ecare India Blog

After the chaos that the HIPAA 5010 implementation has created in the industry, there are multiple unanswered questions before us. It all revolves around two factors – Healthcare implementations and the day to day billing operations. Are we striking proper balance between the two? Are we taking the medical billing and coding implementations seriously? A genuine answer to the questions would be a big ‘no’ from most of us. We all try to cross the bridge as it comes, without analyzing the depth of impact it may have on the day to day operations and vice versa. We try to keep pace with the regular activities until we dodge them aside only to run behind any implementation, while it nears deadline.

Keeping pace with healthcare implementations while sustaining billing productivity:

Starting from HIPAA 5010, we have many other implementations like ICD10 and EHR on Queue that need be worked out before 2013 & 2015 respectively. Every day, it’s becoming tough for the healthcare professionals to adapt to the rapidly changing industry, with ‘uncertainty’ spreading across like an epidemic. Now, it’s high time we streamline the work flow and make room for advancements in our daily schedule.

Here are a few suggestions for physicians and medical billing companies to keep pace with implementations/projects:

• Allot specific time for gathering industry updates
• Enroll for daily email alerts from reliable healthcare organizations
• Discuss with colleagues, social networking peers about the latest developments in healthcare billing on  a regular basis
• Attend important events and meets that discusses on medical billing issues and developments
• Set up project plan & conduct weekly reviews for any implementation like ICD10
• Provide training to staff on a daily basis
• Testing is an important phase before any project goes live. Test every system before it goes live, find and fix the flaws in the system
• During the post implementation phase, monitor and maintain system. Analyze & measure user experience & efficiency with people involved. Document the observations which will provide input for future enhancements

When you are planned and well informed, you can easily manage the medical billing and coding operations and the implementations simultaneously without having to sacrifice the other.

The Speaker of the House of Representatives has announced that the House GOP Caucus has agreed to pass the short-term (two month) SGR fix.  The House could pass the legislation as early as tomorrow but it is also possible that the vote will have to wait until next week.  The bill that is expected to be passed would continue the 2011 Conversion Factor for the Medicare Physician Fee Schedule until March 1.  The Congress will have to pass another “fix” between now and February 29th in order to prevent an SGR related cut on March 1st.

The Holiday Season is here and whilst the entire US and most people across the globe celebrate the festive spirit of the season, there is one large group that gets into a fear psychosis around this time of the year – Not the airline passengers that need to go through increased security by the TSA, but Medicare beneficiaries and their Care Providers – the Physicians.

Every year around this time in December, the SGR rate cut ‘circus’ begins and is brandished at the Practitioners and consequently their Medicare patients.  This year has been no exception.  The Congress passed a resolution on 13^th December putting ‘on hold’ the rate cut for the next two years and actually increasing the Medicare rates by 1% for 2012, but on 20^th December the Senate rejected it.  Though there is wide bipartisan support for repealing the rate cuts, the Congress and Senate do not share the same views on how to pay for this repeal.  Now that the Senate has adjourned for the Holiday Season till 23^rd January (unless the Senate re-convenes for a special session in the first week of January), the slim hope that there could be a solution to this problem before the New Year, unlike previous years, has once again vanished.

The rate cut of 27.4% will come into effect from 1^st January, 2012.  CMS has already announced that Medicare will keep all claims on hold for the first 10 working days of the year so that it can prevent a re-hash of last year, when all the claims were paid with the rate cut and once it was repealed, had to be re-processed at the new rates, resulting in huge administrative costs for CMS and its MACs.  Though CMS has tried to prevent this wasteful expenditure, there is every chance that it might not be successful.

