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EHR Certification Organizations: A Closer Look

Posted by Paul Spencer, CPC, CPC-H in Electronic Health Records, Industry Updates, J. Paul Spencer, CPC CPC-H

Despite all appearances to the contrary, we are not in an age of skepticism. It was hoped that when we entered the age of the 24-hour news cycle, with constant access to information, as well as the accompanying advanced technological tools that go along with it, that the reporting of events would improve by providing a higher volume of information by which the viewer could make an informed decision on events, thereby allowing any one person to speak with an adequate knowledge base by which to debate the issues.

Instead, what we have now is not an age of advanced information, but rather one of hyper-choreography. News networks and wire services with an agenda shave the presented facts to fit a pre-determined narrative. As if that were not bad enough, stories that used to count as nothing more than the postscript to an evening newscast now becomes a “BREAKING STORY!!!”, such as the balloon boy hoax or the fact that a 90-year-old actress is in the hospital (gee, we couldn’t predict THAT eventuality now, could we?).

In the world of electronic health records, it was with great fanfare this past Monday that the Office of National Coordinator for Health Information Technology (ONC) named The Drummond Group of Austin, Texas and the Certification Commission for Health Information Technology (CCHIT) as the first testing and certification bodies for electronic health record systems. Thus far, most of the articles I have come across in the news universe have been the usual straight news pieces, complete with quotes from Mark Blumenthal (the national coordinator) about beginning the process of EHR certification and encouraging vendors to submit EHR’s for testing. A press release is sufficient. Nothing to see here. Move along now…..

Because the current initiatives for EHR adoption have the stated goal of achieving improved access to information as well as interoperability, the choosing of vendors to test EHR systems for meaningful use is an important first step. Finding out who the players are behind the initiative is equally important. I have a lot of questions that my unstoppable curiosity want answered:

  • What’s the background of these companies?
  • Who manages these companies?
  • Whose viewpoint is best represented and advanced by the selection of these companies to be the EHR certifiers?
  • (the true skeptic’s question:) Is there a hidden agenda to be found?

With a mouse and keyboard as my only tools, I set about the task of filling my head with information about the Drummond Group and CCHIT.  

According to their website, the Drummond Group has been in existence since 1999. They specialize in software compatibility testing across a range of operating systems and standards. They currently offer their own certification for tested products that sufficiently demonstrate interoperability. They make it very clear that they do not endorse or produce software in order to maintain “strict vendor neutrality”.

A few members of the management team of the company have ties to the oil industry, with founder Rik Drummond having served with the American Petroleum Institute for four years prior to founding his company. In the past, Mr. Drummond has also contributed to re-election campaigns for Rep. Joe Barton of Texas, the last donation coming in 2002. If that name sounds familiar to you, that is because Joe Barton is the man who humbly apologized to BP executives during Congressional hearings for the federal government forcing them to clean up the recent oil spill in the Gulf of Mexico. Based on the Drummond Group’s reputation for the quality of their testing, I’ll chalk these curious facts up to occupational and social associations. It would be hard to be optimistic about the future of EHR if Mr. Barton’s kind of thinking was represented in the certification of healthcare record systems. Mr. Drummond also has extensive experience in Electronic Data Interchange, which comes in handy when testing and certifying an EHR that presumably would double as a billing system.  

CCHIT is something of a known entity in the world of EHR certification. Founded in 2004 as a non-profit and run by volunteers, their focus is strictly trained on health information technology, as 60% of their name intimates. They have been offering certification and testing of EHR’s since 2006, which makes them something of a lead pipe cinch as a first selection, as they have experience testing  for functionality, interoperability and security.

This past April, Karen M. Bell, MD became the chair of CCHIT. Dr. Bell’s resume is peppered with past work done for payers and community medical groups in New England, such as her stint as the medical director for Blue Cross Blue Shield of Rhode Island.  She also worked as the Director of Health IT Adoption at ONC prior to taking her post at CCHIT. She has spent a good portion of her professional life in a variety of positions related to quality improvement. She also has experience as a practicing internist, albeit one that, given her medical training at Brown and Tufts Universities, was more than likely not one where the everyday headaches of  insurance reimbursement was ever a first-tier concern.

