August 13, 2014

Providers Enrolled as a ‘Sole Practitioner’, or ‘Private Practice’– Medicare Claim Submission Requirements for the Billing and Rendering Information

If a physician is are enrolled as a ‘Sole Practitioner’, or ‘Private Practice’ Provider, only the Billing NPI assigned should be submitted on the claim to Medicare. It is not required to also report an NPI as the Rendering Provider. Incorrectly reporting a Rendering Provider NPI that is not required, the system will automatically reject the claim based on the system editing for the Billing and Rendering information.

Please note that Organizational Groups who are enrolled are required to submit the Billing NPI and a Rendering NPI.

August 12, 2014

Another human resource idea for physician practices

The Austin American Statesman a while back ran an article about Jack Welch, the former CEO of GE. In the article, he was asked about GE's approach to managing people, which focuses on rewarding stars - the top 20% or so - and easing out the bottom 10%, the low performers: "It's differentiation, and I believe in it to my toes. It's somewhat controversial at times." said Mr. Welch.

Mr. Welch advises to take the top 20% as your most important people and "kiss them, hug them, and reward them." For the middle 70%, show them what they are good at  and where they can improve and try to move them up. For the bottom 10%, bring them in and tell them they ought to find work elsewhere.

My question is: Why don't physicians and their management team follow the same philosophy as Jack Welch? Medical practices I must admit do a terribly job at human resources, whether it be hiring, training, mentoring, terminating, etc. Seems like everybody is just too busy. I also do not understand why most medical practices tolerate mediocrity within its employee group.

In the Medical Group Management's annual Best Performing Medical Practices survey each year, it is no surprise that the best performing practices have one thing in common - They do the best at hiring and managing employees.  They do the best job at keeping employees happy and wanting to come to work. They do the best job at retaining employees.

From a business standpoint, it is the employees who will make or break a medical practice, not necessarily the clinical activities of the physicians. A medical practice can have the the most busiest physicians on the planet but without a strong employee group it, it will never be as financially successful as it can be.

Think about all this seriously..............and start identifying and replacing the low performers now.

August 07, 2014

ICD-10 Testing Opportunities for Medicare FFS Providers

On July 31, HHS issued a rule (CMS-0043-F) finalizing October 1, 2015 as the new compliance date for health care providers and health plans to transition to ICD-10.  ICD-10 represents a significant code set change that impacts the entire health care community.

CMS is taking a comprehensive four-pronged approach to preparedness and testing for ICD-10 to ensure that CMS, as well as the Medicare Fee-For-Service (FFS) provider community, is ready:

• CMS internal testing of its claims processing systems

• CMS Beta testing tools available for download

• Acknowledgement testing

• End-to-end testing

For more information, see MLN Matters® Special Edition Article #SE1409, “Medicare FFS ICD-10 Testing Approach.”

Acknowledgement Testing

This past March, CMS conducted a successful ICD-10 acknowledgement testing week. Providers, suppliers, billing companies, and clearinghouses are welcome to submit acknowledgement test claims anytime up to the October 1, 2015 implementation date. In addition, special acknowledgement testing weeks in November, March, and June of 2015 will give submitters access to real-time help desk support and allows CMS to analyze testing data. Registration is not required for these virtual events. Contact your Medicare Administrative Contractor (MAC) for more information about acknowledgment testing.

End-to-End Testing

CMS plans to offer providers and other Medicare submitters the opportunity to participate in end-to-end testing with MACs and the Common Electronic Data Interchange (CEDI) contractor in January, April, and July of 2015. As planned, approximately 2,550 volunteer submitters will have the opportunity to participate over the course of three testing periods. The goals of this testing are to demonstrate that:

• Providers and submitters are able to successfully submit claims containing ICD-10 codes to the Medicare FFS claims systems

• CMS software changes made to support ICD-10 result in appropriately adjudicated claims

• Accurate Remittance Advices are produced

Additional details about end-to-end testing will be available soon.

Check the ICD-10 Medicare FFS Provider Resources web page for the latest information and educational resources to implement and transition to ICD-10 medical coding.

August 04, 2014

Deadline for ICD-10 Allows Physicians Ample Time to Prepare for Change

On July 31, HHS issued a rule finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. This deadline allows providers, insurance companies, and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on October 1, 2015.