The Sustainable Growth Rate (SGR) was part of the Balanced Budget Act which was passed in 1997 to control spending by Medicare on Physician services.  The SGR was supposed to limit the rate at which Medicare spending grew every year to within the GDP growth rate.  But the real problem has been that the Healthcare spending in the US has far outstripped the GDP growth rate in the past decade.  This resulted in ever larger spending cuts proposed every year – but deferred every year by special legislation.  The result is that after 12 years of consistent deferments, the rate cut today stands at an exorbitant 27.4%.  The Congress and the Senate have failed to reach a consensus on permanently fixing this problem.  Healthcare associations like the AAFP, AMA, HBMA, MGMA, HFMA and others have lobbied and consistently spoken against this method.  Some of them like the AAFP have suggested a 5 year moratorium on rate cuts so that alternative methods of ‘spending cuts’ can be tested over a period of time before replacing the SGR.

If the rate cut goes through without any legislation from the Hill, then Physicians will stop caring for Medicare beneficiaries.  There is also a possibility that the instances of fraud/abuse could increase because of this pressure, even though there is an increase in vigilance on the Physicians through the extension of the RAC program.  On the other hand, this would also put pressure on other Healthcare entities like RCM and Medical Billing companies that service the Physicians.  The rate cut and the consequent loss of revenue for the Physicians would translate to requests for realigning the fees for revenue cycle management and medical billing/Coding services from these Physicians.  This would result in a vicious cycle of payment cuts and unemployment in an economy that is slowly trying to recover.

The latest OECD data shows that the US spends $ 3,000 more per individual per annum when compared to other developed nations.  The total of $ 900 billion more spent on Healthcare (compared to other developed nations), essentially does not mean better healthcare for the individual.  By one estimate, wasteful elective procedures and diagnostic tests alone account for $200 billion annually.  When compared to this figure, the SGR rate cut of 27.4% would fetch only about $16 billion per annum.  The more prudent way to approach and solve this problem will be to plug the ‘holes’ in the system rather than trying to cut reimbursement to the already diminishing number of Primary Care physicians.

The call is now to the lawmakers on the Hill to set aside their petty differences and make a meaningful legislation that has some lasting impact on Medicare and its beneficiaries.  Even if it is not achieved before the end of this year, the hope is that the first weeks of the next year could ring in a change so that better sense prevails.

Happy Holidays!!!

EHR has been around for more than 15 years now, but only in the last couple of years has there been an active and conscious move towards adoption.  The impetus was provided by the ARRA Act that incentivized the adoption and implementation of the EHR in Clinical practices.  Though the deadline for implementation is 2015, clinical informatics confirms that more than 50% of the surveyed healthcare professionals are already using EHR for their practice and more than 90% of them are happy and as adept at using the EHR as they were with the paper SuperBills. But, does this mean that the Practices are complying fully and satisfying the main objectives of the incentive plan for EHR adoption? The answer to that question is self-evident. Moreover, just implementing the EHR is beneficial to the Providers to a small extent, but does not meet with the final objectives of either the ARRA Act or CMS.   EHR shouldn’t be implemented out of the fear of getting penalized (after 2015) or for the sake of incentives. EHR should be considered as an aid that makes the delivery of healthcare effective. CMS has clearly stated that the mere buying of the EHR product will not satisfy the needs of the meaningful use.

The agenda behind EHR implementation is to have a de-centralized but inter-operable system for streamlining healthcare delivery and improving quality of care thereby serving patients better.  This is achieved through the inter-operability that exists between the Scheduler, EHR, e-prescribing tool, Medical Billing software and the ability to receive lab and/or radiology reports.  The EHR is also designed to enable greater portability of patient information with enhanced security.    The advantages for CMS is the ability to easily cull data from Providers across the country and process it into actionable information.  A classic example would be something like data about the mean age of onset of diseases partially attributed to lifestyle like Diabetes Mellitus.  With this data, CMS can convert it into actionable information for preventative healthcare guidelines and suggest a rewarding mechanism for patients in the form of ‘credits’ in their next premiums.

Let us discuss the major requirements of ’Meaningful Use‘:

• Buying of a certified EHR with customizable templates and supports inter-operability with other systems like e-prescribing, medical billing software etc,
• Effective use of clinical decision support like the Coding suggestions, Level of care suggestions in E/M procedures etc.
• Recording the observations for future use
• Use EHR for collecting the healthcare statistics in order to report to CMS and other Healthcare entities like the CDC for improving quality of care.
• Securing the electronic information from any data leakage.

