Health Insurance Exchanges: Two Key Issues to Discuss with Patients

The American Academy of Family Physicians (AAFP) is encouraging its members to provide their patients with information regarding health insurance exchanges.

The AAFP website advises: "During patient visits, be prepared to discuss the insurance options available through the marketplaces and encourage patients to make coverage decisions that are appropriate for their health care needs. "But not all doctors are ready to get involved.

The majority of physician respondents to a recent Medscape survey said that they should either have a limited role or no role in providing health insurance and health insurance exchange information to patients.

Yet, spending a few minutes sharing some key information about health insurance exchanges with interested patients may benefit you and your practice in the long run.

Here's why: If your patients that are shopping on the health insurance exchanges don't make well-informed purchasing decisions, you may see them less frequently. In fact, you may not see them at all.

Many of the health plans offered in the exchanges appear to have narrower networks — meaning patients will likely have fewer physicians and health systems to choose from within the plans.

In addition, many of the health plans offered in the exchanges have higher deductibles — meaning patients may end up shouldering more of their healthcare costs.

"They are trying to funnel people into narrow networks overall, and simultaneously shift people into higher cost sharing that is higher deductible, higher copay kind of plans," Kip Piper, a healthcare consultant in Washington, D.C., recently told Physicians Practice.

If patients purchase those higher cost sharing plans, it's likely that they will put off or avoid visiting your practice due to cost concerns, said Piper. In addition, higher patient cost sharing will place more burdens on your collections staff, as they will need to step up patient payment collection efforts. 
For that reason, you might want to consider talking to your patients about the importance of finding a plan that does not require a lot of out of pocket costs. "Make sure that ... they're not enticed by a low premium to pick a plan that has a high cost sharing that then keeps them out of the doctor's office," said Piper.

The narrower networks offered by many of the plans may also pose problems for your practice.

If you are excluded from a plan or if you have decided to opt-out of a plan, you run the risk of losing your patients to providers who are participating in that plan. For that reason, you might want to share which plans you are participating in with patients.

"I'm afraid of a lot of people in January are going to start making an appointment and then they're going to find out they can't go to their doctor," said Piper.

Article By Aubrey Westgate from Physicians Practice http://www.physicianspractice.com/blog/health-insurance-exchanges-two-key-issues-discuss-patients?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03122013

Back to School: Identify How ICD-10 Will Affect Your Practice

In order to be fully prepared for the October 1, 2014, ICD-10 transition, you need to know exactly how ICD-10 will affect your practice. Although many people associate coding with submitting claims, in reality, ICD codes are used in a variety of processes within clinical practices, from registration and referrals to billing and payment.
The following is a list of important questions to help you think through where you use ICD codes and how ICD-10 will affect your practice. By making a plan to address these areas now, you can make sure your practice is ready for the ICD-10 transition.

• Where do you use ICD-9 codes? Keep a log of everywhere you see and use an ICD-9 code. If the code is on paper, you will need new forms (e.g., patient encounter form, superbill). If the code is entered or displayed in your computer, check with your EHR and/or practice management system vendor to see when your system will be ready for ICD-10 codes.
• Will you be able to submit claims? If you use an electronic system for any or all payers, you need to know if it will be able to accommodate the ICD-10 version of diagnoses and hospital inpatient procedures codes. If your billing system has not been upgraded for the current version of HIPAA claims standards—Version 5010—you will not be able to submit claims. Check with your practice management system or software vendor to make sure your claims are in the HIPAA Version 5010 format and that your system or software can include the ICD-10 version of diagnoses and hospital inpatient procedures codes.
• Will you be able to complete medical records? If you use any type of electronic health record (EHR) system in your office, you need to know if it will capture ICD-10 codes. Look at how you enter ICD-9 codes (e.g., do you type them in or select from a drop down menu) and talk to your EHR vendor about your system’s capabilities for ICD-10. If your EHR system does not capture ICD-10 codes and you use another terminology (SNOMED), you will still need ICD-10 codes to submit claims.
• How will you code your claims under ICD-10? If you currently code by look up in ICD-9 books, purchase the ICD-10 code books in early 2014. Take a look at the codes most commonly used in your office and begin developing a list of comparable ICD-10 codes. Alternatively, check your software for an ICD-10 look up functionality.
• Are there ways to make coding more efficient? For example, develop a list of your most commonly used ICD-9 codes and become familiar with the ICD-10 codes you will use in the future; and invest in a software program that helps small practices with coding.

Want more information about ICD-10?
Visit the CMS ICD-10 website for the latest news and resources to help you prepare for the October 1, 2014, deadline. Sign up for CMS ICD-10 Industry Email Updates from CMS.

Courtesy of: Centers for Medicare & Medicaid Services (CMS) Weekly Digest Bulletin

New Measures in Pay-for-Performance Programs

Pay for performance, or P4P as it is more commonly known, is not a new concept and some plans have been using this type of initiative with providers for a decade or more. Those providers that participate in Medicare's Physician Quality Reporting System (PQRS) — which uses a combination of incentive payments and payment adjustments to promote reporting of quality information — as well as those participating in large Blues plans, will be most familiar with this model.

