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PQRS - Reporting, Format and Tools

  
  
  

PQRS 2014Begun as a voluntary program in 2007 by CMS, the Physician Quality Reporting System (PQRS), offered fixed financial incentives to physician and non-physician providers who gathered and reported data metrics for the covered services their practices provided to Part B beneficiaries of traditional Medicare. Through reporting year 2012, a 1.5 percent bonus was paid for successful participation, based on the estimated total allowed charges for all cover services within the reporting period.

The structure of PQRS has changed since its inception, driven by new laws, notably 2010's Affordable Health Care Act (ACA). What before ACA was a voluntary program that incentivized participation through payments to practices has segued into a de facto mandatory program. Those practices not in compliance or who don't participate will be penalized. A 2014 chart from CMS shows historic changes to PQRS's incentive structure. (Incentives and penalties are assessed two years after the reporting year.)

2013

0.5% (performance year for 2015 penalty)

2014

0.5% (performance year for 2016 penalty)

2015

-1.5%

2016

-2%

Physicians who elect not to participate or are found unsuccessful during the 2013 program year, will be charged a 1.5 percent payment penalty, and 2 percent penalty each year thereafter. 

To avoid this, practitioners should become familiar with what data is assessed, how it's defined and reported, and what tools or services can aid them in ensuring the data they submit to CMS for review is selected and submitted in compliance with PQRS standards.

Reporting Format: Individual Measures or Measures Groups

CMS Quality assessments criteria, documentation and procedures are extensive. The structure of the data assessed falls into two categories: individual measures or measure groups. Practices may choose either for their assessments. Practitioners select as reporting options either nine individual measures out of 348 across three National Quality Standards (NQS) domains, or one measures group. For 2014, measures groups are only reportable via a qualified registry. This year, 2014, there are 25 measures groups, such as General Surgery, Total Knee Replacement and Optimizing Patient Exposure to Ionizing Radiation.

Choosing How to Report

For 2014, practitioners may choose from five reporting options:

1. Medicare Part B claims

Practices or their claims vendors report the selected quality data codes (QDCs) with their claims, with a minimum of 9 applicable measures across 3 NQS domains.

2. Qualified PQRS registry

These are “self-qualifying” organizations approved by CMS and ready to support submission of PQRS data to CMS. They attest that they're able to serve individual and group practitioners. As noted above, measures groups' data must be submitted through a registry.

3. Direct Electronic Health Record (EHR) using Certified EHR Technology (CEHRT)

PQRS data may be sent directly to CMS via a Stage Two Certified EHR system.

4. CEHRT via Data Submission Vendor

This is new in 2014. EHR PQRS data from a practice's Certified EHR system may be submitted to CMS through an approved CEHRT vendor.

5. PQRS Registry Systems Tools

A number of registries offer practices an online PQRS submission tools for a nominal fee. The vendors often equate them to PC-based tax preparation tools. These software packages typically collect either group or individual measures, validate the data, submit it to CMS, and advise acceptance or rejection and the reason for rejection. Suitable for small to medium-sized practices, these tools are offered to members of various medical associations. The American Associations of Physicians PQRSSmartWizard is typical of such products. Software that reports PQRS data unique to specialists' practices is also readily available. The American Academy of Dermatology, for example, offers a dermatology-specific PQRS submission tool.

Given the mandated conversion to EHR systems now well underway, we should expect increasingly more PQRS reporting to shift to EHR systems, either directly from larger practices, or through CHERT vendors for smaller group or individual practices.

Getting Started with PQRS

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Current State of EHR With Meaningful Use Stage 2

  
  
  

EHR meaningful use Stage 2In 2015, Medicare providers must begin demonstrating meaningful use of Electronic Health Records (EHR) technology. As of this writing, that's six months away. Nowhere is there any hint that this will be postponed, as was the ICD10 conversion date. Failure to make meaningful use of EHR recordstriggers a 1% reduction in reimbursement each successive year through 2017.