The EHR also has the capability of simplifying the whole Medical Billing process:

Since documentation plays such an important part in Claims being paid faster, EHR are actually designed to prompt and guide a Provider with key steps during the consultation.  The Provider has the choice to ignore these recommendations, but in most instances the adoption of the EHR has actually increased the ‘first pass rates’ of the claims.

Most of the EHR available today also come bundled with its own PMS.  This ensures that some of the data entry functions are now automated since the data that is entered at the ‘Point of Service’ or during the encounter just flows seamlessly into the PMS.

Most EHRs also come bundled with CAC tools and CCI edits that either partially auto code based on the data entered by the Provider or prompt him with a choice of the most appropriate codes.

The combination of the EHR-PMS bundle is directly integrated with a Clearing house and at the click of a button, claims are transmitted to the Payer.

The EHR-PMS is also able to handle the inbound ERAs and some of the higher versions have auto cash-posting abilities as well.

All these features of the EHR-PMS combo makes the entire medical billing process much simpler with manual intervention required only for Audits and for AR follow-up/Denial Management.  This ensures that the claims are paid faster, more consistently with minimal denials.

To conclude, it should be remembered that the EHR is a tool.  As with any tool, it is only as powerful as the skill level of the user.  If properly integrated and utilized, the EHR has the potential to offer some major advantages and savings to the Healthcare industry.

We are going to discuss now, about the features that good medical claims processing – the medical billing software should possess. Well, most of us would have already chosen a software that suits our needs or at least learnt to survive with a software that’s chosen in rush. Some of us may even be in look out for good medical billing software as well. Whatever be the case, we should know the latest advancements that different medical claims processing software companies have introduced in the recent years. Is it really important to spend time in analyzing the features to choose suitable medical claims processing software? Certainly. Experienced medical claims processing professionals would have realized that medical billing software plays a major role in healthcare revenue cycle management process and aids in every step towards collecting money. The better the features are, you will get maximized benefits. But, it is tough to find all advanced features in the same software. The best option is to go for user friendly software that has the most essential features. Let’s analyze the importance of medical claims processing software & review the vital features.

How medical claims processing software helps in enhanced process/ collections?

• Different medical billing software have their own features that will enable you to do certain function that other software doesn’t. This will give you the competitive edge over others, resulting in enhanced reimbursements.
• Certain software will enable you to perform the entire process with the same medical claims billing software, acting as a one stop shop for your medical claims billing needs. This will avoid discomfort arising from switching over to multiple systems at the same time.
• Software that can give you proper insight about your process & performance will aid in revenue improvement, whereas other software may not provide this insight and requires human intelligence to find things out, thereby wasting valuable time which could have been spent in doing productive work.

Features that help in medical billing process enhancement:

• The depth of report that can be provided for appointment scheduling can make the practice more profitable.

For an instance, when a particular patient books for but often skips appointments can be easily tracked and be fined, since the physician is booked for that period & the patient didn’t turn up resulting in waste of time in which the physician could have treated another patient. Features like this will give you better idea about how your appointments are doing & eliminate messy appointments and will make your practice more manageable right from the beginning.

• Good medical billing software should control errors in charge entry. The review screen with visual editing features for charge entry will enable the charge entry professionals to have a look at final screen and eliminate errors. For recurrent appointments the complete patient encounter information should be updated to avoid data entry again.
• Denial management reporting features that provides exhaustive report on denials can be useful to a great extent. It will enable AR analysts to manage denials efficiently and save time as well.