The shift What is new is the shift away from P4P as a "bonus" structure and a shift toward an "earning" structure. That is, the extent to which payers are incorporating P4P into their payment strategies means that a portion (or percentage) of providers' revenue is "earned" through meeting P4P targets or measures.  These new models are referred to as "value-based," shifting away from straight fee-for-service payments to some combination of performance- and fee-based compensation, which puts some of the financial risk on providers. The hope is this type of compensation model will improve the quality of care, reduce medical costs over time, and improve patient outcomes. So you can think of the newer P4P models as Pay for outcomes, or P4O.  Under Medicare  The Affordable Care Act expands P4P efforts in hospitals through the establishment of a Hospital Value-Based Purchasing Program begun last year, where hospitals are rewarded for how well they perform on a set of quality measures, as well as on how much they improve in performance relative to a baseline.  The healthcare law also extends the Medicare PQRS program through 2014. However, beginning in 2015 the incentive payments go away, and physicians who do not satisfactorily report quality data will see their payments from Medicare reduced. This marks the real beginning of P4O, in my view, due to the setting of a "quality care" baseline against which the ability to earn will then be tied.

By commercial payers For commercial payers, value-based contracts are springing up around Patient-Centered Medical Homes (PCMHs) and accountable care organizations (ACOs). However, new and negotiated contracts for generalized services — that is, practices that are not technically a PCMH or ACO — are now typically being crafted with P4P/P4O components that allow practices to "earn" additional dollars or year-to-year increases in multi-year contracts through meeting specific measures and targets.  Theses measure are typically HEDIS-based (Healthcare Effectiveness Data and Information Set) which is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). Many of these measures are focused on high-cost conditions such as heart disease, diabetes, high blood pressure, as well as preventive measures like immunizations and medication management. New and changed measures for 2014 include breast- and cervical-cancer screenings.

 Commercial payers utilizing P4P measures typically have a combination of HEDIS-type "quality" measures as well as "self-reported" measures, where practices can report on items such as EHR implementation and use, and status in achieving NCQA programs such as Patient-Centered Medical Home (PCMH), diabetes, heart/stroke, and back pain recognition programs. In addition to NCQA measures, there is substantial investment underway by the Agency for Healthcare Research and Quality (AHRQ) and other public policy organizations to identify further evidence-based medicine practices that could be used for measurement. And the National Quality Forum (NQF) is leading focused efforts to collect and normalize data, and endorse additional performance measures.

Article By Susanne Madden of physicians Practice http://www.physicianspractice.com/physician-compensation/new-measures-pay-performance-programs?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=31102013

The Evolution of Government Intrusion on the Medical Profession

By Martin Merritt from Physicians Practice

This week found me sitting alone in our law firm library, preparing to defend a physician before the Texas Medical Board. In an era of electronic research, both legal and medical, it is rare to find anyone, (other than me), in the library. I not only enjoy flipping through real pages; some of which were bound and placed on these shelves 70 years ago, I enjoy getting momentarily sidetracked from my original mission.

I picked up this habit as kid reading the World Book Encyclopedia. Regardless of what I might be looking for, I would always stop and absorb eight to ten articles, just to learn about some historical fact I didn’t know existed.  

This week, flipping through historical reports of medical ethics cases, many dating to the 1950s, I began to see a clear picture of something I wasn’t expecting to find.  Virtually every federal regulatory concern currently plaguing the modern practice of medicine also existed in some form in the 1950s.

Comparable to Medicare RAC and external audits; physicians were losing their practices for improper charting and documentation. However, these losses usually pertained to life-and death matters, such as the prescription of narcotics. “Off-label promotion,” similar to the fen-phen scandal, usually concerned mundane, unapproved uses of common household remedies.

For example, a physician in the 1950s lost his license for charging patients $49 each for a treatment to remove gallstones using olive oil. (The board found that the oil, mixed with stomach acid, actually produced “soap balls,” not gallstones, as the physician improperly claimed.)

“Bundling and unbundling” issues were also present sixty years ago when a physician was disciplined by the board for routinely including fee-for-services charges that were already billed to the patient as part of the hospital’s charges.

Time and again, modern coding, charting and regulatory issues “pop” from the pages of history. Some cases represent quaint precursors to FTC “advertising” regulations. These appear as ethics disputes over the size of the lettering appearing on a physician’s office window, to questions about the exact line between acceptable public service promotion and impermissible advertising.

Half a century ago, one party was notably absent from the dusty pages of medical ethics cases: the federal government. There is a reason for this. Until the post-Civil War period of reconstruction, no federal laws governed a person’s conduct in any way. Slowly, beginning with the regulation of racially motivated murder, and laws pertaining to civil rights violations, Title 42 of the United States Code (containing laws related to civil rights and health and human services), began to grow in size and scope.

Today, in addition to racial offenses (42 U.S.C. §1983); Stark Law (42 U.S.C. 1395nn); the Anti-kickback Statute, (42 USC § 1320a–7b); HIPAA (42 U.S.C. § 300gg); and the Medicare law (42 U.S.C. 1395) are located in the growing Title 42 of the United States Code.

Many fear, and rightly so, that as healthcare insurance exchanges offered at healthcare.gov become fully operational, the federal takeover of the practice of medicine will soon be complete.

In the not-too-distant future, the common law principle, “A physician and patient are free to contract for services in any way they see fit,” will seem just as quaintly anachronistic as limits on the size of lettering on a physician’s office window.

