November 21, 2014

"Incident to" and the Initial Visit - Evaluation & Management (E/M) Service Guidelines

The Novitas Solutions Medical Review (MR) Department has observed a continued trend of the utilization of non-physician practitioners to perform initial office visits as "incident to" services. Documentation reviewed by the MR Department indicates that a non-physician practitioner performs the initial visit and the supervising physician documents a note in the medical record similar to the following:

"I have reviewed the Physician Assistant's note, examined the patient and agree with..."
“Nurse practitioner performed the history and physical and I was present for the entire encounter and my treatment plan is as follows……”

This is incorrect use of the non-physician practitioner and incorrect billing under the "incident to" guidelines. This article from Novitas explains the Medicare definition of "incident to" services and the criteria that must be met to properly bill "incident to" services.

An initial history and physical performed by a non-physician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the "incident to" guidelines. As outlined below, the physician MUST perform the initial service. This includes the history and physical, examination portion of the service, and the treatment plan. It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.

Novitas Solutions MR (and I'm sure other Medicare Intermediaries) states that it will deny or down code claims for initial office visits billed as "incident to" when a non-physician practitioner performs the initial history and physical .

CMS defines "incident to" services as “services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”

In order to be covered as "incident to" the physician’s service, the following criteria must be met:

  • Services must be an integral, although incidental, part of the physician’s professional service;
  • Commonly rendered without charge or included in the physician’s bill;
  • Of a type that are commonly furnished in physician’s offices or clinics, and
  • Furnished by the physician or by auxiliary personnel under the physician’s direct supervision

"Incident to" services must be performed under the direct supervision of the physician. CMS directs that “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

CMS further indicates, under direct supervision, “This does not mean, however, that to be considered "incident to", each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be "incident to" when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment.” Hospital and skilled nursing facility services cannot be billed as "incident to" at any time.

For more information and direction on "incident to" services, refer to CMS’ Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Section 60.

November 20, 2014

Are you spending too much time “doing” the work instead of “managing” the work

Are you too busy to take a hard look at your operations to be able to make the changes needed to make the impact your physician practice needs to be really financially and operationally robust?  Are you putting off inevitable decisions because daily routines do not give you the thinking time you need?  Are you keeping a “warm body” on payroll because of the hassle?  Do you know what changes need to be made but don’t have the determination to really make them?

Take a deep breath… are not alone.  Many practice managers suffer from simply being stuck and unable to free themselves from the daily “muck” long enough to take a hard look at practice operations, software needs, employees and financials.  

Too many managers spend too much time “doing” the work instead of “managing” the work.  Here are some hints to help managers who really want to manage better processes instead of fixing the same problems day after day.

  • Define Some Goals – you basically know what they are; you want to decrease AR days, you want to focus on AR greater than 120 days, you want to better train staff on EHR, you want all providers to comply with standards, you want to can Sally, you want to do a better job of front end collections, you want to tell your physician his niece is not working out, you are behind the curve on ICD 10, you want to reduce patient wait times, and many others. Now write them down. Then prioritize them.  That means you need to make time to do this.
  • Do Some Analysis – wait, shouldn’t this come first?  Not necessarily, since you really know what your goals are, you just haven’t formalized them.  What is your business needs to meet the above goals?  What is really keeping you from achieving the goals? What are the external and internal barriers to meeting goals?  Take a really hard look at AR, can you prioritize that work efficiently?  What process needs to be implemented to meet goals?  What will each person’s role be in meeting goals?
  • Plan Implementation – you know what your goals are, you have analyzed what and where changes need to be made to reach goals. Now “plan your work and work your plan.”  Planning is critical, a step by step written down implementation plan is necessary for two reasons.  (1) to keep you focused on the goal (2) to provide a clear pathway to meeting those goals.

The hard work of taking your practice to the next level of excellence requires management commitment, provider by-in and the whole practice focused on results.

Now close your office door, get out some paper and start writing goals…..the process needs your undivided attention to succeed.