Advanced Features:

• EMR/ EHR: EMR/ EHR implementation is talk of the nation now. We need to implement it before 2015 to get along with industry standards. We need to therefore look for medical claims processing software that can integrate with EMR/EHR. EMR software with inbuilt medical claims processing software will be a good option.
• Document Management System: This is an essential feature that would contain complete repository of vital documents mapped to the patient accounts. This will help in handling denials effectively since analyzing will be easy with all important information together. Moreover, if the card copies of patients are scanned and uploaded to the system, it will help in verifying insurance and eliminating errors due to improper insurance eligibility verification
• Manipulation restrictions: Medical billing and coding fraudulent activities are becoming common these days. Since the medical billing software is the claims processing medium, it is good to choose software that is secure as well as restricts manipulations in system.
• Backup Management: Software that has backup management features will help in information management even at times of emergencies
• Dash board features: Dashboard feature is a smart functionally that will give a snapshot of all metrics, to-do list, revenue performance etc., in the ‘startup’ screen itself. This will give an idea of performance and your activities in a glimpse.
• Work flow allocation: Some medical claims processing software enables work flow allocation which is an important segment of handling task. Work can be allocated to different users and managed. The users & the admin would get alerts regarding task and the status would be automatically updated. This vital feature organizes workflow, improves efficiency  and provides better results.

Now, choose the software that has maximum essential features and fits your practice requirements as well. Go for multiples demos from medical billing software vendors, ask your peers  about their experience with the software and then decide a good software.

e-prescribing, as clearly explained by CMS, ‘is the ability of the qualified physicians to electronically generate an understandable prescription and send directly or through commercial pharmacy network to a participating pharmacy’. The main reason behind implementation of e-prescription is to reduce medication errors & improve quality of care in the United States.

Latest research reports on medical errors indicate that every year in the U.S. 1.5 million people are affected and thousands of people die due to ‘medication errors’. The alarming numbers reveal the need to follow a prescribing system that improves the accuracy of prescription. That’s why there is a strong push from the government of the United States to implement e-prescription system.

‘e-prescription implementation – incentive & penalty plan’ put forth by CMS.

CMS encourages physicians to implement the new electronic prescribing system by providing financial incentives if they implement e-prescribing on time and penalizing if they don’t.

Implementing e-prescription:

• Determine your practice requirements to implement e-prescribing
• Educate your patients & your staff, the need for electronic prescription if they resist it.
• Give adequate training to the staff to cope with the changes.
• Keep your vendor aware of the changes so that they are not surprised with an e-prescription from your facility/practice.
• Research and find suitable e-prescribing software that will suit future requirements of ANSI 5010, ICD -10 implementation & most importantly EMR.

Challenges faced while implementing e-prescribing:

• Dependency on system requirements for e-prescribing
• Information security concerns and remote access limitations
• Resistance from patients and staff

While implementing e-prescription, physicians may face many other challenges as well. But e-prescribing provides multiple benefits to physicians that make it worth implementing.

Key Benefits of e-prescribing:

• Legibility of prescription and reduced medical errors
• Compatible for EMR
• Reporting abilities – capability to generate medication report for healthcare analytics
• Time saving and avoids pharmacy call backs
• Cost effective
• Review of medication history that results in enhanced accuracy in prescription
• Alerts – For instance, e-prescribing system alerts physicians for alternative drugs that are more efficient & cost-effective. Warnings – It provides warnings for drug refills so that refills are made quickly
• Greater convenience to physicians and patients
• Improved Patient safety and quality of care

Just adapting an e-prescription alone will not speak success stories.  Diligence & routine check up on the functionality of the system, data analysis, closely monitoring patient’s tolerance etc will boost the efficiency there by reducing cost & maximizing your benefits.

Clinical documentation is an integral part of health Information Management. The clinical documentation needs doesn’t end with diagnosis and treatment of patients. It is also needed for efficient medical claims processing. Clinical documentation remains the source for the coders to assign the exact diagnosis and procedure codes. Let’s explore more about the dependency on clinical documentation with ICD-10.

