-gritty on the how-tos with screenshots (although that would be helpful in a training handbook), but cover the basics:  when is billing done (preferably daily), how is it done (is the note reviewed? Do you use a superbill?), how frequent is claims f/u, what is the process and timeframe for denials, etc.
  • Financial hardships, courtesies and discounts – How do you handle these?  Who can receive a discount? What can a biller or billing manager discount without authorization?  What needs approval?
  • Payment plans – How do they work?  Who can establish them?  What size balance can be paid off in this manner?  Will you collect a credit card and process payments automatically?  Who is responsible for monitoring payment plans? How will that be done and on what timetable?
  • Delinquent accounts – How do you define this?  What do you do with delinquent accounts?  Will you refer a delinquent patient to collections?  When does that happen – after how many collection attempts?
  • Refunds – Define when a refund may be due and to whom.  Who can process refunds? Is authorization needed for any refund or only those over a certain dollar amount? What documentation is made in the system?
  • Patient statements – How often are they sent? How many statements are sent before an account is deemed uncollectable?
  • Write-offs and adjustments – Define these terms so their distinctions are clear.  When are adjustments made?  Are adjustments for contractual allowances, for example, done automatically?  When is a write-off done?  What can be written off automatically?  Do write-offs require authorization?  From whom?

Billing policies are not for the specific steps in performing the process but for the standards and rules of the department and practice.  The more you spell out for your billers, the more effectively they can work because the parameters for using their judgment are clear.  Think about the issues you cover with a newly hired biller and we bet you’ll have the topics for a basic billing policy manual in no time!

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The Balanced MRA Approach

Like grandparents who pepper conversations with comments like, “Back in the day…” we’ve been around the risk adjusted payment methodology since its birth in 2003.  Back in the day LOL the provider community was largely in the dark about many aspects of this huge payment shift.  Remember that in the early aughts, MA payments were based on factors beyond the provider’s control, namely demographics, and documentation was deliberately sparse in prepaid circles because it wasn’t believed to matter to the payment. (That’s the subject of another discussion.)  Additionally, the majority of providers were documenting visits on paper.  Raise your hand if you remember the blue paper problem list filed on the left side of the chart!

So much of our work in early MRA was educating providers and identifying risk adjusted conditions buried in the chart – conditions which had not been previously coded or reported.  That’s perhaps the “fun” part of MRA work: unearthing conditions that may add to the provider’s (or Plan’s) funding.  With time, things shifted and providers were more informed on the conditions under the CMS-HCC model and better at coding them. In time, regulators stepped up their scrutiny of reported conditions and documentation to assure proper compliance with all guidelines, coding and medical. Cue the OIG.  As we’ve reported many times over the years, the Office of the Inspector General (OIG) has commissioned numerous audits of MA plans, questioning the validity of submitted conditions and even making serious accusations of fraudulent activities and “upcoding.”   That’s the non-fun part. 

The balanced MRA approach, therefore, has to embrace the two: identifying new conditions that fall in the CMS-HCC model which have not been reported and assuring that the submitted codes are valid.  Valid encompasses:  using the most specific ICD-10-CM code possible; making sure the evidence supporting the condition is clear, documented and accurate; and requiring comprehensive documentation of a proper assessment of the condition on the date of service for which it is reported. 

In our work, we get to see the MRA activities of many practices, large and small.  Some are heavily slanted toward identifying new conditions – however creatively – but they disregard the validation aspect at their own peril. A few are exclusively archaeologically inclined!  We urge every single provider operating under this payment method to assure your MRA department’s activities are equally split between identifying unreported conditions and making sure what has been submitted will pass muster. 

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PHE Extended but Experts Urge Planning for the End

After some speculation about the end on April 16th to the public health emergency enacted since the start of the COVID-19 pandemic, the Department of Health and Human Services just extended the PHE for another 90 days.  However, experts have been predicting the end is near.  For example, certain flexibilities in place for acute and long-term care are starting to sunset and Federal funds are no longer available for vaccine administration, testing and treatment under the COVID-19 Uninsured Program.

The DHHS has stated it will give a 60-day notice before ending the PHE, so if the PHE will end after this most recent extension, we should expect word no later than May 16th.  In the meantime, healthcare providers should implement plans to return to pre-pandemic policies.

