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Archive for March, 2010

10-Day Payment Freeze Coming: The Senate Strikes Again

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

The latest temporary fix to the Medicare Physician Fee Schedule, which expires on March 31st,  was not renewed prior to the U. S. Senate adjourning for its Spring recess this past Friday. The Senate will now be in recess until April 12th.

In response to this, in similar fashion to a month ago, CMS has declared a 10-business-day freeze on the processing of claims with dates of service of April 1st and after. Because this freeze is measured in business days, it will end on Wednesday, April 14th, which gives the Senate two days to pass a fix.

The latest physician fee schedule fix is attached to a bill that would among other things, extend unemployment benefits. This latest hold was initiated by Sen. Tom Coburn of Oklahoma, who objected based on there not being equal cuts in spending. The ironic twist is that Senator Coburn was a practicing OB/GYN for 11 years prior to beginning his political career. His hold on the bill would appear to complete his journey away from the science of medicine.

As the great songwriter Steve Goodman once wrote, “It’s not hard to get along with somebody else’s troubles”.

March 29th, 2010 | No Comments »

Translating The Health Care Overhaul

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

One of my best friends in Milwaukee is my friend Ben. I’ve known him for a few years, and as soon as we met through mutual friends, it took us about 5 minutes to hit it off. Our friendship is designed mostly around three common themes; politics, ice hockey and beer. For purposes of this post, I’d like to focus on the first of these, more than likely to the great relief of my benefactors here at Fi-Med.

Ben and I have been following the progress of the health care legislation that became the law of the land this past week with great gusto, being the above-average policy wonks that we consider ourselves to be. It’s been an interesting  journey, and as we have discussed this topic in public in different venues around Milwaukee, we’ve tended to suck in random eavesdroppers who are surprised mostly that people are engaged in the process without the tirades and invective so common in the modern world of 24-hour cable news.

Over the past two weeks, random employees of Fi-Med have also informally polled me for my opinions and analysis of the health care reform legislation. Weighing in at 2,409 pages, breaking it down can be daunting. Having said that, I’ll try to focus on the biggest issues that are front and center in the Patient Protection and Affordable Health Care Act.

Covering The Uninsured – The main reason why health care reform was seen as a top priority was the number of uninsured people in the United States. Currently, 83% of Americans have health insurance coverage. After the full phase-in of the new law, that percentage is expected to grow to 95%. There are a few ways the law expands coverage. Medicaid programs will be expanded to cover people with incomes up to 133% of the federal poverty level (currently $29,327 a year for a family of four). If you own a small business (generally defined as less than 50 employees), are self-employed or currently uninsured, the law mandates the creation (or expansion) of state based insurance exchanges, which are basically purchasing pools designed to give smaller groups the same kind of purchasing power as a large employer or other well-heeled insurance customers. There will also be national exchanges available that will be overseen by the same agency that currently oversees the health plans available to members of Congress. Beginning in 2014, if you are not covered by a health care plan, you face a penalty, unless your income falls below a certain level. Additionally, in 2014, if you are employed by a company with more than 50 people, and the government subsidizes coverage for your company, the company faces a penalty of $2000 for each full-time employee, with 2 part-time employees counting as 1 full-time employee for purposes of calculation. Pro - People who do not have coverage will be able to find affordable coverage from multiple sources. Con - On the surface, this would seem to strengthen the hand of an already entrenched insurance industry in the absense of a national public option or the option to buy into the Medicare program while weakening the options of the mid-sized employer.

Pre-Existing Conditions – Beginning in 2014, insurances will no longer be able to use pre-existing conditions (for adults or children) or a person’s gender to deny a person coverage or increase premiums. Since this is four years away, the law also creates a temporary national high-risk pool similar to programs currently available in 35 states. There are only pros in this portion of the law. When healthcare reform was first attempted in 1993, the idea of the elimination of pre-existing conditions was brought forth against the backdrop of over a decade dealing with the AIDS crisis and the challenges it brought to chronically ill patients attempting to obtain coverage. What we ended up with was HIPAA, which was an important first step with regard to patient privacy and protection of medical records, but somewhat far afield from the initial goal. I would imagine that insurance applications are going to look radically different four years from now barring any sudden changes to the law.

