Posted on Fri, May 04, 2012 @ 01:17 PM
Written By: Bob Spoerl, Becker's Hospital Review
http://www.beckershospitalreview.com/hospital-physician-relationships/8-biggest-mistakes-an-aco-can-make.html
Given the recent announcement of the first 27 CMS Medicare Shared Savings Program accountable care organizations, and with health insurance giants such as Cigna, United and Blue Cross Blue Shield touting accountable care models, it's safe to say the phenomenon is both public and private. And regardless of how the Supreme Court rules on the Patient Protection and Affordable Care Act, most healthcare leaders agree that accountable care in one form or another is here to stay.
As more hospitals, physicians and payors nationwide enter into integrated care models, the time is ripe for hospital leaders to consider issues ACOs will face during formation, in order to address the biggest mistakes they might make on the path to starting one. In the coming months, as more ACOs develop, there will likely be a clearer picture of all the issues an ACO could run up against. For now though, here's a list of some mistakes that could spell serious trouble for an up-and-coming ACO.
- Lacking an appropriate governance structure where all constiuents are at the table.
- Operating under exisiting economic incentives incompatible with the intent of an ACO.
- Failing to address antitrust issues.
- Not making information technology a top priority
- Not establishing a meaningful set of quality measures to rate ACO success.
- Failing to involve payors
- Failing to realize the patient is at the center of care in an ACO.
- Underestimating the time it takes to form an ACO.
To read more about each of these eight mistakes click the link above.
Posted on Wed, Apr 25, 2012 @ 10:35 AM
By: Amy Walrod, RN, Product Analyst, HealthMEDX, LLC
In December 2008 hospice regulations went through a major overhaul. Prior to 2008, the regulations had not been updated for 20+ years. Several agencies were forced to shop for a solution and forgo their paper documentation system with the need to standardize the data collection and reporting as a major driving factor.
In 2008 we were introduced to the QAPI (quality assurance/performance improvement) initiative. This regulation was a challenge for hospice agencies and forced many to transition from paper to an electronic medical record. The need to track, trend and report on clinical and operational outcomes was overwhelming to many.
During this time the industry was faced with increased regulatory scrutiny. RAC and ZPIC audits were more and more common among hospice providers. Agencies had to learn how to navigate regulatory compliance in day to day operations. As a result of the regulatory climate, hospice providers are focused on clinical documentation to ensure data elements are being tracked and clinical eligibility is clearly recorded.
These regulatory changes have made an electronic medical record a necessity in most agencies. A paper based documentation system has become inefficient. The need for standardization, enhanced communication, improved efficiency and regulatory compliance has made electronic documentation the tool of choice within the hospice agency.
Hospice agencies are challenged to focus on the changing regulations while maintaining high quality care. The electronic medical record helps by recording consistent data and outcomes while also assisting the clinician support eligibility by using evidenced based protocols.
Posted on Fri, Apr 20, 2012 @ 12:15 PM
The process of selecting an appropriate software solution for long-term, home care, or rehab providers can be challenging. Evaluating system functionality is an important aspect in choosing the appropriate software for your organization. Evaluating your prospective vendor’s preparedness to address ongoing changes to industry regulations, the rapid pace of innovation, and an established goal of 2014 for EHR should be of equal importance in the selection process.
The evaluation of a potential partner’s ability to address these types of issues doesn’t have to be complicated. Asking the appropriate questions of your vendor candidates will help determine their focus and readiness for the issues facing long-term and post-acute care in today’s market. Eight questions are provided below that should always be asked of a potential software partner in an effort to determine their readiness to handle the future. These questions can serve as discussion points between care providers and vendors to ensure a like-minded approach to the issues facing long-term and post-acute care. Questions you should ask are:
- How will you support our organization if we want to be part of an ACO (Accountable Care Organization) or HIE (Health Information Exchange)?
- What steps are you taking to ensure your solution meets industry standards for a certified EHR?
- How do you create enthusiastic end users to avoid resistance to change?
