“We hold these truths to be self-evident: that all men are created equal; that they are endowed by their Creator with certain unalienable rights; that among these are life, liberty, and the pursuit of happiness.” -Thomas Jeffersonnn Welter Healthcare Partners would like to wish you a Happy 4th of July! Our dedicated staff wants you to remember to relax and have a safe holiday.nnAccording to ADT, firework, grilling and water safety are collectively very important for the 4th of July. More than 50,000 fires are caused by fireworks every year and fun water activities have serious risks if the proper precautions aren’t taken! Please make sure to review safety procedures to keep you and your family safe.nnFrom all of us at Welter Healthcare Partners, we hope you take the opportunity to enjoy this day with loved ones and celebrate your freedom.nn
CMS is requesting providers to submit information regarding their concerns, suggestions, and comments on the proposed changes to help patients. The deadline for providers to take part in this request is August 12th. For more information, read the information below. nnnThere is so much talk in the medical community about the proposed “Patients over Paperwork” initiative that many providers have found themselves at a loss for what will happen next. Common questions surrounding this important topic include: What type of documentation changes will help reduce the amount of administrative burden our clinicians currently face? How will documentation changes affect their practice? How will this impact reimbursement? What does this mean for their patient interaction and day-to-day routine? Is there anyone I can talk to so that my concerns are heard?nnIn June of this year, CMS put out another request for information from providers to voice their concerns, suggestions, and comment on proposed changes. Do not delay however because the deadline for this round of comments closes on August 12th. Specific feedback that CMS is looking for can be found by visiting federalregister.gov, where you can also submit your comments. Your participation in this initiative does not have to stop with this RFI. CMS frequently releases opportunities for public comment to address specific areas of concerns and providers should prioritize to take advantage of these opportunities.
Wednesday nights democratic primary debate was dominated by talks of healthcare by the candidates. The discussions ranged from health policies to the skyrocketing drug prices which are among the key issues of the candidates. Each had different views on the topic of healthcare. Read the article below to find out what some of their ideas are and what they think they could do to better the healthcare system.nnDuring Wednesday night’s Democratic presidential primary debate — the first in a two-night event viewed as the de facto launch of the primary season — health policies, ranging from “Medicare for All” to efforts to curb skyrocketing drug prices, were among the key issues the 10 hopeful candidates onstage used to help differentiate themselves from the pack.nnHealth care dominated early, with Sens. Elizabeth Warren (Mass.) and Cory Booker (N.J.) using questions about the economy to take aim at pharmaceutical and insurance companies. Sen. Amy Klobuchar (Minn.) emphasized the difficulties many Americans face in paying premiums.nnBut the candidates broke ranks on the details and not all of their claims stayed strictly within the lines.nnOnly two candidates — New York City Mayor Bill de Blasio and Warren — raised their hands in favor of banishing private insurance to install a government-sponsored Medicare for All approach.nnKlobuchar, a single-payer skeptic, expressed concern about “kicking off half of America off their health insurance in four years.” (That’s correct: In 2017, a majority of Americans had private coverage, with 49% getting that insurance through work, according to the Kaiser Family Foundation.)nnFormer Texas Rep. Beto O’Rourke, who also supports maintaining a private insurance system, outlined his own universal health care plan, based on a “Medicare for America” bill in Congress.nnThe single-payer talk set off other discussions about the role of health insurance and the cost of care. We fact-checked some of the biggest claims.nnWarren: “The insurance companies last year alone sucked $23 billion in profits out of the health care system. $23 billion. And that doesn’t count the money that was paid to executives, the money that was spent lobbying Washington.”nnWe contacted Warren’s campaign, who directed us to a report from the National Association of Insurance Commissioners, a nonpartisan group of industry regulators. It supports her assessment.nnThe report says that in 2018, health insurers posted $23.4 billion in net earnings, or profits, compared with $16.1 billion a year prior.nnThis came up in the context of Warren’s support for eliminating private insurance under a Medicare for All system. However, the financing and price tag of such a system is unclear.nnBooker: “The overhead for insurers that they charge is 15%, while Medicare’s overhead is only at 2%.”nnThis is a flawed comparison. Booker said administrative overhead eats up much more for private carriers than it does for Medicare, the government insurance program for seniors and the disabled. But Medicare piggybacks off the Social Security Administration, which covers costs of enrollment, payments and keeping track of patients.nnAlso, Medicare relies on private providers for some of its programs, and overhead charges there are higher. Medicare’s overhead is less than that of private carriers, but exact figures are elusive.nnThe insurance companies’ trade group, America’s Health Insurance Plans (AHIP), reported in 2018 that 18.1% of private health care premiums went to non-health care services. That includes taxes of 4.7% and profits of 2.3%. The Medicare trustees reported that in 2018, total expenses were $740.6 billion, with administrative expenses of $9.9 billion. That comes to 1.3%, less than Booker said.nnWarren: “I spent a big chunk of my life studying why families go broke, and one of the No. 1 reasons is the cost of health care, medical bills. And that’s not just for people who don’t have insurance. It’s for people who have insurance.”nnIs the No. 1 reason people go broke the cost of health care? We’ve rated similar statements Half True — partially accurate but lacking important context.nnOriginal article from khn.org
In this video, we found there are 5 habits of exceptionally charismatic people! We all know people who exude charisma and always leave the best impression and charm to everyone in the room, and it has been found that charisma can be learned. From her book, Vanessa Van Edwards identifies 5 habits that exceptionally charismatic people follow. Learn why charisma matters and how you can use people skills and body language to adjust your presence and more positively influence everyone around you!nn
UnitedHealth Group has purchased DaVita Medical Group after they reached a settlement with the Federal Trade Commission saying this deal was a long time coming. This was due to the concern about harm to medical competition in Nevada. The original deal in place would have resulted in a monopoly controlling more than 80% of the medical market.nnUnitedHealth Group announced Wednesday it has closed on its $4.3 billion purchase of DaVita Medical Group after the parties reached a settlement with the Federal Trade Commission that resolves the federal government’s concerns about harm to competition in Nevada.nnUnder the FTC settlement, UnitedHealth Group has agreed to sell DaVita Medical Group’s Las Vegas operations, known as HealthCare Partners of Nevada, to Salt Lake City, Utah-based Intermountain Healthcare within 40 days of the deal’s closing. Without that tweak, the FTC said the deal would reduce competition in the Las Vegas area for managed care provider organization (MCPO) services sold to Medicare Advantage insurers and Medicare Advantage plans sold to individual Medicare Advantage members.nnThe original FTC complaint against the proposed deal said it would result in a near monopoly controlling more than 80% of the market for services delivered by MCPOs to Medicare Advantage insurers.”The complaint alleges that elimination of this competition would increase healthcare costs and decrease competition on quality, services and other amenities in the affected area,” the FTC wrote.nnColorado Attorney General Phil Weiser separately announced his office had reached an agreement with UnitedHealth Group and DaVita that resolves its concerns about anticompetitive effects in the Colorado Springs area for people covered under Medicare Advantage plans.nnDaVita Medical Group owns two physician groups in Colorado Springs, and UnitedHealthcare, a sister company to Optum, is the largest Medicare Advantage operator in the region. Weiser filed a complaint independent of the FTC to challenge the Optum-DaVita deal.nnUnder that deal, UnitedHealthcare will lift its exclusive contract with Centura Health for at least 3.5 years, which will expand the network of providers available to seniors covered under Medicare Advantage, Weiser’s office said in a news release. Additionally, DaVita Medical Group’s agreement with Humana, UnitedHealth Group’s competitor in Colorado Springs, will be extended without change at least through the end of 2020.nn”As the people’s lawyer, I am committed to protecting all Coloradans from anticompetitive consolidation and practices, and will do so whether or not the federal government acts to protect Coloradans,” Weiser said in a statement.nnUnitedHealth Group will combine DaVita Medical Group with its Optum subsidiary, which provides primary and secondary care, consulting and data analytics. Optum spokeswoman Lauren Mijajlov wrote in an email that the company is pleased to have reached an agreement with Weiser’s office, and to have closed the deal. DaVita spokeswoman Courtney Culpepper said the same in an email.nnComplete and original article posted on modernhealthcare.com
CMS is requesting feedback on ways to reduce the administrative and regulatory burden with aligning and simplifying coding and documentation requirements. The comment period will close on August 12, 2019, at 5:00 p.m. EDT.nnOn June 11, CMS published a Request for Information (RFI) as part of its Patients Over Paperwork initiative to collect public input on ways to reduce unnecessary administrative and regulatory burden.nnThis is not the first time CMS has sought feedback on methods to reduce administrative burden. Through previous listening sessions and RFIs, CMS collected thousands of comments and is actively working on addressing those comments deemed actionable. The current RFI aims to collect feedback on several specific topics that have not yet been addressed. These include:n
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Aligning Medicare, Medicaid, and other payer coding, payment, and documentation requirements
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Enabling feedback and data sharing to support patient care and the clinician-patient relationship
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Recommendations for when and how CMS issues regulations and how CMS can simplify rules and policies for beneficiaries, clinicians, and providers
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Streamlining reporting and documentation requirements or processes to monitor compliance
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nRespondents should provide clear, complete comments and should include, when possible, data and specific examples. The comment period closes on August 12, 2019, at 5:00 p.m. EDT.nnOriginal article posted on revenuecycleadvisor.com
Do you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nnnn– Click Here to Submit Redacted Surgery Case Study –nn nnADMISSION DATE: 11/28/2017nnnSURGERY DATE: 11/28/2017nnSURGEON: Dr. G, MD PREOPERATIVE DIAGNOSES:n
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Degenerative lumbar spine (L4-L5).
