HHS ‘Implementation Forums’ Begin Next Week
HHS Secretary Kathleen Sebelius sent a letter to state governors July 10 reiterating HHS’ willingness to work with states to help them implement the ACA, to provide assistance and funding to states as they move forward with the establishment of their exchanges, and to allay concerns over Medicaid expansion issues. In her letter, she announced that HHS will host ACA implementation forums in July and August across the country to provide an opportunity to states and stakeholders to learn more about next steps in implementation and to ask questions regarding the establishment of the insurance exchanges. These forums begin next week, starting in Washington, DC. The dates and locations may be found below.n
July 31: Washington, DCnHubert H. Humphrey Building, Great Halln200 Independence Ave., SWnWashington, DC 20201
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August 2: ChicagonSocial Security Administration, Center Auditoriumn600 West Madison StreetnChicago, IL 60661
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August 10: DenvernDavis Auditorium in Sturm Hall, University of Denvern2000 E. Asbury Ave.nDenver, CO 80208
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August 15: AtlantanNational Archives at Atlantan5780 Jonesboro RoadnMorrow, GA 30260
nSource: www.polsinelli.com; Polsinelli Shughart PC; July 18, 2012.
The U.S. Department of Health & Human Services’ Office for Civil Rights (OCR) has made public its long-awaited HIPAA audit protocol, posting it on its website June 26.nnThe Health Information Technology for Economic and Clinical Health (HITECH) Act, which amended the Health Insurance Portability and Accountability Act in 2009, required OCR to conduct a pilot audit program to assess HIPAA compliance. OCR established the audit protocol, which is searchable and organized around modules, to conduct the audits. The first 20 preliminary audits have been conducted; in all, 115 covered entities will be audited in the pilot program, which will end in December 2012.nnThe audit protocol covers the following requirements:n
Recently, the United States Supreme Court issued its long-awaited decision on the constitutionality of the Patient Protection and Affordable Care Act (the “Act”). In a 5 – 4 decision, with Chief Justice Roberts writing for the majority, the Court upheld the constitutionality of the controversial individual mandate and, thus, the remainder of the Act, with one exception discussed below. The Court upheld the individual mandate on the grounds that it was within Congress’ taxing power to require those who choose to not purchase health insurance to, in essence, pay a tax. A majority of the Court did not agree that the individual mandate was a valid exercise of Congress’ power to regulate interstate commerce.nnImportantly, the Court overturned the provision of the Act that would have allowed the federal government to take away all Medicaid funds from states that chose to not extend Medicaid coverage to all individuals under the age of 65 with incomes below 133% of the federal poverty level. This could mean that a number of states will opt out of the Medicaid expansion thereby reducing the number of currently uninsured who will receive coverage in 2014.nnThe Court’s decision means that all of the other provisions of the Act will remain in place including guaranteed issue, no lifetime caps, no exclusions for preexisting conditions, payment and delivery system reforms such as ACOs, and enhanced fraud and abuse enforcement powers.nnThe decision does not necessarily mean that the Act cannot be repealed by congress or a new president. Congressional Republicans have stated they will continue their efforts to defund the Act, and to repeal it if Gov. Romney becomes President and Republicans take control of both houses of Congress.nnSource: http://www.supremecourt.gov/
The health plans are increasingly putting pressure on providers (especially surgeons) to utilize IN-network providers, vendors, facilities, etc.nnOne Example: For years, it has become common place for Out Of Network (OON) surgical assists (many of whom are SA’s or C-SA’s) to get a hold of the surgeons bill for a surgical case and send out claims for 100% of the surgeon’s fee (the total fee prior to any contractual discount or even multiple procedure discounting) on the cases where they participate as first or even second assist. Some states have laws that force the health plan to hold the patient harmless to bills if the surgeon and the facility (or some combination) is IN-Network. The SA’s and some “creative” billing services are capitalizing on this loop hole to send in OON bills at 100% of charges. In many cases they actually get paid these amounts. Making it more profitable to be the SA than the actual surgeon! Imagine having virtually no-risk, no overhead, no staff to pay. You just show up for the case and get up to 5 -10 times what the actual surgeons gets for the case!nnWell, as we have always suspected, the health plans are finally saying NO MORE. In addition, many patients are not aware that there is an OON provider taking part in their case until they (the patient) gets a surprise, a huge bill – if even just the OON Co-Pay from someone they don’t know, never met, didn’t know was going to be in the case. The other un-intended consequence is that the total cost of a case (something that one surgeon is measured against others by) has astronomically gone up due to this practice. The surgeon, who is IN-Network gets a black mark because the overall cost of his/her cases is affected by the charges and network status of everyone involved.nnSome health plans are filing suit, others are forcing their In-Network surgeons (in the case of the OON SA assists) to make their patients aware of the use of an OON provider. We recently have seen United institute this for the use of OON facilities.