- How does the solution support a single, integrated, person centered record?
- What is your objective during the discovery process?
- How do you balance innovation, client needs and regulatory changes in your product?
- How do you assist novice or entry level users in becoming proficient quickly with the system?
- What tools are available to the client to make system adjustments after implementation?
Read our white paper to find out why each of these questions are important!
Posted on Mon, Apr 16, 2012 @ 08:31 AM
By: Mark Solomon, Director of Innovation, HealthMEDX, LLC
I have been developing software for over 25 years now. I have to say HealthMEDX Vision Mobile View has been the most rewarding product creation of those 25 years. To take this venture from idea to working product has been quite an experience. Our goal was to develop a product that began with the mobile clinician in mind. We wanted to make it easy and straightforward to use and have all the features needed by a mobile clinician but at the same time only those features needed.
We went out on a number of home visits with nurses and therapists observing Mobile View’s use in the field. I am always reminded, when in a patient’s home or apartment, how the main thing in all of this is the patient. It is not about technology or some software program; it is about providing care to those who are sick or recovering from illness or injury. I was pleasantly reminded on my last Mobile View home visit how well seniors are adopting technology into their own personal lives.
We were in an apartment of an elderly lady receiving therapy. In the background, I could hear music. As the patient proudly showed me the flower garden she maintained for the apartment complex, I inquired about the music I was hearing. She told me it was from her computer playing Pandora. I was impressed. So, I asked her how many Pandora stations she had created. She informed me she had 15 different stations. I looked on my smartphone and I only had 3. Lesson learned; seniors can adopt technology and do it very well.
As I have observed Mobile View implementations, I have found there are 4 critical items any organization must undertake to be successful.
- Processes Impacted by going to point-of-care solution - No matter what software product you install when you go from paper based point of care to automation there are any number of processes that will change dramatically. It is critical that all processes impacted are identified and modified to support the change to electronic documentation. Furthermore, it is important to try these modified processes in a test environment to make sure the changed processes work as expected. Failure in this area creates confusion and becomes a barrier to getting the results you are hoping for with the implementation.
- Device Selection – This is a very important part of the implementation plan. I cannot tell you which device will work and which one will not. I can tell you making someone who likes Fords drive a Chevy will not work. The same principle applies. My suggestion is to look at a number of devices and test drive them. Involving the nurses and therapists in the selection process will get you a long way towards obtaining their buy-in to the device. Good software coupled with a bad device equals unhappy user.
- Clinical Content - An often overlooked step is the clinical content. Nothing frustrates a nurse or therapist more than being at the patient bedside and not being able to effectively document the care being provided due to the form not having the right question or the care plan not having the right goal or intervention. Early in an implementation, I would recommend doing a content evaluation of what forms and care plan libraries you plan to use. If you can, use the content in paper form as you prepare for the eventual cutover to electronic documentation, it will give your nurses and therapists a chance to test drive the content and become familiar with it. Then, when they see the same content in the electronic documentation, the familiarity will be comforting.
- Software – Good software is certainly a part of a successful implementation. With Mobile View, your clinicians will find an easy to use, intuitive software program they will enjoy using. There are a number of settings that make the software experience a good one. Taking the time to understand these and pilot them in a control group will help you fine-tune the software for your particular implementation. Of paramount importance, is getting the right services to be Mobile View enabled and getting the correct steps identified and sequenced so the product flows smoothly.
It is a paradigm shift from paper to electronic documentation and requires tremendous support of all who are involved. Understand, this is a big change in your organization and the challenge is much bigger than just software. The good news is; it is worth it! There are so many benefits of electronic documentation.
Happy Mobile Viewing.
Posted on Mon, Apr 09, 2012 @ 01:00 PM
By: Don Carlson, Senior Development Manager, HealthMEDX, LLC
The HealthMEDX HIPAA 5010 team has been working on the 5010 project for a little over a year. Since late Spring 2011, development efforts really gained momentum.