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Obesity (BMI 32).
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History of multiple surgeries including umbilical hernia repair with mesh.
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nPOSTOPERATIVE DIAGNOSES:n
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Degenerative lumbar spine (L4-L5).
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Obesity (BMI 32).
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History of multiple surgeries including umbilical hernia repair with mesh.
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nOPERATION:n
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Unusually difficult anterior exposure for lumbar spine arthroplasty (L4- L5).
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lntraoperative fluoroscopy.
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Vessel Guard patch.
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Abdominal x-ray reading.
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nSPINE SURGEON: M E J. DOnnASSISTANT: M M, SAnnANESTHESIA: General endotracheal.nnESTIMATED BLOOD LOSS: Minimal during my part of the surgery.nnCOMPLICATIONS: None.nnFINDINGS: Very large osteophytes making the vascular dissection extremely difficult in addition to the obesity and scar tissue from the umbilical hernia repair with mesh.nnSPECIMENS REMOVED: None during my part of the surgery.nnINDICATION FOR SURGERY: This is a 56-year-old male with an early stage of obesity, who has a degenerative lumbar spine and needs anterior exposure for lumbar spine arthroplasty at the level of the disk L4-L5. The patient had multiple prior abdominal surgeries including right adrenalectomy and umbilical hernia repair with mesh.nnPROCEDURE IN DETAIL:nnThe patient was brought into the operating room and placed on the table in the supine position. After the general anesthesia was administered, the intraoperative fluoroscopy was used to identify the level of the disk L4-L5 and the projection of the disk at the level of the anterior abdominal wall was marked with a transversal line in the abdomen, which was immediately below the umbilical scar. At this point, the abdomen was prepped and draped in the usual sterile fashion. Due to the obesity of the patient and expected scar from the umbilical hernia repair, it was decided to proceed with longitudinal incision, which was placed at the level of the midline, a little bit to the left of the midline below and above the previously placed line with incision extended from the infraumbilical area towards the left side of the umbilical area. The incision was deepened through the subcutaneous tissue and through the fascia. The fascia! flaps were elevated and the left rectus muscle was retracted as lateral as possible. In the upper part of the incision, this dissection was more difficult due to the scar tissue from the previously placed mesh, and the mesh was encountered at this level and needed to be divided a little bit to complete mobilization of the rectus abdominis muscle. In the lower part of the incision below the arcuate line, the retroperitoneal space was entered. A little bit more difficult dissection of the retroperitoneal space was encountered, particularly in the upper part of the abdomen due to the obesity of the patient and probably stiffness of the tissue from the prior surgery. The retroperitoneal space was entered and at this point, the heavy peritoneal sac was carefully dissected and mobilized together with the ureter and pushed to the right side. The ureter was carefully protected. The vascular dissection was started above the left iliac vessel.nnKeeping the dissection close to the lateral wall of the left iliac artery, this artery was mobilized as distal as possible close to the groin. The patient had a rather large amount of fat and also stiff inflamed lymph nodes covering the iliac vessels making the vascular dissection quite very difficult. Using gentle blunt dissection, the iliac vessels were progressively.started to be dissected and pushed to the right side. On the left side of the disk space L4-L5, quite very large osteophytes were encountered. After this initial step of vascular dissection although very difficult, was completed with no incidents. The dissection was further continued using gentle blunt dissection. Below the disk space L4-L5, tedious dissection was done through the inflamed fat and lymphatic tissue to look for the iliolumbar vein and in the vicinity of the disk space, no iliolumbar vein was identified. This dissection allowed further mobilization of the lower part of the iliac vein, which was possible to be pushed further to the right side. Although the dissection of the iliac vessel was rather more extended than normal, it was still extremely difficult to push the vessels all the way to the right side of the spine encountering the right side of the spine also very large osteophyte. At this point, the needle was inserted in the disk exposed and using intraoperative fluoroscopy, the level of the spine exposure was demonstrated. The SynFrame was placed maintaining the exposure al the level of the disk L4–L5 with the impression that the vessels were mobilized all the way to the right side above and to the right of the larger osteophyte in the right side of the spine. It was rather unusually difficult dissection, which was completed at this point with no incidents. At this point, Dr. J came into the operating room and the case was turned to Dr. J for the orthopedic part of the spinal procedure. During the surgery performed by Dr. J, he noticed that it is impossible to obtain dissection on the right side of the spine and asked me to come back to the operating room and to proceed further mobilization of the iliac vessels. I came back to the operating room and I have noticed that now with additional release and destruction of the disk space L4-L5, it was possible with additional blunt dissection to push the left iliac vessel completely further to the right side and it was possible to keep in place these vessels all the way to the right side of the spine with reverse lip retractor. After this was completed with no incidents, I discussed with Dr. J the anatomical landmarks and he felt that now he would be able to complete the procedure with complete diskectomy all the way to the right side of the disk space. I turned the case back to Dr. J for his completion of surgery and after his part of the surgery was completed, I came back to the operating room and I took over the case again. Very good hemostasis was noted. No injury was seen. At this point, a 5 x 7.5 Vessel Guard patch was chosen and was sutured in place with 2 stitches with 4-0 PDS suturing the right side of the patch to the right side of the spine. The patch was able to cover completely the artificial disk implanted and the entire anterior aspect of the spine exposed. At this point, very carefully and gently the retractor blades were removed allowing the great vessels, the left iliac vessels, and the peritoneal sac to come back in a normal anatomical position on top of the patch. At the end of the procedure, very good hemostasis was noticed. Very good flow through the left iliac vessels. No ureteral injuries and no lymphatic leak. At this point, the abdomen was closed in a standard fashion using continuous running #1 looped PDS for the fascial layer. The subcutaneous tissue was irrigated. Local anesthesia was injected. At this point, the intraoperative fluoroscopy was used to x-ray the abdomen for the instrument count and no instruments were found in the surgical field. The subcutaneous tissue was closed with continuous running 2-0 Vicryl and the skin was closed with continuous running 4-0 Monocryl subcuticular closure. Steri-Strips and sterile dressing were applied. The patient tolerated the procedure well and left the operating room in stable condition.
With today’s growing technology, there have been so many gains in the medical community. Especially the use of bots and the evolving doctor-patient relationship that will truly transform how patients are cared for, and how these bots can help a patient with enhancing productivity. There are many positives and negatives to these bots and this article goes into more depth on how it will change the medical field.nnnnIt seems nearly everyone believes U.S. health care needs some transformative change to improve quality, expand access, or lower costs. Many of the contemporary approaches toward that change involve making it easier for patients to see doctors, particularly primary care doctors. While that seems intuitive, we think it is the wrong path.nnImagine it’s 1970 and commercial bank executives are deciding how to help their customers get the banking services they need. One executive remark, “Most of our customers engage with us through our bank tellers–even if they’re later referred to someone behind a desk. To help our customers get the banking services they need, we must make it easier for them to get in front of bank tellers.”nnWhether or not discussions like that really happened, that wasn’t the direction banks took. Instead, banks introduced automated teller machines to improve customer service. As a result of this unshackling of banking from tellers, 25-year-olds today find it unimaginable that their parents contorted their schedule to get cash during the Monday to Friday, 9 a.m. to 3 p.m. window. In the age of Venmo, they can’t imagine the need for cash in the first place.nnAnd yet, fifty years later, health care leaders continue to discuss how to get more patients in front of primary care providers, or in general to make it easier for patients to see doctors. The value-add from the technical knowledge and skills of primary care and specialist clinicians is greater than that from bank tellers, but the principles limiting the value of this strategy are the same. True transformations come from enhancing productivity, and productivity is enhanced by decreasing personnel effort, not increasing it.nnIf we continue to define health care as a service that happens when patients see doctors, we limit our possible productivity gains.nnWriting in The New England Journal of Medicine, we argued that the doctor-patient relationship is health care’s choke point. There’s no technical reason why a variety of common medical conditions—high blood pressure, diabetes, high cholesterol—can’t be managed by a bot and overseen by a nurse with support from a physician only if needed. And as our experience and the supporting evidence increase, more conditions might be directed by guidelines, allowing physicians to direct more of their time to where they’re really needed. Much is made of the comforting aspects of personal relationships between patient and clinician. But do we really need that soft touch to manage hypertension? Maybe sometimes, but certainly not always.nnSo why is it heretical to suggest replacing some of the health care with the facilitated self-service that has transformed the financial, retail, and travel industries? Why was it relatively easy to abandon bank tellers, travel agents, and tax preparers with the introduction of ATMs, travel websites, and tax software, but we get push back when nearly identical approaches are suggested for health care?nnWe think the resistance reflects our social conventions rather than our technical limitations. The technical challenges of safely introducing driverless cars are far more daunting than the technical challenges of introducing bots to manage hypertension and diabetes, yet the prospect of driverless cars seems to be awaited with excitement. We need to solve three problems:nnFirst, the insurance industry—government and commercial—must get better at its job. Because they are ill-equipped to determine whether care was truly needed or appropriately delivered, they use proxy process measures: Was the care face to face? Was the right amount of time spent or the right number of facts documented? Was the right kind of clinician present? Without a measure of what’s good, insurers have found it easier to insist that care be delivered in traditional ways. It’s hard to explore new and potentially better models of care when only old approaches get reimbursed.nnSecond, state-based regulation of insurance and clinician licensure must be replaced by a system that recognizes that health care is not always best delivered locally. Facilitated self-service creates efficiencies across state lines. It’s likely that occasionally some of Wyoming’s 600,000 residents would benefit from care delivered by someone outside the 1,000 physicians practicing in that state—perhaps by a bot with second-line back up from a nurse or a physician elsewhere. State licensure of physicians and insurance regulations reflect federalist principles harder to justify in a connected world.nnThird, we should require the same standards of safety and efficacy for automated approaches to health care that we have come to assume for the safety of pharmaceuticals. Whether that regulation comes from the FDA or elsewhere, it needs to be ramped up to address the volume of potential new approaches. Even if we think a bot can help manage hypertension, it doesn’t mean any bot can do that. The organizations that credential clinicians might find they are well suited to credential robots.nnIf there is a fourth problem, it is our sense of nostalgia. Norman Rockwell’s paintings of what he saw as wholesome and right reflected a time when doctors attended to the whole family, knew some from the cradle and some into the grave, and were paid with a basket of eggs. Facilitated self-service health care doesn’t challenge the appeal of this image, but it does shift it toward those elements of care that can’t as easily be handled by a machine.nnThe health care changes we want, or at least the opportunities to try them, are held back by a combination of technical limitations and social conventions. But our social conventions present greater obstacles. The lesson from other industries is that transformational change requires productivity change. And in health care, that means we must find ways to move past approaches to facilitate care with doctors toward approaches that facilitate care without them.