More certification agencies will be named in the near future. Thus far, despite my best efforts, I find no readily apparent hidden agenda, but I am beginning to wonder if the interests and input of small group practices are being adequately represented, or whether the journey towards mandatory EHR is most comparable to the creation of a series of bitter pills for physicians to choose to swallow. Only time will tell, one can only speculate, move along now, nothing to see here…….

As a physician advocate, I would add “yet”.

11:31 am, September 3rd, 2010 | No Comments »

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Welcome to The RAConteur!

Posted by Paul Spencer, CPC, CPC-H in J. Paul Spencer, CPC CPC-H, RAC / Recovery Audit Contractors, The RAConteur™

If any of us had any doubts about the expected longevity of the Recovery Audit Contractor (RAC) program, this year’s passage of the Patient Protection and Affordable Care Act (PPACA) left no doubt that RAC’s are here to stay.

To date, because of the monetary incentives built into the RAC program, services paid under Medicare Part A have been the preferred target of the four regional RAC contractors. Hospitals and other facilities paid by Part A continue to deal with the ever-expanding demands of the contractors in the realms of both DRG validation and medical necessity. Simultaneously, individual physicians and groups have been existing in a world seemingly beneath the radar of the RAC’s.

The new world under PPACA is about to change this set of circumstances, with RAC’s gearing up to train their sights on a distracted physician population that after years of federal warnings and compliance guidance, remains ill-prepared to weather the storm. The planned expansion of the RAC program into avenues currently traveled by Medicaid Integrity Contractors (MIC’s) only makes the need for data on practice vulnerabilities, and opportunities for coding and documentation improvement, that much more important.

Stepping into this information void comes…….The RAConteur.

As the RAC contractors begin to circle above the heads of the individual and group physician populations, there are steps that can be taken pre-emptively to:

  • Identify probable RAC audit targets;
  • Determine practice vulnerability based on these targets; THEREBY
  • Strengthening your practice’s defenses against your RAC contractor.

Every Wednesday, The RAConteur will focus on RAC information specifically tailored for the physician practice. In future posts, it is my hope that I can assist practices to begin to view the paper trail that accompanies their daily work product with the same highly trained critical eyes developed and possessed by all physicians as part of their medical training. Rather than leaving physicians to continue guessing about where their vulnerabilities may exist. Instead it is my mission to empower the physician to detect errors and modify long-held thinking and behaviors, which will hopefully lead to decreased risk and increased peace of mind.

The paved-over swamp that is official Washington, D. C. has decided that increased audit recoveries are the pathway to offsetting the cost of healthcare reform for the next decade. While the opportunities to weed out the fraud in the American healthcare system is a task for which we all have a positive financial stake, The RAConteur will relate as much information and advice as possible to ensure that you are not the physician providing a high percentage of this healthcare funding.

As we go forward together, I look forward to your comments and questions on specific elements of physician RAC audits, coding, documentation and best practices in a world of hyper-investigation.

Welcome to The RAConteur!

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12:18 am, September 1st, 2010 | 3 Comments »

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The Hidden Costs of Mandatory EMR

Posted by Paul Spencer, CPC, CPC-H in Electronic Health Records, J. Paul Spencer, CPC CPC-H

From a purely spiritual perspective, one of my favorite musicians of all time was John Coltrane. There have been many musicians who have attempted to become one with their instrument in an attempt to achieve something beyond mere virtuosity who, while technically perfect, ended up being vacant in matters of the soul. Coltrane achieved the lofty goal of connecting the known and unknown world with the power of music to an extent not seen before or since.

Coltrane was known for taxing the patience and constitution of his many band mates. One incident involved a drummer who became so tired of trying to keep up with one of Coltrane’s saxophone marathons that in order to end the solo and earn a break, he felt he had no other option but to throw a cymbal at Coltrane. There is a legendary story about John Coltrane and Miles Davis having a conversation about the physical limits of music. John Coltrane was asking Miles Davis how he could control his innate need to continue to play until the musical resolution was discovered, if at all. Davis, in his legendary, gravelly whisper of a voice, looked at Coltrane and said “Take the horn outcha mouth!”.

