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How to Use Social Media in Healthcare to Increase Profits


social media in healthcareSocial media has been successful helping many companies engage their customers and increase revenue. Properly using these tools can have the same effect on medical practices. The key phrase is "properly using."

To properly use social media, your practice should take a few steps to better ensure successful results. These tips have proven to work for companies in all industries. Your practice should reap identical benefits if you follow these steps.

Using Social Media to Increase Practice Profits

Consider using the following tips to develop a social media program that helps increase revenue and profits for medical practices. These suggestions are offered by Oracle, an indisputable leader in digital processes and solutions.

  • Design a creative strategy to maximize social media use. Whether you choose the most popular options, such as Facebook and Twitter, or less well known, but effective social media sites, your strategy to increase revenue and control costs will work if your patients respond to your outreach. If you experience high creativity levels, you can use multimedia sites, such as Pinterest or YouTube, to deliver your message.
  • Be sure your social media setup provides for two-way communications, not just for you to dispense information. Patient feedback can be very important, so give them the opportunity to communicate with you. For example, to encourage patient feedback you could offer a brief survey with important questions, while asking for responses from your patients. These responses will reveal patient perceptions of your practice, providing valuable information about potential improvements you could make to improve it. In a way, just as companies use this technique to better understand their customers' preferences, providers use this two-way communication to learn more about their patients.
  • Control the content you use on your social media pages to ensure that you're offering the information you want. It doesn't matter whether you write the content yourself or outsource it to others. The key is to retain control of your posts so you're comfortable with the focus and text you dispense. Consider offering patients something for 'free,' such as monthly or quarterly newsletters, e-books on healthier lifestyles, or developments in your specialty that would interest your patients.
  • Set your social media goals and track the results. Decide the target results you want and measure your progress. For example, if you want to increase practice profits by five percent, create a social media strategy you believe will accomplish this goal. Measuring your results will give you evidence of the success of your strategy. Even if you don't get the results you want, by tracking your progress, you'll learn what parts of your plan work and which ones need tweaking.

When In Doubt, Get Qualified Help

If you lack the time, desire or expertise to make this a DIY project, get professional help to design and track the results of your social media strategies. While you might call on a web or freelance writing veteran, you should consider outsourcing your social media presence to a leading medical billing firm, such as M-Scribe Technologies.

Proven third party medical specialty firms understand the details of physician and practice goals and components of greater profitability, such as ways to increase practice revenue and control expenses. Additional benefits they can deliver include helping you maintain compliance with HIPAA, CMS, Affordable Care Act (ACA) and private payer regulations, while using social media effectively, always adhering to patient privacy laws.

Data indicates that at least one practice experienced up to 20 percent increased revenues, conversion rates up to 70 percent (since prospective patients perceive that they "know you") and generated new, good reviews of patient experiences. This is valuable information you'll receive when you track and measure your social media results, as they translate to bottom line increases.

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Diagnosis Coding Has Taken Center Stage in Medical Billing


Accurate Diagnosis CoHistorically physicians and payers were 'on the same page' regarding fee-for-service reimbursements. The doctor provided a service, for which the medical professional received a fee. Simple and not complicated. However, along with healthcare reform comes the need for physicians to be thorough and accurate with their diagnosis codes.

The shift to pay-for-performance (P4P) programs, originally initiated by the CMS, but increasingly adopted by private payers, demands this accuracy. Along with offering incentives to physicians for providing quality care, there are now penalties for medical professionals who may not be offering patient care of acceptable quality.

Accuracy Was Always an Issue

While accurately recording diagnosis codes has always been important, until P4P programs, many payers accepted marginally thorough supporting information to approve claims and pay providers. The new emphasis on claims clarity often proves to be challenging for physicians and billing staff, particularly for those providers not in the habit of submitting fully documented reimbursement claims.

In the past, claims with faulty diagnosis codes typically were denied. Yet, some insufficiently explained claim submissions slipped through and were approved. If payer claim reviewers were hurried into claim examinations, it was always possible that some submissions that could have had payers 'scratching their heads' were approved.

However, most of the diagnosis coding rules have changed. Accuracy, always a factor, has become the primary component of claims approval. Along with approved/rejected decisions, medical providers now face quality care issues, requiring further justification and explanation to eliminate payer confusion.