What can your practice do to avoid missed opportunities for reimbursements? Well, Welter Healthcare Partners has the answer for you regarding the risk adjustment model and factor calculations.nnWe continue to see the risk adjustment model being implemented by several large hospital groups and the sooner small practices catch in the better off their business models will be. So why is this so important?nIt’s simple, Centers for Medicare & Medicaid Services (CMS) utilizes this in the analysis of Medicare Advantage patients and that ultimately is a major factor when it comes to your reimbursements. What can your practice do to avoid missed opportunities?nThe first step to the implementation of anything new is education. Make sure your providers are aware of HCC’s and how they play a roll in risk adjustment factor calculations. Welter Healthcare Partners is excited to now offer our clients Risk Adjustment auditing and educations to assist you and your team with the implementation of HCC’s in your documentation, billing, and coding.
Medicare has released a new program called Primary Care First. This program is aimed to save more money in the short run and is mainly focused on reducing hospitalizations. These two models would let primary care clinicians move away from fee-for-service and allow them to stop worrying about up-and-down Medicare revenue. Many who are skeptical are giving feedback with other approaches which are listed below.nnWASHINGTON — Medicare’s new “Primary Care First” program for paying primary care doctors who see Medicare patients maintains a fee for office visits while also paying a monthly per-beneficiary amount for care coordination and other “behind the scenes” work that doctors do. So what’s not to like? Plenty, according to Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, in Pittsburgh. “Part of challenge with primary care is that the benefit is going to be in the longer run, not the shorter run. This model is very focused on trying to do something to save money in the short run; it’s focused almost exclusively on reducing hospitalizations.” The Primary Care First program, which was announced April 22 by the Centers for Medicare & Medicaid Services (CMS), has two models, both of which would let primary care clinicians move away from fee-for-service and allow them to stop worrying about up-and-down Medicare revenue, according to the CMS. The agency would pay monthly population-based payments along with a simple flat fee for primary care visits. The program is slated to begin in January.nnTWO-SIDED RISKnOne of the models focuses on a more general population, while the second model is for advanced primary care practices that typically provide hospice or palliative care services and want to take responsibility for high-need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination, according to a CMS fact sheet on the models.The model involves a potential downside risk of 10%, and an upside risk or bonus of 50%, depending on patients’ outcomes, and performance would be measured on “risk-adjusted hospitalizations” or “the ability to keep patients healthy at home,” Adam Boehler, director of the Center for Medicare & Medicaid Innovation (CMMI), which developed the models, said at a press briefing. “For example, doctors that earn $200,000 today could earn up to $300,000 if their patients stay healthy.” For 2020, the CMS has identified 26 regions where practices can participate.The CMS says that the model’s monthly per-patient payments will help doctors stop worrying about their monthly revenue cycle. However, as Miller noted in an article, “at the same time that Primary Care First eliminates the current E/M [evaluation and management] payments for face-to-face office visits for attributed patients, it creates a brand-new $50 fee for each face-to-face office visit, which is about half as much as the average amount primary care physicians currently receive from Medicare for office visits.””Based on the current average frequency with which Medicare beneficiaries make primary care office visits, this means that more than 40% of a typical practice’s payments would still be tied to face-to-face visits. As a result, if the practice is able to care for patients effectively with fewer office visits, it will lose revenue and it could be unable to cover its operating costs,” he wrote.nnLACK OF RISK ADJUSTMENTnAnother problem with the program is that a primary care practice would receive the exact same monthly payment for a patient regardless of how sick or healthy they are, Miller said. “Since an individual patient who has higher needs will require more time and resources from the practice than other patients, a practice that is caring for that patient will have to reduce the time and resources it devotes to other patients if the payment is the same.”And in addition to those issues, since Medicare payment programs are expected to be revenue-neutral compared with the current budget, “the payment is intended to be the same as what the practice is currently getting,” although the practice will be expected to provide more services than before, including 24/7 patient access and integrated behavioral healthcare, Miller said.Miller is a member of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which advises the CMS on Medicare alternative payment models. “In general, I think there’s been a lot of concern for a long time about [the] need to provide better support for primary care, and most payers in the country have been trying to do some kind of medical home programs for quite a while,” he said. “Medicare has been fairly slow to the game on that.”In particular, Miller is disappointed that the CMS hasn’t shown much interest in pilot-testing the payment models that PTAC has recommended. “With PTAC, two proposals [were submitted] for primary care, and we reviewed them and recommended they be tested and implemented … It’s been a long time since the recommendations were made, and the surprising thing to me was that the [Primary Care First] model that was announced by [the CMS] really didn’t look at all like the models recommended by PTAC.”nnROOM FOR IMPROVEMENTnThere are ways that Primary Care First can be improved, Miller said. For starters, “rather than creating a whole new set of office visit payments, what primary care practices have asked for is to get all or most of their payments as a flexible monthly payment so it’s not tied to office visits.”In addition, the monthly payments should be higher for patients who require more care. “If you have more diseases and more care challenges, you’re going to require more attention from your primary care physician,” said Miller. “The way that happens today is more office visits … but we don’t want to pay more only if they come to the office.”When asked during a press briefing about the Primary Care First model, CMS administrator Seema Verma said the agency was trying to give physicians a variety of options. “What we tried to do is recognize that providers are in different places in terms of their ability to take on risk,” she told MedPage Today. “What we’ve tried to do in this model is provide different options … Some providers may say ‘I want to take full risk on,’ so we’ve allowed for that option.””What we want to do in primary care is have them focus less on revenue cycle … and actually be able to focus on patients,” she continued. “The requirements around 24/7 [availability] — the idea there is that it’s based on some work we’ve already done in primary care and some of [it is] ‘lessons learned’; we’re looking at what we know works.”Some providers differ with that assessment. “I know it was well intentioned, but [the] CMS seems not to understand the day-to-day mechanisms of [how] primary care practices work,” Jean Antonucci, MD, a family physician in rural Maine and the author of one of the alternative payment model proposals that was recommended by PTAC, said in an email. “It is really virtually impossible to figure out how much revenue a practice will receive.””Supposing that my patients are well taken care of so I am placed in the lowest [payment] category of $24 a month; it’s very difficult to [keep patients] out of the hospital for $24 a month, but I might be put in that category because I did a good job. So no good deed will go unpunished,” she said.In her own proposal, she considers the cost of an hour’s worth of phone calls — 15 minutes, four times a month — from a practice to a particular patient. “A [medical assistant] is $15/hr. easy, but often the doctor must be involved, or an RN, and that is $40-$150 per hour, plus they need the driver’s license form or the forms for oxygen … We end up with whining by doctors about not being paid, while payers and pundits complain we want to nickel-and-dime them to death.”nnOTHER POSSIBLE APPROACHESnPrimary Care First’s early reviews “reveal that longstanding conflicts remain between, on the other hand, budgetary savings and administrative feasibility goals and, on the other hand, more ambitious desires in parts of the medical community redesign care to elevate the role of effective primary care (regardless of the short-term costs),” Tom Miller, JD, resident fellow at the American Enterprise Institute, a right-leaning think tank, said in an email. “Perhaps more medical outcomes per se could be improved by simply paying primary care doctors more, but that assumes away the political food fight it would require to get there.”A more straightforward approach to “subsidize patients more directly to find and receive the care that they could choose to receive would upset providers either benefiting from the current system or imagining that they could be winners in the next round of political reimbursement roulette, labeled ‘value-based,'” he added.Gail Wilensky, PhD, senior fellow at Project HOPE in Bethesda, Maryland, and a former CMS administrator, said in an email that the difficulty with the model “seems to be the amount paid is too small and too unreliable … That is certainly consistent with the ongoing CMS attempts. It is certainly reason to be skeptical although the results will only become clear after it is tried, assuming [the] CMS goes forward with it … It has been discouraging how difficult it has proven to be to affect change in this area.”nnOriginal article published on healthleadersmedia.com
Handle the toxic people in your life by identifying their type and using these communication strategies and people skills tips! Dealing with toxic people can be incredibly exhausting, especially if you interact or work with them everyday. Unfortunately we cannot fix them, but by using our people skills and new communication techniques we can try to understand them and create better interactions. In this video, the types of difficult people are identified you have in your life and give you actionable strategies on how to not only deal with them but also stop their negativity and toxicity in its tracks.nn