I love this story for two reasons, one being that it continues to make me laugh after repeated telling, but more so because here we have a perfect illustration of finding a simple solution to a complex problem.

If only the solution to physician documentation and medical records were so easy. Sadly, as we get closer to the beginning of the incentive period for meaningful use of an electronic health record, it appears that the “solution” offered in the form of mandatory EMR is looking a lot like the beginnings of a Rube Goldberg device.

The Office of National Coordinator for Health Information Technology (ONC) projected this week that 50,000 additional IT workers will be needed by providers across the country in order to meet the meaningful use criteria. Without the gift of a calculator on my desk, I quickly compute in my head that with a maximum incentive of $44,000 over a five-year period (remembering that not every provider will qualify for this dollar amount), you would have to find one IT person at a salary of $8,800 a year to break even. If you’d like to place a wager on your odds of finding this unicorn of the IT world in today’s economy, give me a call.

Let’s look at a timeline for a moment to put this in perspective. In order to qualify for maximum incentives, registration of meaningful use of an EHR begins this coming January. At the time of this writing, that’s 126 days away! The Certification Commission for Health Information Technology (CCHIT) is still reviewing applications for companies that will test and certify EHR systems to determine whether they have the ability to meet the meaningful use criteria. Also in the equation is the plan for regional extension centers to assist providers during the transition. Currently, 5 states lack an extension center and 28 states, including California,  have only one center currently open to offer assistance.

Seventy community colleges across the nation are also part of the plan, offering non-degree training courses for IT professionals to bring them up to speed. While the ONC’s website gives a time frame of “six months or less” for this training, the issue of whether 4 months of instruction prior to registration is sufficient will go unanswered up until the moment when the training is most needed.

We all crave simple solutions. The Great Migration currently underway towards the goal of electronic health records, given the rampant shortcomings of paper records, is a noble goal. Yet I may not be alone in rethinking whether the established timeline to qualify for maximum incentive payments is too short to be of value in the long run. Unfortunately, unlike the removal of a saxophone from one’s mouth, an easy fix does not appear to be readily available.

11:14 am, August 27th, 2010 | No Comments »

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Employee Trust In The Modern Environment

Posted by Paul Spencer, CPC, CPC-H in Industry Updates, RAC / Recovery Audit Contractors

In this age of increased technology and business consolidation, I’m finding trust hard to come by lately. Standards that I used to take for granted when I was growing up appear to have been forever cast aside.

I’ll offer this illustrative example, since it involves a subject that’s close to my heart. The homogenization of American business has led to every town in this country having at least two fast food restaurants. Off the top of your head, can you think of an instance when you purchased the same meal from a fast food restaurant in consecutive visits and received food of the same quality (I leave out the word “good” because, let’s face it – IT’S FAST FOOD!)? In most cases, either the fries were warmer the last time you visited, or the sandwich hadn’t been sitting under the heat lamp longer than it should have after the lunch rush. Perhaps the person filling up your drink behind the counter stiffed you this time around, either by not filling your beverage cup to the top or by giving you enough ice to cryonically freeze all of your vital organs for the next millennium to accompany the few teaspoons of raspberry ice tea dancing upon the ice cubes.

My inherent lack of trust isn’t exclusive to products I buy. As a compliance officer,  part of my makeup is to trust no one. On the surface, this may seem like a cynical way to view the universe, but I feel confident that no one is going to slip anything by me. I naturally think the worst of people, which allows for few surprises when I end up being right.

Given the focus and pace of a typical medical practice, physicians have little time to consider such matters when it comes to their staff. Most doctors are in a position of being at the mercy of their non-medical employees to keep the practice moving efficiently and cost-effectively. In an economic situation of near-depression such as the one currently in effect in this country, people who find themselves in dire monetary straits seek opportunities based less on moral imperatives and more on survival and maintaining a status quo for their lifestyle. Many targets present themselves for theft, and none is more tempting than the readily available health care dollars of a medical provider.

It appears a good time for providers to take a moment and ask themselves how much they trust the ancillary staff. With the instances of identity theft stemming from access to patient medical records on the rise,  there is a risk that potentially lies within every person in the reimbursement chain. When someone does something in your name, whether you want to or not, you now have ownership of that person’s actions. While the financial impact of a nefarious employee can be minimized, the effect on your reputation, depending on the scope of the infraction, can lead to long-lasting damage to your practice.