Proper Diagnosis Critical for Payment

Some physicians and billing personnel seem forgetful that Medicare Advantage plans pay, in part, as a function of the number and severity of sickness in the total population of patients. CMS calculates variable per month payments based on the levels of the 'sick' population. Some private payers are endorsing this approach, demanding that physician diagnosis coding 'fits' the matrix.

While some physicians during the fee-for-service era always went the extra mile to fully explain their diagnostic coding and process, many other providers, often because of billing staff time constraints, neglected to thoroughly document their diagnosis procedures. However, providers now risk facing claim denials with P4P programs if payer review staff is unsure that the doctor performed diagnostic services that were necessary to design a treatment plan.

Accurate and thorough coding for chronic conditions is another prime area of payer scrutiny. ICD-9 guidelines require providers to use these codes 'as often as applicable' when treating chronic conditions. P4P quality care evaluation depends on proper use of these codes. The penalty consequences of taking coding 'shortcuts' can result in lower income for the physician.

These are some of the reasons that using accurate diagnosis codes are critical for maximum claim approvals and CMS decisions that physician care qualifies as meeting quality guidelines. The strong focus on procedural diagnostic coding accuracy is here—possibly affecting your compliance and income levels.

Accurate diagnosis coding, backed up by thorough documentation regarding the necessity of diagnostic procedures, is no longer a payer ‘luxury.’ Accuracy and clarity is now a necessity for all physicians. Achieving this result typically demands some combination of the following actions.

  • Designing an almost foolproof internal procedure for billing staff or physicians to review all claim submissions for accurate diagnosis codes and supporting document clarity.
  • Have experienced coders review EHR document derived diagnostic codes before submitting claims.
  • Retaining a leading independent coding and documentation firm, such as M-Scribe Technologies, to assume the responsibility of submitting accurate, clearly explained diagnostic procedure claims for you.
  • Physicians developing the habit of fully documenting all diagnostic procedures for every patient, helping billing staff and payer reviewers to understand the reasons for the diagnosis process used.

Physicians and practices using these tips should remain in HIPAA, CMS and P4P compliance, maintain or increase revenue and create evidence of delivering quality care to all patients. Properly using diagnosis codes and supporting your diagnostic procedures with valid documentation will achieve these results. None of the potential alternative results are acceptable for either doctor or patient.

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Uncover the 'Silver Lining' Of Obamacare for Physicians


Obamacare Advantages resized 600Healthcare reform, otherwise known as Obamacare, has generated mostly negative attention from most of the broadcast, print and digital media. There are some good reasons for this less than complimentary attention.

  • Many healthcare marketplace websites have had serious bugs, preventing people from purchasing mandatory health insurance.
  • Many health insurance products are too expensive for a large number of Americans, particularly the middle class, which is getting financially squeezed by the current economy.
  • The citizenry remains generally unhappy with and/or confused about many provisions in the Affordable Care Act (ACA).
  • High deductible health plans shift too many payment burdens to patients.

These negative opinions and facts typically hide the potential benefits offered by Obamacare—particularly for medical providers. Physicians often hope that Obamacare succeeds, because it’s here whether we want it or not.

Yet, media reports have ignored the possible benefits physicians may receive. Even many medical industry publications and associations largely have ignored the possible ‘silver lining’ that comes with Obamacare.

Less Publicized Benefits

Despite all the negativism, consider the less publicized benefits of Obamacare. While there are numerous less important benefits, the following should qualify as the silver lining of healthcare reform for physicians.

  • Obamacare supplies the top component for increasing physician revenue: More patients. Particularly significant to independent providers with smaller practices, more patients provide the opportunity for physician to grow their practices.
  • The original healthcare reform debates often centered on reducing Medicare reimbursements because of unsustainable payment levels. To date, even with the implementation of the ACA, Congress has kept Medicare reimbursement amounts at former levels.
  • The shifting focus from care quantity to quality of care should motivate physicians to offer and patients to receive high quality care. Providers committed to earning the incentives that come with delivering quality care will enjoy increased income. Although targeted to doctors offering Medicare services, pay-for-performance (P4P) incentives are attracting many major private healthcare payers, who are participating in this initiative.
  • In states agreeing to expand their Medicaid programs, physicians will be reimbursed equally for Medicare AND Medicaid diagnostic and treatment services. Historically, Medicaid reimbursements were significantly lower than Medicare payments. The ACA specifies that Medicaid payments should have parity with Medicare reimbursements for identical treatment and procedures.
  • Incentives to practice in ‘underserved’ areas. The ACA provides bonuses (10 percent) to primary care physicians (PCPs) who open a practice or continue to offer service in ‘medically underserved communities.’ This bonus mirrors the Medicare provision providing incentives for practicing in underserved areas.
  • Insurance must offer coverage for pre-existing conditions. This provision also providers to grow their practices by encouraging patients to seek treatment for pre-existing conditions, often excluded from many health insurance plans before Obamacare. Since the private foundation promoting improved healthcare for Americans, The Commonwealth Fund, in a 2010 research study, found that around 60 percent of people lacking health insurance did not request medical care fearing the cost. The ability to have coverage for pre-existing conditions will have more patients seeking treatment.