EHR Meaningful Use Defined

In 2015, CMS requires Stage Two Meaningful Use compliance by providers who've fulfilled Stage One requirements within the last two to three years. The core requirements for Stage Two compliance are dependent upon successful installation and mastery of sophisticated information systems that can support EHR exchange between providers and patients and between providers and other providers. Some of these are:

  • Computerized provider order entry of medication, laboratory and radiology orders
  • Prescriptions originated and sent electronically
  • Use of clinical decision support systems
  • Online patient access to their health records
  • Online availability of lab results to patient and provide
  • Secure electronic messaging capability between provider and patient

EHR Stage Two Implementation

Stage Two implementation is wholly dependent upon successful installation and operations of EHR software and hardware to support meaningful use (MU) attestation. There's a great deal of money to be made from the installation and management of EHR systems.

Ambulatory and Hospital Inpatient comprise the two types of EHR implementation. As of 2013, according to a report by research firm Software Advice 209,000 practices had attested to full meaningful use of an EHR in ambulatory setting, almost double the figure for 2012. In 2012, 107,000 ambulatory practices had attested to complete EHR use. By the end of 2013, this had increased by 95% to 209,000. The groundswell would seem to signal that practitioners are fully cognizant of the approaching EHR Stage Two requirements and are moving to comply.

In 2012, Ambulatory EHR implementations were served by 437 vendors. One might think the market for EHR systems' vendors saturated at that point, but in 2013, another 119 vendors appeared, an increase of 25%, bringing the total of EHR vendors supporting ambulatory to 556. Of these, ten had 64.2% of the market, with an astounding 456 vendors serving the remaining 35.8%, or 82,555 practices, equating to one vendor for each 181 practices. Whatever the long term effects of EHR on health care, it's certainly fostered a booming cottage industry of systems' vendors. It's also spawned speculation about the inevitability of consolidation, as market forces come into play, post implementation.

Hospital EHR implementations are served by far few vendors, hospitals being far few in number and having much larger and more complex requirements. These installations can run into the hundreds of millions of dollars and threaten the financial stability of the impacted health care systems, even as they boost the profits of major EHR vendors: ten of them designed and installed the EHR systems for 90 percent of attested hospitals, with three firms accounting for half of the hospital attestations.

Is EHR Conversion Worth It?

Health information systems are modernizing as fortunes are spent and fortunes made. The final bill for EHR conversion isn't yet available, but will surely run into the tens of billions. Concerns have been raised: “Evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services,” noted The New York Times.

It will be years before all the metrics of EHR conversion are available, its ultimate success determined by patient outcomes.

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ICD-10 code claims implementation until October 2015 --Implications?

  
  
  

ICD-10 implementationUS legislature has extended the ICD-10 medical billing code claims implementation until October 2015 – What are the implications?

Senate vote delaying the implementation of ICD-10-CM/PCS by at least one year was passed 64-35 on Monday, March 31. Seven lines of bill H.R. 4302 are about Medicare payments to physicians. They state that Health and Human Services cannot initiate the ICD–10 standard until October 1, 2015 or later. Thousands of AHIMA members opposed the ICD-10 implementation delay. Believing that the transition is inevitable and time sensitive, AHIMA highlighted the risks of delay, citing the need to provide the most effective tracking and analysis of clinical services and treatments. In essence, postponement is at odds with the delivery of effective patient care.

A significant number of educational programs have been teaching ICD-10 coding and procedures in preparation for the 2014 deadline. Healthcare organizations nationwide have already begun preparation for ICD-10, with major expenditures devoted to staff training and computer system enhancements or replacement.

The Coalition for ICD-10, with a member body including the American Medical Informatics Association, BlueCross, the College of Healthcare Information Management executives, Siemens Health Services and 3M Health Information Systems, urged that the ICD-10 deadline remain as October 2014.

While some say that patient care organizations that have been in the process of preparing for ICD-10 have wasted their time and resources, this is not the case. This upgrade is inevitable and has only been postponed for a year. The extension can be viewed as a deadline that has been moved forward, offering practices the ability to extend their familiarity with the code set, and hone their procedural, workflow and system testing. Neither resources nor time have been wasted.