Inadequate coding is one of the biggest mistakes a physician can make. E/M coding is some of the most confusing, so our experts at R.T Welter are sharing their tips to ensure the proper coding. At Welter Healthcare Partners we can help make sure that you stop losing money by using incorrect coding and documentation in your practice. We can make sure that our coding tips will help you boost revenue. For more information and inquires you can contact us at (303) 534-0388.nnThe clock is ticking, and you’re trying to select the right E/M level from a drop-down menu in the EHR. Choose a level that’s too high, and you run the risk of post-payment audits and recoupments. Choose one that’s too low, and you may lose revenue to which you’re entitled. You decide just to trust your instincts and go with a code that feels right so you can move on to the next patient.nnChoosing an E/M code based on a gut feeling is one of the biggest mistakes a physician can make, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C. Payers and auditors use a quantitative scoring process that requires specific elements (i.e., history, exam, and medical decision-making [MDM]—or time spent counseling and coordinating care) for each E/M level.nnIf physicians don’t document these elements adequately—or the elements they document don’t make sense given the patient’s presenting problem (e.g., performing a comprehensive exam for a patient with a sinus infection)—payers and auditors may down-code the service or even conduct a more in-depth audit that could expose additional documentation vulnerabilities, she adds.nnIt’s equally risky to report the same E/M level for all patients with the same diagnoses (e.g., diabetes or congestive heart failure) without first considering medical necessity—a trap into which many physicians fall because they assume all patients with the same diagnoses generally require the same work, says Toni Elhoms, CCS, CPC, director of coding and compliance at Welter Healthcare Partners , a healthcare consulting company in Arvada, Colo. “In reality, every single visit could be a different level based on the documentation and circumstances of the encounter,” she says.nnFocus on quality E/M documentation—and the dollars will follownnKnowing what documentation is required for each E/M level is paramount. For example, the history, exam, and MDM must meet or exceed certain requirements for all new patients. The only exception is when the physician selects the E/M level using time as the controlling factor. In this case, documentation must indicate that the physician spent more than 50 percent of the encounter face-to-face with the patient and/or family providing counseling and/or coordination of care. The physician must also explain the specific services rendered and the reasons for them.nnOnly two of three key components must meet or exceed certain requirements for established patients unless the physician bills based on time. Elhoms provides an E/M scoring guide that includes a visual depiction of documentation requirements for each specific E/M level based on whether the patient is new or established.nnSound confusing? Experts agree that even the most experienced medical coders have difficulty translating physician documentation into an accurate E/M code. They cite several reasons why E/M coding is so difficult for physicians—lack of formal training on E/M guidelines, complex documentation requirements that don’t align with clinical practices, and the subjective nature of the MDM component.nnWe’ve asked our experts to share their best documentation tips to ensure accurate E/M reporting. Here’s what they said.n
History
nWhen billing a level 4 or 5 new patient E/M code (i.e., 99204 or 99205), remember to document one specific item from the past medical history (i.e., illness, operations, injuries, treatments, medications, or allergies), one specific item from the family history (i.e., medical events or hereditary diseases that place the patient at risk), and one item from the social history (e.g., use of tobacco, drugs, or alcohol).nnOriginal article published on medicaleconomics.com
In this code spotlight, Welter Healthcare Partners is providing new information regarding the risk factor reduction services that are used for people without a specific illness. This includes screening, brief intervention, and referral to treatment. Welter who recently teamed up with CDPHE created a two-part webinar series on coding and billing for these codes, and also give information on how school-based health centers can take advantage of their services. nnDoes your practice screen patients for risk factors like smoking, alcohol or drug use? Do you know the correct coding for use patterns? According to section guidelines by the AMA, “…used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury. They are distinct from evaluation and management (E/M) services that may be reported separately with modifier 25 when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.”nnThis is especially helpful when we look at codes 99406-99409 and incorporate this into your telemedicine services menu. Welter Healthcare Partners recently teamed up with CDPHE for a two-part webinar series on the coding and billing for these important codes and how school-based health centers can take advantage of the services they support.nn n
The CMS Primary Cares Initiative, being rolled out by officials in the Centers for Medicare & Medicaid Services, spell changes on the horizon for healthcare providers. The initiative is poised to kickstart value-based care, offer five voluntary payment model options, and some significant increases in competition from unlikely places.nnEven as some important questions remain unanswered, the CMS Primary Cares Initiative is generating a lot of excitement. Observers say it opens the door to more competitors for healthcare incumbents.nnThe shift to value-based care has sputtered a bit in the past two years, as hospitals and health systems have waited to see what innovative reforms the Trump administration would push across the healthcare policymaking finish line.nnDespite a litany of attempts—and two years of a Republican-controlled Congress—the administration has neither repealed nor replaced the Affordable Care Act and the value-based payment provisions embedded within it. Even with its individual mandate neutralized and its constitutionality under judicial review, the ACA remains law, and officials in the Centers for Medicare & Medicaid Services are using the ACA’s authority to roll out a potentially transformative undertaking: the CMS Primary Cares Initiative.nnThat initiative, industry stakeholders say, is poised to kickstart value-based care in Medicare and beyond, ushering in a new wave of consumer-centric competition that could help to shake off some healthcare providers’ risk aversion.nn”There was a sense that things were flattening out. It wasn’t going backwards. It wasn’t going down. It just was not progressing as fast as we all had hoped,” says Norman H. Chenven, MD, founding CEO of Austin Regional Clinic in Texas and vice chairman of the Council of Accountable Physician Practices.nn”With this announcement for Medicare—again, with the caveat that the devil is in the details—there is a sense that this is going to be a shot in the arm and we’re going to see some real new energy, innovation, and evolution of the value-based movement,” Chenven tells HealthLeaders.nnThe initiative, which CMS announced last month, has a total of five voluntary payment model options split between two paths. There are two options under the Primary Care First (PCF) path and three options under the Direct Contracting (DC) path. The idea behind all five options is to demonstrate how risk and reward can lead to investment in primary care that ultimately reduces overall healthcare spending and boosts quality outcomes.nnWhile there are still key details we don’t know about how the new models will operate, they appear to present opportunities for healthcare providers that are strategically positioned to make big moves in value-based primary care.nnBut there also seem to be significant threats, including potential competition from some unlikely sources.nnComplete and original article published on healthleadersmedia.com.
Do you have a complicated surgery case need help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nn– Click Here to Submit Redacted Surgery Case Study –nn nnnnDATE OF OPERATION: 11/12/2018nnNEUROSURGERY OPERATIVE REPORTnnPREOPERATIVE DIAGNOSIS: Right frontotemporal dural-based tumor with skull base and orbital invasion.nnPOSTOPERATIVE DIAGNOSIS: Right frontotemporal dural-based tumor with skull base and orbital invasion, probable meningioma with atypical features.nnPROCEDURES: Right frontotemporal craniotomy, resection of dural based tumor, suture of bovine pericardial dural graft, Synthes facet bone putty, subtemporal drain, titanium mesh cranioplasty, intraoperative microscope, ICG fluorescence visualization, lateral orbitotomy, and extradural clinoidectomy.nnCO-SURGEONS: Dr. Z, who performed the right frontotemporal craniotomy, resection of dural based tumor, sutured bovine pericardial dural graft, Synthes facet bone putty, subtemporal drain, titanium mesh cranioplasty, intraoperative microscope, and ICG fluorescence visualization.nnCO-SURGEON: L. M., M.D., who performed lateral orbitotomy and extradural clinoidectomy.nnASSISTANT SURGEONS: Dr. M was the assistant surgeon for Dr. Z’s portion of the surgerynnSECOND ASSISTANTS: A. P., MD and C. B., PAnnINDICATIONS: The patient is a 55-year-old left-handed female, with a positive history of left handedness, who presented with a complex past medical history including hypertension and uncontrolled diabetes, with problems of headache, nausea, vomiting, and vertigo. She had a proximally 6 month history of diabetic retinopathy with blood in her eye and was followed closely by her eye doctors for vision changes. She subsequently developed proptotic changes and blurring of the right vision like a film such that her visual acuity was finger counting in the right eye, with the ability to read with retain on the left. Imaging studies were initially performed that demonstrated a complex skull base meningioma with orbital invasion, particularly at the lateral orbital region. She was initially scheduled for surgery, however, because of uncontrolled diabetes, anesthesia colleagues wanted her under better control prior to the procedure. Thus, she was admitted to the medical service for optimization of glucose control and surgery was performed 72 hours later. The patient and her family underwent detailed informed consent, which is documented elsewhere in the electronic health record.nnPROCEDURE DESCRIPTION: Following the attainment of general anesthesia, all performance measures were and had been accomplished including a preoperative time-out, the administration of antibiotics and approved shave and Betadine preparation. The patient’s head was secured in Mayfield-Kees pin fixation and the stealth was registered. The patient’s head was positioned supine with a bump in a vertex down 30 degree facing to the left approach so that the zygoma was at the highest point in the presentation. A modified Yasargil designed flap to include more temporal and frontal lobe exposure was fashioned entirely behind the hairline with the preservation of the anterior hair in a rubber band for cosmesis. After the stealth registration and the designing of the skin incision to the zygoma, a Betadine preparation was performed and local anesthetic was infiltrated in the subcutaneous tissue. The 10 blade knife was utilized to incise the skin and Raney clips were used to secure the drape. The Bovie was used to reflect the pericranium in the anterior portion of the incision and Metzenbaums were used to dissect inferiorly. The fascia was reflected forward using sharp dissection, and the temporalis muscle was reflected inferiorly down to the level of the zygoma with a superb sphenoid wing exposure. The bone flap was designed with the understanding that the tumor in the sphenoid wing region preoperatively was seen to erode through the bone with hyperostosis and direct bony invasion as there was evidence of tumor in contrast-enhanced regions inferior to the temporalis muscle on the outside of the bone. It was also recognized that there was tumor that had transcended the bone of the lateral orbit and was impacting the lateral rectus muscle. Given that, the bone flap was fashioned in a conservative way outside the area of obvious invasion, first using the Codman perforator and the Midas Rex drill. After this, the pineapple bur was used to primarily remove the region of the sphenoid and lateral orbit involved directly with tumor. A specimen of tumor underneath the temporalis and involving the pericranium was removed, and dissection was performed at that level to minimize the amount of observed tumor. With that, multiple specimens were obtained. Hemostasis was obtained by coagulating the dura primarily. The extradural clinoidectomy was performed expertly by Dr. M., who provided his special training in skull base to address the lateral clinoidectomy and the lateral orbitotomy. The dura was gently mobilized and reflected in order to accomplish both of these procedures safely. The dura was then opened until the tumor was identified and a Sonopet was used to remove portions of the tumor. IC-Green was used under the operating microscope to identify the middle cerebral vessels and identify, which vessels were emphasized and which vessels were going directly to the tumor. This technique worked expertly and was useful in safe dissection. The lateral wall of the orbit was removed and the dura was left intact. Some of the superior orbital roof was also reflected. Every aspect of the dura that was clearly involved with tumor was then removed in an en bloc fashion after the tumor had been safely reflected from the sylvian