November 18, 2014

Good physician practice customer service focuses on these things

In the time it takes you to read this blog, many of your patients will be asked a question about what doctor they use….why they like or dislike.  Do you know what they are saying?  If you don’t then you are not listening.

Expectations are high, patients are smarter, the internet can answer any question they have, and your practice is either effectively managing the healthcare of your patients or they are finding another provider to do so.

There are 5 things your practice should be focused on:

  1. It’s about the patient – have you ever walked into a doctor’s office and they are absorbed in private conversation…..they are sharing a private joke…they are celebrating a staff members birthday or they are just sitting there oblivious?  From the moment the patient calls for an appointment (remember they are calling because they need help) until they get their final bill your focus should be them.  If it isn’t, nothing else you do will matter.
  2. Create an environment that welcomes – Patients are not visiting your practice because they have nothing else to do.  They have carved time out of their busy schedules because they need your expertise.  Welcome them with the décor, the lighting, the efficiency of staff, the minimal wait time, and that free water or cup of coffee.  Little things mean a lot.
  3. Be Prepared – part of the staffs schedule today should be focused on who is coming tomorrow.  What their insurance requirements are, did they have the lab work done, do you have the results, did they receive bad news the last visit and need some extra care, do they have special needs that you are aware of and can help with, is the flow of patients through the office such that they can get in and out with minimal hassle, do they understand what your expectations are of them?
  4. Use your web site to inform and instruct – more and more patients spend time on the internet.  They look up their symptoms, their drugs, and their diagnosis.  Provide answers they are looking for on your web site. Give them the answers you need them to hear on your web site.  Give them clear instructions (written) on how to access web site and patient portal.  Give them a sense that you are concerned about them, their needs, their questions, their concerns.  You can only do that by focusing on them.
  5. Use the EHR efficiently – everyone knows that electronic medical records are the future.  Let them see you using it, speak positively about the benefits, print out for them a visit summary.  They are not interested in excuses or blaming; they simply want to know you are embracing the EHR and it’s to their advantage.  They will understand a learning curve; after all they had one too.  For older patients, ask them about their use of computer, you will be amazed at how many have embraced the technology.

Healthcare delivery is complex, and there are many many components to that delivery.  But if you will focus on these really simple principles, you will find that you have the time and energy to focus on the really hard stuff.

November 14, 2014

ICD-10 Resources for Small Physician Practices

CMS has released three new resources to help small physician practices prepare for ICD-10. These resources also provide Continuing Medical Education (CME) and Continuing Education (CE) credits to health care professionals who complete the learning modules, and anyone who takes them will earn a certificate of completion. If you are a first-time visitor to Medscape, you will need to create a free account to access these resources.

Keep Up to Date on ICD-10

Visit the ICD-10 website for the latest news and resources to help you prepare.

November 13, 2014

Cybersecure your physician medical practice

The Office of thte National Coordinator for Health Information Technology has a web-based security training module on its website entitled "Cybersecure: Your Medical Practice." This is a great compliance training tool.

The module uses a game format that requires users to respond to privacy and security challenges often faced in a typical small medical practice. Users choosing the right response earn points and see their virtual medical practice flourish. But users making the wrong security decisions can hurt their virtual practices.

I think the use of gameification is a very innovative approach aimed at educating all physician providers and their staff to make more informed decisions regarding privacy and security of health information.


November 12, 2014

Don't forget importance of your practice management system

Your practice management system is your healthcare practice’s pathway to the revenue stream.  Your biggest dollar investment is probably your practice management system (although now, your EHR and IT costs may exceed PM)

  • Your primary contact with payers is your practice management system.  
  • Your ability to contract with those carriers productively depends on your      analysis of codes and payments within the practice management system
  • Your daily, weekly, monthly, yearly revenue reports originate in the practice system data. Your analysis of that data helps you to plan strategically for the future.
  • Data analysis will help you identify lags of payments, under-payments, denial trends and how efficiently your follow-up teams are working the accounts receivables.
  • Your ability to comply with ICD 10 without loss of cash flow will begin with      your practice management system.
  • Your assurance that every charge has been captured is in the practice      management system.
  • All of your charge and payment history resides in your practice management system
  • All of your patient data (apart from clinical data) resides in your practice      management system
  • Your ability to talk to patients about their charges and their insurance      questions depends on the practice management system
  • When the CEO calls about a specific patient who has called them, you go to the practice management system
  • When a physician wants to know how much is paid for a specific procedure, your answer comes from the practice management system
  • All of your business operations is dependent upon the practice management system, from appointment scheduling to issuing the final bill.