Courtesy of Physicians Practice http://www.physicianspractice.com/blog/evolution-government-intrusion-medical-profession?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=22102013

“Expanded Coverage Under the Affordable Care Act: Information for Health Care Professionals” Fact Sheet — Released

The “Expanded Coverage Under the Affordable Care Act: Information for Health Care Professionals” Fact Sheet (ICN 908826) was released and is now available in downloadable format. This fact sheet is designed to provide education on the Health Insurance Marketplace under the Affordable Care Act. It includes information health care professionals need to know about the Marketplace, an explanation of how the Affordable Care Act expands access to health coverage, and an explanation of the Marketplace, how it affects health care professionals and their patients, and resources.
From Medicare Learning Network eNews update.

How Health Reform Is Changing How Physicians Care For Female Patients

Health reform is bringing about massive changes: from shifting reimbursement, to increasing emphasis on health IT, to new models of care.

It's also beginning to change the way female patients interact with physicians, the services female patients request from physicians, and the services physicians might want to consider recommending to their female patients.

"Generally it takes a little bit of time for the general public to really start to use any sort of implementations of a new law," Lauren Fifield, senior health policy advisor at Practice Fusion, recently told Physicians Practice. "With health reform, there are a handful of things that have already come into effect, and I think that those are only going to become more and more applicable to physician offices."

One of the biggest changes physician offices might encounter with female patients is increasing demand for preventive services, said Fifield, adding that insurers must now make certain preventive services available to women without a copayment or co-insurance.


Some of the most recently added preventive services to fall into this category include:

•  Well-woman visits
• Gestational diabetes screening for women 24 to 28 weeks pregnant, and those at high risk of developing gestational diabetes.
• Domestic and interpersonal violence screening and counseling for all women.
• Breastfeeding counseling from trained providers; access to breastfeeding supplies.
• Contraceptive services and counseling.

Of note for physicians: Many of these services include an element of counseling, said Fifield. "These are all sort of really focused on not just, let's give a patient a medication or make sure they have a mammogram, but ... making sure that they are treating the patient more holistically."

Physicians may also experience higher demand from female patients in general moving into 2014, and they may encounter more female patients with undiagnosed chronic conditions or conditions that have gone untreated for a long period of time. That's because more female patients will become newly insured in 2014 due to the health law.

"I think providers will start to have higher volumes of patients and also have to really work as a care team ... to manage the care of women that are going to be sort of entering the healthcare space newly with their new insurance," said Fifield.

So how should physicians prepare for these changes?

Ensure key individuals in your practice are aware of the preventive services that are available without cost to patients. That way they can inform patients of these services during visits.

In addition, pay close attention to the counseling elements associated with these preventive services and ensure your practice is prepared to incorporate that into its work flows, said Fifield.

"I also think that really utilizing technology will be incredibly helpful," she said. "Technology for doctors to help make scheduling more efficient, to make visits more efficient since they may be dealing with higher volumes of patients, and an [EHR] or other tools that help a care team manage their patients and sort of coordinate that care will be important." 

Article By Aubrey Westgate of Physician Practice http://www.physicianspractice.com/blog/how-health-reform-changing-how-physicians-care-female-patients?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=17092013

Update – ACA Increased Medi-Cal Payments for Primary Care Physicians (California MediCaid)

The Department of Health Care Services (DHCS) plans to implement increased fee-for-service Medi-Cal payments for primary care physicians in late October 2013.

 

The Patient Protection and Affordable Care Act (ACA), as amended by House Resolution 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, requires that payments to primary care physicians be increased to the Medicare equivalent for certain Evaluation and Management and Vaccine Administration services.

 

These increased payments are contingent upon pending Centers for Medicare & Medicaid Services (CMS) approval of a DHCS State Plan Amendment (SPA). The increased payments are retroactive for dates of service on or after January 1, 2013.

 

The first interim payment will be issued in October. A final settlement of payment owed but not reimbursed by the interim payment will be issued as early as February 2014.

 

The increased payments are not automatic. Providers must attest to their eligibility, but DHCS estimates that less than half of eligible providers have self-attested. Completing your attestation prior to CMS approval of the SPA and system updates will ensure you receive increased payments as soon as possible. Visit the Medi-Cal ACA Program Page on the Medi-Cal website for more information or to submit a self-attestation form.

 

You should complete your attestation form as soon as possible.

Attestation form link: https://www.medi-cal.ca.gov/acaattest/acaattestmenu.aspx

 

 

What Practices Need to Do Now to Prepare for HIPAA Omnibus Changes

The September 23, 2013, deadline for when covered entities such as physician practices must be in compliance with the HIPAA Omnibus Final Rule is quickly approaching. The rule marks the most sweeping changes to the HIPAA Privacy and Security Rules since they were first implemented.

While the final rule brings about many changes, there are three in particular that likely warrant the most attention from practices now. The following column identifies those changes and provides practical guidance to meet the new requirements.