These are but some components of the little publicized physician—and patient—benefits of Obamacare. Instead of focusing on the negatives of healthcare reform, physicians should evaluate the benefits and take appropriate action to maintain or increase practice income by growing their practices and qualifying for incentives offered when delivering high quality care.

Providers that use P4P as a positive motivator can eliminate most of the negative perceptions surrounding Obamacare. Instead, forward-thinking and creative providers will enjoy the often disguised positive advantages for physicians offered by the ACA. Doctors are encouraged to reap the rewards, not endure perceived penalties.


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How to Avoid PQRS Penalties (2% of Medicare Annual Revenue!)


tips to avoid pqrs penaltiesAlthough the physician and medical community is underwhelmed, sometimes openly hostile, to the implementation of the penalty phase of the Physician Quality Reporting System (PQRS) made a permanent regulation under The Medicare Improvement for Patients and Providers Act of 2008, penalties will take effect in 2015. Penalties will apply for non-compliance for activities during the period January 1 through December 31, 2013.

Therefore, practices should implement action plans to avoid 2015 PQRS penalties NOW. CMS believes their 2013 reporting options give eligible providers sufficient time and choices to comply with PQRS requirements.

PQRS Penalties

Medical providers who do not comply with PQRS requirements can have their Medicare and Medicaid reimbursements reduced by 1.5 percent. Since CMS reimbursements are "conservative" (polite designation) already, receiving only 98.5 percent of scheduled payments could partially cripple a practice's revenue stream.

PQRS penalties will increase to 2 percent payment reductions in 2016 for those providers that continue to operate in non-compliance. CMS, in a classic government-generated language softener, refers to these penalties as "payment modifiers," not income penalties. The resulting revenue damage, however, achieves the same negative result.

Avoiding PQRS Penalties (or "Payment Modifiers")

Yes, it's getting late; but it's not too late to avoid 2015 PQRS penalties and definitely sufficient time to avoid the heavier 2016 penalty cost potential. Since it's late 2013, most of your previous options have disappeared per the calendar. But, you still have the following options for 2013 and 2014.

  • Start using PQRS codes immediately.
  • Learn and use PQRS measure specifications for all future Medicare patients.
  • Before the end of February 2014, use a data registry and ensure that you provide PQRS-compliant care.
  • Ensure your billing staff or third-party medical billing service is using PQRS codes for Medicare reimbursable procedures, diagnosis and treatment.
  • Use the CMS "calculated administrative claims-based reporting mechanism."

While the CMS incentive program is important to increase your revenue, the penalty phase is even more vital to keeping your revenue stream healthy. Avoiding PQRS penalties, by taking these precautions, will serve the same--or more important--purpose.

Medical providers are busy. Billing staffs are busy. However, CMS offers multiple measures for compliant PQRS reporting. If your practice encompasses many Medicare or Medicaid patients, you need not incur PQRS penalties.

Adopting some measures as soon as possible--today is good--will avoid revenue-damaging penalties. Among the options to avoid PQRS penalties you can take are the following actions.

  • Initiate claims-based reporting, as defined by CMS procedures (using "G" codes).
  • Use registry-based reporting with CMS approved registries.
  • Implement electronic health records (EHR) reporting.

These reporting systems will help you avoid PQRS penalties, as you will have evidence that you have used CMS approved reporting systems. Using proper PQRS codes and CMS reporting methods help you avoid damaging penalties that will reduce your income.

Preparing and taking avoidance actions now is imperative. Be aware that CMS changed its definitions of individual and group medical practices. Originally, group practices included those with 25 or more eligible providers. Now practices that include only 2 or more eligible providers qualify as "group practices." If your practice includes as few as 2 physician and non-physician providers or as many as 99, you have a CMS-defined group practice.