• ICD-10 is an organized coding system that contains more than 150,000 specific ‘diagnosis and procedure codes’ for diseases. In ICD-10, due to its ‘specificity’, coding is much dependant on clinical documentation for medical billing reimbursements. So, the clinical documentation should capture all possible observations including even minute variations in procedure done for patients, which will be captured in coding through specific ICD-10 codes and the claims will get paid for the allotted amount for that procedure. Which means ‘better the clinical documentation; better will be coding and thus reimbursements’.
• It’s essential to evaluate the current clinical documentation procedure of ICD-9 and explore the clinical documentation needs for ICD-10. This GAP analysis will enable better focus to clinical documentation. Claims that are sent on/after Oct01, 2013 will strongly depend on specificity of clinical documentation.
• It is necessary to identify the introduction of new terminologies in clinical documentation and get the coders acquainted with the terminologies to get along with ICD-10 in a faster pace.
• Consulting a ‘clinical documentation specialist’ or recruiting them can help a lot when you start with ICD-10.
• When you work with clinical documentation, it is essential to decide on the point of communication – whom you will contact in case there are discrepancies in clinical documentation.
• Improper documentation will not only lead to denials or low reimbursements, but also increase documentation queries and reworks resulting in increase of the medical billing cycle.
• Consulting a ‘clinical documentation specialist’ or recruiting them can help a lot when you start with ICD-10.

Therefore, when implementing ICD-10, clinical documentation should also be given necessary attention so that it will not be a last minute surprise for you.

Many healthcare entities as well as medical coding & billing companies are concerned about ICD-10 transition. What’s stopping medical coding & billing companies? Apart from the initial hurdles and cost factor, the main troubling parameter is productivity drop during ICD 10 transition. It is estimated that there will be a drop in productivity by 20-50% during ICD-10 implementation, varying for different medical claims billing entities.

It is common that there will be stagnancy in work during implementation of any new process. But ICD-10 has turned out to be a big challenge to the medical claims billing industry, affecting the daily operations. To balance this, it is essential to follow a streamlined productivity improvement plan that will efficiently solve the productivity issues.

Estimate the potential of your coding team:

Monitor the current productivity of your medical coding team for a month and calculate their daily productivity in numbers to know the actual potential. This report will be the baseline for your ‘productivity improvement plan’.

Divide your coding team in to 3 vital groups:

Once you start with ICD-10, you have to organize your coding team in-to 3 groups based on the skill set, experience and interest of the coders. By doing this, focus on productivity will not be lost and teams will be able to perform better.

1. Backlogs: Have a team handle any backlogs since completing this is essential to get a smooth start to ICD-10. You can use your coders with average experience on this.

2. Day-day work: Similarly you can assign newly joined coders who have little experience to handle the day-to-day work.

3. ICD 10 transition: Once this assignment is made the experienced coders with analytical skills can work on the ICD-10 transition.

Arrange for regular meetings:

Meetings are a must when implementing a plan. So, arrange for regular meetings and discuss with the 3 teams separately about their progress and check if they face any issues in their current scope of work. Help them out and encourage them to do well. Discuss on parameters like productivity, controlling errors & time management. Track productivity of the groups – only numbers can speak when productivity is concerned. Provide extra support to your ICD team to face the new challenges.

Provide periodical training sessions:

Based on the scope of work, provide quality training sessions to coders to handle their task more efficiently. Better the training, you will get better results.

Use technology to boost productivity:

Technology can transform processes and reduce complexity of a work. Analyze and find out tools that can help you in completing your task faster, thereby reducing the ‘turnaround time’ and increasing productivity. Errors and rework can affect productivity. So, go for system that can do better check on errors by providing alerts.  Have a system in place to track your productivity.

Monitor & review the results: Finally, you have to measure the results of your productivity plan. Make quarterly reviews to know the outcome of the change.  Once the ICD 10 initial setup is over, you can arrange for planned knowledge transfer sessions for other two groups and cross train them.

These guidelines can help you in managing the productivity drop in medical coding & billing operations during ICD-10 transition in a better way and deliver enhanced results.

If you are a physician billing company providing physicians billing services to hospitals & medical practices, you have to take extra care to implement ICD-10. As a provider of physicians billing services, you will be responsible for complete ICD-10 transition and you cannot depend majorly on your clients.