Insurance Basics – Some long-held standards in the basics of insurance coverage change with the new law. Parents will be able to keep children insured on their policies until age 26. Beginning in 2014, childless adults below the federal poverty level will be eligible for Medicaid coverage. Pro - College graduates can continue coverage under their parents’ plan in a challenging job market. Con - Really? Your children don’t have a plan by age 26? Sell their X-Box when they’re not looking and put their possessions at the curb. Explore tough love.

Senior Citizens - By 2020, the so-called “doughnut hole” in Medicare Part D coverage which doesn’t cover up to $1,720 of prescription drug costs, will be substantially addressed. This will begin modestly this year with a $250 rebate to seniors facing the out-of-pocket expense incurred after the first $2,830 of benefits have been exhausted. Beginning in 2011, seniors will begin to receive a 50% discount on brand-name drugs, which will slowly increase to 75% by 2020. The bill also has a cap on annual increases in Medicare spending, which will be closer to 2%. This is down from the 4% increases seen in the past. Pro – The onerous gap in prescription drug benefits for seniors is belatedly addressed. Con – A back-door gift to the larger players in the pharmaceutical industry, as generic drugs are not subject to the same discounting procedures. Decreases in Medicare spending more than likely will be felt in the elderly wallet. This could theoretically turn into a pro for drivers like me, as the elderly will have less money for fuel to drive their Buicks in the left lane at 35 miles per hour on the expressway as I’m trying to pass.

Dollars and Cents - The plan has an estimated cost of an average of $94 billion dollars over the next ten years. While the total seems high at first blush, comparing it with the costs of the ongoing military operations in Iraq and Afghanistan (remember those?) suddenly makes that number seem small. A tax on investment income of 3.8%, as well as increased taxes on individuals making more than $200,000 per year and married couples making over $250,000, pays for some, but not all of the bill. Pro – When held up to the projected costs of a full government takeover of healthcare with a public option, this appears not to be a lot of money. Con – When a citizen overdraws his personal checkbook, we get a nasty letter and a fine from our bank. When an American legislator of either party overdraws the country’s checkbook, they congratulate themselves, get checks from their corporate benefactors and get re-elected. This is one of the big reasons why I’m in the slender minority of people who want to see global warming actually succeed, so we can usher in a Humankind 2.0 that in theory will be able to properly operate a calculator.

PQRI – Less talked about in the greater news media is the fact that the new law mandates the use of the Physician Quality Reporting Initiative beginning in 2014. As with the current statute regarding electronic medical records, there will be gradual reductions to a physician’s Medicare payments if quality reporting is absent. This shouldn’t come as a surprise to anyone in this industry, as this has been an eventual goal of the program from the very beginning.

Physician Payments -The current state of the physician fee schedule was not addressed with the new law. This is still tied to another piece of legislation that extends unemployment benefits and rural satellite TV. Senator Tom Coburn of Oklahoma has objected to the bill in the same fashion as the objection by outgoing Senator Bunning of Kentucky to the last extension. The Senate adjourns on March 31st for a two-week recess, leaving 5 days for the temporary fix to the Medicare Fee Schedule to remain in place before reverting to the 21.3% cut mandated by current law.

As many of the provisions of the new law do not take effect for a few years,  the results will not be immediate. As the law stands, it should be viewed as a beginning, as both sides of the political fence fight to either expand or contract the law in its current form. I know that my friend Ben and I are optimistic. Now if only we were so optimistic about our respective teams’ chances in the Stanley Cup Playoffs that start in a few weeks….

March 26th, 2010 | 3 Comments »

The Long Overdue CMS Signature Requirements

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, J. Paul Spencer, CPC CPC-H

In the 43 years and roughly 11 months that I’ve walked the planet, there have been a number of hoaxes that have been identified after careful study. From Clifford Irving’s “autobiography” of Howard Hughes to the Tassadai Tribe to the Hitler diaries to Balloon Boy, there is no shortage of things in our culture that appear authentic on first blush that turn out to be nothing more than elaborate inventions.