In addition to HealthMEDX efforts, clients have made significant progress with 5010 preparation and testing. Clients began reported their first 5010 production approval in August of 2011 and the first MAC blanket vendor approval was received in September of 2011. Since the inception of the project, the HealthMEDX team has identified, and are tracking, just over 300 client lines of business for 5010 claim format upgrades. Currently, over 85% of Medicare lines of business have passed testing and/or are getting 5010 claims paid in production within the HealthMEDX client base. In addition, client Medicaid lines of business have over 60% within that same status!
In late December, 2011, Medicare announced a 90 day discretionary period where they would not force the use of 5010 claim formats until March 30th, 2012. Before that deadline, Medicare extended another 90 days through the month of June.
Despite the extension of the discretionary period by Medicare, HealthMEDX clients have been exceptional in preparing for the upcoming regulatory change. To move 100% of HealthMEDX clients to a completed testing status and move them into production with the 5010 claim format, there is still some work to do. It might be a natural reaction to relax 5010 testing efforts during this extended discretionary period, but HealthMEDX is driving the continued assistance of clients in their efforts to complete this testing now.
With over 75% of HealthMEDX clients already prepared for the HIPAA 5010 change, clients are making significant strides to be ready for the 5010 transition.
Posted on Thu, Apr 05, 2012 @ 01:30 PM
Effective Jan. 1, 2012, healthcare transactions began their journey across the new 5010 transaction format. On March 15, 2012, CMS’ Office of E-Health Standards and Services announced that it would again delay enforcement of the HIPAA Version 5010 transaction standards for three months. Physician practices may therefore continue to submit electronic claims using Version 4010 through June 30, 2012, without penalty. Although CMS will not enforce compliance until July 1, the implementation date for Version 5010 is still Jan. 1, 2012, and all covered entities should continue to make every effort to comply with the new standards.
Physician groups may be experiencing unusual denials, payments sent to an incorrect address or less expedient cash flow since Jan. 1, 2012. These issues should be reported to payers and clearinghouses immediately for resolution; groups can work with their payer representative, clearinghouse or billing agency to ensure these issues are being addressed.
As expected, there have been disruptions in processing claims by some payers. The effects of these disruptions vary among physician practices and depend heavily upon the specific payer mix of each practice and the readiness of those payers. Medical Management Professionals, Inc. (MMP) has observed the following:
- A significant spike in payer denials, directly related to 5010.
- Some payers still have not converted to 5010.
- Payers that did not adequately test prior to the deadline have had significant problems.
- Some payers have had to migrate backwards from 5010 to 4010 in order to process claims.
- Some payers that successfully tested before the deadline had catastrophic claim payment errors when claim payment systems were moved to full production.
- Errors on production claims that were not present in the testing process due to different edits in payers’ production systems.
- Payers that were successful in production one week spiked claim denials in a subsequent week when they turned on additional edits in their production systems.
- The first months of the year are typically difficult cash flow months due to the restart of many patient deductibles as well as the difficulty in collecting patient payments; but preliminary data suggests that 5010 had an additional negative impact on cash flow.
- Please note that these are payment “delays” not payment “losses.”
The ideal response
Daily vigilant monitoring of claim denials for all payers is the most precautionary way to reduce risks in revenue, as well as ensuring ongoing dialogue with billing system vendors, payers and clearinghouses regarding claim denials and corrective actions. Currently, temporary work-arounds and permanent fixes are in development to eliminate 5010 denials. Monitoring industry publications for specific information on problems with specific payers will keep your practice in front of the major issues affecting the change.
The next step: ICD-10-CM
As practices implement 5010 transactions, the next logical step is preparation for ICD-10 code
changes. There are significant issues and potential concerns that hospital-based practices should be aware of with respect to ICD-10 implementation. By preparing early, however, practices can alleviate several operational and budgetary issues. Below are some recommendations for practices as they start the implementation process.
- Keep cost considerations in mind. Practices should consider all facets of their business as they estimate costs for ICD-10 implementation, including size, physician training, technology and overall adaptation.