However, telehealth will continue for at least 180 days past the PHE based on a separate government exemption.

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What We’re Reading – Top 7 Takeaways from EEOC’s COVID-19 & Vaccine Webinar for Employers

Fisher & Phillips has always been one of our top sources for employment law issues and we’re always happy to pass along their important insights.  F&P’s summary of a recent the Equal Employment Opportunity Commission’s (EEOC) webinar regarding COVID-19 vaccines conveys helpful reminders for healthcare employers subject to CMS’s vaccination requirement.  Apparently, vaccine disputes account for almost half of all the pandemic-related charges filed by employees since December, with about 20% of all lawsuits relating specifically to the vax. F&P expects this number to continue rising as cases make their way thought the investigation phase and become actual suits.

To recap some important points:

  • Employers can lawfully ask workers about their vaccination status without violating anti-discrimination or HIPAA laws.  The question, however, is limited to that which would elicit a yes-or-no answer from the employee.
  • Although many employers are dropping the vaccine mandate as a condition of employment – assuming they are not otherwise required to enforce it, of course – they may still request vax status for business travel, attending conferences and even for accepting employees back into the workplace after their having worked remotely.
  • The EEOC recommends that a religious accommodation exemption request be generally accepted as sincere unless there is an “objective basis to question it.”  The original F&P article contains some useful links that delve more deeply into this exemption.
  • Employers are required to offer a “reasonable” accommodation but not necessarily an across-the-board exemption.  Employees can be subject to certain requirements, such as needing to attend meetings virtually instead of in-person, meeting additional safety guidelines (such as PPE) when on-site), and even regular COVID-19 testing.
  • Teleworking (or working remotely) should be one of the reasonable accommodations in the employer’s arsenal as long as the employee can perform his/her job in that manner.  Additionally, if the employee successfully worked remotely during the pandemic, for example, the EEOC encouraged employers to consider it an accommodation.
  • Workers with COVID may qualify as having a disability under the Americans with Disabilities Act.  Similar to any disability inquiry, employers must be careful when facing this possibility.  F&P linked a good article expanding on this subject.
  • The last point in the article touches on the possibility that an employee may be a caregiver for someone dealing with pandemic-related issues.  This scenario is fraught with potential peril, so – as with all thorny employment related matters – contact your legal counsel for guidance.

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The Personnel File

Given that labor is generally the largest expense in any business – especially a service business like health care – personnel files are integral.  These days, they can be paper-based, purely electronic or a combination of both. Personnel files can contain a number of important documents but the most common are:

  • Application for employment and/or resume and contact sheet with next of kin
  • Copies of licenses and certifications
  • Background screening and Medicare exclusion results, if required
  • Verification of employment references
  • Health documents:  examples include pre-employment drug testing results, and COVID-19 vaccine status for healthcare businesses mandated to obtain this info or those employers whose policies require it.
  • Pre-employment testing or any competency assessment documentation
  • Payroll & benefits documents, such as W-4 or W-9 (for contractors), benefits election
  • Immigration status (I-9)
  • Appraisals and disciplinary records

In addition, many companies keep copies of onboarding materials, such as acknowledgements of orientation, job description, employee materials (e.g., handbook, uniforms, access badge, etc.) and more.

Many personnel files have a set structure but that is not always the case, especially for small companies that can tend to run informally. We’ve seen files that contain a W-4 and application, and that’s it.  Others are uber-organized with sections and sub-sections.  Use your judgment and avoid setting up a system that will be difficult to maintain and make information hard to find. Combining like documents into general sections (e.g., hiring, payroll, testing) will at least give some organization.  

Please note that I-9s are not filed in the personnel file because they are not part of the file, per sé.  Instead, keep I-9s (form and copy of required documents) in a binder, preferably with A to Z tabs. This will make information easy to produce during an audit. Additionally, health docs are usually in a sealed section or manila envelope.

The last thing we’ll touch on is audits.  Most business owners want to get ahead of a regulator or auditor and personnel file reviews are crucial to that end.  Set up a system to go through your files on a regular basis, and if you find outdated documents, set about obtaining the current replacements.  Many HR systems are affordable and let you enter and track document expiration dates; in this way, you can set a 30-day reminder before a document expires so you can request replacement from the staff member.  Depending on the size of your workforce, a simple calendar program can be a great tool as well.