Being a natural cynic and skeptic, when these frauds rear their head, I begin to expand the thought model and wonder about accepted interpretations of long-standing monuments of human existence. What if Stonehenge was just some crazy person’s attempt at modern housing gone terribly wrong? What if the Inca roads were actually an ancient horse race track? What if the Egyptian hieroglyphics that have been interpreted by historians as blessings to the god Ra actually translate to “Thursday: Ate eggs. Worshipped the cat. It was hot again in the desert”.

As a medical chart auditor, when confronted with the average physician’s handwriting, it is easy to fall back into this pattern of thought. Thankfully, I also carry with me the curse of horrible penmanship, so I’m uniquely suited to look at handwritten physician documentation. Sadly, as of yesterday, that skill set may not be enough.

Beginning March 18th, CMS brought forth signature requirements for physician documentation that are much more stringent than in the past. These rules stemmed partially from a sudden sharp increase in the Comprehensive Error Rate Testing (CERT) error rate in 2009, with missing or illegible signatures on medical record documentation being one of the main drivers of the error rate spike.  

Aside from a mass reintroduction of the Palmer Method to the physician community, there are definitive ways to get the physician signature recognized as legitimate on documentation.

Let’s begin with the premise that the physician has an illegible signature. If the physician utilizes a record that is pre-printed with his or her full name and credentials, identifying the physician of record can be as easy as circling the physician’s name on the record and providing a signature on the same page. If the provider provides an illegible signature over his or her typed or printed name, this is also acceptable. In the absence of records pre-printed with the physician’s name, the last method of identifying an illegible physician signature is through the use of a signature log, which would contain the provider’s printed name and credentials along with the physician’s signature.

A legible signature can take the form of either the full first and last name of the physician, or the physician’s first initial and full last name. It is not recommended that an initial be used in place of the physician’s last name unless the physician’s name is pre-printed on the medical record or is accompanied by a signature log, as in the examples above.

If the physician neglects to sign a portion of a handwritten note, but the note page contains other entries in the same handwriting that are signed, the documentation is considered acceptable.

A signature stamp, or the words “Signature on File” without a corresponding physician signature are not considered acceptable documentation of the physician’s signature.

While the annals of history have provided us with multiple interpretations of the same landmarks or events, audits of physician documentation by CMS and their contracted entities are not nearly as open-minded or forgiving. While many interpretations can be reasonably argued, a lack of a signature that clearly identifies the physician of record presents an unnecessary risk of a negative audit finding to a physician. Following the steps outlined above offer the shortest root to the beginnings of a defensible medical record.

March 19th, 2010 | 4 Comments »

James Offutt, CTO

Posted by Lisa Velasquez in Fi-Med's Executive Team

For more than ten years James Offutt has served as chief technology officer at Fi-Med Management, Inc., providing high-level direction on network security and the technology investments essential to Fi-Med’s rapid, agile growth.

Through a decade flush with advancements in medical billing technology, Offutt has led Fi-Med from an un-networked office of five workstations in the mid-1990s to a robustly-networked national firm with an award-winning IT team. His expertise in security, process automation and records digitization has helped place Fi-Med at the fore of a marketplace just now beginning to make those transitions industry-wide.

Offutt attributes Fi-Med’s success largely to its aggressive, proactive approach to catching and eliminating inefficiencies through initiatives cost-of-process studies that drill down and measure the steps, time and resources of a processing cycle end-to-end. The result: the company’s growing reputation for quick, lean solutions to changing regulations, and the ability adapt services to a market that can often be a moving target.

Working closely with Fi-Med’s IT team, Offutt has helped to spearhead the development of custom, in-house medical billing applications that will help keep them moving at the industry’s leading edge, and he continues to help Fi-Med navigate the security, networking and data challenges inherent to growth and acquisitions as the company continues to expand – keeping cycles moving smoothly and eliminating duplications that can impact efficiency.

