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12 posts from July 2011

July 28, 2011

Regularly Evaluate Your New Doctor Associate

Any expectations you have for a new Associate only works if you follow through with frequent evaluations. However, I am often struck by how little attention senior doctors give to basic personnel management of newly employed physicians. 

Groups commonly schedule regular evaluation ses­sions for newly hired lay employees, yet overlook them at the physician level. You've invested too much in your new hire — especially if you're promising fu­ture partnership — to adopt a sink or swim attitude. 

New hires need attention 

Today's young doctors in particular often feel over­whelmed when confronted with the reality of seeing patients day to day. I've recommended mentoring in the past, so the new doctor will have one physician s/he feels comfortable talking with about these feel­ings. Don't assume an established physician doesn't need a mentor as well. Maybe s/he came to your pri­vate practice from an academic setting. At the least, support his or her developing referral contacts and medical community relationships for a while. 

Set up informal evaluations, or "checking in" ses­sions, on a regular basis at least every three months for the first year. If you see problems or patterns oc­curring, increase the frequency. Assign the mentor or one or two senior physicians to the task of conducting these informal sessions. Assuming everyone in your group is taking care of it usually means no one ends up doing it. 

Formalize a routine 

Make it clear in your employment agreements that new hires will have sit-down performance review ses­sions every six months. Make the job description and resulting evaluations deal with all aspects of the new associate's work — both clinical and interpersonal. Dis­cuss strengths and weaknesses, and be sure to explore personality factors. 

It's difficult to confront and correct difficult behav­ioral traits at any stage, but it's best to handle them early on. And although these sessions may feel awk­ward, many associates actually welcome the feedback. Besides, the more regular the evaluations become, the less awkward they'll feel for the employee physician and for the senior doctor doing the evaluating. 

Follow through 

Too many groups fail to follow through - You may have the best intentions and start off on the right foot. The associate appears to be perform­ing fine and everyone seems too busy to hold evaluation sessions. Soon, small problems begin to appear. Senior doctors pull out the file and realize they missed the last evaluation. 

Such a scenario lets a potential problem magnify, and backing off evaluations gives your potential part­ner the wrong signal. What's more, it deprives you of the chance to mold the new doctor into the kind of partner you really want. 

Actually, good group governance demands evaluat­ing all physician-members' performance — even that of the most senior member. At least, though, you can establish the feedback process with your new doctor hires from Day One, even if it seems nearly impossible to install it at the senior level.

July 27, 2011

The 2011 release of ICD-10-CM is now available.

The 2011 release of ICD-10-CM is now available. It replaces the December 2010 release.

The National Center for Health Statistics (NCHS), the Federal agency responsible for use of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) in the United States, has developed a clinical modification of the classification for morbidity purposes. The ICD-10 is used to code and classify mortality data from death certificates, having replaced ICD-9 for this purpose as of January 1, 1999. ICD-10-CM is planned as the replacement for ICD-9-CM, volumes 1 and 2.

The ICD-10 is copyrighted by the World Health Organization (WHO)External Web Site Icon, which owns and publishes the classification. WHO has authorized the development of an adaptation of ICD-10 for use in the United States for U.S. government purposes. As agreed, all modifications to the ICD-10 must conform to WHO conventions for the ICD. ICD-10-CM was developed following a thorough evaluation by a Technical Advisory Panel and extensive additional consultation with physician groups, clinical coders, and others to assure clinical accuracy and utility.

The entire draft of the Tabular List of ICD-10-CM, and the preliminary crosswalk between ICD-9-CM and ICD-10-CM were made available on the NCHS website for public comment. The public comment period ran from December 1997 through February 1998. The American Hospital Association and the American Health Information Management Association conducted a field test for ICD-10-CM in the summer of 2003, with a subsequent report Adobe PDF file [PDF - 1.8 MB]External Web Site Icon. All comments and suggestions from the open comment period and the field test were reviewed, and additional modifications to ICD-10-CM were made based on these comments and suggestions. Additionally, new concepts have been added to ICD-10-CM based on the established update process for ICD-9-CM (the ICD-9-CM Coordination and Maintenance Committee) and the World Health Organization's ICD-10 (the Update and Revision Committee). This represents ICD-9-CM modifications from 2003-2009 and ICD-10 modifications from 2002-2008.

The clinical modification represents a significant improvement over ICD-9-CM and ICD-10. Specific improvements include: the addition of information relevant to ambulatory and managed care encounters; expanded injury codes; the creation of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition; the addition of  sixth and seventh characters; incorporation of common 4th and 5th digit subclassifications; laterality; and greater specificity in code assignment. The new structure will allow further expansion than was possible with ICD-9-CM.