Depending on the length of service of current staff, due diligence in the form of background and credit checks are a simple and cost-effective way of mitigating this risk. In order to feel secure, the psychological hurdle of the feeling of “prying” has to be weighed against the risks posed by the possibility of misdeeds.

We now find ourselves on the brink of a period of increased scrutiny from governmental payers. With the coming expansion of the Recovery Audit Contractor program, coupled with increased investigations from a larger and more aggressive OIG, being able to trust the work product of ancillary staff will be of paramount importance in positioning your practice for the gathering storm of hyper-analysis. Allowing yourself a few moments of skepticism before entering this new era can give you the peace of mind necessary to prepare for the coming environment.

10:59 am, August 20th, 2010 | No Comments »

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Surviving The Times

Posted by Paul Spencer, CPC, CPC-H in Fi-Med Services

Being an obsessed fan of music as I am, I’ve realized over a period of time that it’s difficult not to develop something of a fascination with self-inflicted casualties and the personalities behind them.

I’ll give you an extreme close-up of a salient example relating to my own life. In 2004, due to a number of life circumstances that I won’t get into here, I made the decision to change my birth name. I began thinking of musicians that I admire, and I revisited the story of Alexander “Skip” Spence.

Skip Spence was the first drummer for the Jefferson Airplane back in 1966 (the year of my birth). He was something of an itinerant and kept his own mental schedule, which was incompatible with the rest of the band, and he was fired prior to their greatest success as a band. He later took his guitar-playing and songwriting skills to the band Moby Grape, another San Francisco band of the era. Through a series of record label miscalculations and ludicrous promotional planning, Moby Grape became the gold standard for how not to succeed in the music business, but Skip Spence wrote, and the band performed, the song Omaha, which is a musical touchstone of the era.

Skip was also a victim of the attitudes and excesses of his time. During the sessions for Moby Grape’s second album, Skip descended into madness fueled by excessive intake of LSD, to the point where he showed up at the studio one day in 1968 looking for the band’s drummer while carrying a fire axe. He spent the remainder of his life battling advanced mental illness until his death in 1999 at the age of 52. To mercifully abbreviate this long story, inspired by the unique music he left behind, I am now known to the world as John Paul Spencer. I added the final “r” so as to not appear as too pretentious to the world around me.

While the history of recorded music has its share of self-abuse stories similar in outcome to what you’ve just read, not all self-inflicted casualties of their times occur consciously. The many companies and corporations who have come and gone since the Industrial Revolution disappeared because they could not adapt to changes in products, demand or business conditions.

Today our medical delivery system finds itself at just such a crossroads. Over the next four years, business principles such as comparison shopping, outcome measurements and diversification are going to be applied to medical practices and hospitals in ways not previously seen.

Take a moment to internalize just how much of a philosophical shift this represents to a physician in private practice. At its core, we are now instructing a person who spent 10 years of his or her life (at great monetary expense) in rigid study and training towards their life’s occupational goal, to learn flexibility. Medical delivery by its very nature is tightly controlled, not typically lending itself to improvisation or random chance. Most established medical problems have been researched, measured and treated to such a degree that treatment protocols zero in on the problem faster now than at any time in human evolution. As the gatekeepers of this collective knowledge, physicians are trained to eliminate all questions, diagnose and treat.

Many smaller medical practices now find themselves in a time of soul-searching. Due to the technical demands brought about by healthcare legislation over the past two years, a perception is beginning to take hold that the independent physician cannot survive and will either have to merge with another larger practice or seek a health system affiliation. Add to this the increased anxiety over the expansion of fraud and abuse investigations by Medicare and other large payers, and the medical marketplace suddenly becomes threatened with shrinkage not from consolidation, but rather attrition similar to the long-lost corporate brand names of the past.

Beings and entities survive based on the ability to adapt and successfully navigate the harsh nature of their surroundings. The human advantage in this equation is the gift of critical thinking and analysis, leading to judgment. Each provider of medical services has within them a unique area of expertise, focus and patient approach that differs from their colleagues in the marketplace. Rather than being a self-inflicted casualty of the changing times, it now becomes the responsibility of each physician to let the world know what it is about them that makes them stand out among their medical brethren. I believe that the identification and greater application of this proficiency holds the key to surviving the changing landscape of healthcare delivery over the next decade.