During this extended period, those who aren’t prepared have the opportunity to become prepared—preparation that should be supported by large organizations with the expertise to advise practitioners, including the federal government. Aetna’s reaction to this delay is:

“We will continue working on our ICD-10 projects to ensure that our systems, vendor tools, and business processes and policies will be ready for the new compliance date. We’ll follow guidance from the Department of Health and Human Services and Centers for Medicare & Medicaid Services. We will work closely with the medical community to monitor compliance and manage risk.”

Here is some advice for 2015 compliance:

  • Contact billing and software vendors to obtain and discuss their ICD-10 conversion and test plans
  • Scrutinize clinical, financial, billing and coding processes to identify the impact of conversion to ICD-10 on your organization
  • Obtain ICD-9 to ICD-10 mapping guides and templates. CMS provides General Equivalency Mappings for converting ICD-9 codes to ICD-10 codes.
  • Continue to follow the direction of regulatory authorities, and adapt your implementation strategy as needed.
  • Sign up for CMS ICD-10 Industry Email Updates and follow CMS on Twitter to stay abreast of changes.
  • Robust testing is essential to success. Waiting until the deadline invites failure. Providers must test their billing systems with clearing houses and payers to validate and refine practice procedures and diagnosis combinations six months before going live.
  • Access tools that provide reimbursement trend alerts and enable providers to locate bottlenecks. The insight they offer will help eliminate inefficiencies and foster a successful transition.
  • Communicate - daily team meetings with those involved in claims processing or ICD-10 coding can help identify issues and solve problems as they arise. These meetings should take place both before and after ICD-10 compliance begins and can help iron out transition difficulties.

The delay in ICD-10 implementation was the result of combining a Medicare MD Payment Bill with ICD-10 implementation. It was passed in a very hurried way with little preparation time offered to legislators. ICD-10 is not a convenience; it’s a proven, sophisticated code set used internationally to track and analyze health and treatment patterns. Adoption of this ICD-10 is essential to implementing effective modern medicine. A commitment by all players to meet the 2015 deadline is required.

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In Obamacare world Use Latest Technogies to Keep Practice Profitable

  
  
  

heathcare technologyMedical practices are under increasing pressure to remain profitable for multiple reasons. While the easy--and popular--culprit is the Affordable Care Act (ACA), or Obamacare. However there are more factors involved, of which some may be more significant than the effect of the ACA.

Some Pressure-Creating Factors

Family practices face issues that force physicians to take a hard look at their business--as a business--not just a healing medical practice. The reality that these pressures come from other businesses and governments leave no other logical or effective solutions for family physicians. The source of this pressure is not likely to evaporate any time soon.

  • Pay for performance (P4P);
  • Incentives that can quickly become disincentives;
  • EHR requirements, which if not met, will result in penalties in 2015 and beyond.
  • Payers becoming more strict with claim accuracy demands that often result in reimbursement reductions, delays or denials; and
  • Higher co-pays that put more pressure on collecting from patients.

These are some of the sources of pressure on family practices to remain profitable. Family practitioners and primary care physicians should recognize the potential downsides of these issues and address them to better ensure their profitability.

Technology Can Help

Using some new technology can meet the current requirements to cut and manage costs, while meeting HIPAA, CMS and ACA regulations and targets. Doing so will keep the cash flow coming without damaging interruptions. Among the technology trends and options available to maintain profitability, the following often are the most effective.

  • Using the "cloud" to save money while enjoying convenience and speed of response;
  • Installing integrated practice management software;
  • Employing patient portals, raising productivity and improving patient care;
  • Using mobile app solutions to increase productivity when you're on the go;
  • Adopting "certified" EHR software to maximize compliance and reimbursement levels;
  • Learning to use state-of-the-art metrics and analytical tools to measure performance to make better practice decisions.

Technology is never the answer to every operating problem. However, cutting-edge technology can alleviate many of the profit-stealing issues the current healthcare environment creates for family practices. For example, shifting some IT responsibilities to cloud technology delivers at least three benefits.

  • Ability to access important data with only a PC and Internet connection.
  • Access auto updates of vital information.
  • Ability to access data 24/7 wherever you may be, even on the road with mobile apps.

This is a graphic “snapshot” of the physician benefits delivered by current technology that improves productivity and profitability for family practices. If these requirements appear daunting, consider using a top third-party medical billing and documentation firm, like M-Scribe Technologies, to manage all these responsibilities for you.