Change 1: The definition of what a "breach" is has been modified.
What it means: Under the old law, a breach was an event that "compromises the security or privacy of the protected health information (PHI) such that the use or disclosure poses a significant risk of financial, reputational or other harm to the affected individual." Under the new rule, the definition of a breach is expanded to include even just the "risk" of impermissible use or disclosure of PHI. For example, if you have patient records on a thumb drive and that drive is lost, if the records are not password-protected or encrypted, that will be considered a breach even if the data is never accessed by anyone. An incident report should be filed with your HIPAA officer. If you lose a laptop but can prove the computer is encrypted and nobody is able to access the information without a secure ID, thus indicating a low probability of the PHI becoming compromised, you will not have committed a breach.
What practices should do: Perform a complete risk assessment in an effort to minimize security holes and prevent possible breaches. Three of the most common causes of breaches are stolen laptops, lost or stolen external hard drives or thumb drives, and sending PHI through unsecured email.
Change 2: The definition of a "business associate" (BA) has been completely reworded.
What it means: A BA is essentially a company or any person who is not a member of the workforce for the covered entity but has access to PHI. This would include contractors and now, under the new rule, subcontractors under the BA. 
What practices should do: Review all BA agreements to see if they need to be revised or replaced. With older agreements, a BA could potentially include a clause that says the BA cannot be held liable for PHI breaches. Now, a BA can be held directly liable. BAs can still try to include the clause to remove themselves and their subcontractors from liability, but a practice would be wise to object to such a request and a BA will lack a strong argument for the clause's inclusion. An example of when a BA might be liable: If an IT company has an off-site data backup and somebody steals the backup device, the BA can be found personally liable for breach of all of the health records on that device. An example of when a subcontractor might be liable: If the IT company were to bring in a subcontractor to run network cable and electric lines in a new service center, that subcontractor would then be considered a BA and potentially liable since it could have access to PHI.Since all BAs are more stringent under the new HIPAA security laws, BAs themselves need to now remain HIPAA compliant.
Change 3: HIPAA audits will happen more frequently, fines will be substantially higher, and auditors will be incentivized to find security problems.
What it means: Periodic HIPAA audits by HHS were already authorized and underway, but covered entities can expect them to happen more frequently once the new rule is enacted.In addition, fines associated with penalties due to HIPAA violations will become significantly higher and essentially without a limit.Finally, auditors will receive what amounts to a "kickback" for each security violation discovered during an audit, which incentivizes auditors to dig deep and find any and all holes. 
What practices should do: The best practice is to perform at least quarterly risk assessments. This will help ensure security hole fixes put in place are working and holding and identify other potential problems. If you can indicate to an auditor that you performed a risk assessment, identified a problem, and have a plan in place to fix it, the auditor is more likely not to consider the problem an issue unless it remains unresolved. Many covered entities rely upon an external company to perform such risk assessments. These companies are not only skilled in identifying security problems and issues often overlooked by covered entity staff members, they have the knowledge and ability to take care of requirements such as creating policies and procedures for administrative safeguards, setting up employee training and changing all IT systems so they have a data backup plan, specific user names, and password policies in place.
Larger organizations may consider hiring someone to handle these responsibilities, but this may be cost prohibitive. For smaller organizations, it's often more cost-effective to hire a company to handle all of these tasks and help ensure year-round compliance.
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Article By Nelson Gomes and Michael Daly of Physicians Practice http://www.physicianspractice.com/blog/what-practices-need-do-now-prepare-hipaa-omnibus-changes?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=10092013

Health Reform Doesn't Mean the End of Independent Medical Practices

By Wayne Lipton, Physicians Practice                                                   

There seems to be much public and private hysteria these days over the Affordable Care Act (ACA), or what many call "Obamacare." The rush for implementation of the health insurance exchanges has made real the intended changes to the healthcare system both locally and nationally. In the midst of all this uncertainty, I'm reminded of the British philosophy of, "Keep calm and carry on."

While a good message, I do understand why physicians are concerned. Physicians' earnings have been stagnant over the past several years, despite so-called bonuses for primary care and EHR implementation. Worse has been the uncertainty over Medicare —Will it or won't it get slashed? Because the work keeps getting harder, patients' needs are increasing, and the risks of operating an independent business grow more intense, many physicians feel driven to seek out "protection" by accepting employment with their local hospitals. After all, aren't the hospitals with their layers of administration better prepared for the changes this national "mandate" has created?

Not so fast say some practice management experts. One of the odd consequences of the political shift which accompanied the reform law is a focus on the way hospital systems are reimbursed. Many hospitals are not only seeing reductions in Medicare revenue but are also seeing state-based initiatives in the form of direct taxes on services with the thought that greater reimbursement of uncompensated care will shore up their bottom lines.

If anything, hospital administrators are looking more and more critically at physician employee compensation with an eye toward reducing their outpatient costs and increasing physician productivity. The message is that the fat package offered at the outset to physicians who "sell" to the institution is likely to be reduced significantly when renewal time arrives.

So it's time to take a closer look at decisions to sell or merge a medical practice. And this is where we get back to the infamous British philosophy.

Physicians who want to remain independent or who don't want to feel forced to sell their practices need to stop and really consider what is really happening in the market and what it means for their practice and patients.

Here are some important points to consider:

1. The ACA makes a point of assuring adequate primary-care reimbursement in two different ways. First is the broader definition of preventative services and the means by which providers are paid. Many of the newly insured patients registered with the exchanges will be facing large deductibles. However, the preventative services (those without copays) are paid first by these insurers so physicians will have fewer burdens chasing those patients for money initially.

2. A further mandate for those primary care physicians who provide Medicaid services is that their evaluation and management (E&M) services will now be paid at the federal Medicare level rather than the state, meaning more stability in revenue.

3. Those completing EHR conversion are beginning to see their checks. If you are with a large medical system or hospital, as a physician employee, you may not see those monies. If you have your own practice, you will.