10:43 am, August 13th, 2010 | No Comments »

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Court Ruling Obliterates “Good Cause” for RAC Audits

Posted by Paul Spencer, CPC, CPC-H in CMS, Hot Topics, RAC / Recovery Audit Contractors

Life is nothing without meaning.

As a demonstration of this statement, imagine for a moment that everything in your life that has some kind of fixed value or representation suddenly shifts. Here are a few illustrations to help you: the nickels in your pocket are now worth nine cents, the dishwasher in your kitchen is now used for the cleaning of clothing and your family dog is now an animal known as a boopwiffle.

To the best of our abilities, we have attempted to assign shape and definition to everything that exists. The moment of debate occurs when someone else applies a different set of definitions to things in our world with a long-established value. Depending on the new person’s definition, the result is either a clearer understanding of the things that surround us (such as someone like Copernicus or Galileo) or a complete and total breakdown of established order, leading to chaos. Last week, a judicial decision was handed down from a U. S. District Court in a case involving a hospital and a Recovery Audit Contractor that, if left to stand, could hold dire consequences for all providers of medical services paid by the Medicare program.

In February of 2009, CMS issued Change Request 6157, that stated that a contractor could go back as far as 4 years to reopen an initial determination on a claim, provided that the contractor has ”good cause” for the reopening. Specifically, this update clarified what constituted new and material evidence needed to substantiate good cause. The Change Request stated that the information has to be something that was not readily available at the time of initial determination. There was a key passage in this document that was at issue in last week’s case:

“A contractor’s decision to reopen based on the existence of good cause, or refusal to reopen after determining good cause does not exist, is not subject to appeal.”

The plaintiff in this case sued the Department of Health & Human Services, stating that a RAC auditor reopened a claim 20 months after the initial determination without sufficiently providing just cause for the reopening. The final decision of the judge was that a decision by a contractor to reopen a claim is not subject to appeal, regardless of whether “good cause” exists.

In summation, this decision means that RAC’s and ZPIC’s no longer have to follow any rules for the reopening of claims. No appeal rights are available to any provider to force the disclosure of a reason for claim reopening and no court can provide relief. Any contractor can reopen any claim at any time for any reason, and CMS isn’t interested in monitoring contractor reopenings to determine whether good cause exists.

While the RAC program as designed on paper was to find both overpayments and underpayments, there is no financial incentive for the RAC’s to identify both with the same veracity. If one factors in that RAC’s keep anywhere from 9% to 12.5% of all overpayment dollars collected depending on geographic area, the judge’s decision has devastating potential.

If I were to identify one silver lining with regard to the RAC’s, it would be the success rate of appeals of RAC determinations. Currently, 8.2% of all RAC decisions have been appealed by providers with a success rate of 64.4%. This indicates a high error rate on initial determination, and provides a great argument for internalizing an inherent mistrust of any RAC determination. Thanks to a short-sighted court decision, appeals against a RAC as it relates to the administration of statute are limited. Yet if the decision of the RAC as it relates to the payment determination for services seems incorrect, anecdotal evidence strongly suggests that it is, and that’s worth an appeal.

I can’t promise that the process is as easy as taking your boopwiffle for a walk around the park, but half of survival is the art of making yourself an unappealing target for predators. An aggressive response is a provider’s best defense against continued RAC audits.

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11:29 am, August 6th, 2010 | No Comments »

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The Many Ways of Being Newsworthy

Posted by Paul Spencer, CPC, CPC-H in Coding and Compliance, Electronic Health Records, In the Press, J. Paul Spencer, CPC CPC-H

As I begin this post, it’s been a typical Friday. My 4-year-old son took an interminably long time getting dressed this morning, I showered, shaved, ate breakfast and my picture ended up on the front page of the Milwaukee Journal Sentinel….

OK, so one of those things is atypical. I’ll give you a hint: I usually eat breakfast.

