Aug 5, 2014 | Uncategorized
The Centers for Medicare and Medicaid Services (CMS) has issued its final rule officially setting the ICD-10 transition date for October 1, 2015. Asserting that the new date “allows ample time” for the healthcare industry to prepare for the change, the final rule confirms what the agency told the industry in May after the one-year delay was voted through as part of the Protecting Access to Medicare Act of 2014.n
“ICD-10 codes will provide better support for patient care, and improve disease management, quality measurement and analytics,” said Marilyn Tavenner, Administrator of CMS in a press release announcing the finalization. “For patients under the care of multiple providers, ICD-10 can help promote care coordination.”
nAfter being blindsided by the unanticipated delay, CMS has only provided sporadic updates to the industry as it reworked its timelines, testing, and transition plans. Earlier in July, six Congressional leaders asked Tavenner for details about any newly laid plans for the conversion even as healthcare providers have been largely forging ahead with education and technical activities on their own.nnThe final rule has been published in the Federal Register and is available in full here.nnSource: www.ehrintelligence.com; Jennifer Bresnick; July 31, 2014.
Jul 22, 2014 | Uncategorized
“Eligibility” is not what it once was! Commercial health plans have HMO’s and PPO’s and various other plan types, they also have various products within those categories, and just to make it more complicated some plans have plans within the plan specific to a given employer or group’s requirement. The Affordable Care Act has added to this confusion by adding more plan types, and those plans have various benefit calculations and yes, provider networks.nnEven Medicare and Medicaid have plans within plans. A patient who presents with “Medicare” could have straight/traditional Medicare but they could also have a Medicare Advantage plan with a specific network. Medicaid now has commercial carriers and many have very specific networks of providers, and patients can move in and out of these plans frequently. All of these changes are designed to help control costs and direct patients to the right place.nn(It’s not all bad thing – there is opportunity here – see below.)n
Performing patient eligibility checks, in real time, is more important than ever:
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- Does the patient have the insurance they think they have?
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- Do they have the coverage they think they have?
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- Are they seeking care from the right provider?
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- Is your provider/practice in-network with the patient’s insurance?
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- Is the patient on an exchange plan? Have they paid their premiums (to ensure your provider will be paid for the services they provide)?
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- What is the patient’s co-pay, deductible and co-insurance, and what have they already met?
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nThe good news: Most of this can now be automated! Many of the good clearinghouses have a component that checks patient eligibility. Most can be done in real-time with up to the minute check of benefits and participation in a specific plan. Most can also check to see if your specific services are in-network, allowed and payable. This can now be done with the click of (a few) key strokes and fast internet connectivity.nnIt takes good and conscientious staff, constant training of your staff (to stay on top of changes), and the re-design of some work flows and seamless systems that talk to each other. The other great thing about clearinghouses is that they report mistakes – those reports just have to be read, analyzed and used as a tool for process improvement.n
Opportunities:
nWith such sophisticated systems out there, practices now have the opportunity to collect for services up front (if deductibles and co-insurance are not met) instead of tracking down payment from the patient afterwards. This will result in increased revenue and cash flow for the practice! Dentist offices have done this forever – it is time for medical practices to do the same!nnHealth plans and payers of all sorts are looking for those who can be and are willing to be “Eligible” to provide cost effective care. It may not be reimbursed in the traditional fee-for-service method but these niche opportunities do exist!
Jul 22, 2014 | Uncategorized
L55.0 — First degree sunburnnnL55.1 — Second degree sunburnnnL55.2 — Third degree sunburnnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Jun 23, 2014 | Uncategorized
W55.52XA — Struck by raccoonnnL23.7 — Contact with poison ivynnT62.1X1A — Toxic effect of poisonous berries
Jun 23, 2014 | Uncategorized
It appears that the Veterans Administration will allow Veterans to seek care from private providers!
nWe need to look into how this will be done, to be prepared. n
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- How does a provider contract for this?
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- Credentialing?
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- Possible volume and where?
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nnUnder pressure to improve care, the Department of Veterans Affairs will allow more veterans to use private medical services to meet growing demands for healthcare, the department announced Saturday. Veterans Affairs Secretary Eric K. Shinseki said in a brief statement that as part of an expansion of services, veterans will be able to seek care at private clinics and hospitals in areas where the department’s capacity to expand is limited. In such situations, the VA “is increasing the care we acquire in the community through non-VA care,” Shinseki said.nnThe agency will provide more specifics on these options in the next few days, said Victoria Dillon, a department spokeswoman. It is unclear how much this service expansion will cost. The VA already spends about 10% of its budget on private care, which cost $4.8 billion last year. The new directive comes as Shinseki faces calls for his resignation amid allegations that VA employees have been covering up long wait times for medical care and falsified appointment records to hide the delays. A number of Republicans, at least two Democratic lawmakers and the commander of the American Legion have called for Shinseki to step down.nnTwenty-six VA facilities — including sites in Phoenix, San Antonio and Fort Collins, Colo. — are under federal investigation. Shinseki is expected to present President Obama a preliminary report on the facilities in the coming week. Rep. Jeff Miller (R-Fla.), chairman of the House Veterans’ Affairs Committee, said he was pleased by the policy change to allow private care, but thought it should have come earlier.nn”It appears the department is finally taking concrete steps to address the problem,” he said in a statement. He called the move “a welcome change from the department’s previous approach, which was to wait months for the results of yet another investigation into aa problem we already know exists.” Miller supports legislation that would let veterans turn to private care when the VA can’t meet their needs within 30 days.nnThe idea of increased private care has been embraced by some Republicans and Democrats as a possible response to the growing issue of shortcomings in the department’s care. Sen. John McCain (R-Ariz.) has embraced the idea, and House Minority Leader Nancy Pelosi (D-Calif.) has said she is open to it. Amid the allegations of treatment delays, the administration is scrambling to show a new responsiveness to criticism of how it handles the growing number of injured and ill veterans.n
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nSource: www.latimes.como; Paul Richter; Richard Simon; May 24, 2014.
Jun 10, 2014 | Uncategorized
Seems to be the Season for the Notice of Material Change!
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The health plans are required to send out a NOMC anytime there is a change that may affect provider compensation. nnTimes, must be a changing, as we are seeing an unprecedented number of NOMC notices.nnManaged care contracting is, increasingly, more about strategy than just rates, fee schedules and dates on a page. The health plans now have more competition: more plans, payment models and methodologies. They are also competing not just for the traditional employer business, but also for individuals. We (yes We – as you are a part of it, like it or not) are in a mad race to create and market plans that sound like PPO (with open networks) but are in reality very narrow networks with very specific patient cost share and steerage components.nnNavigation of these wild times requires strategy (both contracting strategy and billing know how)! Let us help you navigate the treacherous currents and eddies and help you be successful…after all it is a $2 Trillion industry, there is plenty of money, it’s just in different places than it used to be.n
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