fissure and sylvian vessels. There was a question of brain invasion at the right frontal lobe, which was very limited. Otherwise, there was intact pia over the temporal and frontal lobes abutting the tumor. Once the dura was resected and the bone areas of tumor removed, as well as some of the infratemporal tumor, a bovine pericardial dural graft was then fashioned and secured using 3 mm MRI compatible Synthes screws as well as Tisseel as a tissue glue to prevent drainage through the inlay dural graft. The superior aspects of the graft were closed primarily with running and interrupted 3-0 Nurolon sutures. The bone that was not involved with tumor was replated using Synthes plates and screws, and a mesh was secured over the area of the lateral sphenoid that had been primarily drilled and resected due to involvement with tumor over that. A fast setting bone putty was used for cosmesis with a superb closure and cosmetic result. The wound was irrigated copiously at many stages through the procedure with antibiotic solution including through the dura prior to the placement of the Tisseel. A subgaleal drain was used and remained in place for a prolonged period of time with the tip underneath the temporalis muscle and curvature underneath the galea, so that there were holes picking up any subgaleal fluid and also CSF to serve as a CSF diversion, successfully allowing the dura to close over for a period of several days postoperatively. The alternative would have been to place an external ventricular drain or a lumbar drain; however, this subgaleal drain placed under the temporalis worked superbly as a diversion for CSF to allow excellent healing. The temporalis muscle was secured using 2-0 Vicryl pop-offs. The fascia was secured using 2-0 Vicryl pop- offs. The galea was closed using 2-0 and 3-0 Vicryl interrupted sutures, and the skin was closed with staples with a 3-0 Prolene stitch at the drain exit site, and a Vicryl buddy stitch at the drain exit site. Sterile dressings and a full head wrap were placed. Sponge, needle, and cottonoid counts were correct at the conclusion of the case.nnFINDINGS: The pathology was consistent with meningioma and given the erosion through structures, the final results were consistent with atypical or grade 2 features as expected from the preoperative imaging studies and the findings intraoperatively. The unplug tumor was biopsied and there were also areas of focal probable brain invasion along the right anterior and inferior frontal lobe. There was confirmed involvement of the pericranial aspect of the temporalis muscle with extradural invasion of the lateral orbit and presumed positive bone.nnSPECIMENS: Multiple frozen and permanent section specimens were sent.nESTIMATED BLOOD LOSS: Between 500 and 700 mL.nANESTHESIA: Performed expertly by general endotracheal intubation with Dr. T., Dr. B., and Dr. W.; all contributing to the patient’s care.nnCULTURES: None.nnDRAINS: One 10-French subtemporal subgaleal drain was placed.nnBLOOD REPLACEMENT: Two units of packed cells were placed for intraoperative hematocrit of 24, as I recall.nnThe patient has continued to do well with preserved vision in her right eye and an excellent postoperative resection with no evidence of stroke and no evidence of new deficit.nnDr. Z. was the surgeon for the right frontotemporal craniotomy, resection of dural based tumor, sutured bovine pericardial dural graft, Synthes facet bone putty cranioplasty, subtemporal drain, titanium mesh cranioplasty, intraoperative use of microscope, ICG fluorescent visualization. Dr. M. was the surgeon for the lateral orbitotomy and extradural clinoidectomy. The 2nd surgeon was required due to his particular expertise in training in skull base approaches, which was not otherwise available at our facility.
As we head into the future, more and more employers are going to be more proactive about the health of their employees, according to a new survey. This means that by 2020, almost 40% of employers are looking at opening a health center at their offices, hoping to increase employee productivity, health, and on-the-job satisfaction. Here at Welter Healthcare Partners, we understand that employee health is essential to your company’s productivity, and we applaud this progress. nnEmployers are increasingly focused on improving access and quality of care for their workers, according to a new survey.nnWithin the next three years, nearly half of employers plan on implementing high-performance networks (HPN), centers of excellence (COE), onsite or nearby health centers and accountable care organizations (ACO) as ways to provide quality and affordable healthcare options, according to a Willis Towers Watson (WTW) survey released Wednesday morning.nnEighty percent of respondents intend on having COEs within a health plan, a 29% jump year-over-year, and the number of employers who plan on including HPNs more than doubled to 65%.nnBy 2020, almost 40% of employers are looking at opening a health center at their offices, while more than 25% plan to offer one near their facilities.nnThese trends have gained momentum in recent years, as more than 80% of employers with an onsite or near-site health center reported that the move has “succeeded in improving employee access to convenient health care services,” “enhancing employee productivity and bringing absenteeism under control,” while also “delivering and promoting preventive health screening and services, getting ahead of medical issues through early detection and by instilling healthy habits.”nnThe survey also shows that employers are increasingly more concerned with quality of care provided than cost savings as the “most important feature” when considering an HPN.nnSandy Ageloff, managing director, west region health and benefits consulting leader, told HealthLeaders that the survey results indicate that the shifting thought process among employers is being driven by four major paint points.nnThese include the need for better care access, especially around mental health services for employees, providing high quality care, making care cost effective, and concerns about system complexity.nn”I think employers have done a lot to try to improve cost and quality, but what we’re realizing is that employees and their family members are challenged to understand all of the various pieces of the puzzle,” Ageloff said. “Employers are now embracing the need to say, ‘You need to help people navigate through what we’ve done to create beneficial, high-quality programs that provide affordable costs.'”nnComplete and original article published on healthleadersmedia.com.
Now that we are all familiar with ICD-10 it’s time that we start focusing more on specificity when it comes to diagnosis. It’s not just import for patient charts, with HCC becoming the new standard and payers tracking things like readmissions it’s becoming more important than ever for Coders to capture as much in their code selection as possible.nnICD-10 includes a classification system implemented to capture data, which previously was not tracked. Classifications such as “underdosing of drugs” can prove to be vital when readmission rates are not only tracked but also could affect a practice’s reimbursements. As coders, it’s not only important that we extrapolate this information from the documentation but also code why the drug was not taken correctly or, in some cases, not at all. Classification codes T36-T50 (utilizing a fifth or sixth character of “6”), deals with specific drug underutilization while Z codes Z91.12- Z91.19 classifies the patient’s non-compliance with medical treatment and regimen. Z codes should, when known, be accompanied by the correct underdosing code to help account for intent.nnThe Journal of AHIMA wrote about this back in 2016, however this topic will continue to become more relevant as Risk Adjustment Models are adapted by more practices and payers.nnCLICK HERE to read the full article, “Potential Impact of the ICD-10 Underdosing Classification System” in the Journal of AHIMAnn
Colorado Governor, Jared Polis, has been in the news for his “roadmap” to reduce healthcare costs for all Coloradans. In this article, we dive into the latest developments: which bills are still on the table, how they plan on lowering health care costs, and whether there’s still enough time and money to make this a possibility. nnColorado Gov. Jared Polis stood outside of Denver Health Medical Center almost a month ago laying out his “roadmap” to save people money on health care.nnAs the Boulder Democrat ticked off his list of plans, both short term and long term, it quickly became apparent that most of the governor’s ideas to lower health care costs in Colorado weren’t possible unless state lawmakers passed a series of bills.nnDemocrats and Republicans have come together to create the beginnings of a public option health plan and make hospitals turn over more of their financial data. But with a week left in the 2019 session, several items on the governor’s list still haven’t passed and the big question remaining is whether there’s enough time, money and political will to get the rest of them across the finish line.n
Reinsurance
nA high-priority bill that might not make it through in the final days of session is one that has lowered people’s premiums in other states by essentially providing an insurance plan for health insurance companies to help offset the costs of their most expensive patients.nnIt’s called reinsurance, and its sponsors basically rewrote House Bill 1168 for a third time Thursday afternoon.nn“It’s always been an issue of how to pay for it,” said Sen. Bob Rankin, R-Carbondale, as he presented the latest changes to a Senate committee.nnColorado wants to get matching dollars from the federal government for its reinsurance program. The first version of the bill was unlikely to win approval from the Trump administration, and the funding mechanism on the second jeopardized other federal dollars.nnRankin and Sen. Kerry Donovan, D-Vail, were frank with their colleagues that the new way to fund the program isn’t ideal, but Donovan said it’s the best way they could find with time running out on the 2019 legislative session.nnThe new plan is to have Colorado hospitals contribute $40 million, take $26 million from a premium tax that would otherwise go into the general fund and potentially take another $15 million to $40 million from a fee that was originally meant to raise money for affordable housing.nn“We don’t want the program to die,” Rankin said. “We want to use every possible avenue to get this program moving.”nnReinsurance is waiting on a vote by the full Senate.n
Prescription drugs from Canada
nPolis and other Democratic lawmakers see our neighbors to the north as a potential cure for the high drug prices Coloradans pay every day.nnThat’s why Democrats introduced Senate Bill 005 on the first day of the 2019 session. It directs the Department of Health Care Policy and Financing to create a program to buy prescription drugs from from licensed Canadian suppliers and then distribute them to pharmacies and hospitals across the Centennial State.nnThe bill passed the Senate a month ago, but it has yet to clear the House.nnColorado would need a waiver from the federal government to legally bring those drugs across the border, and it’s unclear whether the White House would allow that. Both the Bush and Obama administrations rejected requests from other states.n
Prescription drug transparency
nAnother bill aimed at lowering the price people pay at the pharmacy is running out of time.nnHouse Bill 1296 would authorize the state Department of Insurance to collect data from every part of the prescription drug supply chain, analyze it and report annually to lawmakers on ways to reduce costs. It also would require drug companies to publish certain price increases on the DOI’s website 30 days before they go into effect.nnThe bill has yet to get a vote from either chamber.n
Out-of-network billing
nTwo different bills — one from each chamber — would limit how much money patients can be charged for out-of-network services they likely unknowingly received during an in-network hospital visit.nnThey’re called surprise or balance bills, and this is the fifth time lawmakers have tried to pass some kind of legislation to address them. House Bill 1174 appears to be on its way to becoming law; it’s awaiting a final vote in the Senate.nnOriginal article published on denverpost.com.