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March 16th, 2010 | No Comments »

Better News For The Physician Fee Schedule

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, In the Press, Industry Updates, J. Paul Spencer, CPC CPC-H

It’s been an interesting few weeks with regard to the Medicare Physician Fee schedule.

In my post on February 26th, I detailed the last-minute objections by lame-duck Kentucky Senator Jim Bunning to the passage of the bill which contained a 30-day hold on the 21.3% decrease in the physician fee schedule. Due to Bunning’s hold, CMS was left no alternative but to instruct carriers to hold all claims with dates of service March 1st and beyond for 10 business days in the hopes that the bill would be passed in the Senate. On March 2nd, after several hours on the Senate floor shaking his fists and yelling at clouds as only an elderly man can for the viewing pleasure of the C-SPAN audience, Bunning relented, the bill passed, President Obama signed the legislation into law and the claims hold was lifted almost immediately.

Due to the new deadline of April 1st, the issue was taken up again this week by Congress. The Senate actually acted first this past Wednesday, passing a bill that would extend the hold on the fee schedule decrease until October 1st. This legislation now returns to the House of Representatives for consideration next week.

What is still needed, and apparently not being talked about on the legislative side, is a permanent fix to the sustainable growth rate formula. The October 1st deadline now represents the 4th moving of the goalposts in a period of 3 months. While no one wants to see the 21% cut, the chorus from those wanting a permanent fix continues to grow louder.

With better news, we now enter a world more plagued by uncertainty than even the payment fix, this being the continuing saga of the broad healthcare legislation currently coursing its way through Congress at the rate of a sloth in an opium den.

From what I can gather from news reports, it would appear that a final vote on healthcare legislation is going to occur by the end of the month. President Obama has delayed a planned trip to Guam, Australia and Indonesia that was scheduled to take place from March 18-24 by three days in order to concentrate on getting healthcare legislation passed and enacted into law. So many variables remain on the table as the bill enters final negotiations that it would be premature of me to predict the shape of the final legislation. Judging by what I’m hearing, my optimism isn’t high.

As is often the case in Washington, the inflated sense of self-importance so prevalent in American politics tends to rear its head in the most ugly fashion possible when one side perceives that they aren’t getting everything they want right this minute. The cacophony of nonsense that has poisoned the well of civilized political discourse for the last 20+ years insures two outcomes, the first being ever expanding concentric circles of bad legislative decisions and the second being a chronic loss of interest in the issues that count from the rational people who most need to be part of the debate.

Rather than ending on a pessimistic note, I’ll end with a happier tone. St. Patrick’s Day is now five days away. I’ll be “out of the office” on Wednesday, March 17th. If you happen to be out in the great beyond of Milwaukee this coming Wednesday and you come across someone with brown hair wearing a Guinness hockey jersey, do the right thing and prop me up.

Until then, have a great weekend!

March 12th, 2010 | No Comments »

Wondering if a lockbox is right for your practice?

Posted by Lisa Velasquez in Fi-Med Services, Hot Topics

The AMA published an article a few years ago in American Medical News about the use of bank lockboxes in response to a question about whether or not it was worth the expense. Although the article did a great job of explaining the benefits of using a lockbox to expedite deposits, it did not answer the second part of the question asked, which was, “Are there any alternatives?”

CEO, Adrian Velasquez and COO, Christine Krause have always recognized the benefits to physicians of using a lockbox service and prior to creating Fi-Med’s internal bank and lockbox service, they used to encourage all of their clients to use a lockbox if at all possible. Unfortunately, not all banks provided lockbox services to their customers, and those who did often charged very high fees making the use of a lockbox not a very practical solution for most physicians.

Adrian and Christine consulted with several banks in order to find an affordable solution for their clients. As they began to work with banks they realized that there was a very important component to the lockbox process that all banks were missing. The problem? Banks don’t understand medical billing. They don’t understand what an Explanation of Benefits (EOB) is. They have scanning technology but their employees aren’t trained to recognize and capture all the important information that a medical practice needs. They don’t do this intentionally, they just don’t understand how medical billing works. Adrian and Christine realized that in order to provide the best service to their clients, they were going to need to create it themselves.  