- Adapt to the changes. Physician practices, hospitals and referring providers must quickly adapt to necessary documentation changes.
- Communicate with vendors. Billing companies such as MMP are currently working with billing system vendors, claims clearinghouses and outsourcing partners to ensure they are ready for ICD-10.
- Stay abreast of payer payment policies. Most commercial insurance carriers have indicated they will “crosswalk” ICD-10 codes back to ICD-9 codes for payment purposes.
- Brace the group for revenue changes. Practices can and should prepare for a potential disruption of cash flow.
Strategic thinking and preparation that involves costs analyses and effective communication with vendors and payers will ensure that practices will be ready to implement these changes by 2013. In many cases, a third-party billing or practice management company can help a practice keep up with 5010 compliance measures and prepare for ICD-10 implementation in regard to the above tactics.
In any case, practices must prepare now for the financial implications that will occur as ICD-10 is implemented.
Written By:
Joseph Degati - Chief Technology Officer, Medical Management Professionals, Inc.
http://www.physbiztech.com/how-to/keep-watchful-eye-5010-claims-denials-while-stepping-toward-icd-10-readiness
Posted on Thu, Mar 29, 2012 @ 04:57 PM
Quality matters, and keeping track of data and providing good outcomes in skilled nursing facilities is crucial, especially as failure to do so could seriously impact a facility’s bottom line, said a panel of experts at the National Investment Center for the Seniors Housing & Care (NIC) Skilled Nursing Symposium in Boca Raton, Fla.
Documentation, Documentation, Documentation
Documentation is key, the panel said.
“If you don’t have documentation, you stand risk of being in trouble if you’re audited,” said Trissie Copses Farr, Senior Vice President at Formation Capital/Formation Healthcare Group, adding that getting audited isn’t actually a matter of “if”—it will happen. “It is crucial to the success of your clinical practice that documentation is accurate, appropriate, and done correctly.”
“If it’s not written down, it wasn’t done,” said Michael Jones, CEO and Principal of Healthtique Group.
Carefully keeping track of staff training and time is crucial, and inaccurately entering Minimum Data Set (MDS) data can lead to increased citations. This can in turn lead to reduced Medicare reimbursements and lower quality scores, which could also result in legal liabilities if families of residents see bad marks on nursing facilities’ public “report cards.”
Being prepared for survey teams is critical, Jones said, as bad surveys can lead to an increased number and/or severity of citations, along with an increase in impositions and enforcement. Managing staff time while surveys are being conducted is another consideration, as labor accounts for roughly 65% of operating expenses.
“Quality of care is very important, but you also have to be able to manage the survey process,” he said. “Be efficient with data collection.”
Public Perspective’s Impact on Financial Outcomes
How well facilities with Medicare and Medicaid census perform clinically is public knowledge, thanks to Nursing Home Compare and the Centers for Medicare & Medicaid Services’ (CMS) five-star ratings.
That means that when government surveys are conducted, the results are available to anyone, including potential residents or their families, lenders, and investors.
Additionally, those entering rehabilitative skilled nursing are getting younger, which often means they’re more “tech savvy,” said Farr, and they could be more likely to research available services and access relevant data.
And if the public is seeing bad outcomes and poor ratings, they’re less likely to choose that facility, which leads to less revenue.
However, there are ways to combat poor reputation through good marketing strategies, says Jones. He gave an example of a particular facility with good quality of care and favorable outcomes, but a bad reputation in the marketplace. The facility’s administrators began a concerted effort to build relationships with hospitals and launch additional marketing efforts, and when CMS introduced its five-star rating system, it bestowed the facility with all five stars.
The facility went from thinking about shutting down and selling for about $1.5 million, to being valued at about $7 million, thanks to marketing and good clinical outcomes, Jones concluded.
Other financial impact from public perception can stem from U.S. News’ annual “Best Nursing Homes” of the year list, or even a regional ad placed in the Wall Street Journal that listed eight one-star facilities, telling readers to call if they’d been a victim of elder abuse at one of those low-rated facilities, said Jones.