The ICD-10 codes on a claim are used to classify diagnoses and procedures on claims submitted to Medicare and private insurance payers. By enabling more detailed patient history coding, ICD-10 can help to better coordinate a patient’s care across providers and over time. ICD-10 improves quality measurement and reporting, facilitates the detection and prevention of fraud, waste, and abuse, and leads to greater accuracy of reimbursement for medical services. The code set’s granularity will improve data capture and analytics of public health surveillance and reporting, national quality reporting, research and data analysis, and provide detailed data to enhance health care delivery. Health care providers and specialty groups in the United States provided extensive input into the development of ICD-10, which includes more detailed codes for the conditions they treat and reflects advances in medicine and medical technology.

Using ICD-10, doctors can capture much more information, meaning they can better understand important details about the patient’s health than with ICD-9-CM. Moreover, the level of detail that is provided for by ICD-10 means researchers and public health officials can better track diseases and health outcomes. ICD-10 reflects improved diagnosis of chronic illness and identifies underlying causes, complications of disease, and conditions that contribute to the complexity of a disease. Additionally, ICD-10 captures the severity and stage of diseases such as chronic kidney disease, diabetes, and asthma.

The previous revision, ICD-9-CM, contains outdated, obsolete terms that are inconsistent with current medical practice, new technology, and preventive services.

ICD-10 represents a significant change that impacts the entire health care community. As such, much of the industry has already invested resources toward the implementation of ICD-10. CMS has implemented a comprehensive testing approach, including end-to-end testing in 2015, to help ensure providers are ready. While many providers, including physicians, hospitals, and health plans, have completed the necessary system changes to transition to ICD-10, the time offered by Congress and this rule ensure all providers are ready.

For additional information about ICD-10, please visit the ICD-10 website.

July 30, 2014

HIPAA Phase 2 audits about to begin

The U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) will soon begin a second phase of audits (Phase 2 Audits) of compliance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy, security and breach notification standards (HIPAA Standards) as required by the Health Information Technology for Economic and Clinical Health (HITECH) Act. Unlike the pilot audits during 2011 and 2012 (Phase 1 Audits), which focused on covered entities, OCR will conduct Phase 2 Audits of both covered entities and business associates. The Phase 2 Audit Program will focus on areas of greater risk to the security of protected health information (PHI) and pervasive noncompliance based on OCR’s Phase I Audit findings and observations, rather than a comprehensive review of all of the HIPAA Standards. The Phase 2 Audits are also intended to identify best practices and uncover risks and vulnerabilities that OCR has not identified through other enforcement activities. OCR will use the Phase 2 Audit findings to identify technical assistance that it should develop for covered entities and business associates. In circumstances where an audit reveals a serious compliance concern, OCR may initiate a compliance review of the audited organization that could lead to civil money penalties.

July 29, 2014

2013 NSCHBC Physician & Dental Practice Statistics Report - How Do You Compare?

The National Society of Certified Healthcare Business Consultants (NSCHBC) (for which I have been a long standing member) has produced their annual Practice Statistics Report (2013).  This statistics report contains practice data from 2,492 professional practices representing 5,252 FTE doctors.  The aggregate data is reported on 60 dental and medical specialties.

Practices that utilize NSCHBC consultants are proven to produce more revenue and bottom line income, in most cases, than those practices that do not utilize expert professionals in assisting in the management and oversight of the business.  Additionally, practices included in the NSCHBC statistics report continually exceed revenue and profits of those practices contained in the MGMA annual practice surveys.  Here is a sampling of some of the 2013 report findings.

Family Medicine w/o Obstetrics ◦ Average annual revenue per practice grew by about $45,000 or 3.6% and $33,000 or 5.1% per FTE Doctor ◦ Avg income increased by 10.3% per practice and increased 13.4% per FTE Doctor ◦ Avg OH decreased by2.6% per practice and decreased 2.7% per FTE Doctor

Family Medicine w/ Obstetrics ◦ Average annual revenue per practice grew by about $120,000 or 10.2% and $120,000 or 18.4 % per FTE Doctor ◦ Avg income dropped by 1.7% per practice and grew by 8.0% per FTE Doctor ◦ Avg OH grew by 3% per practice and 2.3% per FTE Doctor

