Payer pricing transparency: Next generation steps
Beware of broad terms about what the payer may publish, such as “Provider agrees to be included in our online and paper provider listings.” That used to mean your name and contact information, and you’d want that published but now it could mean something much different.
These terms initially mean that it’s time that the contract negotiations include a frank discussion with the payer about what products it offers and what information it plans to make available to enrollees.
If the payer is compiling its own data, ask where it gets the data. Are they from a Web site, a state hospital association, or CMS? Or, is the payer creating them?
Perhaps the payer is basing its rankings on your own coded claims. If so, ask yourself whether you’re including all of the information to make the payer’s picture of your organization as accurate as possible.
If you come out on top of the quality rankings and you’re coding your claims as completely as possible, then maybe you really are the stellar provider in your community, and patients should take this into consideration. But when the data [are] assembled by someone else and they are responsible for making decisions about what is included and how they rank, you must make sure that [they are] accurate.
May 19, 2008 in Managed Care | Permalink | Comments (0) | TrackBack (0)
Product Watch: Another Credentialing Software
Yesterday's post suggested two managed care credentialing software products you might want to check out; here's another - it's called Visual CACTUS:
http://www.visualcactus.com/Public2002/HomeFramedPage.htm
May 19, 2008 in Managed Care | Permalink | Comments (0) | TrackBack (0)
New Form for Misclassified Workers
The IRS has developed a new form for an employee who has been misclassified as Independent Contractors by an employer. Uncollected Social Security and Medicare Tax on Wages, Form 8919, will now be used to figure and report the employee’s share of uncollected social security and Medicare taxes due on his/her compensation.
The worker must meet one of the following criteria indicating he/she was an employee while performing the services:
- Filed Form SS-8, Determination of Worker Status for Purposes of Federal Employment Taxes and Income Tax Withholding, and received a determination letter from the IRS stating he/she is an employee of the firm.
- Designated as a section 530 employee by his/her employer or by the IRS prior to January 1, 1997.
- Received other correspondence from the IRS that states he/she is an employee.
- Previously treated as an employee by the firm and he/she is performing services in a similar capacity and under similar direction and control.
- Co-workers are performing similar services under similar direction and are treated as employees.
- Co-workers are performing similar services under similar direction and control and filed Form SS-8 for the firm and received a determination that they were employees.
- Filed Form SS-8 with the IRS and has not yet received a reply.
- The IRS will electronically share Form 8919 data with the Social Security Administration to facilitate crediting the worker’s social security and Medicare taxes to his/her social security record.
Source: IRS News Release IR-2007-2003, Dec. 20, 2007
May 18, 2008 in Taxes | Permalink | Comments (0) | TrackBack (0)
Product Watch: Credentialing Software
Here are two credentialing products you might want to check out:
OneApp Pro http://www.symed.com/products_OAP.aspx
and Enroll DR http://www.enrolldr.com/Software/index.html
May 18, 2008 in Managed Care | Permalink | Comments (0) | TrackBack (0)
Simple ideas for employee retention
When you find good people, you want to keep them. Here are a few simple ideas to help retention of these good people:
1. Handwrite a personal note telling an employee how much you appreciate him or her.
2. Take staff to breakfast, lunch, or dinner.
3. Take entire team out to celebrate a special event.
4. Get physicians involved to deliver praise for a job well done.
5. Create local, fun activities for your team.
6. Place a call to the spouse. Tell the spouse how valuable the employee is to your organization and thank them for their support.
May 16, 2008 in Human Resources | Permalink | Comments (0) | TrackBack (0)
CMS Issues Clarification Regarding "Incident To" Services
From the Vinson Elkins law firm (www.velaw.com):
On May 2, 2008, in response to multiple inquiries, CMS issued a set of clarifying instructions regarding policies for services furnished incident to a physician or non-physician practitioner (NPP) service in the office setting. The clarifying instructions, issued in Change Request 5288, amend and add new material to Chapter 15 of the Medicare Benefit Policy Manual. Among the key points set forth in the clarification include:
- When contractors are aware that a service is furnished by staff other than the supervising physician/NPP, contractors will not make payment for the service as “incident to” the physician/NPP service unless there is documentation in the medical record authorizing the service.
- The medical record must also contain the name and professional identities of the persons who furnished the incident to services.
- Contractors will apply the policies for incident to services furnished in the office setting only to services furnished in the identifiable boundary of an office or a single room.
- When services are provided outside the office, e.g., in the home or in the SNF outside the boundaries of an office suite, the supervising physician or NPP must be in the same room as the patient and the staff furnishing the incident to service, providing the equivalent of personal supervision.
The full manual update can be found on the CMS website here. A provider education article can be found in the MLN Matters section of the CMS website here.