If you believe ignorance is bliss and a regulator can’t hold you responsible for a mistake – say you don’t collect I-9s or check for Medicare exclusions – guess again. So really, audits are the way to lower your stress and avoid costly fines and penalties.

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Three Reasons Why Relatives Are Not Your Ideal Employee Source

Over the years we’ve worked with countless start-up and small healthcare businesses and one common thread is usually the employment of family and friends.  This is certainly understandable, especially when launching a new company, since funds are usually tight and well, it’s a no-brainer to want to turn cheerleaders into workers.  Over 20 years in consulting and decades more in health services management confirm that more often than not, this is a recipe for disaster. Here’s why:

1. Loved ones don’t always have your back.

In the start-up phase, desperation usually moves us to consider family to fill a new business’s employment needs.  That can soon expand to friends, friends of friends and then the acquaintances of friends. While loyalty is certainly a factor, there is no ignoring the workplace trends across the generations.  Skill, initiative and work ethic vary from Boomers to Millennials and though their hearts may be with you, their minds may be elsewhere.  And the more diluted the family connection, the less “invested” individuals can be, simply taking advantage of a good situation:  high trust coupled with #2 below.

2. It’s usually difficult to hold people accountable.  And doubly so when they’re your relatives. 

Whether they’re being paid or not, the idea that family and friends are “helping” you might be at the forefront and also make for a handy excuse to not put forth their best efforts. Colloquially speaking, whatchagonnado?  Fire them?  That’ll sure make for a happy home life and holiday gatherings!  The more likely scenario is that you’ll accept less than their best because, frankly, you don’t know how to do otherwise.  And you’ll begin hiring non-loved ones into your business, believing you can bolster your operations and thus…. What?  Fire the relatives?  Doubtful.  From there, it’s a hop, skip & a jump to the double standard:  family gets away with murder (getting paid for low performance) and the bulk of the work falls on “outsiders,” causing resentment and a loss of respect.

3. Things will end badly.

Family in the workplace in these scenarios never ends well.  We’ve seen businesses take drastic steps after item #2 becomes unsustainable as the owners begin leaning on relatives to pull their weight.  Often these are half-hearted attempts with no “teeth” to change the dynamic until something gives and you do the otherwise unthinkable:  fire a family member. Aside from the personal chaos this decision may bring outside the workplace, it will cause ripples within as well.  The more family and friends you employ, the more divisive this action will be, giving bitterness and resentment seats at the break room table.   

What’s a business owner to do?

First of all, objectively (if possible) assess the performance and standards of the family and friends employed in your business – actually, of ALL the people employed in your business.  If it’s difficult to truly be objective, consider bringing in a consultant to assess the operations.  If relatives work as hard as everyone else, meet their responsibilities and bring about the results you expect, you’re truly blessed!  Just make sure you treat everyone uniformly, not (at least blatantly) granting permissions to family that others don’t receive.

Chances are the above does not describe your business, and if so, you’ve got a long road with a definite and a positive end.  First, assess your business operations and make sure that performance standards exist, are well communicated to everyone and are regularly monitored.  You may need to take baby steps in this regard as you redefine how you want things done and who is responsible for what.  Then, make it a point of measuring and monitoring for results on a regular basis.  That means systematically and not just when your business is underperforming.  Focus on the result and not the person, be quick to point out where workers are falling short and once again, clarify what you expect. 

It helps to have a strong (non-family member) manager who can take on this role and add distance between you and the relatives.  Give it time and a lot of coaching to evaluate everyone’s progress.  If or when the terminations come, these individuals can’t say they didn’t see it coming because you’ve been assessing & correcting toward a concrete performance objective.

