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.

Affinity had leased a digital copier from a company in New Jersey. The copier was equipped with a hard drive that saved every piece of data that went through the copier. When the leased copier was returned to its owner, the hard drive was not erased, leading to a security breach.

In thinking about the world we live in in 2010, there are very few places we can go that offer safe haven from the digital age. What many people fail to realize is that every bit of data ever transmitted in a digital format either already has been or at the very least offers the opportunity to be saved and stored forever.

I must admit that the very idea of this can be frightening. Every text message from my phone, every night spent playing computer games and every profanity-laced tirade in e-mail form that has ever been emitted from my fingertips can be accessed by someone somewhere. I guess we can scratch off a career in politics from my to-do list.

Now let’s bring this ominous fact of life into the realm of medical billing and compliance. It’s safe to say that in every office involved with protected health information, there exists the possibility of the information becoming vulnerable.

The Affinity case is a good starting-off point. The thing that really jumped out at me in this story was the idea that an unsuccessful job applicant of Affinity being contacted perhaps years later and being told “Remember all of that personal information you gave us before we flatly rejected you? It’s freely available in a warehouse in New Jersey”. When it is determined that an employee isn’t a good fit after the interview process, companies are used to sending out the standard “we’ll keep your resume on file for six months” letter and moving forward, with the company holding all of the cards. Now imagine the embarrassment of having to send out a second letter years later telling the person you never planned on seeing again that you exposed them to identity theft via the office copier.

HIPAA regulations make very clear the responsibilities of digital gatekeepers of patient information. It is best to remember that the computer screen in front of you and the servers to which it is connected are only a small part of machinery utilized on a daily basis that stores PHI for a legitimate business purpose. Take a quick look around you. Did anyone leave papers on the copier? Fax Machine? In a common area while getting a beverage? Take a moment to think about what documents you have placed in a medium offering some type of digital storage.

After that, look around your work area. Ask yourself whether in the eventuality of someone breaking into the office whether your desk is vulnerable to letting PHI fall into the wrong hands.

As a pertinent afterthought, I’ll share this. Spaces such as this included, more people are sharing their thoughts with an ever expanding worldwide audience on a variety of subjects. When someone feels passionate about a topic, it is now easier than ever before to stand on a virtual rooftop and shout extemporaneously to the world at large. It is the world unfiltered, and it’s unlike any form of communication that came before it. It brings into focus not only how many bright and talented people have been falling through the cracks for generations, but it is also demonstrating how many unhinged people once took a typing class.

While life has been simplified to a degree in the digital age when it comes to quick access to information, in the immortal words of Peter Parker’s Uncle Ben, great power also brings with it great responsibility. Take a moment to internalize the idea that hitting the delete button does not translate to the end of life in the digital age. Conversely, itis also a good idea to review what you have typed prior to hitting the Send button. Consider everything you do with anything that can be plugged in and has the ability to store data to be permanent and retrievable once it has left you. The biggest thing this story has taught me is that it should be a long time before anyone sits on a copier with their backside exposed again.

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”.

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….

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!

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.

Adrian and Christine began Fi-Med Management as a financial medical management consulting firm in 1993.  As the healthcare environment continues to evolve we return to our roots in assisting the independent physician maximizing revenue and reducing operational expenses.  A sneak peak on consulting services includes sophisticated analytics including E&M and Acuity Analysis, Fee Schedule Analysis, Cost and Contract Profitability, and Productivity Analysis to name a few.  Continue to look for additional details on these consulting services.

Similarly, while operating billing offices for the Management Division, HMS is constantly learning through actual experience and continuously updating the Medical Management System for the benefit of Turnkey users. 

The Turnkey Division combines powerful industry-standard hardware and the HMS Medical Management System software for practices that desire their own independent billing operation. The software provided is specific to each hospital-based specialty, with the focus of automating as many functions as possible, providing the easiest functions for day-to-day operations, and including the most comprehensive reporting available to guide important practice decisions.

The robust HMS software retains its edge because HMS has a unique process for prioritizing its enhancements.   The HMS Users Group, wholly-independent from HMS, meets twice each year to recommend ideas for enhancements to the system.  The group is led by its board of officers and funded by annual membership dues from the client members.  HMS attends all of the meetings, and therefore, knows just what its clients need all the time. 

The Practice Management Division provides billing outsource solutions for groups who do not wish to face the challenge of an internal billing operation.  HMS employs experts to monitor the changes pertaining to each specialty, and maintains memberships in the key organizations that propel and monitor changes in the medical billing and practice management industry, which gives their clients confidence about their investment in the future.

Learn more about Healthcare Management Systems, A Fi-Med Company.

You may ask why I’ve opened a blog that deals with medical billing, coding, compliance and health information with a short biography of an old actress. Please bear with me for a few paragraphs.

There is one credit on Ann Sothern’s resume that sticks out in my mind and is relevant to today’s dissertation. In 1965, Ms. Sothern played the voice of a dead woman in a television show that most critics now point to as one of the worst shows in the history of television. That show was My Mother, The Car. The show followed the exploits of a young man who one day buys an antique automobile from a used car lot. When he turns on the radio in the car, who should be on the radio but his dead mother offering life advice from beyond the grave. Mercifully, this show only lasted one season and to my great glee is not available on DVD.