Don't wait any longer, if your practice accepts Medicare or Medicaid insurance. While the incentives for complying with PQRS are beneficial, the potential penalties are damaging. Avoiding these penalties is well worth the compliance and submitting claims that satisfy PQRS regulations.

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Removing the Common 'Mystery' of Code Modifiers


physician payment doubtSome practice medical billing personnel, even those with experience, exhibit misunderstanding of code modifiers when submitting claims. If you research some payer statistics, you'll find numerous examples of medical providers re-submitting previously denied claims using the identical modifiers that generated original payer confusion. Payers typically again deny these claims.

Modifier Misuse Results

While most medical billers understand the purpose of modifiers, to further clarify the physician action during patient encounters, sometimes coders repeatedly misuse modifiers, increasing payer confusion. Inaccurate claim submissions increase reimbursement delays or generate claim denials, achieving two negative results.

  • Decrease income to the physician, and
  • Increase billing costs, as staff time is wasted by re-submitting unreimbursed claims.

Denied Claims Re-Submission Issues

Re-submitting denied claims by using the same modifiers that caused the original payer decision is an exercise in futility. Coders failing to use different modifiers or including additional documentation for clarity have little hope for a positive payer reimbursement decision.

Although difficult to justify, this billing action is an all-too-common procedure. Payers often become equally mystified by claims re-submissions that offer no additional documentation or clarity, leaving payers no alternative but to further delay or deny these claims once again.

If your billing staff submitted the original claim with no modifier, re-submitting with the appropriate modifier helps the payer reverse denial decisions. However, using a potentially ambiguous modifier without clarification often heightens payer confusion, a common reason for the original claim denial.

This lack of accuracy and level of detail can escalate from claim denials, reducing practice income, to costly payer audits, investigations and, sometimes, fines. Frequently submitting claims without modifiers or containing the wrong modifiers generates payer red flags that can cause even more costly actions, increasing the effect of lost income opportunities.

Consider Examples of Modifier Use and Misuse

Modifier 25 is one of the commonly misused modifiers. Targeted to encourage payment for care evaluation and management (E&M) services performed the same day physicians provided an additional procedure for the same patient, coders sometimes append this modifier to the procedure claim in lieu of using the proper E&M code.

Modifier 24 misuse is another example worth noting. Intended for use when a physician provides an E&M service during a post-operative period, but the service is unrelated to the original procedure. Attempts to ‘unbundle’ this service from the original claim when the E&M service obviously relates to the original surgical procedure create payer denials, since they already reimbursed for the procedure. This modifier should only be used for unrelated services, e.g., addiction counseling, not for post-operative evaluations of patient recovery from surgery.

Properly using Modifier 59 allows providers to successfully unbundle claims, when justified. This modifier alerts payers that physicians performed procedures outside normally bundled services. A proper use example is when treating different injuries at sites other than stated in the original claim.

Removing the ‘Modifier Mystery’

The benefits of avoiding claim delays and denials need no further evidence. For reasons that should be equally obvious, removing the ‘cloud of mystery’ created by misuse of modifiers should be a top medical provider priority. These tips should help achieve this goal.

  • Review claims before submission. If it confuses the medical provider, the odds are the claim will also confuse payer staff. Provide sufficient documentation that clarifies use of modifiers if you’d like to get paid.
  • Be careful when ‘unbundling’ claims. Payers have become more diligent in examining claims for unwarranted unbundling. The increasing incidence of provider attempts to use modifiers to increase payments that are outside payer definitions of unrelated services originally reimbursed has caused payers to closely examine these claims. Successfully unbundling claims requires more clarity to generate payer approval.
  • Train billing staff in the proper use of modifiers. The cost of education and training will be more than offset in decreasing claim denials and increasing income.
  • Use a top medical billing firm. Leading billing and documentation organizations, like M-Scribe Technologies, use experienced coders who fully understand the proper use of modifiers to increase physician income.
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Modifier codes for Medical Billing: Considerations and Examples


Medical coding modifiersIt promises to be another whirlwind year for medical billing and coding, the ongoing conversion to EHR compliances and PQRS for incentives and potential penalties makes it very hard for billers and coders to comply with all the rules and regulations. Though ICD-10 has been pushed for another year, and despite the added functionality ICD-10 codes lend to diagnoses and billing, modifier codes will still be used, as claims will still need to be modified. Fortunately modifiers work equally well with ICD-9 and ICD-10 codes and are remaining unchanged. Even so, change may affect them. It seems a good time to review their structure and utility, and the possible impact new practice systems may have on their usage.