Todd Welter has some opinions when it comes to the upcoming Colorado State Bill HB19-1174 Out-Of-Network Health Care Services Provided To Covered Persons. Read it for yourself to see why he believes that the government should not be in the process of setting prices, and why health insurance companies should keep their patients’ best interest in mind by keeping prices low for the future.nnOur very own Todd Welter has been invited to the Colorado State Senate hearing on HB19-1174 Out-Of-Network Health Care Services Provided To Covered Persons.nnIn his own words, “The government should not be in the business of setting prices, there are too many unintended consequences. A free and transparent market should set prices.”nnThis bill would require “health insurance carriers, health care providers, and health care facilities to provide patients covered by health benefit plans with information concerning the provision of services by out-of-network providers and in-network and out-of-network facilities; outlines the disclosure requirements and the claims and payment process for the provision of out-of-network services; requires the commissioner of insurance, the state board of health, and the director of the division of professions and occupations in the department of regulatory agencies to promulgate rules that specify the requirements for disclosures to customers, including the timing, the format, and the content and language in the disclosures; establishes the reimbursement amount for out-of-network providers that provider health care services to covered person at an in-network facility and for out-of-network providers or facilities that provider emergency services to covered persons; and creates a penalty for failure to comply with the payment requirements for out-of-network health care services.nnRead the rest of the bill here. (PDF)nnIf the state government sets prices for out-of-network services the health plans will be encouraged to use this as a ceiling rate. Any provider who has a higher rate (specialists in rural areas, very unique services, new procedures, etc.) will simply get their contracts terminated allowing the payers to use the state imposed ceiling rate.nnPlease contact your government representatives and make your opinion known!
Simon Sinek has a simple but powerful model for inspirational leadership — starting with a golden circle and the question: “Why?” His examples include Apple, Martin Luther King Jr. and the Wright brothers.nnThis talk was presented to a local audience at TEDxPuget Sound, an independent event. TED’s editors chose to feature it.n
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Welter Healthcare Partners would like to wish you a Happy 4th of July! Our dedicated staff wants you to remember to relax and have a safe holiday.nnAccording to ADT, firework, grilling and water safety are collectively very important for the 4th of July. More than 50,000 fires are caused by fireworks every year and fun water activities have serious risks if the proper precautions aren’t taken! Please make sure to review safety procedures to keep you and your family safe.nnFrom all of us at Welter Healthcare Partners, we hope you take the opportunity to enjoy this day with loved ones and celebrate your freedom.nn 
nnThere is so much talk in the medical community about the proposed “Patients over Paperwork” initiative that many providers have found themselves at a loss for what will happen next. Common questions surrounding this important topic include: What type of documentation changes will help reduce the amount of administrative burden our clinicians currently face? How will documentation changes affect their practice? How will this impact reimbursement? What does this mean for their patient interaction and day-to-day routine? Is there anyone I can talk to so that my concerns are heard?nnIn June of this year, CMS put out another request for information from providers to voice their concerns, suggestions, and comment on proposed changes. Do not delay however because the deadline for this round of comments closes on August 12th. Specific feedback that CMS is looking for can be found by visiting 
Health care dominated early, with Sens. Elizabeth Warren (Mass.) and Cory Booker (N.J.) using questions about the economy to take aim at pharmaceutical and insurance companies. Sen. Amy Klobuchar (Minn.) emphasized the difficulties many Americans face in paying premiums.nnBut the candidates broke ranks on the details and not all of their claims stayed strictly within the lines.nnOnly two candidates — New York City Mayor Bill de Blasio and Warren — raised their hands in favor of banishing private insurance to install a government-sponsored Medicare for All approach.nnKlobuchar, a single-payer skeptic, expressed concern about “kicking off half of America off their health insurance in four years.” (That’s correct: In 2017, a majority of Americans had private coverage, with 49% getting that insurance through work, according to the Kaiser Family Foundation.)nnFormer Texas Rep. Beto O’Rourke, who also supports maintaining a private insurance system, outlined his own universal health care plan, based on a “Medicare for America” bill in Congress.nnThe single-payer talk set off other discussions about the role of health insurance and the cost of care. We fact-checked some of the biggest claims.nnWarren: “The insurance companies last year alone sucked $23 billion in profits out of the health care system. $23 billion. And that doesn’t count the money that was paid to executives, the money that was spent lobbying Washington.”nnWe contacted Warren’s campaign, who directed us to a report from the National Association of Insurance Commissioners, a nonpartisan group of industry regulators. It supports her assessment.nnThe report says that in 2018, health insurers posted $23.4 billion in net earnings, or profits, compared with $16.1 billion a year prior.nnThis came up in the context of Warren’s support for eliminating private insurance under a Medicare for All system. However, the financing and price tag of such a system is unclear.nnBooker: “The overhead for insurers that they charge is 15%, while Medicare’s overhead is only at 2%.”nnThis is a flawed comparison. Booker said administrative overhead eats up much more for private carriers than it does for Medicare, the government insurance program for seniors and the disabled. But Medicare piggybacks off the Social Security Administration, which covers costs of enrollment, payments and keeping track of patients.nnAlso, Medicare relies on private providers for some of its programs, and overhead charges there are higher. Medicare’s overhead is less than that of private carriers, but exact figures are elusive.nnThe insurance companies’ trade group, America’s Health Insurance Plans (AHIP), reported in 2018 that 18.1% of private health care premiums went to non-health care services. That includes taxes of 4.7% and profits of 2.3%. The Medicare trustees reported that in 2018, total expenses were $740.6 billion, with administrative expenses of $9.9 billion. That comes to 1.3%, less than Booker said.nnWarren: “I spent a big chunk of my life studying why families go broke, and one of the No. 1 reasons is the cost of health care, medical bills. And that’s not just for people who don’t have insurance. It’s for people who have insurance.”nnIs the No. 1 reason people go broke the cost of health care? We’ve rated similar statements Half True — partially accurate but lacking important context.nnOriginal 
UnitedHealth Group has purchased DaVita Medical Group after they reached a settlement with the Federal Trade Commission saying this deal was a long time coming. This was due to the concern about harm to medical competition in Nevada. The original deal in place would have resulted in a monopoly controlling more than 80% of the medical market.nnUnitedHealth Group announced Wednesday it has closed on its $4.3 billion purchase of DaVita Medical Group after the parties reached a settlement with the Federal Trade Commission that resolves the federal government’s concerns about harm to competition in Nevada.nnUnder the FTC settlement, UnitedHealth Group has agreed to sell DaVita Medical Group’s Las Vegas operations, known as HealthCare Partners of Nevada, to Salt Lake City, Utah-based Intermountain Healthcare within 40 days of the deal’s closing. Without that tweak, the FTC said the deal would reduce competition in the Las Vegas area for managed care provider organization (MCPO) services sold to Medicare Advantage insurers and Medicare Advantage plans sold to individual Medicare Advantage members.nnThe original FTC complaint against the proposed deal said it would result in a near monopoly controlling more than 80% of the market for services delivered by MCPOs to Medicare Advantage insurers.”The complaint alleges that elimination of this competition would increase healthcare costs and decrease competition on quality, services and other amenities in the affected area,” the FTC wrote.nnColorado Attorney General Phil Weiser separately announced his office had reached an agreement with UnitedHealth Group and DaVita that resolves its concerns about anticompetitive effects in the Colorado Springs area for people covered under Medicare Advantage plans.nnDaVita Medical Group owns two physician groups in Colorado Springs, and UnitedHealthcare, a sister company to Optum, is the largest Medicare Advantage operator in the region. Weiser filed a complaint independent of the FTC to challenge the Optum-DaVita deal.nnUnder that deal, UnitedHealthcare will lift its exclusive contract with Centura Health for at least 3.5 years, which will expand the network of providers available to seniors covered under Medicare Advantage, Weiser’s office said in a news release. Additionally, DaVita Medical Group’s agreement with Humana, UnitedHealth Group’s competitor in Colorado Springs, will be extended without change at least through the end of 2020.nn”As the people’s lawyer, I am committed to protecting all Coloradans from anticompetitive consolidation and practices, and will do so whether or not the federal government acts to protect Coloradans,” Weiser said in a statement.nnUnitedHealth Group will combine DaVita Medical Group with its Optum subsidiary, which provides primary and secondary care, consulting and data analytics. Optum spokeswoman Lauren Mijajlov wrote in an email that the company is pleased to have reached an agreement with Weiser’s office, and to have closed the deal. DaVita spokeswoman Courtney Culpepper said the same in an email.nnComplete and original 
nnThis is not the first time CMS has sought feedback on methods to reduce administrative burden. Through previous listening sessions and RFIs, CMS collected thousands of comments and is actively working on addressing those comments deemed actionable. The current RFI aims to collect feedback on several specific topics that have not yet been addressed. These include:n