The  Fi-Med lockbox brings the best of both worlds to our clients—the security and efficiency of a  lockbox that is more affordable than most traditional bank lockboxes, combined with years of medical billing experience. Fi-Med’s lockbox is more affordable than most traditional lockboxes. There is no need to change your existing banking relationship, payments are immediately scanned and deposited by ACH into your bank account of choice and you can view daily deposit activity online.

The Fi-Med lockbox service trims more than a week off the normal payment cycle for most clients and  eliminates time spent opening and sorting checks and Explanation of Benefits (EOB), filling out deposit slips and taking deposits to the bank. Fi-Med’s lockbox service takes human error at the office level out of the equation, completely eliminates the potential of employee theft and makes account reconciliation faster and easier. 

Fi-Med staff is bonded and follows GAAP in the separation of duties and responsibilities. Fi-Med is committed to excellence, offering its clients reduced costs so that they can concentrate on maintaining a high level of care for their patients and a competitive advantage.

March 5th, 2010 | No Comments »

Embracing Reimbursement Opportunities in Lean Times

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, J. Paul Spencer, CPC CPC-H

There is evidence to suggest that the first week of March is the unkindest time of year for funny fat guys. Lou Costello and William Frawley (from “I Love Lucy”) died on March 3rd, John Candy died on March 4th and John Belushi died on March 5th. If I didn’t have enough incentive to start losing weight, a look at this list during the past week would have been all I needed to move forward, as this would appear to be an unfriendly time for those with excess weight.

Historical patterns also suggest that all empires and times of excess eventually come to an abrupt end. We tend to mark the ages of man by the main national force of the time frame, chronicling the times of lapsed cultural powers, from Ancient Egypt to Greece to Rome. The modern advantage we all share is the ability to review history and learn from it. When we embrace the lessons learned, humanity has the ability to come out on the other side of lean times stronger than ever before.

Our country currently finds itself in a profound time of economic challenge, which threatens the stability of long-established institutions. With the U6 unemployment rate (which measures total unemployed, underemployed and long-term unemployed only marginally attached to the workforce) currently measuring at 17.9%, effects begin to move through parts of our economy at different rates. There is a feeling in our industry that the economy has unceremoniously arrived at the door of the healthcare delivery system. Combine our current economic morass with the double-digit premium increases foisted upon those who still have coverage from the health insurance sector (none of which is returned to healthcare providers in the form of more favorable contract terms) and it becomes of paramount importance to look for unexplored ways to increase collections.

There is a direct correlation between the reduction of workers and the increase in the self-pay population presenting for healthcare services. This burgeoning population requires increased due diligence on the part of registration and front-desk staff to minimize the impact of this group on a provider’s bottom line. The following simple steps can assure that providers protect themselves and retain full value for their services:

  • Insurance Demographic Verification – When an established patient either presents for services or contacts you for an appointment for future services, verify that the patient’s coverage is still in force. This will give both parties a clear picture of the patient’s liability for services rendered.
  • Know Your Fees – The self-pay population, particularly a provider’s established patients, will want to know their liability for services. Having your fees for certain services on hand will help front-end staff in designing a payment schedule for the patient.
  • Compliance Awareness – Routine blanket waivers of co-payments, deductible and coinsurance are considered a violation of federal law if you see Medicare or Medicaid patients in your practice. Federal law does allow for economic relief for a patient due to financial hardship. In each case where a patient requests forgiveness of all or a portion of their outstanding balance, economic information unique to that patient should be taken into account before arriving at a dollar amount.
  • Know Your Referral Rules – Specialists must be acutely aware of referral and prior authorization rules and requirements for insurances utilized in their area. Without this knowledge, the number of non-covered services for patients with active insurance coverage needlessly increases, often with no opportunity for appeal. There are some carriers that will allow for retro-authorization, but this is not such a large number that a provider should gamble with reimbursement of legitimate services.