THIS WEEK — The Supreme Court of the United States should be ruling on four separate issues:n
Credentialing is NOT just filling out paper work…nCredentialing IS an increasingly complex and time sensitive process where the right information has to get to the right place, correctly, (even in the right color ink) and on-time in order for you to be paid correctly and consistently!nnFailure to properly fill out the “paper work” will cause, and has been causing disruptions in payment, inability to obtain referrals, improper co-pay and deductibles being applied and even regulatory audits (when a provider is mis-categorized and loaded improperly in the payer’s system!).nnIf your practice is experiencing:n
Some practices may find that they cannot increase revenue as easily as they can decrease expenses. Both or a combination of the two can make a practice more profitable.nnExpenses:nRent, personnel, supplies, equipment, etc. What if you could lower the cost of one or more, maybe all of these?nnRent:nIf space is not needed don’t rent it! If you can out source a function that takes up space, it may be worth it.nnPersonnel:nThese days no one wants to be laid off or suggest that there be a reduction in staffing, but if it makes sense to do so, you have got to do it. Health care is complicated and new regulations and challenges may require new/different people and processes. Maybe even less people but higher skilled.nnSupplies:nGet tough, get what you pay for, get lean. There is a lot of competition out there to supply your office. With that competition come JIT (Just In Time) delivery. You may be paying for space to store supplies when you could get the supplies cheaper and delivered with a day of need!nnEquipment:nSome things you have to have. But when it comes time to replace them don’t be afraid to be creative. Look carefully at leasing. Like supplies, there is a lot of competition for your business. Computers and anything electronic is coming down in price, but be careful – often times paying a little more may get you a whole lot more. Consider outsourcing your IT hardware, especially server needs!nnCall us! We can help with all of the above. Spending money is okay if it is done with strategy and with a plan to bring down overall Expenses. You don’t have to just increase revenue to increase your profitability!
The payer and provider communities are still dealing with HIPAA 5010, and trying to shift attention to ICD-10 is tough,” says Craig Collins, division chair for revenue cycle and administrative lead of the ICD-10 transition at the Rochester, Minn.–based Mayo Clinic. “We put together a strategic plan and process map because we’re trying to be first to the plate to do the ICD-10 testing with the payers. Our hope is that in early 2013 we can begin testing with larger payers.”nnThe Mayo Clinic, like many other healthcare organizations, is making strides to prepare for the largest overhaul of healthcare codes in the past 30 years. The process—regardless of Health and Human Services’ decision to extend the ICD-10 transition deadline to October 2014—includes a process map of the revenue cycle in the hopes of keeping this project revenue neutral.nnAlthough the code set change is intended to be revenue neutral, ICD-10 includes more than 155,000 codes, a significant expansion from the current 17,000 codes in ICD-9. The transition touches nearly every member of a hospital or health system: physicians, clinicians, coders, IT, HIM, and finance. The mandated coding expansion influences documentation, productivity, contracts and business processes, HIM, practice management, budgets, payment conversions, claims edits, and disease and utilization management.nnICD-10 is expected to have significant impact on the revenue cycle. Nearly half of healthcare leaders (46%) expect to lose money while shifting to the new system, according to the July 2011 HealthLeaders Media Intelligence Report, ICD-10 Puts Revenue at Risk. An important step to avoid revenue hits is completing a process map that digs into the effect the transition will have on the revenue cycle.nnThe process map is work flow plan driven by multiple repositionable notes created to give an accurate picture of all the activities connected to the current and future processes at an organization. It is a full structural analysis of how all processes flow and connect to each other. The map can show gaps in specific areas that are preventing optimal performance or, in the case of ICD-10, areas that will require special attention to prevent an impact on the organization’s revenue.nnWith some 212 IT systems and 80 geographical sites across Minnesota, Arizona, and Florida that include physician practices and several hospitals, the Mayo Clinic finds the process map to be essential for a successful ICD-10 conversion—and that starts with the right team and clear accountability. 