Instead of purchasing complex software, training staff and needing a practice IT guru to keep it performing, third-party firms can offer evidence of proven performance by fully-trained and experienced staff familiar with the most current software operation. You’ll enjoy the added benefits of cost-control, compliance and better nights’ sleep, along with a healthy practice bottom line.

Survey Responses Confirm the Problem

Noted consulting firm, Deloitte, completed a 2013 survey of US physicians with confirmatory results of the problem. The most striking and troublesome statistic were family and primary care physicians stating they were the least satisfied (41 percent) with practicing medicine of the respondent groups.

Reducing admin costs must be matched with adopting technology that keeps practices in compliance, while maintaining reimbursements at former or higher levels. The Deloitte survey confirms the perceived current challenges facing family practices today.

Family practice overhead appears to gobble up around 60 percent of gross revenues. This stat makes it imperative that physicians employ the most cost-effective and efficient solutions to minimize expenses balanced by offering the quality patient care that qualifies for incentives, while avoiding penalties.

Talk to An Expert

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How to Maximize Collections from Patients

  
  
  

practice collectionMore money is due from patients than ever before. While self-pay patients are always a concern, the primary reasons more dollars are due is a function of those patients who have healthcare plans in force.

Two reasons dominate the issue.

  • The increasing use of high deductible healthcare insurance plans; and
  • Carriers increasing co-pay amounts regularly.

If your practice has had issues with insurance carriers who make a habit of paying late, you have probably installed procedures to hasten payments from these lackadaisical payers. But, what about your patients having high deductible plans or those enduring higher co-pays.

Why allow your accounts receivable increase while your cash flow decreases? Establish a plan to maximize your collections from patients. It need not be overly complex or challenging to execute. However, your plan should include these components, at a minimum.

Collection Plan Considerations

  • Make it clear and understandable. Avoid confusing "legalese" or sophisticated terminology and buzzwords.
  • Fill any "holes" and eliminate ambiguities in the written procedure. Unless you use an attorney who specializes in collections or veteran collections consultant, you may allow some loopholes or ambiguous statements to inhabit your practice policy. After you believe your collections strategy is complete and ready to be published, read it again, specifically trying to find any holes or language that may be ambiguous.
  • Communicate with and train both front- and back-office staff on the new policy. Unless you plan on collecting co-pays and deductibles personally, your staff will have this duty. Expecting even seasoned personnel to enforce a procedure of which they are unaware is foolhardy. Having training sessions will give them the information they need to follow the policy, while encouraging questions about any features they may not understand at first glance.
  • Include a procedure to contact late payers around every two weeks to remind your patients they have a balance due. This approach allows practice staff to be diplomatic and friendly, before the balance becomes seriously overdue.
  • Publish the policy, posting the major components (if possible), so your patients know what is expected of them. With various independent studies indicating that co-pays alone can account for up to 20 percent of practice income, posting your policy helps eliminate patient comments like "I didn't know I had to give you my co-payment before or immediately after my visit." Displaying your patient collection policy in a prominent, heavily viewed place reminds your patients that plan co-pays are payable at the time of service or treatment.
  • Remain objective, keeping your "feelings" out of your collection policy. This is not the time to become "Marcus Welby, M.D." (that was only a 1960s TV show, anyway). You became a physician to keep patients healthy or make sick people get well, but you can only fulfill your mission if your practice remains open and financially sound.
  • If your A/R aging is reaching unacceptable levels, have procedures to collect seriously overdue outstanding balances. This may seem obvious, but some provider-designed collection strategies and plans do not address this condition. Whether you train your practice staff how to be "firm, but courteous" or farm out overdue balances to a medical collections firm, make a policy for handling these situations.

These are some of the important components of collecting more monies due from your patients. Those that always pay on time can disregard the practice policy, as they do not need to know its features. However, those patients who habitually require more formal collection efforts may become profitable, making co-pays and remitting balances faster.

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Adopt "Certified" EHR Technology to Qualify for Incentive Payments

  
  
  

not using EHR
As the conversion to EHR continues, the importance of using "certified" EHR technology becomes ever more important. Yet, many practices remain unsure of how to accomplish this necessary goal.