 

Thin times often call for defensive measures. With the understanding that each provider’s field of practice offers with it unique considerations, internalizing and following the above steps can provide a healthy head start towards seeing a practice from current lean times to (hopefully) brighter and heavier days ahead.

March 5th, 2010 | 2 Comments »

A New World Coming Monday!

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

UPDATE (2/26/2010, 4:23 PM EST): Since my creation of the following post this morning, it has been learned that the Senate has adjourned for the weekend and will not be passing the temporary reduction freeze in time for the Monday deadline.   

The latest temporary measure was to be attached to another measure granting an extension of unemployment benefits for 12 million people whose benefits have run out. Jim Bunning, the senior senator from Kentucky currently in his final term, filibustered the bill based on the bill either not having equal cuts in spending to pay for itself or because the funds for the bills would not come from leftover money from an earlier stimulus package. The Democratic majority was unable and/or unwilling to break the filibuster, and the Senate has now adjourned until Monday. 

CMS has since issued a press release that states that they are instructing the MAC’s to place a hold on claims for the first 10 business days in March. It is believed that this will provide ample time for Congress to issue another temporary payment fix.  

It was 104 years ago today that my grandmother was born in the western suburbs of Philadelphia. Some of the only positive memories I hold of my childhood stem from the time I spent with my grandmother in her kitchen. She had a breakfast table in her kitchen that looked out upon her back yard. Just beyond her backyard was the Route 100 line, that sent trolley cars from 69th Street in Philadelphia to their final destination to the west, in Norristown, with many stops in between. It was easy to get lost in the great potential the world offers a small child standing in her backyard on a sunny day, with the subtlest hint of clouds in the sky and the clickety-clack of the trolley passing every 15 minutes. 

My grandmother left this world in April of 1994, In the nearly 16 years since, the memories I’ve carried with me of the time I spent by her side reappear at strange times. It could be the sound of a distant train or the smell of her veal recipe that I still make for my wife and son from time to time. Yet when her memory comes forward, after remembering a funny story or a brief glimmer of a moment in past time when the two of us occupied the same space, the very last thing I feel when such memories arise is loss, and the change in my life that losing this one person brought forward. One can only dance inside their head for an instant before the reality of subtraction appears before them. 

Which brings me to today’s urgent topic. Over the past 6 weeks, the medical community has watched with a combination of anger and exhaustion as Congress has failed to definitively act on the issue of the 21.3% decrease in Medicare payments set to take effect this coming Monday. As I type this, yet another piece of legislation has been introduced to delay the pay cut until March 28th, which would create yet another window of opportunity to create a permanent solution to this annual occurrence. 

As I described in an earlier post on this topic, we have become desensitized to this process, as a white knight with long flowing hair, cleverly disguised as the latest legislative stay of execution, has until now always arrived in the twilight moments of the latest deadline. With the two days between now and March 1st falling on a weekend, the possibility exists that perhaps this is the time when the knight has either fallen asleep or found other worlds to save. 

While it is certainly within the realm of possibility based on past precedent that a temporary pay fix will pass before the Monday deadline, the sobering reality still exists that no fix may be coming. A question immediately appears in my head, wondering how many physicians have truly prepared themselves for this darker eventuality. If someone in this industry takes a moment to imagine the medical delivery landscape in a world where 21% of the largest payer’s receivables suddenly disappear like water vapor, it is more than likely a post-apocalyptic vision. 

Lou Reed, with a mix of poetry and a New Yorker’s gift for blunt assessment, once wrote “There’s a bit of magic in everything/and then some loss to even things out”.  The healthcare system now finds itself facing an unwelcome loss, while once again hoping for the annual act of prestidigitation that makes a pay cut disappear right in front of your eyes. While those of us involved in the industry can do all we can in the next few days by inundating Congress with faxes and telephone calls demanding a remedy to this situation, be mindful of what this change actually means to our system. Without that awareness, the reimbursement realities of today could become the memories and sense of loss of Monday.

March 1st, 2010 | 3 Comments »