July 26, 2011

June false claim settlements by the OIG


After it self-disclosed conduct to the OIG, University of Nevada School of Medicine (UNSOM), Nevada, agreed to pay $138,321.70 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that UNSOM submitted or caused to be submitted claims for physicians' services provided by two physicians to beneficiaries of Federal health care programs using the provider identification numbers of two physicians who did not furnish the services.


Daniel Herrington, the owner of One Source Medical Services a durable medical equipment (DME) company, Florida, agreed to pay $124,141.50 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Herrington, through the DME company, billed Medicare for custom molded diabetic shoe inserts when in fact only prefabricated inserts were provided to beneficiaries.


After it self-disclosed conduct to the OIG, WellStar Cobb Hospital (WCH), Georgia, agreed to pay $9,216.73 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that WCH employed an individual that it knew or should have known was excluded from participation in Federal health care programs.


After it self-disclosed conduct to the OIG, University of North Texas Health Science Center at Fort Worth (UNTHSC), Texas, agreed to pay $859,500 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that UNTHSC submitted claims for physicians' services provided to beneficiaries of Federal health care programs using the provider identification numbers of 103 physicians who neither furnished the service nor personally supervised the services rendered.

July 25, 2011

Avoid turning mistakes into the "customer's" problem

Correct your group's mistakes immediately and overwhelmingly in your customer's favor. The customer may be the patient, local hospital, a referrer or someone else you simply do business with, like a local creditor you accidentally underpaid. Cor­recting patient mistakes proves particularly critical in these litigious times. Errors don't have to be clinical in nature. They may have to do with a patient's bill, ap­pointment or simple miscommunication. 

Every practice makes mistakes – we are human. What matters is how quickly and completely you and staff work to correct them. Accepting respon­sibility is a good business prac­tice, while looking to put blame elsewhere — particularly on the customer impacted by the mis­take — makes for bad business. The positive "publicity" and customer loyalty that comes from accepting your mistake and correcting it in the customer's favor make up for any money you lose from the mistake itself. 

There are, of course, other business practices that can put you in a positive or negative light. The bottom line is to make your policies and daily actions are atten­tive to community reputation and customer loyalty. Avoid "undoing" the hard work you put into building your practice’s reputation.

July 20, 2011

Top 10 challenges facing medical practices today

In the recent issue of the MGMA magazine Connexion (www.mgma.com), the following are the top ten challenges facing medical practices today per a survey of the MGMA membership:

  1. Preparing for reimbursement models that place a greater share of financial risk on the practice
  2. Participating in the CMS EHR meaningful use incentive program
  3. Dealing with rising overhead costs
  4. Selecting and implementing a new EHR system
  5. Implementing and/or optimizing an accountable care organization
  6. Managing finances with the uncertainty of Medicare reimbursement rates
  7. Modifying the physician compensation formula to more heavily emphasize quality measures
  8. Recruiting physicians
  9. Negotiating contracts with payers
  10. Maintaining physician compensation levels

I agree with all of these - I see my clients facing and dealing with most of them on a daily basis. So how are you gearing up to meet these challenges????

July 18, 2011

New FAQ on Payment for the Medicare EHR Incentive Program

The following question was recently submitted to CMS regarding the EHR Incentive Program:

"I am an eligible professional (EP) who has successfully attested for the Medicare EHR Incentive Program, so why haven't I received my incentive payment yet?" 

CMS Reply: For EPs, incentive payments for the Medicare EHR Incentive Program will be made approximately four to eight weeks after an EP successfully attests that they have demonstrated meaningful use of certified EHR technology. However, EPs will not receive incentive payments within that timeframe if they have not yet met the threshold for allowed charges for covered professional services furnished by the EP during the year. 

The Medicare EHR incentive payments to EPs are based on 75% of the estimated allowed charges for covered professional services furnished by the EP during the entire payment year. Therefore, to receive the maximum incentive payment of $18,000 for the first year of participation in 2011 or 2012, the EP must accumulate $24,000 in allowed charges. If the EP has not met the $24,000 threshold in allowed charges at the time of attestation, CMS will hold the incentive payment until the EP meets the $24,000 threshold in order to maximize the amount of the EHR incentive payment the EP receives. If the EP still has not met the $24,000 threshold in allowed charges by the end of calendar year, CMS expects to issue an incentive payment for the EP in March 2012 (allowing 60 days after the end of the 2011 calendar year for all pending claims to be processed). 