4. Many physicians are beginning to recognize the value of alternative practice models such as full model or hybrid concierge programs. These programs give physicians who want to remain independent that option — plus, and this is important — they provide real choices and options for patients.

Most advisors I speak with have recognized for a long time that solvency in independent medical practice is dependent upon growth. Many primary-care practices have focused on reducing overhead and securing better fees. This "hunker down" mentality has resulted in stunted growth and reduced compensation. It's understandable why those practices would feel the need to consider selling. However, those practices that have embraced growth by looking at alternative practice models, or growing their practice by adding more physicians, extenders, and other specialized services, continue to see growth. This often involves financial investment in a practice by way of loans, but the added revenue often more than offsets the related expenses and improved income can be expected.

The message is — don't panic — and don't sell because you think there are no options. Independent primary-care practice should be able to flourish in this new environment giving physicians who want it the ability to own and maintain their destinies. In fact, the current environments make them more valuable as there are fewer independents physicians, making those services greater in demand.

The key is an eye toward growth and diversification of the medical delivery model. Implementing and/or expanding the physician extender model and incorporating an element of concierge care to facilitate compensation growth while ensuring the practice continues to meet the needs and preferences of all patients.

Article By Wayne Lipton, Physicians Practice            
http://www.physicianspractice.com/blog/health-reform-doesnt-mean-end-independent-medical-practices?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03092013

Compliance FAQs... How Much is Too Much?

How much information can a biller leave on an answering machine when calling for address or insurance updates?

Answer: Because the biller cannot know for sure who will listen to a message, even when calling a telephone number provided by the patient, it is wise to leave the minimum amount of information necessary to accomplish the reason for the call. Various legal concerns, including the HIPAA Privacy and Security rules, state that confidentiality and privacy laws and debt collection statutes and regulations can be implicated and should be taken into account.

A bare bones message may contain little or no revealing information while still accomplishing the task.

EXAMPLE 1: "This message is for [patient]. We are calling to verify your current mailing address (or insurance information) in order to bill for recent medical services you received. Please contact us at xxx-xxxx during office hours."

Here is another message scenario that gives minimal information.

EXAMPLE 2: "This is Medical Billing Office calling for [patient]. We need to contact you for an updated / corrected mailing address (or insurance information). Please call us at xxx-xxxx at your earliest convenience."

Various factors should be considered in deciding how to draft scripts or instructions for your staff regarding outbound messages.

• What is the purpose of the call / message?
• Who is the provider / client? Are they well known in the community?
• Do they practice in a sensitive specialty, such as family planning, mental health, etc.?
• Is there a reason you would need to disclose the client's identity or other detailed information at all?
• What would be the risk if someone other than the patient or a close family member heard the message?

If additional information would be helpful and would not unnecessarily reveal personal health information (PHI) or sensitive information, it can also be included in the message.

EXAMPLE 3: "This message is for [patient]. I am calling for the billing office at [General Hospital Radiology Group]. Please contact our office to update your mailing address (or insurance information)."

 

CMS has published FAQs that are generally related to this question. By analogy, they support the conclusion that a biller may leave a minimum amount of information on an answering machine to solicit a response and gather information to enable proper billing.

The official HIPAA FAQs can be found on the website of the DHHS Office of Civil Rights at www.hhs.gov/ocr/privacy/hipaa/faq/index.html.

 

From the Office of Civil Rights HIPAA website:

May physician offices or pharmacists leave messages for patients at their homes, either on an answering machine or with a family member, to remind them of appointments or to inform them that a prescription is ready? May providers continue to mail appointment or prescription refill reminders to patients' homes?

Answer: Yes. The HIPAA Privacy Rule permits health care providers to communicate with patients regarding their health care. This includes communicating with patients at their homes – either through mail, phone, or in some other manner. In addition, the Rule does not prohibit covered entities from leaving messages for patients on their answering machines. However, to reasonably safeguard the individual's privacy, covered entities should take care to limit the amount of information disclosed on the answering machine. For example, a covered entity might want to consider leaving only its name, number, and other information necessary to confirm an appointment, or ask the individual to call back.

A covered entity also may leave a message with a family member or other person who answers the phone when the patient is not home. The Privacy Rule permits covered entities to disclose limited information to family members, friends, or other persons regarding an individual's care, even when the individual is not present. However, covered entities should use professional judgment to assure that such disclosures are in the best interest of the individual and limit the information disclosed. See 45 CFR 164.510(b)(3).

In situations where a patient has requested that the covered entity communicate with him or her in a confidential manner, such as by alternative means or at an alternative location, the covered entity must accommodate those requests, if reasonable. For example, the Department considers a request to receive mailings from the covered entity in a closed envelope rather than by postcard to be a reasonable request that should be accommodated. Similarly, a request to receive mail from the covered entity at a post office box rather than at home, or to receive calls at the office rather than at home are also considered to be reasonable requests, absent extenuating circumstances. See 45 CFR 164.522(b).

 

Courtesy of:  http://www.hbma.org/news/public-news/n_compliance-faqs

 

 

Health Insurance Exchanges: Good News, Bad News for Physicians

USA Today recently reported that people have been signing up for health insurance exchanges for in excess of expected levels.

Staff writer Kelly Kennedy reports that a survey of each of the 50 states yielded 19 states reporting estimates for how many of their uninsured residents they expect will buy through the exchanges. The reported 8.5 million would far outstrip the federal government's estimate of 7 million new customers for all 50 states under the Affordable Care Act (ACA).