Lenders’ Perspective on Clinical Outcomes
“Lenders aren’t looking to take on any risk. They want to avoid risk, and don’t feel that [loan] covenants are going to make up for the risk associated with an operator who’s having problems,” said Len Lucas, a senior director at Love Funding.
Poorly performing facilities often land on the so-called “Special Focus List,” and it’s very difficult to get financing for a facility on that list, Lucas continued. And even if it’s in a portfolio where the Special Focus Facility isn’t the focus, its presence on that list is going to have an impact on the other properties. Smaller operators are hurt by this more than the bigger ones, he said, because they don’t have as many properties to spread the risk on.
Written by Alyssa Gerace
Senior Housing News
http://seniorhousingnews.com/2012/03/27/nic-2012-why-quality-care-outcomes-matter-to-your-bottom-line/
Posted on Thu, Mar 22, 2012 @ 11:45 AM
Washington -- Federal officials have extended by an additional 90 days the enforcement deadline for physicians, health plans and claims processors to comply with the 5010 electronic transaction standards under the Health Insurance Portability and Accountability Act.
The decision to delay again the full implementation of the electronic transaction standards used to bill services throughout the health system comes as physician practices continue to report problems with claims processing, creating millions of dollars in unpaid claims. A number of outstanding issues led the Centers for Medicare & Medicaid Services to make the decision to hold off on enforcing the standards through June 30, the agency said in a March 15 statement. In late 2011, CMS had decided to move the enforcement date from Jan. 1 to April 1.
The latest postponement means that electronic submissions using the old 4010 HIPAA transaction format, or using the new 5010 standard but with formatting errors, will continue to be processed and paid without penalty. Despite the initial 90-day grace period at the beginning of 2012, the American Medical Association and others reported that physicians continued to experience payment problems. The organizations asked for an additional 90-day delay.
"CMS made the right call, and we appreciate the considerable effort they made to work with the AMA and respond to our concerns regarding the readiness of the industry," said AMA President Peter W. Carmel, MD. "The key to successful implementation of the industrywide standard is through continued collaboration with all stakeholders."
Health plans, vendors and physician practices have made steady progress by adopting the new standards, CMS said in its statement. The Medicare agency reported processing more than 70% of hospital claims and more than 90% of physician claims in the 5010 format.
But some practices that did attempt to make the switch to 5010 this year -- or whose billing representatives did so -- ran into cash-flow problems as a result.
In February, perinatologist Carlos Fernandez, MD, said revenues were reduced to a trickle at his practice in Toms River, N.J. His clearinghouse and the insurance companies that he bills were not using the same HIPAA format, and his claims were being rejected as a result. Processing improved when services were billed on paper instead of being sent electronically, he said.
Dr. Fernandez said he is not fully confident that his vendors and payers have addressed problems with 5010 to the point where they would be ready for the date CMS starts enforcing the new format. "Hopefully things are squared away, but I don't know if they are still submitting claims on paper."
Delaying enforcement will help the health care industry to continue to address problems, said Robert Tennant, senior policy adviser with the Medical Group Management Assn. He urged physician practices to monitor automated claims acknowledgement transaction reports, or 277CAs, that identify compliance issues with electronic claims.
A practice should lodge a complaint with CMS if a health plan or clearinghouse is not HIPAA-compliant, Tennant said. Physicians also can place market pressure on those causing payment problems by terminating relationships with claims clearinghouses or billing services.
"There are cases of $300,000, $400,000, $500,000 in outstanding claims from a clearinghouse and we said, 'Switch clearinghouses,' " he said. "And, in three days, they had their claims paid."
Posted on Wed, Mar 21, 2012 @ 10:00 AM
March 08, 2012
http://www.renalandurologynews.com/coping-with-icd-10/article/231160/
The move from ICD-9-CM to ICD-10 is enough to strike fear into the hearts of physicians and staff alike. Making the leap from 14,000 codes to almost 69,000, topped with the huge cost to make that change, is understandably daunting. The more you know, the better off your practice will be. Following is some information about the new system and tips for preparation.