Payments to Medicare EPs will be made to the taxpayer identification number (TIN) selected at the time of registration, through the same channels their claims payments are made. The form of payment (electronic funds transfer or check) will be the same as claims payments. 

Bonus payments for EPs who practice predominantly in a geographic Health Professional Shortage Area (HPSA) will be made as separate lump-sum payments no later than 120 days after the end of the calendar year for which the EP was eligible for the bonus payment.


July 15, 2011

Are You Billing Established Patient Visits Correctly

TrailBlazer (the MAC for Colorado, New Mexico, Oklahoma, Texas, and Virginia) recently identified potential improper utilization of established office visit services (codes 99211–99215) billed to Medicare. According to TrailBlazer, two widespread probe reviews were conducted to verify if this perceived improper utilization was actual or not. These reviews are called “widespread” becausedocumentation is evaluated from multiple providers. TrailBlazer used the Progressive Correction Action (PCA) process to identify a random sample of 200 claims (two reviews) containing established office visits with dates of service from January 1, 2010, through June 30, 2010. The selection of providers for this review was based on a scoring methodology that considered the following variables: 

  • Distribution of claims volume for CPT codes 99211–99215.
  • Distribution of paid dollars for CPT codes 99211–99215.
  • Percent of claims billed with modifier 25.
  • Percent of claims billed with CPT codes 99211–99215 billed as 99214/99215.
  • Frequency of services per beneficiary for CPT codes 99211–99215 compared to the peer average. 

One probe review (100 claims) was conducted on selected providers in Virginia. The other probe review (100 claims) was conducted on selected providers in Colorado, New Mexico, Oklahoma and Texas. 

The Probe’s Findings 

Overall error rate for each probe review was: 

Virginia: 51.43 percent.

Colorado, New Mexico, Oklahoma and Texas: 91.32 percent.

Findings Conclusion - Medicare expects providers who bill these services to: 

  • Bill an E/M service only when the service meets medical necessity requirements and document sufficiently to support the medical necessity of the E/M service billed. Medicare determines “medically reasonable and necessary” separately from determining the work described by a reported CPT code performed. The patient’s condition (severity, acuity, number of problems, etc.) is the key factor in determining medical necessity for Medicare payment for services.
  • Bill the level of E/M service appropriate to treat the patient’s presenting problems. Documentation of E/M services billed for Medicare payment must ensure the patient’s clinical condition and reason for the service are documented in enough detail for a reasonable observer to understand the patient’s need and the practitioner’s thought process. The E/M code billed must reflect patient’s needs, work performed and medical necessity. Though an E/M service may code to a high level based on the documentation of key component work, it is inappropriate to request Medicare payment when the patient’s effective management does not require the code’s work.
  • Medicare generally expects to see E/M services billed every three months for patients with chronic, stable conditions.
  • Comply with the requirements for use of the 25 modifier. Modifier 25 is used when a significant, separately identifiable E/M service is performed by the same physician on the same day as a procedure or other service. The E/M service must meet the following criteria:
    • Must have been performed and documented according to CPT code requirements and statutes concerning coverage and payment.
    • Must be coded according to its medical necessity and documented CPT physician work.
    • Must be a separately identifiable service provided on the same day, on the same patient and by the same practitioner as a therapeutic medical/surgical and/or diagnostic medical/surgical procedure with either a zero- or 10-day global period. The E/M service may result in the decision to perform a zero- or 10-day global procedure when the need to perform the procedure was not planned, was not foreseeable and the condition for which the procedure was necessary could not have been determined to exist without having performed the E/M service (i.e., new problem or new, previously undisclosed event related to a known problem).
    • Must not have resulted in a decision to perform a major operative procedure (surgery). 
    • Must be a significant service, above and beyond the usual preoperative and postoperative work/care required by the therapeutic or diagnostic service also performed.

July 13, 2011

Hospital embezzlement scheme could happen in a physician's office

On Thursday, June 3, Roosevelt Hairston, Jr, a former lawyer for the Children’s Hospital of Philadelphia, was arrested and charged for embezzling $1.7 million over the course of the 12 years he served as general counsel for the hospital

According to a Philadelphia newspaper, the charges represent one of the most serious embezzlement schemes in Philadelphia in recent history. However, they also reveal the failure of the hospital’s financial auditing system to identify and stop significant financial waste, or in this case – serious fraud. Could this happen to a physician’s medical practice? You bet – happens more than you might think.