Has the point been made yet?  Your investment in the practice management system and people who operate that system is what keeps the practice going.  It provides the revenue to pay the bills and the people.  While it is indeed a cost center; it is the vehicle revenue centers are dependent upon for proper handling of charges, denials and payments.  

How efficiently your practice manages the system and the people primarily responsible for the system determine the financial success of your practice.

November 06, 2014

Do you realize it's all about the "front end"?

With the current trend of higher deductibles and co-pays, health care practices need to evaluate their current self-pay (patient portion) strategies and make needed adjustments. There is a growing need for practices to mitigate the effects of a growing self-pay population.

The most important thing a physician practice can do is to develop a policy and live by that policy.   Many practices may need expert advice and there are many ways of getting that advice. But here are 4 steps every practice can take to increase cash flow from front end collections.

The first step is for practices to assess and define the scope and responsibility of the front end in the revenue cycle.  The front-end of most practices, while becoming perhaps the most critical piece of business cycle, continues to be the least paid person in the practice.  Think about that! By analyzing the impact of self-pay on your practice (self-pay being defined as patient portion) and collecting on the front end will save substantial dollars by not having to employ a collection agency to collect on the back end.

Step two is training of front end personnel.  And by this I mean specifically designed classes, mandatory classes that purposely deal with collecting techniques. I cannot stress this enough.  Expecting the front end to collect and not giving them the tools needed to meet that expectation is setting them up for failure. The front end staff must also use available tools to calculate what that payment is.  Most insurance carriers have websites where plans are clearly laid out and co-pays and deductibles published.  By knowing these rules prior to the patient presenting, how much to collect should be matter of fact.

Step three is clearly defined, carefully communicated payment policy that all patients read and sign. Creating the expectation of payment to your patients means compliant patients. Offering a discount to self-pay patients (those without insurance in this case) is widely used and an acceptable means of collection.  That discounted payment should be collected at time of service.  For those patients needing hospitalization or surgery, hospital social workers are trained to deal with these situations and can offer one of several programs to help patients with these high cost services.

There are a growing number of patients who have been laid-off, filed bankruptcy or have been adversely affected by the slumping economy.  These patients require special attention.  Having financial counselors available to review (privately) their situation and make payment arrangements is a good pro-active way of dealing with these patients and also helping them to pay for services rendered.  If a patient has included health care debt in their bankruptcy, then you may have to make a hard decision about seeing that patient.  Each physician practice will need to think about and decide what their policy will be.

Step four is to develop a clear and easy to read patient statement.  Many studies have shown that the closer to time of service these statements are sent out, the greater the likelihood of collection.  Communicate, communicate, and communicate.

Numerous studies indicate that cash flow will see at least 10-20% increase by developing a plan and collecting on the front end. Money collected at the front end, is money saved on the back end.  The more efficiently your practice is at collecting owed dollars at time of service, the less it will cost you to collect after time of service.

November 04, 2014

Dear Doctor - Are you ready for retirement?

Are you a physician who finds himself or herself in a position where you are facing future retirement with not nearly enough money to have the retirement you would like? This could be for many reasons. It could be the result of a costly personal or professional divorce, making poor investment choices, having your money grow too slowly due to an incompetent or overly costly advisor, poor savings habits, an unrealistic view of what retirement should be, or more commonly, simply living too high on the hog for too much of your career. Essentially, many of you put off saving for a rainy day until the storm clouds appeared on the horizon. Then sometimes it's too late. You will have to change your lifestyle because the amount of money you'll have to live on in retirement will be much smaller.