For more information on my 14th minute and 58th second of fame in my lifetime, click here (I’m the guy with the orange guitar). The story accompanying my grainy image is self-explanatory. So as not to worry readers who may not click through about the reasons for appearing in the newspaper, it doesn’t involve an indictment, a drunken man running onto a baseball field or (surprisingly, to those who know me) a vicious automobile accident. In these troubled and trying times, it’s nice to be part of a good story for a change, and I’m looking forward to tomorrow’s events as described in the article.

So now that we all know what a happy story looks like, let’s explore the flip side as it applies to health care compliance. I came across a story out of Florida that is a good case in point. A couple from a town called Land O’ Lakes (like you, I immediately thought of butter) were making their Sunday run to their local recycling center. When they got there, they found that there was no room for their paper items in the designated dumpster at the center. This was because someone had filled the paper bin to capacity with discarded medical records. In some cases, the records included Social Security, credit card and driver’s license numbers in addition to medical information.  

The first thing I thought of with this story was regarding EHR, and how stories like this may become obsolete within five years. Then I begin to think the opposite, with the personal theory that as practices transition from a paper record to an electronic record, we may see instances like this more often thanks to record destruction companies attempting to cut corners.

Then I begin to daydream, first about dancing in rain made of Newcastle Brown Ale to the music of the Who, then shaking my head and quickly transitioning to the government’s recent re-dedication to recovering money lost from Medicare and Medicaid due to fraud.

Having been involved with coding and compliance for several years, I’ve learned that there really is no end to to the devious machinations of the ethically-challenged in our business. From podiatrists who bill foot care on patients who have had previous foot amputations to DME suppliers forcing unneeded power mobility devices on the local population of elderly residents, extending to the virus of identity theft currently infecting  some medical practices, you need a chain saw to cut through the levels of immoral behavior in this industry.

The damage that these assorted criminals inflict is not restricted to the CMS trust funds. Medical providers who spend their waking hours operating by the rules inadvertently find themselves in the outer remnants of the spotlight that shines on the crooks. The doctors acting above board and rendering legitimate services ultimately pay a high price for the actions of the bad seeds in increased regulation, investigation and bad public relations for the health care industry as a whole.

The current administration has doubled down on recovery of overpayments through fraud and abuse investigations. For the future of Medicare and Medicaid, I see this as overdue. There are many ways to make the news, but perhaps the best approach for the honest medical provider is to implement and follow policies that insure that you end up in the non-”perp walk” portions of the local news.

10:15 am, July 30th, 2010 | 1 Comment »

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Where Will Your Contracts Take You?

Posted by Paul Spencer, CPC, CPC-H in Hot Topics, J. Paul Spencer, CPC CPC-H

Today’s post requires that I share a bit of personal philosophy with the reader. This will be the less frightening parts of my psyche, so you can stop trembling.

To start out with a bracing dose of truth, I tend to live by very few rules, mainly because I fall back on survival instincts for most of my decision making process. This includes not dancing barefoot in poison ivy, realizing that I’m not cut out for living in the forest and stopping at the occasional red light. However, when it comes to what is referred to in more puritanical quarters as a moral code, my list of rules is rather short: don’t kill, don’t steal and don’t profit from other people’s bad luck (there’s one more multitiered rule that’s rather graphic and won’t be shared in this forum).

A good example of the application of these ideas is the fact that on the side, I’m a singer. My mother once suggested to me that there could be money to be made singing hymns at funerals and I found this idea incredibly revolting and insulting. It’s not enough that someone has just lost a loved one, but you’re going to stick a hand in the family’s pocket for the act of ushering the deceased into the next life with song? I find the very thought disgraceful.

As an extension of this rule, I have a deeply wired disdain for anyone who makes a living profiting from human misfortune. My hit list of occupational vultures includes funeral homes, pawn shops, payday and title loan stores and drug dealers. For purposes of this posting, let’s add an obvious one to the list: health insurance companies.

It is a well-documented reality that since the introduction of “managed care”, insurance companies are making out pretty well on the profit side. Hand in hand with this is the fact one study indicates that in 2007, 62% of all bankruptcies filed were due to outstanding medical expenses. Of that number, 80% had health insurance coverage. Given this statistic, why are we calling the purchased product “insurance”, as the very definition of this term suggests a contract that provides a guarantee against loss?