Using other technology can disqualify physicians from receiving incentive payments. It is important that medical providers become familiar with the certification process before embarking down the wrong road. As the Meaningful Use regulations are now in Stage 2, EHRs are vital, as is using certified EHR technology.

Certification Process

The process is defined by the Office of the National Coordinator for Health Information Technology (ONC). The standards and certification criteria target meeting Meaningful Use goals and objectives.

Although a Temporary Certification was available, physicians should now focus on the Permanent Certification Program, since the final rule has been published. Pursue permanent certification since the ONC HIT Certification Program replace the Temporary Certification Program in October 2012.

To learn more about the certification process, visit the HealthIT.gov site to read the specifics about technology certification and view FAQs.

Certified EHR Technology

To be certified by CMS and ONC, systems must meet capability, functionality and security standards as defined by these agencies. To learn those systems that qualify, visit the Certified Health IT Product List at the ONC website.

A key feature of software certification is that the software must store patient data in a consistent, structured format. By mandating an acceptable storage structure, providers can retrieve and transfer EHRs in consistent formats, making the process easier and more reliable.

It is important to note the wisdom of the cliché, "never assume." If you are already using an EHR system qualified for other Medicare incentive programs, you have no guarantee that your system is certified for use in the EHR Incentive Program. Always verify that you use software that is certified by the ONC and adopted by CMS for this specific program.

Understanding Meaningful Use and Certified EHR Technology

Using certified EHR technology advances the satisfaction of Meaningful Use requirements in the following ways.

  • Improves the quality, safety and efficiency of healthcare, removing disparities;
  • Engages patients and their families in their healthcare efforts;
  • Creates and improves coordination of care incentive requirements;
  • Improve the quality and delivery of healthcare to the public; and
  • Maintains the privacy and security of patient healthcare records.

The three primary components of Meaningful Use are dependent on using certified EHR technology.

  • Using certified EHR systems in meaningful ways, such as e-prescribing.
  • Certified EHR technology helps make electronic exchange of health information more efficient to improve the quality of healthcare; and
  • Clinical Quality Measures (CQM) submission by certified EHR software is more effective.

As it has always been, the primary goal of Meaningful Use remains the same: To use secure data capture and sharing systems to permit advanced clinical processes, which lead to improved treatment outcomes.

The Time for Certified EHR Technology Is NOW

Since the reimbursement "adjustments" (disincentives) begin in 2015, and 2014 is almost one-half over, the time for using certified EHR software is upon us. Qualifying for incentives requires certified EHRs, but not using this technology will soon result in reimbursement downward adjustments, reducing your CMS payments.

If you do not currently use certified EHR software and/or have not added a module that brings your EHRs into compliance, consider an alternative. Evaluate a top medical billing and documentation firm, such as M-Scribe Technologies, to use a cost-effective alternative to installing certified EHR systems in your practice. Why invest in new software and staff training requirements if you do not have to do so? Let a leading firm, with state-of-the-art certified EHR technology operated by trained personnel do it for you.

The choice of earning EHR Program incentives or having your reimbursements "adjusted" seems clear. Whether you do-it-yourself of have a professional firm do it for you, the "thrill of victory" (earning EHR incentives) is much more preferable to the "agony of defeat" (enduring reduced reimbursements).

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Best Purchases to Help Physicians Improve Their Practices

  
  
  

doctor practiceInvesting in some favorite items can help improve your practice in diverse ways. Here are some possibly surprising investments that offer a good ROI to physicians and their practices.

These items were noted by Physicians Practice and were chosen by other medical providers, who named these their “favorite purchases” for their practices.

