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Archive for July, 2010

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.

July 30th, 2010 | 1 Comment »

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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July 23rd, 2010 | 1 Comment »

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.

July 16th, 2010 | No Comments »

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.

July 9th, 2010 | No Comments »

The Road to EHR Investment Begins

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

Currently in my house, we are in a yearly three-week cycle of gift-giving. It starts with Father’s Day, moves on to my wife’s birthday on the 30th of June and ends this coming Sunday with my son’s 4th birthday on the 4th of July. With a little bit of planning, some very cryptic questions from my wife and I back and forth to one another, and the realization that my son is currently in what I refer to as ”The Superhero Period”, everyone comes away happy (I won’t mention that the ice hockey video game my wife gave me for Father’s Day is frustrating the daylights out of me and leading me to use language not usually seen by readers of this space; how do you make that little glowing guy with the Finnish surname pass the puck  forward?).

While the spending going on currently in my house is mostly in the realm of personal happiness and general frivolity, medical providers are currently contemplating an investment of a more serious nature. With incentives of up to $44,000 from the government for the adoption of electronic health records on the horizon, and with the mandatory use of EHR following close behind, practices are on the brink of making what could become the most important decision of their careers.

On June 18th, buried amidst the Sturm und Drang of the latest Medicare Physician Fee Schedule fix, HHS’ Office of the National Coordinator (ONC) for Health Information Technology released a final rule concerning standards for gaining certification of an EHR system. This sets the stage for the final rule defining “meaningful use” of an EHR system, which is set to be released within the next few weeks. This rule release can be considered the humble beginning of the providers’ decision process. 

The final rule for certification did not differ dramatically from the proposed rule, but there were some interesting tidbits. First. the final rule opens the door for more than one certification agency being involved in the process. Currently, the Certification Commission for Health Information Technology (CCHIT) is the only certifying agency, but as of yesterday HHS began to accept applications from companies wishing to become certifying agencies. I’m interested to see how this particular corner of the process develops, particularly as it relates to business relationships between certification agencies and software developers. While the certification standards come from ONC, how will compliance to the standards be measured to guarantee transparency in the certification process?

Once the testing agency applications are approved and certifications are granted, ONC will keep a list of certified software products on its website. Even though the approved certification agencies will more than likely publish the same listing, I recommend going right to the source once this list begins to be compiled.

As October 1, 2012 looms in the distance as the deadline by which practices can begin to demonstrate meaningful use of EHR in order to qualify for the maximum incentive payment, there is a healthy allotment of time to choose the EHR system offering the best fit for practices. When considering such a life-changing investment of financial resources,  this time element presents itself as a positive in the process. With the impending release of the meaningful use rule, it is hoped that the map of the road about to be traveled is revealed to be the shortest distance between the two points of selection and implementation.

July 2nd, 2010 | 2 Comments »