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nnIt seems nearly everyone believes U.S. health care needs some transformative change to improve quality, expand access, or lower costs. Many of the contemporary approaches toward that change involve making it easier for patients to see doctors, particularly primary care doctors. While that seems intuitive, we think it is the wrong path.nnImagine it’s 1970 and commercial bank executives are deciding how to help their customers get the banking services they need. One executive remark, “Most of our customers engage with us through our bank tellers–even if they’re later referred to someone behind a desk. To help our customers get the banking services they need, we must make it easier for them to get in front of bank tellers.”nnWhether or not discussions like that really happened, that wasn’t the direction banks took. Instead, banks introduced automated teller machines to improve customer service. As a result of this unshackling of banking from tellers, 25-year-olds today find it unimaginable that their parents contorted their schedule to get cash during the Monday to Friday, 9 a.m. to 3 p.m. window. In the age of Venmo, they can’t imagine the need for cash in the first place.nnAnd yet, fifty years later, health care leaders continue to discuss how to get more patients in front of primary care providers, or in general to make it easier for patients to see doctors. The value-add from the technical knowledge and skills of primary care and specialist clinicians is greater than that from bank tellers, but the principles limiting the value of this strategy are the same. True transformations come from enhancing productivity, and productivity is enhanced by decreasing personnel effort, not increasing it.nnIf we continue to define health care as a service that happens when patients see doctors, we limit our possible productivity gains.nnWriting in 
We think the resistance reflects our social conventions rather than our technical limitations. The technical challenges of safely introducing driverless cars are far more daunting than the technical challenges of introducing bots to manage hypertension and diabetes, yet the prospect of driverless cars seems to be awaited with excitement. We need to solve three problems:nnFirst, the insurance industry—government and commercial—must get better at its job. Because they are ill-equipped to determine whether care was truly needed or appropriately delivered, they use proxy process measures: Was the care face to face? Was the right amount of time spent or the right number of facts documented? Was the right kind of clinician present? Without a measure of what’s good, insurers have found it easier to insist that care be delivered in traditional ways. It’s hard to explore new and potentially better models of care when only old approaches get reimbursed.nnSecond, state-based regulation of insurance and clinician licensure must be replaced by a system that recognizes that health care is not always best delivered locally. Facilitated self-service creates efficiencies across state lines. It’s likely that occasionally some of Wyoming’s 600,000 residents would benefit from care delivered by someone outside the 1,000 physicians practicing in that state—perhaps by a bot with second-line back up from a nurse or a physician elsewhere. State licensure of physicians and insurance regulations reflect federalist principles harder to justify in a connected world.nnThird, we should require the same standards of safety and efficacy for automated approaches to health care that we have come to assume for the safety of pharmaceuticals. Whether that regulation comes from the FDA or elsewhere, it needs to be ramped up to address the volume of potential new approaches. Even if we think a bot can help manage hypertension, it doesn’t mean any bot can do that. The organizations that credential clinicians might find they are well suited to credential robots.nnIf there is a fourth problem, it is our sense of nostalgia. Norman Rockwell’s paintings of what he saw as wholesome and right reflected a time when doctors attended to the whole family, knew some from the cradle and some into the grave, and were paid with a basket of eggs. Facilitated self-service health care doesn’t challenge the appeal of this image, but it does shift it toward those elements of care that can’t as easily be handled by a machine.nnThe health care changes we want, or at least the opportunities to try them, are held back by a combination of technical limitations and social conventions. But our social conventions present greater obstacles. The lesson from other industries is that transformational change requires productivity change. And in health care, that means we must find ways to move past approaches to facilitate care with doctors toward approaches that facilitate care without them.
We continue to see the risk adjustment model being implemented by several large hospital groups and the sooner small practices catch in the better off their business models will be. So why is this so important?nIt’s simple, Centers for Medicare & Medicaid Services (CMS) utilizes this in the analysis of Medicare Advantage patients and that ultimately is a major factor when it comes to your reimbursements. What can your practice do to avoid missed opportunities?nThe first step to the implementation of anything new is education. Make sure your providers are aware of HCC’s and how they play a roll in risk adjustment factor calculations. Welter Healthcare Partners is excited to now offer our clients Risk Adjustment auditing and educations to assist you and your team with the implementation of HCC’s in your documentation, billing, and coding.
One of the models focuses on a more general population, while the second model is for advanced primary care practices that typically provide hospice or palliative care services and want to take responsibility for high-need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination, according to a CMS fact sheet on the models.The model involves a potential downside risk of 10%, and an upside risk or bonus of 50%, depending on patients’ outcomes, and performance would be measured on “risk-adjusted hospitalizations” or “the ability to keep patients healthy at home,” Adam Boehler, director of the Center for Medicare & Medicaid Innovation (CMMI), which developed the models, said at a press briefing. “For example, doctors that earn $200,000 today could earn up to $300,000 if their patients stay healthy.” For 2020, the CMS has identified 26 regions where practices can participate.The CMS says that the model’s monthly per-patient payments will help doctors stop worrying about their monthly revenue cycle. However, as Miller noted in an article, “at the same time that Primary Care First eliminates the current E/M [evaluation and management] payments for face-to-face office visits for attributed patients, it creates a brand-new $50 fee for each face-to-face office visit, which is about half as much as the average amount primary care physicians currently receive from Medicare for office visits.””Based on the current average frequency with which Medicare beneficiaries make primary care office visits, this means that more than 40% of a typical practice’s payments would still be tied to face-to-face visits. As a result, if the practice is able to care for patients effectively with fewer office visits, it will lose revenue and it could be unable to cover its operating costs,” he wrote.nnLACK OF RISK ADJUSTMENTnAnother problem with the program is that a primary care practice would receive the exact same monthly payment for a patient regardless of how sick or healthy they are, Miller said. “Since an individual patient who has higher needs will require more time and resources from the practice than other patients, a practice that is caring for that patient will have to reduce the time and resources it devotes to other patients if the payment is the same.”And in addition to those issues, since Medicare payment programs are expected to be revenue-neutral compared with the current budget, “the payment is intended to be the same as what the practice is currently getting,” although the practice will be expected to provide more services than before, including 24/7 patient access and integrated behavioral healthcare, Miller said.Miller is a member of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which advises the CMS on Medicare alternative payment models. “In general, I think there’s been a lot of concern for a long time about [the] need to provide better support for primary care, and most payers in the country have been trying to do some kind of medical home programs for quite a while,” he said. “Medicare has been fairly slow to the game on that.”In particular, Miller is disappointed that the CMS hasn’t shown much interest in pilot-testing the payment models that PTAC has recommended. “With PTAC, two proposals [were submitted] for primary care, and we reviewed them and recommended they be tested and implemented … It’s been a long time since the recommendations were made, and the surprising thing to me was that the [Primary Care First] model that was announced by [the CMS] really didn’t look at all like the models recommended by PTAC.”nnROOM FOR IMPROVEMENTnThere are ways that Primary Care First can be improved, Miller said. For starters, “rather than creating a whole new set of office visit payments, what primary care practices have asked for is to get all or most of their payments as a flexible monthly payment so it’s not tied to office visits.”In addition, the monthly payments should be higher for patients who require more care. “If you have more diseases and more care challenges, you’re going to require more attention from your primary care physician,” said Miller. “The way that happens today is more office visits … but we don’t want to pay more only if they come to the office.”When asked during a press briefing about the Primary Care First model, CMS administrator Seema Verma said the agency was trying to give physicians a variety of options. “What we tried to do is recognize that providers are in different places in terms of their ability to take on risk,” she told MedPage Today. “What we’ve tried to do in this model is provide different options … Some providers may say ‘I want to take full risk on,’ so we’ve allowed for that option.””What we want to do in primary care is have them focus less on revenue cycle … and actually be able to focus on patients,” she continued. “The requirements around 24/7 [availability] — the idea there is that it’s based on some work we’ve already done in primary care and some of [it is] ‘lessons learned’; we’re looking at what we know works.”Some providers differ with that assessment. “I know it was well intentioned, but [the] CMS seems not to understand the day-to-day mechanisms of [how] primary care practices work,” Jean Antonucci, MD, a family physician in rural Maine and the author of one of the alternative payment model proposals that was recommended by PTAC, said in an email. “It is really virtually impossible to figure out how much revenue a practice will receive.””Supposing that my patients are well taken care of so I am placed in the lowest [payment] category of $24 a month; it’s very difficult to [keep patients] out of the hospital for $24 a month, but I might be put in that category because I did a good job. So no good deed will go unpunished,” she said.In her own proposal, she considers the cost of an hour’s worth of phone calls — 15 minutes, four times a month — from a practice to a particular patient. “A [medical assistant] is $15/hr. easy, but often the doctor must be involved, or an RN, and that is $40-$150 per hour, plus they need the driver’s license form or the forms for oxygen … We end up with whining by doctors about not being paid, while payers and pundits complain we want to nickel-and-dime them to death.”nnOTHER POSSIBLE APPROACHESn