ICD-10 is a diagnostic classification that has been used since 1994 by many World Health Organization Member states. Aside from being a way in which insurance companies determine billing, it is used for health management and epidemiologic purposes.
The Centers for Medicare & Medicaid Services (CMS) says the move to ICD-10 is being made because its predecessor is outdated, lacks specificity, and does not provide enough details regarding health data (such as disease severity and complexity), thus making it difficult to reimburse accurately.
Possible delay
The original date for the transition to ICD-10 was set for October 1, 2013, but the Department of Health and Human Services is considering extending the deadline. This should not halt the switching process if providers are already working on the transition, said Rhonda Buckholtz, vice president of ICD-10 training and education at AAPC (formally the American Academy of Professional Coders), a credentialing and certification organization.
“We don't know when it will be – it could be months or a year,” she said. “We are in a waiting game right now, so one of the things that we have been telling everyone is that if you have begun preparing, you shouldn't stop.”
Preparation
According to CMS, this process can be broken down into the following stages:
Planning. CMS recommends creating a project management structure, a plan to communicate with vendors and other partners and understanding risk management.
Communicating with staff. Physicians will need to assess what kind of training is required and develop a training plan. Then they will have to meet with staff to discuss their new responsibilities.
Assessment. Aside from the new staff impact, providers will need to understand how the change will affect their business policy, operations, technology, vendors, and so forth.
Implementation. This includes system migration strategies, business and technical changes, and training. AAPC recommends waiting until late 2012 to begin training so staff will retain the information.
Additionally, there is internal and external testing and the transition to the live environment, which includes ongoing support.
Cost
One consideration for switching over is cost. According to a report by the Medical Group Management Association, small practices can expect to spend about $83,000; medium groups will spend $285,000; and large practices can expect to spend $2.7 million to comply with the mandate. The cost will come from six areas: education and training for the staff; analysis of insurance contracts and documentation; superbill changes; IT changes; documentation costs; and cash flow disruption.
Vendors
Buckholtz has seen with both HIPAA and 5010 that some vendors waited until the last minute and told providers they weren't ready. Don't let this happen to you.
Both hardware and software have to be compatible with the new system. Because ICD-9 may still be around for some time (some entities like worker's compensation are not required under HIPAA to switch), a system needs to have the capacity to accommodate both codes.
Other than compatibility, accommodation for both systems, cost, and system availability, providers should ensure that their vendor will also be available for testing, implementation, training, and customer support.
Resources
Physicians can look to practice management organizations and vendors, many of whom are providing free training and webinars on the topic. Researching now will avoid a last-minute crunch to prepare. Following are some places to start.
- CMS provides timelines, vendor information, and handbooks here.
- AAPC provides a free online newsletter on the switch. You can sign up by going here.
- Everything you need to know about choosing a vendor can be found on AHIMA's Web site here.
Posted on Thu, Feb 09, 2012 @ 08:00 AM
The Centers for Medicare & Medicaid Services released a revised memo on January 20 in regards to "Reporting Reasonable Suspicion of a Crime in a Long-Term Care Facility (LTC)".
The memo is revised to include updated versions of the Questions and Answers and Appendix One documents. In order to promote timely application of the protections offered by section 1150B of the Act for LTC facility residents, we are explaining now the current obligations of LTC facilities to comply with the law as it is plainly written, without any delay that might be occasioned by waiting for any administrative rule-making process that might further clarify application of the law.
"This memorandum informs SAs of the new section 1150B of the Act, which was established by section 6703(b)(3) of the Affordable Care Act and is entitled “Reporting to Law Enforcement of Crimes Occurring in Federally Funded Long-Term Care Facilities.”
In order to promote timely application of the protections offered by section 1150B of the Act for LTC facility residents, we are explaining now the current obligations of LTC facilities to comply with the law as it is plainly written, without any delay that might be occasioned by waiting for any administrative rule-making process that might further clarify application of the law.
Click here to download the memo.