A modifier is a two digit code by which a reporting physician indicates that a performed service or procedure has been altered by some specific circumstance, though without a change to the basic procedure and its defining CPT code. Modifiers can be used with any CPT code. Properly used, modifiers make claims reporting easier: their considered use eliminates the necessity of separating procedure listings to describe modifying circumstances, and accurately applied, lowers the risk of claims rejection by the patient’s insurer. Practices should incorporate modifier code usage in any review of their coding and claims submission procedures.

Modifiers are a critical component of coding and using them incorrectly can result in lost revenue and audits. Knowing your modifiers and their proper usage can reduce the risk of lost income and improve audit compliance.

When to Use Modifiers

Modifiers are used under the following circumstances:

  • When a procedure is performed more than once on the same day.
  • When more than one procedure is performed on the same day
  • When a procedure is a non-covered service
  • When more than one assistant surgeon completes a procedure
  • Provision of a procedure in a specific location, such as an HPSA area, teaching facility, rural area
  • When necessary to differentiate between the professional and technical portions of a procedure done in a hospital setting.
  • When multiple providers share or split work on the same surgical procedure
  • To reflect increase, reduction or discontinuation of a procedure
  • To reflect participation of the provider in a government-funded incentive program, such as PQRI or Electronic Prescribing
  • When a patient falls within a global period from a previous procedure

New Practice Management Systems and Modifiers

Many practices are changing to newer medical billing practice management systems and software to support their conversion to ICD-10, and as part of their EHR conversions. Easily overlooked amid meeting the many challenges these present are the relatively few and unchanging modifier codes. A new system may impose new requirements on the use of modifiers, such as only allowing numeric modifiers, or limiting the number of modifiers for a procedure. It may require different sequencing, e.g., convention has long dictated the listing of modifiers affecting reimbursement go before those that are informational. Will this sequencing be supported within a new claims management system?

Although CMS itself has no modifier code rules, carriers often do, publishing their own guidelines so practices will be able to conform to their claims submissions requirements. If you find these guidelines unavailable, you should contact your payer in writing well ahead of any planned changes to a new practice management system.

Researching changes to modifier code usage in advance may well save you time, money and frustration later on.

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Obamacare Deductibles Affect Medical Billing Efficiency


high deducible health insuranceThe growing necessity for people to buy high deductible health plans for cost control is a concern for billing reasons. Potential negative effects concern physicians and hospitals alike. The high deductibles, with a minimum of $1,250 for single coverage and $2,500 for family plans, are mandated by federal law, leaving little room for creativity.

Potential Negative Effects

There are two primary potential problems for medical practices associated with high deductible plans.

  • An increase in accounts receivable as patients struggle to meet deductible amounts
  • Potential decrease in physician quality ratings, resulting in delayed or denied claims

Both of these possible issues relate, directly or indirectly, to the efficiency of your billing function. If your medical billing procedures which starts with claim submissions are managed accurately, these potential problems should not occur. However, if you have not improved your billing and claim submission procedures, your practice revenue and quality ratings may suffer.

Issues with More Consumer Responsibility Enrolling in High Deductible Plans

  • Increased aging of accounts receivable;
  • Rise in bad debts, as consumers may not have the cash flow to pay higher deductible amounts;
  • Requirement to improve billing and collection policies and/or procedures to minimize revenue declines;
  • Greater focus on 'point-of-service' collection action; and
  • Creation of affordable patient installment plans to maintain practice cash flow levels.

With the graphic shift from fee-for-service to pay-for-performance (P4P) by the CMS and many private payers, you need to maintain evidence of delivering quality care, while improving your billing, claim submission and collection efficiency.

The provisions of the Obamacare aka Affordable Care Act (ACA), combined with dramatic deductible increases, P4P incentives or penalties and timely, accurate billing procedures, mandate that most providers make significant changes and improvements in their operating policies. Even if your practice historically functioned like a fine-tuned race car, the massive changes in the healthcare landscape demand that you should update your former procedures, however efficient they may have been.