May 16, 2008 in Medicare | Permalink | Comments (0) | TrackBack (0)
HIPAA is very serious business
I found this little item in yesterday's issue of Modern Healthcare's Daily Dose electronic newsletter (www.modernhealthcare.com). It just goes to show that HIPAA can have a strong bite to it:
A 30-year-old Oklahoma City woman pleaded guilty to one count of a criminal violation of the privacy protection provisions of the Health Insurance Portability and Accountability Act of 1996, according to a news release by U.S. Attorney John Richter in Oklahoma City.
Leslie Howell was an employee of an unnamed Oklahoma City counseling center when she allowed two people to take files from her workplace that contained individually identifiable health information, according to the release. Because there was intent to obtain personal gain, prosecutors were able to seek the most severe HIPAA privacy penalty against Howell, who now faces up to 10 years in prison and a fine of up to $250,000.
Howell was indicted Feb. 15 and accused of providing more than 100 patient files to a pair of accomplices, according to an Associated Press report.
The release from Richter’s office stated that Howell allowed Ryan Jay Meckenstock and Nicole Lanae Stevenson, both of Oklahoma City, to obtain patient files. In October 2007, both Meckenstock and Stevenson pleaded guilty to federal charges of fraudulently obtaining credit cards and aggravated identity theft. Neither Meckenstock nor Stevenson were charged with HIPAA violations, however, as a controversial 2005 advisory issued by the legal counsel office of the Justice Department limited the ability of federal prosecutors to charge individuals with criminal HIPAA violations.
May 15, 2008 in Regulatory | Permalink | Comments (0) | TrackBack (0)
Looming retirement becoming a major concern
In a recent survey of CPAs holding the personal financial specialist credential, 9 out of 10 CPAs surveyed said their individual clients were concerned about retirement. The research also noted that almost 32% of the respondents said clients approaching retirement age are postponing their retirement for financial reasons.
I personally cannot believe still how many physicians there are in the country THAT HAVE TO WORK; in other words, they can't retire! I won't go in to the "why's" of this but the major reason is that most physicians just don't PLAN for their retirement.
Every working physician must commit to retirement planning in some form or fashion. Though the costs are high, get a retirement plan started within the medical practice..........start a program of savings.
Here a simple piece of advice: create a situation where money is taken away BEFORE you have the ability to spend it (ex. have monies drafted out of your bank account in to a saving vehicle). This works for many if not all individuals.
May 15, 2008 in Personal Finance | Permalink | Comments (0) | TrackBack (0)
New Worries for 401(k) Plans??
I found thia article in the recent issue of Legal Times magazine; this is something you might want to talk to your financial advisor about if you have a 401k plan in your medical practice or healthcare business:
The Supreme Court ruled on Feb. 20 that an investor in a 401(k) plan can sue to recover losses from the plan's breach of fiduciary duty. How do companies need to respond?
In LaRue v. DeWolff, Boberg & Associates, the Supreme Court concluded that an individual participant -- not just the 401(k) plan, as in the past -- can recover losses under the Employee Retirement Income Security Act. James LaRue alleged that the 401(k) plan administrator breached its duties by failing to follow his investment directions, thereby costing him about $150,000.
Because of the explosion of 401(k) plans throughout the United States, the consequences of this legal action are potentially far-reaching. Although LaRue's suit dealt with the mishandling of investment selections, other areas of 401(k) plans may be affected in the future.
BEWARE DELAYS
In responding to LaRue, companies and their in-house counsel should be thinking about the following issues:
Most obviously, companies should take steps to safeguard themselves against the mishandling of employees' investment instructions, the issue in LaRue.
If implementing investment instructions is delegated to a third-party service provider, you need to understand the provider's system for implementing the participant's investment selections accurately and timely. With the increase in paperless transactions, this becomes extremely important. The service provider should notify the participant immediately of all changes in investment selections.
Even if you delegate these functions to the service provider, I recommend that the administrator of the 401(k) plan should review or test the service provider's internal control system, before you use this provider.
Companies also need to be careful about their own delays in placing employee contributions into 401(k) accounts. The law requires employers to separate employee 401(k) contributions from their general assets as soon as practicable, but in no event more than 15 business days after the end of the month in which amounts are contributed or withheld from wages.
Employers might be tempted, either because of administrative convenience or cash flow needs, to delay contributions.
But, in addition to the legal requirement, there is also the risk of harm to the participant's investments. If the contributions are delinquent, these contributions are not being invested timely. With the potential of significant market changes every day, this could cause investment gains or losses. If a loss occurs as a result of delay, it may give rise to lawsuits or, at a minimum, the need to make the participant whole.
Too many times, I have seen employers think that the 15 days of the following month is the safe harbor rule. This is absolutely not true. As a practical matter, the time period in which to act could be when the paychecks go out.
CHECKING UP
There are a number of other issues relating to the 401(k) plan that need to be watched.