Best Purchases Returning Impressive Returns on Investment (ROI)

  • Fish tanks: People hate to wait for anything. Patients visiting their doctor compound this issue by coming with anxiety. An impressive fish tank in your waiting room psychologically puts your patients at ease, minimizing their anxiety. Instead of spending extra—and non-billable—time calming patients’ fears and apprehensions, give them the “soothing” effect of watching fish swim around their tank in your waiting room.
  • Single serve coffee brewers: Doctors and practice staff must remain alert through busy, stressful days welcoming and seeing patients. Many physicians named single serve coffee makers as one of the best purchases to make their practices more efficient. By reducing waste from unfinished pots of coffee, single serve brewers also decrease the cost of providing coffee.
  • Flatbed or multiple page scanners: As the healthcare industry moves to electronic health records (EHRs), scanners are quickly becoming favorite purchases to improve the efficiency and profitability of medical practices around the nation. Physicians also enjoy additional benefits by reducing the volume of paper by saving all documents electronically.
  • Speech recognition programs: Instead of dictating chart information into a recorder and waiting for practice personnel to transcribe this data on a computer, speech recognition software allows the physician to directly record—and edit—his or her information into practice computer systems. This time- and money-saving option is a welcome aide for all physicians hopting to conserve hours.
  • In- and out-house billing options: Top third party billing firms, such as M-Scribe Technologies, save practices both time and money. Smaller and mid-sized medical practices reap these consistent benefits. Larger practices, staffed by more “traditionalist” physicians, may want to invest in cutting-edge software and pay the extra cost of more staff to keep billing in-house. Those that want to keep this function must commit to thorough staff training and design a verification policy that double checks claim billing information before submission. Both choices deliver benefits, although in-house billing comes with added cost and responsibility.
  • Real time locating systems: These systems help doctors save time (and money) by locating needed people or things (instruments, machines, exam aides, etc.) to save time when consulting with patients. Mid-size and larger practices benefit most from these systems that display their exact floor plan in real time for the physician. While the provider cannot bill for using these systems, these locators can save valuable time, particularly important when seeing a high volume of patients daily.
  • Lactation scales: Pediatric practice physicians find these items among their favorite purchases for multiple reasons. These scales measure the quantity of breast milk ingested by infants, helping physicians calculate the volume of milk transfer. Lactation scales also reassure new mothers that their babies are getting sufficient milk for good health and proper growth. These scales can also alert the doctor to any ingestion deficiencies they need to address.
  • EHR software systems. Unlike some other favorites, this is a larger scale investment, but helps doctors and practices transmit health information instantaneously, with high-level security. Since the healthcare industry is converting patient medical records from paper to electronic data, many physicians name this investment a favorite.

Physicians Practice offers this list of favorite purchases for and chosen by other doctors to improve their organizations. You might already have your own list of favorites, but consider some of these as potential additions to or replacements for a few of your current favorites.

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How to Secure HIPAA Compliant texting for medical practices.

  
  
  

HIPAA and textingBreaking news: Texting has pervaded the world of healthcare providers. After years of avoiding this form of communication, providers are now using text messages to get patient information to the right people.

However, along with the benefits of fast communication, texting comes with some risks. Those who send unencrypted text messages of Electronic Protected Health Information (ePHI) face some major risks of falling out of compliance with HIPAA and HITECH regulations.

Avoiding Unsecured Texting Risks

As enforcement of HIPAA regulations intensifies, the risks of sending unencrypted text messages also increases. Although communicating with colleagues via text messaging is convenient and fast, encryption is vital to maintain HIPAA and HITECH compliance with patient privacy rules.

A medical organization should take the following steps, at a minimum, to avoid the risks. Of course, the common practice of faxing patient information to another provider is even less secure, but texting faces many similar risks.

To avoid the dangers of insecure texting and enhance HIPAA compliance, consider these three components to design a text message strategy. These steps lay the groundwork for a thoughtful plan to better secure your texts.

  • Establish a written policy for text communications.
  • Evaluate and select a secure text message solution.
  • Design and manage the texting solution chosen.

Since the HIPAA Security Rule requires your practice to perform a risk analysis, including addressing text messaging as a component, you must identify effective “administrative, physical and technical controls” necessary to minimize the risks of sending patient information by text. Compare current text messaging methods versus other options that could better protect ePHI.

HITECH also requires the practice to note the methods adopted for “breach notification,” to comply with the HIPAA Privacy Rule. Breaches include “the acquisition, access, use or disclosure” of PHI, including lost or stolen cell phones falling into the hands of others not authorized for access to patient records. How do you plan to notify about a breach and eliminate PHI that may reside on a lost or stolen cell phone?