Avoiding Negative Effects of High Deductible Health Plans

According to Forbes Magazine, the primary culprit is Obamacare. The increased financial demands on consumers because of federal mandatory healthcare coverage are the source, however unintended, of the shift to higher deductible plans. Compounding the issues is the continuing uncertainty of providers regarding the details of inputting sufficient information in electronic health records (EHRs) to verify delivering of quality care.

The following tips should help physicians and practices successfully navigate these 'troubled waters.'

  • Design and install up-to-date billing and collection procedures that directly address these new challenges.
  • Thoroughly re-train billing staff on the new realities created by high deductible health plans.
  • Evaluate top third-party medical billing and documentation firms, such as M-Scribe Technologies, with a focus on finding a cost-effective solution to increased billing and claim documentation accuracy requirements.
  • Update former lax collection policies that may appear 'haphazard,' having your staff or third-party billing firm employ tighter patient and payer collection procedures and some fail-safe methods ensure timely, accurate billing.
  • Create high deductible health plan monthly installment plans to help patients meet their responsibilities, while maintaining sufficient cash flow to keep your practice profitable.
  • Closely monitor cash flow and accounts receivable aging for at least six months to give your staff and patients time to adjust to new billing and collection procedures.
  • Immediately address any negative trends you identify, making appropriate procedural 'tweaks' in your collection procedures.

While these suggestions to avoid high deductible health plan issues are not overly difficult to implement, physicians must be diligent in their follow-up and monitoring efforts to identify potential negative income trends. Should any problem be uncovered, providers must act quickly to find solutions before revenue slows dramatically.


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Slow Start of Stage 2 Meaningful Use


Meaningful use stage 2As Stage 2 of meaningful use (the federal Health Records Incentive Program) is upon us, implementation progress appears to be getting off to a ‘slow start.’ Medical providers who satisfied Stage 1 demands are slowly proceeding to Stage 2.

There are a variety of reasons for many of the roadblocks to a fast start. Unfortunately, hard data of the slowness of getting ‘off the starting line’ is not yet available, still several months into the future.

There is some evidence of the conditions influencing this slow start. From a ‘glass half full’ view, at least Stage 2 progress is happening. It does appear, however, that many of the integral components may have underestimated the demands of a successful migration from Stage 1 to Stage 2.

Primary Issues Fueling Slow Start for Stage 2 Transition

Transitioning from Stage 1 to Stage 2 meaningful use involves some challenging issues that providers and payers must overcome. There is, however, one overriding factor facing all physicians and practices.

  • Medical providers must ‘juggle’ numerous healthcare reform issues at the same time, causing ‘detours’ in the transition to Stage 2. If there were one solitary issue, migration to Stage 2 would proceed faster, but multiple issues, involving new EHR requirements, ACA provisions and pay for performance (P4P) demands, needing to be addressed simultaneously are slowing the process.

Unfortunately, there are also companion issues causing further ‘bumps’ in the road to Stage 2.

  • Software vendors face tight deadlines in bring their EHR capability to satisfy Stage 2 standards and guidelines.
  • Interoperability levels required by EHR standards remain a problem for some vendors.
  • Lack of clarity of appropriate testing methods for appropriate usability and compliance of EHR software continues to hold back faster migration to Stage 2.

While some observers and providers continue to question the entire meaningful use initiative for viability and sustainability, more acceptance and agreement is building for its virtues, including its potential ability to make healthcare reform a positive experience. Whether this growing approval level can be maintained over the long-term is a question awaiting an answer.

Solutions for Faster Stage 2 Transitions Are Few

Smoothing and speeding the migration to Stage 2 meaningful use levels is not a problem that inspires numerous solutions. Skeptics can point to the apparent sufficiency of time periods for transition planning between the first stage of meaningful use guidelines (2011) to Stage 2 implementation (2014-2015), leaving little room for empathy. However, the seemingly constant delays in implementation deadlines created more questions than answers in how to streamline the transition to more complete meaningful use standards.

Yet, many physicians support meaningful use, as a viable healthcare reform factor. As one experienced provider says, “I really look at this as an opportunity to get off the hamster wheel.” This physician also states that he has grown ‘tired’ of the disorganized environment pervading healthcare in the past.

Before EHRs, a physician could recommend ad nauseam that a patient have a mammogram, MRI or other test, without knowing if the patient ever had the procedure. EHR standards encourage the provider to order the test—and referral—electronically to the appropriate specialist or imaging facility.