he right to withhold payment and request refunds for improperly coded services.nn99211 is a minimal level service, but it is still governed by the same billing and documentation rules that ALL E&M codes have.nnAs with all services billed to Medicare, code 99211 services must be reasonable and necessary for the diagnosis or treatment of an illness or injury. Unlike the other E/M CPT codes, the CPT book does not specify completion of particular levels of work for code 99211 in terms of key components or contributory factors. Also, unlike the other E/M codes, CMS did not provide documentation requirements for CPT code 99211 in the “E&M Documentation Guidelines”.nnAmong other reasons, code 99211 should not be used to bill Medicare/Secure Horizons:n
Medicare Revalidation – Medicare requires that ALL enrolled providers and Suppliers to revalidate enrollment information every 5 years. The revalidation initiative is currently in process and will continue through March 2015. You have 60 days from the date of the revalidation notice to submit your application(s).nnProviders are required by regulation to submit updates and changes to enrollment information in accordance with specified time frames. Reportable changes include: 1) Change in legal business name, 2) Practice location, 3)Ownership, 4) Authorized/delegated official, 5) Changes in payment information such as changes in EFT information and, 6) final adverse legal actions.nnFailure to comply with any of these requirements in a timely manner may result in Medicare billing privileges being deactivated.nn nn
nnIn order to power this increased resolution, the new iPad has an A5X processor which is quad-core meaning apps will run quicker. Initial reports suggest that this iPad will ship with 1GB of RAM which means the overall ease of use, multitasking and switching between apps will be improved. Furthermore, the faster processor could help with screen sharing and remote control apps (e.g. Citrix) and remote virtual apps (e.g.OnLive) which could open up more tablet EHR options. The improved graphics processing capability will help improve 3-dimensional modelling such as that seen in the Visible Body or the NOVA anatomy apps.nnThe next major feature which will impact physicians is the introduction of voice dictation. Whilst Siri is noticeably absent from the new iPad, there is now a button which allows the user to dictate. This obviously has numerous medical applications from recording patient notes and entering data into EMRs to dictating letters. It will be interesting to see if the voice dictation feature can cope with medical terminology although regardless, data entry speed is sure to be enhanced. This introduction of voice recognition also paves the way for Siri integration in a future update.nnThere is an enhanced five MegaPixel camera in the new iPad which is similar to the one found in the iPhone 4S. The enhanced resolution of this camera combined with the improved graphics processing in the A5X chip means that the iPad has the potential for improved integration and usage in telehealth care. The new iPad has the ability to record video in 1080p HD resolution which would offer increased resolution in a telehealth care setting.nnAnother major feature announcement is that the new iPad will have high speed 4G LTE internet available on both major carriers, Verizon and AT&T, although you will have to purchase a specific iPad depending on your carrier. High speed internet combined with the increased graphics capability and camera resolution is sure to have numerous applications in telemedicine and mHealth in general.nnIn adnnThe iPad model allows healthcare providers to connect to Bluetooth-enabled medical home monitoring devices that collect patient data. Specifically, Bluetooth-enabled medical devices such as stethoscopes, blood pressure monitors and pulse oximeters can measure a patient’s diagnostics and securely transfer the data to the iPad.nnData from these medical devices can also be quickly added to a patient’s electronic health record or to a personal cloud-based health record such as Microsoft’s HealthVault, either or which can now be monitored remotely by a physician with an iPad.nnSource: www.imedicalapps.com; Tom Lewis; March 7, 2012; www.beckersasc.com
PAHCOM Shares Knowledge!nFounded in 1988, PAHCOM is a national organization dedicated to promoting professionalism in physician office practice management by providing professional development opportunities including continuing education, networking, online tools & resources, and nationally recognized certification (CMM) for health care office managers.nnOctober 16, 17, 18, 2012 Susan and Todd speak at PAHCOM’s national meeting in Clearwater Beach FloridannPAHCOM 
Did you know?: Welter Healthcare Partners has several long term training affiliations with local, regional and national residency training programs. We routinely meet with the residents (1st year, 2nd year and 3rd year’s) to teach and discuss coding, contracting and business principals of healthcare. Does your residency program need industry experts to come speak to the residents?
Colorado’s Primary Care Fund provides grants to healthcare providers who care for underserved populations and meet specific qualifications. The funds are generated from the collection of tobacco taxes in accordance with Section 21 of Article X (Tobacco Taxes for Health Related Purposes) of the State Constitution.nnThe Primary Care Fund application process requires that providers must use a formula to submit the percent of unduplicated users/patients served by the applicant agency who are enrolled in Medicaid and CHP+ or medically indigent. This data must be certified (or verified) by an outside entity prior to the submission of the application.nn Welter Healthcare Partners is qualified as an outside entity to complete the certification of the numbers of unduplicated user/patient counts for the Primary Care Fund application. If you need assistance with your Primary Care Fund application, contact Welter Healthcare Partners immediately at 303-534-0388.nnFor more information, visit 
Did you know that Medicare is having ALL providers re-validate over the next 2 years? This has to be done right, on-time, even with the proper color ink! Don’t leave this to chance or to someone who does not have experience. Failure to do it right and on-time will cause your payments to stop. You will drop out of Medicare if this is not done properly!
We have found that CPC Certification NOW will allow for a much easier transition to ICD-10 than waiting for ICD-10 to be incorporated into the CPC exam. If you are thinking about becoming certified – do it today!
Gone are the days where we used to sit on opposite sides of the table and throw rocks at each other. The payers need the providers and the providers need the payers! We can work together. It still takes a clear understanding of data, timing and leverage to make for a good business relationship. Learn more…
Payers make mistakes – If you find that you are swimming in appeals, payment errors, loading issues, late payments, improper adjustments, etc. it may be a Credentialing issue, it may be a bad contract. We have solutions.