HIPAA Compliant Texting Policy

Your practice policy should apply to everyone in your organization, physicians and support staff alike. Even independent contractors and some vendors may fall under your policy if they have a Business Associate Agreement (BAA) in force with your practice.

To avoid non-compliance, include the following features in your texting policy.

  • All text messages, whether sent by mobile device or computer, containing ePHI, must be transmitted in encrypted form.
  • These messages should not be decrypted and stored on cell phones or the cellular providers’ servers that could be accessed by unauthorized persons.
  • Establish safeguards for practice staff when sending or receiving ePHI-based text messages, including password protection, device automatic locking during inactivity and sending minimum patient information only.

Suggested Policy and Implementation Guidelines

These guidelines should be “must do” actions when texting PHI.

  • Always confirm the identity of the text recipient.
  • Confirm delivery and receipt of text messages.
  • Don’t use any shorthand or abbreviated terms.
  • Never text patient orders.
  • Document all text messages (or notations thereof) in patent medical records.
  • Delete all text messages with ePHI as soon as possible or when enclosed information is no longer needed.
  • Report unencrypted text messages, sent or received, containing ePHI to the practice HIPAA Security Officer immediately.

By including the noted safeguards in your practice policy and implementing them will better secure your text messaging. Your written texting security policy, followed by using it as designed by practice personnel, should avoid HIPAA non-compliance problems.

Installing appropriate solutions to maximize the security of your text messages, along with remedial procedures should you suspect a breach, helps you protect and defend your patient medical records from unauthorized viewing or use. You will have satisfied the intent, focus and mandates of the HIPAA Security Rule.

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How to Avoid the Most Common Claim Denials

  
  
  

Claims deniedOne of the most frustrating situations for physician and patient alike is a health insurance claim delay or denial after a treatment or diagnosis appointment. When this occurs, both the medical provider and the patient suffer.

Understanding the most common reasons for claims denials, gives physicians vital data to help avoid reimbursement delays and denials. Consider these common triggers for claim denials.

Common Reasons for Claim Denials

  • Patient identifier information errors. Even a simple name misspelling is sufficient to generate a denial. Other patient information suffering a typo, such as date of birth, subscriber or group number errors, also commonly generate delays or denials. Double check the accuracy of spelling and numeric data before submission to avoid this common pitfall.
  • Terminated coverage. Many practitioners fail to verify in-force insurance before treatment. This condition is more common than it should be, but will always generate a claim denial. To avoid this problem, the provider or practice staff should verify coverage, particularly if there are signs that coverage may no longer be active.
  • Missing authorization or precertification data. Many claims related to non-emergency services require prior authorization, particularly for some radiology procedures (such as U/Ss, CTs and MRIs). Submitting claims for these services, but lacking evidence of precertification, is an exercise in futility, as payers will deny them. Before you order that expensive MRI, be sure to get authorization from the payer for the procedure.
  • Excluded services. Most health insurance coverage includes some services that are excluded from coverage. While providers and their staffs cannot be expected to memorize every nuance or exclusion in each health insurance policy from multiple different carriers, they should be aware of the most common exclusions in many major insurance companies coverage. Whenever a question about excluded coverage arises, practice staff should verify the covered and non-covered services.
  • Not sending medical records, when required. Some healthcare plans require sending medical record documentation, e.g., patient medical history, to verify the propriety of some claims. Neglecting to send the requested medical records will, at a minimum, delay payment—and, often, results in a denial. These requests sometimes come after the original claims submission. Requests for certain medical records should be filled immediately to allow the payer to evaluate and adjudicate the claim quickly.
  • Erroneous coordination of benefits information. This claim denial reason is more common than it should be. Common misinformation includes neglecting to advise the payer of other coverage which is primary and missing EOBs, particularly regarding co-payments made. Billing staff must be sure additional insurance, particularly if primary coverage, does not exist or, when it does, to advise the payer of this fact. Including all pertinent insurance information and the appropriate EOB will avoid claim denials for this reason.
  • CPT or HCPCS Coding Errors. Billing code errors remain common reasons for denials. Practice billing staff should develop the habit of reviewing and/or verifying proper coding before claim submission. The extra minute or two it takes to verify use of correct codes is much less than claim delays that can stretch to weeks or appealing a claim denial.