If test results are not received, the physician can discover if the test took place. After learning the truth, the provider can take appropriate action to remedy an unsatisfactory situation.

Supporters of meaningful use initiatives want the process to be successful. Since the project is here and appears to be more firmly established, it is time for the majority of providers to get aboard. If this result happens, it should be its own solution for faster transitions.

Implementation delays will still occur. Installing certified EHR software is the beginning, not the end. Providers and staff must develop the habit of using the software and procedures that become second nature to all. This can only happen over time, but the time to begin is now. The sooner you begin, the sooner you benefit from the results.


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Obamacare: Overcoming Issues with 'Medicine by Mandate'


Medical mandateUpon passage of the Affordable Care Act (ACA)—and its subsequent implementation delays—medical providers realized healthcare reform would bring major changes to the health insurance landscape. Yet, many did not consider the true magnitude of these changes. To date, results increase responsibilities and duties, accompanied by decreasing revenues.

Unfortunately, many private payers have adopted cost-savings measures for themselves that demand increasing documentation, placing more responsibility on medical providers and staffs. For example, requiring additional data supporting a diagnosis and treatment plan are more common.

These mandates are basic examples of “shifting” the work burden away from the payers to the consumers (physicians), much like banks do with ATMs, which place the responsibility on the bank’s customers to process their own transactions.

‘Medicine by Mandate’ Issues

Some of the issues fueled by healthcare reform and the ACA include the following new provider responsibilities.

  • Transfer of many duties from payers to physicians and practice staff;
  • Longer time to input patient data into electronic health records (EHRs);
  • Spending more computer time at the expense of face-to-face time seeing patients; and
  • Payers requesting more and more data from attending physicians to verify the quality of providers’ diagnosis and treatment efforts.

These and other less significant issues change the way physicians must operate their practices and maintain former revenue streams. Practice managers also face more complex operational challenges.

Providers and practice managers must devise answers to the following questions.

  • How to efficiently capture the additional patient data necessary to verify quality care?
  • How to allocate the additional staff time needed to input more patient data?
  • How to ensure the practice is using the most efficient software and IT systems to produce satisfactory and secure EHRs?
  • How to maintain high quality care, while satisfying new data demands of payers?
  • How to avoid claim reimbursement delays or denials by providing the documentation CMS and private payers want?

The answers to these questions are vital to overcoming the ‘medicine by mandate’ issues that meaningful use and ACA regulations demand. Here are some suggestions to meet and manage these new potentially negative mandates.

Overcoming Healthcare Reform Issues

Physicians are still in charge of determining the diagnosis and treatment of patient problems, but healthcare reform mandates affect at least two important considerations.

  • Delivering high quality care within the provisions of the law (ACA) and payer (CMS and private) requirements; and
  • Maintaining or increasing timely revenues while submitting accurate documentation to ensure former income levels.

Evaluate these suggestions to overcome new challenges:

  • Accept that ‘medicine by mandate’ is a reality, for better or worse. Instead of fighting these new rules, consider them a new challenge to the practice of medicine to be managed.
  • Create policies that satisfy regulations without adding significant operating costs. Thorough staff training and procedures to ensure documentation accuracy, such as a double check of claims before submission are two methods of maintaining timely reimbursements.
  • Implement cost-controls to maintain profit margins. Providers must use creativity to keep practice operating expenses in-line without sacrificing quality patient care. During your evaluation, consider using a top third-party billing and medical documentation firm, such as M-Scribe Technologies, to manage this critical function while delivering cost-certain controls.
  • Focus on procedures that allow you to continue delivering quality care. No one knows your practice as well as you. Implement streamlined procedures that maximize patient contact and minimize additional expenses.
  • Use the most effective IT solutions to save staff time, while maximizing accuracy of claims. If you determine your claim software is unacceptable or requires major staff time commitments to input EHR data, consider investing in more modern IT systems.

Depending on the ‘environment’ of your practice, you should summon up the height of your creativity to overcome these challenges. It appears they are here to stay, demanding efficient long-term solutions. Treat ‘medicine by mandate’ as another potential roadblock to be circumvented by designing methods to manage these additional responsibilities.

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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.)


0.5% (performance year for 2015 penalty)


0.5% (performance year for 2016 penalty)





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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