Don’ts

• Don’t procrastinate or don’t do it in haste: Have an implementation plan and work accordingly. The implementation goes live on Oct 01, 2013. So, don’t do it fast and mess up or don’t procrastinate on ICD-10 implementation, waiting for others to start or the deadline to change. Start now – The more you delay, the more you are at risk of working at the last minute. Let things happen on its own pace, as planned, so that you have time to sort out any issues arising of the implementation, well in advance.

• Don’t leave everything to coders alone: The complexity of the ICD coding system demands lot of groundwork from the coding team. Since the coders have to manage with ICD implementation as well as current work, don’t make them solely responsible for the implementation. The ICD 10 transition should be a combined work involving the transition management team, IT team and the medical insurance billing team as well.

Dos:

• Give proper training to the coding team: ICD-10 requires comprehensive training sessions for coders. Apart from educating the coders about ICD-10 codes, add real life – case based exercises and medical terminologies to the training module that will induce logical thinking in coders and help them act independently when they start coding for ICD-10. ICD-10 also requires basic insight on ‘Anatomy and Pathophysiology’ modules. So include these as short courses in the ICD-10 training sessions.

• Choose the right technology: Many healthcare IT companies have launched tools to aid with ICD-10 implementation. You need to be cautious in choosing the right system to suit your requirements. CMS provides latest updates on these tools in its website.

• Be in loop with latest ICD-10 updates: Though the implementation of ICD-10 is dated to OCT 01, 2013, many healthcare entities have started preparing for the implementation. Updates with ICD-10 are being made by medicare frequently and you need to be well informed about the latest changes happening in the industry to keep pace with the ICD implementation. Make it a practice to look for medical insurance billing & ICD-10 updates in CMS website

• Update your clients: Update your clients regularly regarding ICD-10 implementation initiatives taken by you. Explain them your plan and in fact any hurdles that you face so that they will know your commitment to ICD-10 implementation.

The ICD-10 is not a mere update in the coding system. ICD-10 is a streamlined set of codes that enables greater ‘specificity’ in indicating the exact medical condition of a patient and procedure done. This specificity will provide multiple benefits to the medical insurance billing and coding as well as healthcare industry.

Improved quality in clinical documentation: The ICD-10 coding system is much dependant on clinical documentation. Since thousands of diagnosis & procedure codes have been added to ICD 10, the precision of the codes depend on the clinical documents. So, with the implementation of ICD-10, quality of clinical documentation will improve.

Improved quality in healthcare: With ICD-9, the major focus was to improve reimbursements. But, ICD-10 coding setup supports ‘performance based payment’ system rather than aiming at returns. This will change the way healthcare is and will improve the quality of care.

Preventing healthcare fraudulent activities: National Healthcare Anti-Fraud Association (NHCAA) cites that anywhere between $70 billion and $234 billion is lost annually through healthcare frauds.  Healthcare frauds are becoming common in the medical billing industry also, focusing majorly on medical insurance billing and coding manipulations involving medical billing services providing companies, hospitals and other healthcare entities. ICD-9 is more generic and allows tweaks to be made in coding to get better reimbursements. But, in ICD-10, the codes are specific and prevent manipulations to a great extent. This will over a period of time, have control over medical billing fraudulent activities as well.

Reporting features: Since the ICD codes are used for health surveillance and researches also, specificity in ICD-10 will reveal the exact health condition of people in the US. For instance, for ‘Brain tumor’, the ICD-9 CM assigned was generic. In ICD-10 CM, there are specific codes to mention if the ‘right’ or ‘left hemisphere’ is affected and whether it is ‘occurrence or recurrence’. All this will provide better insight to the healthcare department & help in efficient ‘disease management’.

Interoperability:

Sharing of health information with other countries is difficult to US with ICD-9, since all other countries except a very few, follows ICD-10 coding system. Now, with the implementation of ICD-10, US will be able to bridge the gap by sharing information across borders more efficiently and thereby empowering quality of care.

Great accuracy with fewer codes: ICD-10 will contain nearly 150,000 codes including CM & PCS. Though there are thousands of codes newly included, you can accurately describe a medical condition or encounter with fewer codes when compared to ICD-9 that needs more number of codes to indicate the same.