So think to yourself - can I retire and live the lifestyle I currently have or want? If not, you've got some work to do. NOW.

October 31, 2014

High deductibles and your physician practice's collection policy

One thing we are all seeing is the of high deductible insurance coverage.  High deductibles have always been around; the difference is this…..volume.  In most practices, the volume of high deductibles has been sparse as most patients are either covered by their employers or government in the form of Medicare or Medicaid.  This meant that practices could see patients with non-emergency visits and collect whatever the patient said they could pay without affecting the cash flow of the practice.  With the advent of the ACA and employer's continuing desire to reduce costs, the volume of patients with high deductibles will inevitably go up and that is a dilemma for many practices.

Each physician practice must take the time and thought needed to develop a policy that works for that practice.  Collection of payment at time of service is becoming the most popular and most followed practice.  The question with most high deductibles is how much to collect at one time?  Projecting cost of treatment at each visit and collecting the estimated amount is a practical solution.

There will always be patients who simply fail to pay for healthcare costs even as there will always be patients who feel the responsibility to pay for treatment and care received but who cannot afford the care and look for alternative payment options. How a practice determines to work with patients with high deductibles or no insurance for payment of services is probably the most needed policy at this moment of time in the business of healthcare discussion. A policy decision based on the values of the practice will be well received by patients if communicated in a straightforward way and applied consistently.  Communication to patients is always appreciated by patients.  Dealing with individual cases that fall outside the norm should be managed as that….outside the norm.

Take a look at your practices collection policy and determine if it is the right policy going forward. 

October 30, 2014

Is your physician practice using a portal to communicate with your patients?

Patient portals as a way of communicating with and to patients is now becoming more popular with patients and physicians.  While patient portals require no small amount of IT expertise and over-sight to build and maintain; once established, they provide a platform for patient/practice communication.  

The first step to success with patient portals is communication with patient on how to use and what they can expect from use.  This communication is vital.  How a patient perceives patient portals and their initial success in using will set the stage for a successful implementation and use of the patient portal.

Included in patient portal information should be medical history, visit summaries, access to lab results, appointment capabilities, and secure email from provider to patient.

A patient can at their convenience log into patient portal and receive follow-up information from provider on lab results, view those results, look at pending appointments, make appointments, ask routine questions via email, look at statements on line, make payments, and get other routine information that previously required a phone call.

Each time a patient calls the practice for information they could receive via the patient portal; the patient should be reminded that the information they have requested is available on the portal.  Of course, not all patients will or can utilize….but most patients will comply with expectations if initial experience successful.

Setting up the portal in a logical and easy to follow menu based way is a key to success.  This is true not only for the patient, but also for the provider.  If the providers experience with using the portal is logical and saves them time, they will use.  If they find it cumbersome, difficult and takes too much time, they will not use.  It’s that simple.  

Planning how the portal will look, how it will be populated, how implementation will be initiated and how both providers and patients will experience the value it will bring to practice is critical.  Poor planning always leads to a poor experience.

Here are some things you can do to create success with the patient portal:

  • Celebrate small wins – you won’t have full implementation overnight, so be aware when things go right and be positive about them with provider and patients.
  • Speak up about problems – while no one wants to be the one to point out problems or be seen as a nay sayer, not speaking up about issues will actually create more problems in the long run.  If you see something is not working… about it.  Try to achieve resolution.  Don’t allow it to fester into something out of control.
  • Even though implementing technology, don’t forget to communicate – technology is a way to increase efficiency, cut costs and time and increase      revenue.  It will not replace, nor should it, communication. Communicate each day with staff, providers and patients on how patient portal working, how to make it better, what staff can do to keep a positive attitude with patients just learning to use.
  • Remember your primary mission – to deliver quality healthcare to patients who need it.  We often get sidetracked by technology and fail to keep in front of us the value that technology brings to our overall mission.

Technology is a tool….a useful And productive tool.  An efficient patient portal will bring value and resources to your practice and patients.  Design it well……implement it carefully, use it as a tool. Remember we now live in a technology savvy world and patients are beginning to expect this type of communication with their doctors!