The effects of this same industry upon the provider community are no less damaging. Due to over 20+ years of deleterious contract terms, providers across the country are struggling with the costs of practice operation. With the proliferation of PPO plans that expand abhorrent fee schedules and payment rates to insurers across the country through the use of silent PPO’s and wraparound plans, the reimbursement playing field is evolving into a mine field.

It is my duty to inform the provider community that after six paragraphs, 400+ words and a brief discussion of funeral music, I’ve reached the point in this narrative where I can relay some good news; these mine fields have maps, and these would be your insurance carrier contracts.

Provider contracts make for interesting reading. What at first presentation will sound like an opportunity to expand your patient base to another insurance population can quickly shift in shape to something more resembling indentured servitude with the simple act of a signature. Knowing this, there is no longer any valid reason for not reviewing your insurance contracts on a regular basis, at the very least yearly.

In addition to the base contract, it is equally important to be wary of any and all amendments to that contract that are offered after initial contracting. I recently came upon a case where a physician had been under contract with an insurer for 4 years (with no legitimate review of the base contract language in that time span) and was sent an amendment that he dutifully signed which gave the insurer permission to share their pricing structure with other insurers. This had the effect of extending already negative contract terms far afield to insurers to which the provider had never been formally introduced.

Health care delivery finds itself on the brink of entering a world of increased physician cost and time investment. If a provider looks at his or her bottom line today and can see beyond all doubt that the current path is unsustainable, the best way to plug the income leak engulfing the practice is to go right to the source, which would be your insurance contracts. There are many directions that can be taken with regard to building a successful and sustainable medical practice. Given what we know about the singularly predatory nature of the modern insurance industry, the time has come to ask the most important question; where are your contracts taking you?

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10:57 am, July 23rd, 2010 | 1 Comment »

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CMS Releases Final Rule for Meaningful Use of EHR

Posted by Paul Spencer, CPC, CPC-H in Electronic Health Records, Industry Updates, J. Paul Spencer, CPC CPC-H

Two things made this a beneficial week for people in America.

The first positive thing is just knowing that the World Cup of soccer won’t be occurring for another 4 years. My mind marvels at the fact that the rest of the world loves this sport with a passion. On television, a great majority of this sport looks like ping pong expanded to fit onto a field. In addition, apparently if you breathe on someone the wrong way in soccer, it’s common practice that the offended party throws themselves on the field as if they have just been assassinated. I haven’t seen acting this bad since the explosion scenes in the second and final season of The Rat Patrol. Thankfully, ice hockey training camps open in 7 weeks to assist me in getting memories of this “sport” out of my head.  

The second positive thing that occurred holds the promise of transforming a great deal of the health care system in the United States. The final rule was released by CMS this week involving the meaningful use of electronic health records (EHR).

The rule clarifying meaningful use differed slightly from the proposed rule. Originally, there were 25 standards that had to be satisfied in order to meet the definition of meaningful use. In the final rule, only 20 markers will need to be met in the beginnings of the program, with the 25 standards having been divided into two groups.

The first group consists of 15 “core” standards which must be met. These include such things as electronic prescribing, implementing and maintaining lists of drug interactions and drug allergies, the recording of patient smoking status and the reporting of quality measures to CMS. The remaining 10 standards are now placed in what is called a “menu set”. In order for a provider to demonstrate meaningful use, one can meet any five of the remaining ten criteria from the menu in addition to the core standards. This would be in effect for the first part of the incentive program, with the expectation that the remaining 5 standards on the menu will eventually be satisfied. 

Based on the number of comments received on the proposed rule about the burdensome nature of meeting some of the core standards, CMS has sharply reduced the percentage of patients that must fall under 8 of the standards.

With the release of this final rule, providers can now begin a one-year journey toward demonstrating meaningful use and maximizing incentive payments from CMS. The process of selection of a certified EHR system can now begin in earnest, if it has not already. As stated in a previous post here, the Office of the National Coordinator for Health Information Technology (ONC) is currently in the process of certifying health systems with the ability to meet the meaningful use standards. After selection of a certified EMR system, a registration link through the CMS website will become available sometime in January of 2011 that will allow providers to register to participate in the incentive program.