In the short term, this is great news for physicians' practices. This statistic means there will be 8.5 million new paying customers. This is even better news for physicians in states which have refused to expand Medicaid to the level mandated by the reform law, commonly termed "Obamacare."

Prior to the law, many states were permitted to set their own limits for Medicaid eligibility. Alabama, for example, reportedly disqualified a family from Medicaid eligibility if the family earned 25 percent of the federal poverty level (about $6,000 per year for a family of four). Under the reform law, states would have been required to expand Medicaid roles to conform to a new national standard of 133 percent of the federal poverty level (about $31,300 per year for a family of four). On June 28, 2012, the U.S. Supreme Court upheld the constitutionality of most of the ACA in the case National Federation of Independent Business v. Sebelius. However, the Court held that states cannot be forced to participate in the law's Medicaid expansion under penalty of losing their current Medicaid funding. Therefore, patients in states which did not expand Medicaid roles to include these "newly eligible" patients are able to purchase federally subsidized private plans through health insurance exchanges, which is the subject of the USA Today article.

This is good news for physicians’ practices, because Medicaid simply doesn’t pay very well (so low in fact, about one-half of all physicians would refuse to accept a new Medicaid patient).) Private plans which are subsidized by the government would almost certainly provide reimbursement rates which are above the rock-bottom rates for Medicaid patients. Open enrollment begins October 1, 2013, and coverage is set to begin January 1, 2014.

Before we all get too drunk on all this free government Kool-Aid, recall that the Kool-Aid isn’t "free." The reform law was enacted because the Medicare trust fund could not afford to pay for all the aging baby boomers set to turn 65 in the next few years.

The idea behind the law was to save Medicare by forcing more healthy Americans into the system through individual mandates, employer mandates, expansion of Medicaid for the poorest Americans, and providing health insurance exchanges for those who are just above the level needed to qualify for Medicaid. But how is this supposed to help save the Medicare trust fund? Obviously, by cutting future Medicare reimbursement rates.  But on what part of "planet crazy" does it make sense for the government to pick up the tab of the cost for all the newly insured, (which was supposed to save the system from failing, because the government is broke)?

In her book, "Your Doctor is Not In," Jane Orient draws the analogy between our nation’s healthcare model and the one created by Ptolemy, which contained multi-layered epicycles to explain the universe. "Wheeling and whirring, the Ptolemaic universe could be turned to predict almost any observed planetary motion — and when it failed, Ptolemy fudged the data to make it fit," Orient writes.

Here, the Obama Administration is so desperate to make the healthcare reform law work, any solution that will keep the wheels whirring, is perfectly acceptable. By the time anyone figures out it is a bad model, the president will be working on a location for his presidential library, and paying for healthcare will be the next administration’s problem.

Article By Martin Merritt http://www.physicianspractice.com/blog/health-insurance-exchanges-good-news-bad-news-physicians

What Health Insurance Exchanges Mean for Physicians

Congress enacted the Affordable Care Act (ACA) to provide the means for uninsured Americans to purchase healthcare coverage.  Despite many legal battles and slipped deadlines, the new healthcare insurance exchanges — also known as marketplaces — will begin open enrollment on Oct. 1, 2013. The law provides for three options: one, where states will create and run their own exchanges; two, where they will create a hybrid exchange run by both the state and federal government; and three, where the federal government creates and runs the exchanges for states that have opted out. Coverage through the plans begins on Jan. 1, 2014.

Aside from great reservations expressed by many states, there are a number of unanswered questions where physicians and their practices are concerned. In part because so many states were reticent to fund and undertake the creation of a state-based exchange, progress to date varies widely. As of May 10, 2013, 25 states have been conditionally approved to operate some type of state-based exchange, according to The Center for Consumer Information & Insurance Oversight (CCIO).

And, because each state exchange is unique, the number and type of insurance companies that participate in the exchanges will be singular to each state.

So, what does this mean for physicians and their practices?

Sarah Dash, a faculty member at the Health Policy Institute at Georgetown University, says "fundamentally the exchange plans are just insurance plans. …The market is organized for the purpose of the consumer gaining easier access to those insurance plans. So, to some extent, it is the same thing." Since many people put off seeing the doctor because they are uninsured and can't afford the cost, experts have suggested that there will be a flood of sicker patients once the exchanges provide health insurance. Dash calls it "pent up demand." However, she is not convinced that this will be the case. She points out that the premise of the reform law's "insurance mandate" was to provide a good mix of healthy younger patients with older, potentially sicker patients. Owen Dahl, a practice management consultant based in The Woodlands, Texas, also believes that practices won't be deluged with new patients — but for a different reason. He says people who don't have insurance now are generally those who don't understand how it works and can't afford to pay for it.  "If I've been going to the emergency room for 15 years to get my care, [patients will say] 'Oh look, I've got this insurance, well I'm still going to go to the emergency room,'" says Dahl. He thinks that it will take time for people to change their behavior, which means practices will have plenty of time to prepare for newly insured patients. There is also trepidation among physicians that plans offered on the insurance exchanges will not pay well. As it is nearly impossible to predict reimbursement rates until the exchanges are fully established and patients are enrolled, it is perhaps a wasted effort for practices to dwell on this aspect. Dahl feels that plans offered on the exchanges may behave like managed-care plans. He says that it is likely that exchange plans will be offered by the major payers such as Blue Cross. "As far as the rates are going to be concerned, I think the best-case situation we could expect would be Medicare rates," he says. While that could mean lower revenues for practices, there are other aspects of the reform law which may be to their advantage. Dash says that "the point of the ACA is not to just give people an insurance card. It's to give people an insurance card that they can use. By that I mean, if the cost sharing is too high [in the forms of copays and deductibles], certainly that could be a deterrent."  She argues that through the law, patients will have access to tax subsidies and cost-sharing subsidies that should make it easier for patients to pay their bills. Certainly these changes will bring added administrative burdens to practices, but in many cases, they have already begun to implement new processes and quality improvements required by programs like Patient-Centered Medical Homes. Dahl advises practices "Do not panic." He says that while the business of medicine is most certainly changing, it won't happen overnight. "The important thing is for doctors to think about [the law] and to be prepared for that, but not react," he says.