Internal Medicine ◦ Average annual revenue per practice grew by about $75,000 or 6.6% and $72,000 or 12.4% per FTE Doctor ◦ Avg income increase by 19.3% per practice and grew by 20.1% per FTE Doctor ◦ Avg OH decreased by 6% per practice and decreased by 4.7% per FTE Doctor

Additional Information

All primary care practices increased in the last 5 years, but Family Practice without OB increased the most, by 144%. Cardiology, OB/GYN and Plastic Surgery decreased over the same period by 46%, 2% and 12%, respectively. Of those three, OB/GYN and Plastic Surgery were down more than that but have shown an upswing in the last two years. During the same 5 years General Dentistry and Orthodontics have stayed even with a small increase. Periodontics, however, has seen relatively steady growth until 2012 where there was a drop.  Overall, however, Periodontics is up 22% over the last 5 years. Overall, General Surgery has been the most consistent in the last 5 years. Plastic Surgery dropped in 2009 by over 32% but has slowly increased in the last 2 years to a net 12% loss.

Visit the NSCHBC website to find out more how your practice compares to like practices or contact a member consultant to assist you in benchmarking your practice today.

July 25, 2014

Sample monthly reports for physicians

  • Total Billed - total for practice and brokend down per provider/compared to prior year
  • Total Collected - total for practice and broken down per provider/compared to prior year
  • Aging Analysis - by Insurance Group and figures comparing this month to previous month.
  • Patient Count Comparative Report - tracks patient #s (new, established, and totals) by month by year so you can guage growth/decline.)
  • Total # Procedures - in total and by provider.
  • Procedure Analysis - procedure groups by billings and collections posted
  • Overtime pay by employee
  • Profit and Loss Statement/compared to prior year

July 24, 2014

Billing for Physician Extenders

A physician extender is a licensed health care provider (not a physician) that provides medical services, typically performed by a physician. The term physician extender is commonly used to identify trained health care professionals such as physician assistants and nurse practitioners. Physician extenders typically work under the direct supervision of physicians.


Health plans are free to develop their own policies for credentialing and reimbursing physician extenders. Some health plans will credential the physician extender and some plans will not. Some plans follow Centers of Medicare and Medicaid (CMS) "incident to" guidelines and some plans do not. Therefore, it is important to contact each health plan to determine their policy regarding physician extenders. Below are a list of questions that the practice should ask the payer:

Do you credential physician extenders such as, nurse practitioners (NPs) and physician assistants (PAs)? Do you include them in your provider listing? Do you require any specific level of supervision? If the physician extender is not credentialed with the payer, then can the physician extender bill under the contracted supervising physician's billing numbers with the appropriate modifier? Confirm the appropriate modifier. Do you recognize and follow CMS "incident to"? What is the reimbursement rate for physician extenders if the service rendered is not "incident to"?


Physicians who bill Medicare for "incident to" will be reimbursed at 100% of the Medicare allowable. However, the following criteria must be met:

The physician has to have seen the patient at a previous visit and developed the plan of care that the physician extender will carry out.

The physician has to remained involved in the patient's care.

The physician extender has to be an expense to the physician/practice.

The physician must be physical present in the building.

The services must be provided in the office.

Important: If the patient is being seen by the physician extender for a different problem then this does not qualify as "incident to".

July 23, 2014

“Accountable Care Organizations: What Providers Need to Know” Fact Sheet — Revised

The “Accountable Care Organizations: What Providers Need to Know” Fact Sheet (ICN 907406) has been revised and is now available in a downloadable format from CMA. This fact sheet is designed to provide education on Accountable Care Organizations (ACO) under the Medicare Shared Savings Program. It includes a definition of an ACO, and information on how to participate in an ACO, how shared savings will work, how this program is aligned with other quality initiatives, and how ACOs help doctors coordinate care.

July 18, 2014

Fraud Alert-Laboratory Payments to Referring Physicians

The Office of Inspector General of the Department of Health and Human Services today issued a Special Fraud Alert pertaining to relationships between laboratories and referring physicians.  Payments from labs to physicians who refer were targeted in the Alert.  The Alert also reiterates their suspicion of so-called "carve out" compensation relationships where state and federal healthcare program dollars are removed from the payment formula (which was previously addressed last year in Advisory Opinion 13-03).  While the Alert does not add anything new to the government's view of such relationships, it does underscore the very suspect view the OIG has of payment relationships between labs and the physicians who refer to them.