It is a time of paradigm shift in American health care. The release of this final rule brings all of us one step closer to fundamentally altering the doctor/patient end of the delivery system. A period of high drama, either from dread anticipation of this final rule or from attempting to guess which soccer player pretends he’s just been killed, has come to an end, with many new beginnings to follow.

2:18 pm, July 16th, 2010 | No Comments »

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Mental Preparation for Healthcare Change

Posted by Paul Spencer, CPC, CPC-H in Industry Updates, J. Paul Spencer, CPC CPC-H

I’d like to begin today’s post by admitting to the world at large of a personal habit that can at the very least be viewed as politically incorrect and at worst terribly insulting and possibly bigoted.

I like making fun of old people.

There are a number of reasons for this, but when I try to get to the root of my mocking attitude towards the elderly, it comes down to two influences on my psyche that are the most extreme examples of poor behavior in one’s twilight years: Abe Simpson from the now-iconic TV show The Simpsons and my own father.

In Abe Simpson, we have an extreme study of a stereotypical senile old man who spends his time watching Matlock, falling asleep mid-sentence while trying to verbalize a flight of ideas and yelling at clouds. In my father, I see a man so internally and ideologically consumed by resistance to change that when he begins to verbalize his belief system in horrifying detail, I begin to look around me to make certain that no one who may have any small control over my human fate isn’t around to hear the man with whom I share DNA spouting such abominable and atavistic nonsense. It is in the general – if not exact – example of my father where today’s journey begins. 

“Set in their ways” is one of the most common terms I hear from others in describing older people. We’re often told that the 18-54 age group is “the money demographic” in advertising terms, as the belief goes that this age range hasn’t found one particular product, lifestyle or set-in-stone place in society to the point where they can’t be convinced to change their mind about something. By extension, people beyond this age range are seen as having made up their minds about everything and are less able to be convinced to try something new or make a switch to a different product.

For better or worse, we all reach different definitions of “comfort zone”, from the cars we select to drive to the music we choose to hear. If you’re a provider of medical services, the way in which you practice medicine is developed after years of study and one-to-one patient interactions. While you’ve weathered the dozens of adverse changes in the reimbursement for your services, the fundamentals of your practice may not have seen such a drastic overhaul to the point where the root of your profession is adversely affected.

Over the next roughly 42 months, a paradigm shift is going to occur within the walls of the comfort zone that is your medical practice. From the moment a patient enters your sphere of treatment, your well-honed approach must be modified. I wish I could tell you that this is mere opinion, but the volume of changes about to sweep over the landscape moves this into the realm of impending fact.

The mandatory conversion to an electronic health record (if you haven’t already) will change the way your information is stored and shared. What is documented in that record will need to change to accommodate the long-delayed conversion to ICD-10 for diagnostic reporting. With quality reporting and patient outcome indicators moving from its current voluntary model to one of compulsory permanence, the patient record will need to include a level of detail that will require you to go through a period of adjustment.

Many providers should begin a short period of assessment immediately to decide how these changes will be handled on the practice level. The first uncomfortable idea I’d like to bring forward is this one; nothing is off the table. Many providers have no doubt begun to enter a self-examination phase, questioning the changes and the effect these will have on them as doctors. My advice is to expand that analysis to every aspect of your practice as it currently stands. Perhaps you have a front desk staff that has been with you for many years, but are these trusted people savvy enough to handle the coming environment? Do your billing agents have the expertise to seize every reimbursement opportunity for your practice? Are the documentation habits of any ancillary staff such that they could pose a risk in the days to come?

3 1/2 years seems like a long time, but one by one, the changes in our industry will transform from ideas and initiatives to possibly uncomfortable new realities. Channel the mental anguish you may be feeling about the future into a vision for a pliable yet compliant medical practice.

As a postscript, I know that some of you who may be older are saying, “just wait, sonny. Your time to be mocked is coming”. In answer to that, I approach age in this way. As long as there’s one person on the Earth who’s older than I am, I’m still a young man. Recently, a 130-year-old woman was discovered in Russia. I figure I’ve got a lot of young living to do, so go get in your Buick and get ready for bed.

12:26 pm, July 9th, 2010 | No Comments »

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