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DOL Violations Go Beyond Wage & Hour Issues

Many of the US Department of Labor enforcement actions and penalties have to do with Wage & Hour violations, which inspired our 2021 blog series on various related topics.  Recently, we noticed a few other violations prompting action from the DOL, specifically:

  • A Georgia hotel owner
    • Paid flat salaries without regard to the number of hours worked, which led to minimum wage violations when average hourly wage rates fell below the federal minimum wage.
    • Paid flat salaries and failed to pay time-and-one-half rate for overtime when workers exceeded 40 hours in a workweek.
    • Engaged in discriminatory actions and violated workers’ federally protected rights when they retaliated against workers suspected of filing complaints.
  • A New Jersey construction company was cited twice by OSHA for not providing fall protection, allowing unsafe ladder use, and failing to ensure eye protection at a worksite.  The second violation was deemed “willful” and prompted an additional penalty.  While this specific scenario is not relevant to health care, our industry does expose workers to other hazards from which they must be protected. Brushing up on OSHA regulations and assuring solid workplace practices will keep your workers safe and help your employer avoid needless scrutiny.
  • A California McDonald’s franchisee was fined for employing minors in hazardous occupations; in this case, 18 minor employees loaded and operated indoor trash compactors.  With summer approaching, many workplaces might be considering the hiring of high schoolers, for example, to help with certain tasks.  Be sure to check Fair Labor Standards Act provisions for child labor and make sure your managers are especially informed about the tasks that minors can perform in your business.

Had these businesses employed qualified human resources and risk management personnel to advise them, these companies may have avoided unsafe and unlawful practices that landed them in hot financial water.  Consider adding these individuals to your company roster, even in a consulting capacity.   

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Medicare beneficiaries will be able to access free at-home COVID-19 tests

The federal government announced that sometime in early spring, Medicare beneficiaries with Part B coverage and Medicare advantage members will be able to receive up to eight over-the-counter COVID-19 tests per month for free.  The OTC tests must be FDA-approved and will be available through eligible pharmacies and other participating entities.

Until that time, free tests are still available via:  request for home delivery of four OTC tests from covidtests.gov, visiting a free testing site, at a lab that performs PCR tests and antigen tests ordered by a medical practitioner, pharmacist. 

In addition to accessing a COVID-19 lab test ordered by a healthcare professional, people with Medicare can also already access one lab-performed test without an order, also without cost sharing, during the public health emergency, CMS said.

Medicare Advantage plans may offer coverage and payment for over-the-counter COVID-19 tests as a supplemental benefit in addition to covering Medicare Part A and Part B benefits.

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Substance-induced Disorders may be Incorrectly Supported

From time to time, we run into risk adjusted conditions that are “newly discovered” by coders without fully applying the diagnostic criteria.  Those conditions are then suggested to providers, who may not be up on the requirements for the condition and who may report them incorrectly.  As we’ve blogged countless times before, the goal of risk adjusted payments is to correctly fund the care of members with conditions that are costly today and for which future healthcare costs will be high.  While leaving behind bonafide risk adjusted conditions can be financially deadly, reporting unsupported conditions brings about the same end sooner or later.

One set of conditions gaining popularity is the substance induced disorders.  These are conditions that result from someone abusing or being dependent on a substance, such as alcohol, opioids, sleeping pills or illicit drugs.  Believe it or not, caffeine is also included in this group, as is tobacco. The induced disorders include mood disorders like bipolar and depression, anxiety, sleep disorders, sexual dysfunction and a few more. 

So, here’s where creativity runs amok:  a patient has insomnia and the social history reveals the patient drinks coffee (example #1).  Next thing you know, the coder is querying the provider to consider that the insomnia is resulting from the caffeine.  Here’s another scenario (example #2):  a 60-year old male with erectile dysfunction abuses alcohol.  Here too, the coder may suggest linking the dysfunction as an induced disorder.  At first glance, these can be intuitive conclusions, except that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or DSM-5, outlines very specific criteria for linking substances to induced disorders, and it’s not as easy as you’d think.

For a complete understanding of substance induced d/o, we strongly recommend that you read the DSM-5, but below are the basics.

Proper linkage of an induced d/o requires that symptoms appear during or shortly after substance intoxication or withdrawal, terms that are specifically defined by the DSM-5.  In our two situations above,

Example #1: Linking insomnia to caffeine requires that five or more symptoms begin shortly after recent consumption of more than 250 mg of caffeine. (This is the definition of caffeine intoxication, for you Starbucks fans.)  In addition, the DSM states that symptoms cannot have preceded the onset of substance use; symptoms cannot persist for a substantial period (e.g. about one month) after cessation of intoxication; and there should be no evidence suggesting the existence of a non-substance induced disorder. 