Article By Erica Sprey - See more at: http://www.physicianspractice.com/blog/what-health-insurance-exchanges-mean-physicians#sthash.oenrJwFk.dpuf

"New" CMS-1500: WCMS-1500CS-12 Date of Implimentation Unknown (as of August 2013)

1500 Health Insurance Claim Form Change Log 6/17/2013 
The following is the list of changes between the 1500 Claim Form 08/05 version and the 02/12 version.

 

Header: The barcode was removed.

Header: The language “PLEASE DO NOT STAPLE IN THIS AREA” was removed from the left-hand side.

Header: The rectangle with “1500” was added in black ink to the left-hand side.

Header: The title “HEALTH INSURANCE CLAIM FORM” was moved from the lower, right-hand side to the left-hand side.

Header: The language “APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05” was added to the left-hand side.

Header: The language “TEST VERSION – NOT FOR OFFICIAL USE” was added to the right-hand side. This language will be removed when the form is approved by OMB.

Box 1: “TRICARE” was added above “CHAMPUS”.

Box 1: Under CHAMPVA, “VA File #” was changed to “Member ID#”.

Box 17a: The box was split in half length-wise.

Box 17a: This area was shaded. This box will accommodate other ID numbers.

Box 17a: Two vertical lines were added. This field will accommodate a two byte qualifier for other ID numbers.

Box 17b: This field was added.

Box 17b: Two vertical lines were added with the “NPI” label. This field will accommodate the NPI number.

Box 21: The lines after the decimal point in items 1, 2, 3, and 4 were extended to accommodate four bytes.

Box 24: The line with the alpha indicators was removed. The alpha indicators were moved next to the respective titles in the title fields.

Box 24: The line numbers to the left of Box 24 were increased in size and centered with each line.

Box 24: Each of the six lines were split length-wise and shading was added to the top portion of each line. This area is to be used for the reporting of supplemental information.

Box 24: Vertical line separators on each of the six lines have been removed from the shaded area,               except for the lines before Boxes 24I and 24J.

Box 24C: “Type of Service” was removed. This field is now titled “EMG”.

Box 24D: The field became wider by three bytes.

Box 24D: Shading was added vertically between “CPT/HCPCS” and “MODIFIER”.

Box 24D: Vertical lines were added in the unshaded “MODIFIER” section to accommodate four                  sets of two bytes.

Box 24E: The title was changed from “DIAGNOSIS CODE” to “DIAGNOSIS POINTER”.

Box 24E: The field was decreased by three bytes.

Box 24G: This field was increased by one byte.

Box 24H: This field was decreased by one byte.

Box 24I: The title was changed from “EMG” to “ID. QUAL.”.

Box 24I: A horizontal line was added length-wise across the field separating the shaded and unshaded portions of the field.

Box 24I: The label “NPI” was added in the unshaded portion of the field.

Box 24J: The title was changed from “COB” to “RENDERING PROVIDER ID. #”. 1500 Claim                            Form Change Log – 11/29/05

Box 24J: A dotted horizontal line was added length-wise across the field separating the shaded and unshaded portions of the field. The NPI number is to be reported in the unshaded field. An other ID number can be reported in the shaded field.

Box 24K: This field, “RESERVED FOR LOCAL USE”, was removed.

Box 32: Boxes 32a and 32b were added at the bottom.

Box 32a: This field was added to accommodate reporting of the NPI number and is indicated by the shaded label of “NPI”.

Box 32b: This shaded field was added to accommodate the reporting of other ID numbers.

Box 33: Parentheses were added after the title to indicate the location for reporting the telephone number.

Box 33: Boxes 33a and 33b were added at the bottom.

Box 33a: The title of this field was changed from “PIN#” to “a.”.

Box 33a: A shaded label of NPI was added to the box to indicate the reporting of the NPI number.

Box 33b: The title was changed from “GRP#” to “b.” to accommodate the reporting of other ID numbers.

Box 33b: The field was shaded.

Footer: The language “NUCC Instruction Manual available at: www.nucc.org” was added to the left-hand side.

Footer: The OMB approval numbers were removed and the language “OMB APPROVAL                 PENDING” was added. The numbers will be added after approval has been received by OMB.

Back: The following language was added in the last line at the bottom of the form: “This address     is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM  FORMS TO THIS ADDRESS.”