Third-Party Billing Firms

In most cases, a practice will avoid these common causes for claim denials by using a top third-party medical billing organization. Well-trained and experienced staffs seldom make these common errors—that is why top firms have such high ratings.

Their accuracy tends to be high-level and consistent. They employ quality control systems to help ensure they submit correct claim documentation. Their staffs are thoroughly trained in all current codes, including those that may have been recently updated or changed.

In all cases, top firms take every precaution to avoid claim denials. Practices that employ professional billing firms often have fewer claim denials while also enjoying excellent cost control of their all-important billing function.

   12 Tips to Regain Control of your Bil

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EHR, E-Prescribing and P4P Affects Your Practice--for Better or Worse

  
  
  

ehr p4p ep resized 600Although Medicare and Medicaid issued the first incentives for electronic health records (EHRs) and pay for performance (P4P), private payers are very interested in adopting similar programs. The luster of newness has now worn off and many medical providers are making the transition.

However, these digital solutions often create challenges and demands for more efficient IT systems and software. Not all practices have the computing power to record and share lab test results, e-prescribe or the capacity to use computerized physician order entry (CPOE).

Practice IT Infrastructure

Those medical practices that have upgraded their systems have the ability to participate cost effectively in all data sharing opportunities. Practices that have yet to install next generation systems will encounter time and cost challenges participating in some EHR, e-prescribing, lab data sharing and P4P incentives.

If their IT systems lack sufficient speed and capacity, practice staff needs to manually intervene, as they have in the past, to transmit data and documents. To maximize the incentives, more staff intervention equals more cost and potential for errors. In these situations, the lack of up-to-date hardware and software could hurt, not help, practice revenue and profitability.

E-Prescribing

While some practices have become quite comfortable with e-prescribing, there are still many that remain unfamiliar with the process. Although there are many online and print resources, including flow charts and diagrams, that display the components of every type of transaction, the process often remains a mystery to some physicians and practice staff.

Understanding the process and benefits of e-prescribing is important to using EHR and P4P to maximum advantage. Employing the best systems makes the process cost effective and profitable. The steps are quite straightforward and clear.

The Prescriber

  • Physicians, clinicians or practice staff logs in to the system, after appropriate security verification.
  • Prescribers identify the patient health record (PHR) to the system.
  • Physicians prescribe, add or modify medication and select the pharmacy to fill the prescription.
  • Prescribers transmit this data to a transaction hub, which checks patient eligibility, makes formulary evaluation and fill status decisions, sending hub conclusions back to prescribing entities.

Transaction Hub

  • Links prescriber, pharmacy and pharmacy benefits manager (PBM) together.
  • Maintains a database of a master patient index and pharmacies.
  • The PBM determines eligibility, formulary and meds history back to the hub, which transmits back to the prescriber, awaiting a proceed or cancel decision.

Pharmacy

  • Receives prescription and confirms receipt with the hub.
  • May contact physicians’ offices through the system to verify renewal requests.
  • Sends data regarding patient medication pick-up to prescribers back through the system.

E-prescribing is a graphic example of the way having the best IT system can help a practice with digital solutions. The other side of that same coin dictates that having an outdated system can increase costs, while reducing revenue and profitability.

Changing Practice IT Infrastructure

EHRs are dictating changes in practice computer infrastructure. E-prescribing is only one important component, but possibly the most effective cost and time saving element. It seems that employing the most efficient IT systems make a major difference in cutting or increasing costs.

Sharing lab data also improves your P4P profile, but without up-to-date digital systems, your P4P incentive may be offset by the increased costs of staff time locating, preparing and faxing requirements to share this important information with other physicians.

EHRs, e-prescribing and P4P are intended to help practices increase revenues and cut costs. However, they require up-to-date, efficient IT systems to reach these goals. Those with out of date systems should strongly consider upgrading their IT to help their practices earn more revenue, while cutting costs. The alternative will only hurt your practice revenues and profits. This is a wise technology investment.

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