In plain language:  if the person has a history of insomnia, or the insomnia continues after the caffeine intoxication has ended, or if there is another cause of the insomnia, it’s not an induced disorder.

Example #2:  Linking sexual dysfunction to alcohol follows similar reasoning.  First, the symptoms must appear during or shortly after intoxication or withdrawal after heavy or prolonged use. The person must exhibit at least two symptoms of withdrawal, such as pulse greater that 100 bpm, sweating, increased hand tremor, seizures or other specific issues. Or the person must exhibit one or more symptoms of intoxication, which include slurred speech, unsteady gait, stupor or other specified issues.

In addition, just as with our caffeine patient, symptoms must be clearly linked to the substance and not precede the onset of substance use, do not persist for a substantial period (e.g. about one month) after cessation of intoxication or withdrawal, and are not better explained by a non-substance induced disorder.

This means that if our 60-year-old male has a history of erectile dysfunction that preceded the intoxication or withdrawal, or if symptoms persist about a month after intoxication or withdrawal, and/or are better explained by other issues (such as age or prostate problems), it’s not appropriate to link it to the alcohol.

As you can see, the cavalier coding we’ve seen in some charts will probably not stand up to DSM-5 scrutiny.  Obviously, induced disorders do exist, and providers need to be cognizant of the criteria so they can document an airtight case, linking the requisite symptoms to the behavior.  Please feel free to request our FREE bulletin on substance-induced disorders.

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Knowledge is Power: The Basics for Launching a Long-term Care-related Business (updated)

The third installment in our series aimed to give new entrepreneurs knowledge and power expands on the prior messages. Not a week goes by without someone inquiring about how to open a long-term care related business.  Whether it’s because of the state of the economy, fears of downsizing or burgeoning entrepreneurial spirit, the demographics in Florida are certainly in our favor.  In case you’ve flirted with a similar idea, here are some points to consider:

  • Decide on the type of services you want to offer.  Skilled services are those that require a licensed professional, such as a nurse or therapist.  Non-skilled services encompass personal care, such as assistance with bathing, grooming, eating, etc.  Homemaker/companion services are also non-skilled, but include no “hands-on” care of patients.
  • Evaluate the various payors you would like to pursue.  Skilled services are medically necessary, so Medicare and third-party health insurance are the primary sources of revenue.  For non-skilled services, Medicaid, long-term care insurance and self-funding (private pay) are the most common options; some Medicaid plans will pay for personal care and clients should inquire with each payor. Health plans can make annual changes to their benefit offerings so we urge clients to periodically check with payors in case their policies related to your ideal business type change.
  • Based on the services you expect to provide and payors you will pursue, decide on the structure of your business.
    • All home health agencies (HHA) (skilled and non-skilled) are licensed by AHCA.  Those that will offer skilled care require accreditation from one of three organizations.  A one-year timeline from getting started, in earnest, to final accreditation isn’t unrealistic.
    • Nurse registries (NR) are also licensed by AHCA but do not require accreditation.  These can generally be launched in four to six months.
    • Homemaker/Companion Services (HCS) are registered with AHCA, do not require accreditation and can open in about 30 days.
    • Assess your background and candidates for leadership positions.  HHAs require a qualified administrator, an alternate and director of nursing for skilled agencies or RN supervisor for non-skilled.  NRs need an administrator and alternate, as well as a nurse.  HCS have no special personnel requirements.
    • Capital requirements are hard to predict.  AHCA reviews financial projections for the first two years of the HHA and for one year for a NR.  The various financial schedules, based on the business’s projected overhead and patient volume, yield the amount of capital required.  In addition, Medicare has separate financial requirements based on the costs reported by agencies in the proposed business’s geographic area.  For an HCS, AHCA does not have capital requirements.

Obviously, many other issues factor into the decision to start a business, but consider that the US Census Bureau projects that over 49 million Americans are over the age of 65, and that this figure will grow to over 65 million in 2025.  The Census Bureau also estimates that, in 2021, almost 21% of the Florida population was over age 65. Each day, more than 10,000 Baby Boomers turn 65 years of age and become prospects for your long-term care related business.

Read about the AHCA licensure process as you continue to gain knowledge and power for your new business venture.

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