 

Courtesy of HMBA

New Claim Adjustment Reason Code (CARC) to Identify a Reduction in Federal Spending Due to Sequestration

MLN Matters® Number: MM8378
Related Change Request (CR) #: CR 8378
Related CR Release Date: July 25, 2013
Effective Date: June 3, 2013
Related CR Transmittal #: R2739CP
Implementation Date: January 6, 2014

Provider Types Affected This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), carriers, Regional Home Health Intermediaries (RHHIs), Durable Medical Equipment Medicare Administrative Contractors (DME/MACs) and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

Provider Action Needed This article is based on Change Request (CR) 8378 which informs Medicare contractors about a new Claim Adjustment Reason Code (CARC) reported when payments are reduced due to Sequestration. Make sure that your billing staffs are aware of these changes.

Background As required by law, President Obama issued a sequestration order on March 1, 2013. As a result, Medicare Fee-For-Service claims, with dates of service or dates of discharge on or after April 1, 2013, incur a two percent reduction in Medicare payment. The Centers for Medicare & Medicaid services (CMS) previously assigned CARC 223 (Adjustment code for mandated Federal, State or Local law/regulation that is not already covered by another code and is mandated before a new code can be created) to
explain the adjustment in payment.

Effective June 3, 2013, a new CARC was created and will replace CARC 223 on all applicable claims. The new CARC is as follows:

• 253 - Sequestration - Reduction in Federal Spending

Also, Medicare contractors will not take any action on claims processed prior to implementation of CR8378.

Additional Information The official instruction, CR 8378 issued to your Medicare contractor regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2739CP.pdf on the CMS website.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2012 American Medical Association.

Courtesy of: Palmetto GBA and CMS http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~9A6QUB1811?opendocument&utm_source=J1BL&utm_campaign=J1BLs&utm_medium=email

4 J code Options Help you Determine Strep Throat Diagnoses: ICD-9 to ICD-10

Wait for lab results before assigning the final code.

ICD-9 coding: When using the ICD-9-CM code set, you report 034.0 (Streptococcal sore throat) if the patient suffers from streptococcal laryngitis. The ICD-9 manual also directs you to 034.0 if the patient suffers from streptococcal tonsillitis or pharyngitis.

ICD-10 changes: When ICD-10 becomes effective in October 2014, you won't have a simple catch-all code for streptococcal throat infections. Instead, ICD-10 will differentiate between streptococcal laryngitis, pharyngitis and tonsillitis, so your documentation will need to specify type. The four diagnosis choices will be:

• J02.0 (Streptococcal pharyngitis)
• J03.00 (Acute streptococcal tonsillitis, unspecified)
• J03.01 (Acute recurrent streptococcal tonstillits)
• J04.0 (Actue laryngitis)

Code j04.0 requires you to use an additional code to report the infections agent. For strep, that code would be B95 (Streptoccoccus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere), with the exact code depending on the nature of the streptococcus.

Documentation tip: Don't report the strep throat diagnosis code unless your physician receives confirmation from a lab test (either rapid strep or throat culture) indicating that the patient tested positive for a streptococcal throat infection. If you don't have a positive lab test confirming strep throat, you should simply report the diagnosis codes for the symptoms (such as sore throat, fever, etc).

Vital: Your documentation must include a copy of the laboratory report confirming that the patient had strep throat before you select your diagnosis code.

The family physician will ned to clearly note which type of throat condition the patient has, so you can code accordingly to whether the pateint's streptococcal infection affected the larynx, pharynx or the tonsils.

In addition, if the patient suffers from streptococcal tonstillits, you will have to further delineate whether he is experiencing an unspecified or recurrent acute condition. If you use, J03.01 (recurrent), your documentation must confirm that the patient has suffered from the condition in the past.

Coder tips: Make sure that you print the new strep throat codes on your superbills prior to ICD-10 implementation, and let your practicioners know that they will need to differentiate between streptococcal laryngitis, phyryngitis, and tonstillits.

Courtesy of: The Coding Institute: Family Practive Coding Alert

House bill would stop ICD-10 mandate

Legislation introduced in the U.S. House would prohibit the Dept. of Health and Human Services from mandating that physicians use ICD-10 diagnosis codes beginning Oct. 1, 2014.

The bill, the Cutting Costly Codes Act of 2013, would stop the required transition to new diagnosis code sets by physicians who are billing for medical services, verifying patient eligibility, obtaining pre-authorizations, documenting patient visits, and conducting both public health reporting and quality reporting. The mandated switch to the 68,000-code system had been established in a 2009 regulation. HHS announced in 2012 that its implementation deadline had been delayed by one year to 2014.

The American Medical Association wrote an April 26 letter to Rep. Ted Poe (R, Texas) in support of his legislation. Physician practices must bear the cost of training, software upgrades and testing of the new system. The projected cost of ICD-10 implementation ranges from $83,290 to more than $2.7 million per practice, the AMA letter stated.

“The timing of the ICD-10 transition could not be worse, as many physicians are currently spending significant time and resources implementing electronic health records into their practices,” the AMA said. “Physicians are also facing present and future financial burdens in the form of penalties if they do not successfully participate in multiple Medicare programs already under way, including e-prescribing, EHR meaningful use, the physician quality reporting system and value-based modifier programs.”

The House legislation also would authorize the Government Accountability Office to study ICD-10 and recommend ways to mitigate upgrade disruptions within the health care system.

 

This article courtesy of: http://www.amednews.com/article/20130513/government/130519980/10/?utm_source=rss&utm_medium=&utm_campaign=20130708