Primary Care First’s early reviews “reveal that longstanding conflicts remain between, on the other hand, budgetary savings and administrative feasibility goals and, on the other hand, more ambitious desires in parts of the medical community redesign care to elevate the role of effective primary care (regardless of the short-term costs),” Tom Miller, JD, resident fellow at the American Enterprise Institute, a right-leaning think tank, said in an email. “Perhaps more medical outcomes per se could be improved by simply paying primary care doctors more, but that assumes away the political food fight it would require to get there.”A more straightforward approach to “subsidize patients more directly to find and receive the care that they could choose to receive would upset providers either benefiting from the current system or imagining that they could be winners in the next round of political reimbursement roulette, labeled ‘value-based,'” he added.Gail Wilensky, PhD, senior fellow at Project HOPE in Bethesda, Maryland, and a former CMS administrator, said in an email that the difficulty with the model “seems to be the amount paid is too small and too unreliable … That is certainly consistent with the ongoing CMS attempts. It is certainly reason to be skeptical although the results will only become clear after it is tried, assuming [the] CMS goes forward with it … It has been discouraging how difficult it has proven to be to affect change in this area.”nnOriginal 
The clock is ticking, and you’re trying to select the right E/M level from a drop-down menu in the EHR. Choose a level that’s too high, and you run the risk of post-payment audits and recoupments. Choose one that’s too low, and you may lose revenue to which you’re entitled. You decide just to trust your instincts and go with a code that feels right so you can move on to the next patient.nnChoosing an E/M code based on a gut feeling is one of the biggest mistakes a physician can make, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C. Payers and auditors use a quantitative scoring process that requires specific elements (i.e., history, exam, and medical decision-making [MDM]—or time spent counseling and coordinating care) for each E/M level.nnIf physicians don’t document these elements adequately—or the elements they document don’t make sense given the patient’s presenting problem (e.g., performing a comprehensive exam for a patient with a sinus infection)—payers and auditors may down-code the service or even conduct a more in-depth audit that could expose additional documentation vulnerabilities, she adds.nnIt’s equally risky to report the same E/M level for all patients with the same diagnoses (e.g., diabetes or congestive heart failure) without first considering medical necessity—a trap into which many physicians fall because they assume all patients with the same diagnoses generally require the same work, says Toni Elhoms, CCS, CPC, director of coding and compliance at Welter Healthcare Partners , a healthcare consulting company in Arvada, Colo. “In reality, every single visit could be a different level based on the documentation and circumstances of the encounter,” she says.nnFocus on quality E/M documentation—and the dollars will follownnKnowing what documentation is required for each E/M level is paramount. For example, the history, exam, and MDM must meet or exceed certain requirements for all new patients. The only exception is when the physician selects the E/M level using time as the controlling factor. In this case, documentation must indicate that the physician spent more than 50 percent of the encounter face-to-face with the patient and/or family providing counseling and/or coordination of care. The physician must also explain the specific services rendered and the reasons for them.nnOnly two of three key components must meet or exceed certain requirements for established patients unless the physician bills based on time. Elhoms provides an E/M scoring guide that includes a visual depiction of documentation requirements for each specific E/M level based on whether the patient is new or established.nnSound confusing? Experts agree that even the most experienced medical coders have difficulty translating physician documentation into an accurate E/M code. They cite several reasons why E/M coding is so difficult for physicians—lack of formal training on E/M guidelines, complex documentation requirements that don’t align with clinical practices, and the subjective nature of the MDM component.nnWe’ve asked our experts to share their best documentation tips to ensure accurate E/M reporting. Here’s what they said.n
Does your practice screen patients for risk factors like smoking, alcohol or drug use? Do you know the correct coding for use patterns? According to section guidelines by the AMA, “…used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury. They are distinct from evaluation and management (E/M) services that may be reported separately with modifier 25 when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.”nnThis is especially helpful when we look at codes 99406-99409 and incorporate this into your telemedicine services menu. Welter Healthcare Partners recently teamed up with CDPHE for a two-part webinar series on the coding and billing for these important codes and how school-based health centers can take advantage of the services they support.nn n
Even as some important questions remain unanswered, the CMS Primary Cares Initiative is generating a lot of excitement. Observers say it opens the door to more competitors for healthcare incumbents.nnThe shift to value-based care has sputtered a bit in the past two years, as hospitals and health systems have waited to see what innovative reforms the Trump administration would push across the healthcare policymaking finish line.nnDespite a litany of attempts—and two years of a Republican-controlled Congress—the administration has neither repealed nor replaced the Affordable Care Act and the value-based payment provisions embedded within it. Even with its individual mandate neutralized and its constitutionality under judicial review, the ACA remains law, and officials in the Centers for Medicare & Medicaid Services are using the ACA’s authority to roll out a potentially transformative undertaking: the CMS Primary Cares Initiative.nnThat initiative, industry stakeholders say, is poised to kickstart value-based care in Medicare and beyond, ushering in a new wave of consumer-centric competition that could help to shake off some healthcare providers’ risk aversion.nn”There was a sense that things were flattening out. It wasn’t going backwards. It wasn’t going down. It just was not progressing as fast as we all had hoped,” says Norman H. Chenven, MD, founding CEO of Austin Regional Clinic in Texas and vice chairman of the 
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Employers are increasingly focused on improving access and quality of care for their workers, according to a new survey.nnWithin the next three years, nearly half of employers plan on implementing high-performance networks (HPN), centers of excellence (COE), onsite or nearby health centers and accountable care organizations (ACO) as ways to provide quality and affordable healthcare options, according to a Willis Towers Watson (WTW) survey released Wednesday morning.nnEighty percent of respondents intend on having COEs within a health plan, a 29% jump year-over-year, and the number of employers who plan on including HPNs more than doubled to 65%.nnBy 2020, almost 40% of employers are looking at opening a health center at their offices, while more than 25% plan to offer one near their facilities.nnThese trends have gained momentum in recent years, as more than 80% of employers with an onsite or near-site health center reported that the move has “succeeded in improving employee access to convenient health care services,” “enhancing employee productivity and bringing absenteeism under control,” while also “delivering and promoting preventive health screening and services, getting ahead of medical issues through early detection and by instilling healthy habits.”nnThe survey also shows that employers are increasingly more concerned with quality of care provided than cost savings as the “most important feature” when considering an HPN.nnSandy Ageloff, managing director, west region health and benefits consulting leader, told HealthLeaders that the survey results indicate that the shifting thought process among employers is being driven by four major paint points.nnThese include the need for better care access, especially around mental health services for employees, providing high quality care, making care cost effective, and concerns about system complexity.nn”I think employers have done a lot to try to improve cost and quality, but what we’re realizing is that employees and their family members are challenged to understand all of the various pieces of the puzzle,” Ageloff said. “Employers are now embracing the need to say, ‘You need to help people navigate through what we’ve done to create beneficial, high-quality programs that provide affordable costs.'”nn
Now that we are all familiar with ICD-10 it’s time that we start focusing more on specificity when it comes to diagnosis. It’s not just import for patient charts, with HCC becoming the new standard and payers tracking things like readmissions it’s becoming more important than ever for Coders to capture as much in their code selection as possible.nnICD-10 includes a classification system implemented to capture data, which previously was not tracked. Classifications such as “underdosing of drugs” can prove to be vital when readmission rates are not only tracked but also could affect a practice’s reimbursements. As coders, it’s not only important that we extrapolate this information from the documentation but also code why the drug was not taken correctly or, in some cases, not at all. Classification codes T36-T50 (utilizing a fifth or sixth character of “6”), deals with specific drug underutilization while Z codes Z91.12- Z91.19 classifies the patient’s non-compliance with medical treatment and regimen. Z codes should, when known, be accompanied by the correct underdosing code to help account for intent.nnThe Journal of AHIMA wrote about this back in 2016, however this topic will continue to become more relevant as Risk Adjustment Models are adapted by more practices and payers.nn
Colorado Gov. Jared Polis stood outside of Denver Health Medical Center almost a month ago laying out his “roadmap” to save people money on health care.nnAs the Boulder Democrat ticked off his list of plans, both short term and long term, it quickly became apparent that most of the governor’s ideas to lower health care costs in Colorado weren’t possible unless state lawmakers passed a series of bills.nnDemocrats and Republicans have come together to create the beginnings of a 
nnThis bill would require “health insurance carriers, health care providers, and health care facilities to provide patients covered by health benefit plans with information concerning the provision of services by out-of-network providers and in-network and out-of-network facilities; outlines the disclosure requirements and the claims and payment process for the provision of out-of-network services; requires the commissioner of insurance, the state board of health, and the director of the division of professions and occupations in the department of regulatory agencies to promulgate rules that specify the requirements for disclosures to customers, including the timing, the format, and the content and language in the disclosures; establishes the reimbursement amount for out-of-network providers that provider health care services to covered person at an in-network facility and for out-of-network providers or facilities that provider emergency services to covered persons; and creates a penalty for failure to comply with the payment requirements for out-of-network health care services.nnRead the rest of the