As we stand back and look at this plot line, we begin to wonder not only why such an atrocious idea ever made it to air, but what person, when this idea was pitched to them, thought that something like this would appeal to the viewing public. Worse yet, the young man in the show was played by Jerry Van Dyke, whose entrance onto the American entertainment landscape acts as the ultimate symbol of what happens when we let a talented person’s less gifted siblings share a piece of the spotlight.

I brought forward the example of My Mother, The Car to illustrate that no matter what the quality, all any idea really needs is a benefactor; someone who hears an idea and states “I think that’s great! Let’s run with it”.

Which brings me to the proposed rule defining “meaningful use” of electronic health records (EHR) that was released on December 31st by CMS. In early 2009,when it was announced that physicians would receive incentive payments for the meaningful use of EHR in mid-2011, there was much excitement that a new day was dawning in the way our health care infrastructure managed and shared patient medical information.  Before meaningful use was defined, the Certification Commission for Healthcare Information Technology (CCHIT) created a certification for EHR systems that would meet the standard. Some systems gained CCHIT certification prior to the release of the proposed rule, which I pointed to in an earlier post as premature. 

Since the proposed rule listing 24 specific requirements needed to meet meaningful use was released on the last day of 2009, many practices who took the plunge and purchased an EHR prior to a clear definition of what was needed to meet the standard are experiencing buyer’s remorse, realizing that a large investment has been made for systems that may not meet the standards if the proposed rule is implemented as written.

The requirements demonstrate high ideals of treatment and public health. An example of this is the idea of EHR’s being able to share important patient condition information with immunization registries and public health agencies. Under this proposed requirement, at least one test must be performed to assess the EHR’s ability to provide electronic lab results to a public health agency. We heard a lot about interoperability when the discussion of meaningful use began in earnest last year, but a requirement such as this can only work if the relevant public health agencies have the ability to receive the information electronically.

Also put forth is the proposal that any certified EHR system be able to provide patients with an electronic copy of their health information upon request. The key word in that phrase is “electronic”. While some more sophisticated EHR systems and larger health care institutions now have this capability, this requirement places a large privacy and security burden on smaller practices that lack the IT infrastructure support to create a secure electronic pathway from the office to the patient.  

It is the intersection of high ideals and the execution of the same that presents itself as a formidable challenge to any idea. Between now and the release of the final rule, which is expected sometime after March of this year. I encourage those that have yet to purchase an EHR system, and even those who have implemented an EHR in their practice believing it would meet any standard, to review the proposed rule. If these requirements outlast scrutiny and become final, this may someday be seen as an idea that slowly took on a life of its own, consuming everything in its path until it was too late. This would be similar to the thought all those years ago that a dead mother talking to her son through a car radio would be appealing to a wide audience.

We are now two weeks into a world where Medicare has eliminated reimbursement for inpatient and outpatient consultation codes. To many specialists for whom consultations have become a way of life, it is tempting to see themselves as a manufactured post-apocalyptic film character similar to the one above. It is my duty, as a compliance officer, certified coder and budding writer of screenplays to inform you that it doesn’t have to be that way.

In a previous post on this blog, I demonstrated one way to navigate the imperfect crosswalk that exists between inpatient consultations and the CPT codes for initial inpatient encounters (99221 through 99223) that are now to be used in its place. In the past weeks, the Medicare administrative carriers have released their own guidance about what should be billed in place of a consultation code if the documentation does not meet the requirements of CPT code 99221.

For Palmetto GBA, First Coast and WPS, the suggestion is that CPT code 99499 (Unlisted evaluation and management service) be utilized for services formerly billed as 99251 or 99252. When using this code, be aware that it lacks a set payment. The reimbursement of this code is driven on a case-by-case basis and is determined by carrier review of documentation for the service. When billing 99499 to a carrier that accepts it, always be certain to include the documentation for the service.

National Government Services, as well as other carriers, is suggesting that the appropriate inpatient follow-up code (99231 through 99233) be billed in place of a low-level consultation. The choice of code would depend on the depth of the documentation for the service.

The second challenge that has been brought forth is the question of consultations when Medicare is the secondary payer (MSP). In the final revision of the new consultation policy in MedLearn Matters article MM6740,  there are two solutions that can be used. You can either choose not to bill consultations at all to a commercial payer and be reimbursed for E/M services by both commercial and MSP, or you can bill the consultation to the commercial payer, then report the amount paid and bill an equivalent E/M code to Medicare to determine whether additional reimbursement is due.

The first solution is the path of least resistance, as this eliminates consultation billing from your practice immediately and entirely. Financially, this may not be the most advantageous approach. While commercial payers are expected to eventually follow CMS’ lead and eliminate reimbursement for consultations, these codes are still active with commercial payers at reimbursement rates that are typically larger than equivalent E/M codes based on documentation.  Contractually, if you are still receiving healthy reimbursements from commercial payers for consultations, the second approach may be more to your advantage.

The reimbursement landscape has changed, but it has not been irrevocably altered for the worse. The road to reimbursement commensurate with services performed now has a few more detours than it did a month ago, but water recedes and bridges can be rebuilt. With increased attention to documentation detail and increased awareness of the new rules of the road, providers can successfully navigate a world without consultation reimbursement.

Paul Spencer CPC, CPC-H