According to the U.S. Attorney’s office, Hairston created false companies, forged invoices, and even created fake email accounts in order to continue the scheme and cover his tracks. His fraud continued, completely unabated, for about 12 years before hospital auditors finally caught up with him.

According to the federal statement, Hairston utilized his money laundering and embezzlement scheme by establishing himself in a “position of trust” within the hospital. So why did it take 12 years to catch him?

Aside from the embarrassment caused by such a highly placed and well-trusted person embezzling so much from the Children’s Hospital, the situation really begs the question – were hospital financial auditors sleeping on the job?

Why did it take 12 years for investigators to identify and uncover the stolen funds? Is financial waste such a prevalent part of the hospital’s financial systems that it takes 12 years to identify $1.7 million dollars in erroneous charges?

Apparently, Hairston got away with the scam for so long, because he had identified the tremendous flaws in the system, discovered areas where vendors and suppliers could charge the hospital without any questions asked, and then used those vulnerable financial areas to siphon almost two million dollars from the hospital.

July 12, 2011

Product spotlight - freemedicalbilling.net

Ran across this software from a colleague referral. Check it out at http://www.freemedicalbilling.net


Software Fee: Free

Setup Fee: $0
Monthly Maintenance: $12.50 / Provider
Scheduler: $10.00 / Practice
Patient Statements: 22 cents + first class postage
Paper Claim Fee: 15 cents + first class postage
Patient Statement Web Portal : $25 / practice

July 11, 2011

Physician excluded from Medicare for tax evasion

From the CCH Medicare and Medicaid Reimbursment Newsletter:

A physician was properly excluded from enrollment as a Medicare supplier based on his felony conviction for a financial crime. On February 11, 2000, the physician was convicted and barred by CMS from enrollment in any federal health care programs for a period of ten years. The physician argued that his application should not have been denied because the Office of Inspector General (OIG) had determined not to exclude him from participation in federal programs under a different authority.

There was substantial evidence to support the finding of CMS because it has authority under 42 C.F.R. §424.530(a)(3)and Soc. Sec. Act §1842(h)(8)to revoke his enrollment as a Medicare supplier based on his felony conviction because CMS determined it was detrimental to the best interests of the program and its beneficiaries. Since there was no requirement in either §1842(h)(8) or §424.530(a)(3) that a felony conviction must be related to Medicare or health care for CMS to deny enrollment, the physician’s argument that his offenses were not health care related did not mean CMS erred when it denied his application.

Furthermore, the OIG’s determination not to exclude the physician under Soc. Sec. Act §1128(a) had no bearing on CMS’ authority to make its finding. Finally, this court does not have the authority to grant equitable relief. Review in this case was limited to whether CMS had a legal basis to deny enrollment. Accordingly, CMS' motion for summary judgment was granted. Garib v. CMS, HHS Departmental Appeals Board, Civil Remedies Division, Doc. No. C-10-881, Dec. No. CR2289, December 2, 2010, ¶122,373.

Felony reporting requirement

CMS was authorized to revoke a provider’s billing privileges and enrollment due to his failure to report both his felony conviction for filing a false tax return and the related loss of his medical licenses in three states. The provider’s felony offense qualified as a “financial crime” detrimental to the best interest of the program and its beneficiaries under 42 C.F.R. §424.535(a)(3)even though the offense was not included in the enumerated list of offenses in the language of the regulation. The listed offenses are considered automatically detrimental to the program, but the language “such as”, which precedes the list, permits CMS to determine on a case-by-case basis whether a non-listed offense is similar to those listed and therefore, detrimental (see 42 C.F.R. §424.535(a)(3)(i)).

The preamble to the regulation, found at 71 FR 20768, demonstrates CMS’s intention that false statements which result in a financial benefit or loss are to be considered as a “financial crime,” thus the filing of a false tax return, which is also similar to the enumerated offense of income tax evasion, qualified as a financial crime which the provider was required to report under 42 C.F.R. §424.535(a)(9).

The provider’s contention that he was not required to report the conviction or loss of licensure (see 42 C.F.R. §424.516(d)(1)(ii)) because his failure to report was unintentional and he had not seen any Medicare patients while unlicensed was irrelevant because neither reporting regulation contains an intent requirement nor an exception for providers who stop seeing beneficiaries. Providers whose privileges are revoked are barred from reinstatement for 1 to 3 years under 42 C.F.R. §424.535(c), which did not allow the provider to appeal the duration or imposition of his re-enrollment bar. Tolliver v. CMS, HHS Departmental Appeals Board, Civil Remedies Division, Doc. No. C-10-737, Dec. No. CR2281, November 23, 2010,