- How do you know if the employee contributions and investment earnings are being properly allocated to the participant? If a service provider provides a certification of investment activity, it is usually at the trust level only (the entire plan) and does not apply to the allocation of investment income to the participant's account. You will need to review the service provider's internal controls and any outside reports about these controls. If there has been no outside report, I strongly recommend that the plan review and test these controls, even independent of any financial audit.
- Do you ever verify that the total of the individual participant accounts equals the total amount of investments in the trustee report? If you don't, you should. Internal Revenue Service Revenue Ruling 70-125 requires this.
- In times of economic difficulty such as today, participants may be tempted to borrow from their 401(k) plans. Trustees need to verify that the proper amount is borrowed (there are limitations) and that the proper documentation is prepared, authorized and approved. The plan also needs to monitor the repayment of the loans. Delinquent loans are required to be reported to the Labor Department.
- In your administration of the 401(k) plan, you should verify that the plan has a fiduciary liability policy in force, with reasonable deductibles. You should review the policy to determine what exclusions exist, if any.
- Along with LaRue, one of the hottest issues in 401(k) plan management is investment fees. The public is being inundated with information about the effects of fees, including efforts by the Employee Benefits Security Administration of the Labor Department.
Understanding the plan fees is part of the plan sponsor's fiduciary responsibility. It is imperative that the trustees understand how the service provider is compensated and, when choosing among providers, compare fees. The Labor Department has a 401(k) fee disclosure form on its Web site that assists in determining the actual fees charged. (Remember, though, that cost is only one component in the evaluation of providers.)
EFFECTIVE AUDITS
Evaluating these details about the 401(k) plan is no easy task, and many corporate counsel, who don't specialize in ERISA matters, may wish to engage their outside auditor for this specific task. If so, keep several things in mind.
First, you should understand the difference between a “financial audit” and a more detailed compliance audit.
The financial audit is required by ERISA and must be performed by an independent, qualified public accountant. Generally (and there are exceptions), plans with 100 or more participants at the beginning of the year are required to have a financial audit. The auditor's objectives and responsibilities are established under generally accepted auditing standards. The audit is an important ERISA tool to protect plan participants, but this type of audit is not designed to ensure compliance with all legislative and regulatory requirements.
A compliance audit is much more detailed than a financial audit. It involves much more compliance testing, as well as other work that may not be required in a financial audit.
Even if a 401(k) plan has completed a financial audit, the plan may still be blindsided by problems that a compliance audit would have uncovered.
Second, you should ascertain that your auditor has experience with 401(k) plans. This is a specialized field. Knowledge of the Labor Department requirements are a must. Prohibited transactions, supplemental schedules, and certain footnote disclosures are unique to 401(k) plans. The more an auditor understands the 401(k) field, the more effective that audit will be.
Third, you need to provide the auditor copies of all agreements with third-party service providers. If the plan has reviewed the internal control structure of a service provider, that review should also be provided.
In any event, the auditor will need to satisfy himself of the internal control structure of the 401(k) plan and the provider's portions of the plan. This work should be performed before the audit.
Fourth, make sure that the audit complies with the new Statement of Auditing Standards No. 104 through No. 111, which apply to all audits for periods beginning on or after Dec. 15, 2006 (namely calendar year 2007). These standards, known as the risk assessment standards, require a vastly different approach than the ones applicable to previous audits. Different documentation, questions, and evaluations will be required that haven't been required in past audits.
Finally, you should make sure that the auditor has obtained all requested documentation before the audit. Contracts, investment statements, and participants' files are some of the more common requests. There should be agreement about who prepares the IRS Form 5500 to file with the government. If the auditor doesn't prepare the form, the auditor must review it.
Quality audits are very important to the 401(k) plan, and LaRue makes them even more so. The ultimate consequences of LaRue have yet to materialize, but careful review and monitoring of the 401(k) plan -- and especially of the plan's third-party service providers -- is the appropriate corporate response.
Joseph Musher is a certified public accountant and a senior partner on the employee benefit plans audit team in the Rockville, Md., office of Buchbinder Tunick & Co. He has more than 35 years of auditing and accounting experience.
May 14, 2008 in Personal Finance | Permalink | Comments (0) | TrackBack (0)
How to better validate your patients' coverage
Validating patient coverage before you begin treatment is increasingly important. You run the risk of financial loss if you mistakenly accept or treat patients whom you believe are current members of a plan that your practice accepts or whose treatments you mistakenly believe are covered services.
You need an effective process and clearly assigned job duties to ensure validation of each patient's coverage before you begin treatment. Take these four steps to minimize your risk of losses:
- Print out schedules one or two days early.
- Assign one employee to verify coverage for each patient on each day's schedule.
- Flag the charts of any patients whose coverage the staffer could not validate.
- Photocopy both sides of patient insurance cards.
May 14, 2008 in Practice Management | Permalink | Comments (0) | TrackBack (0)
