From the Consultant’s Corner 6/27/13

Covering Your Bases: Preparing for ICD-10 Cash Flow Impacts
By Brad Boyd

You know those routine chart audits you regularly complete as part of your billing compliance program to make sure patient encounters are coded and documented correctly? That audit process can be invaluable when it comes to your ICD-10 conversion.

Imagine for a moment your organization’s conversion to ICD-10. You’ve trained your coders and physicians on the new code set and even done some test runs. Despite this, 30-60 days after October 2014—right around the holidays—your organization experiences a dramatic drop in cash flow. After looking into the issue, you realize that you’re not getting paid as much as you once were. Gaps between current documentation and coding processes and ICD-10 requirements will impact reimbursement.

To avoid this situation, I suggest to medical group clients that they leverage their current claim auditing and coding education program to look for gaps between ICD-9 and ICD-10 coding and documentation requirements, as well as reimbursement impacts. Here’s how the process works. After you audit your current charts for ICD-9 compliance, you determine what the reimbursement would be for those charts. You then figure out what needs to be documented to achieve the same level of reimbursement if the charts were coded in ICD-10, revealing potential gaps that need addressing.

One way to close gaps is through physician and coder education. I also suggest you go a step further and share information about gaps with your vendors who are currently in the process of designing upgrades to ICD-10 coding and documentation tools. By providing feedback about gaps to vendors right now, you give them the opportunity to address those disparities, further ensuring tools and solutions that adequately meet your organization’s needs.

Despite thorough planning, your organization’s cash flow may still take a hit for a period of time after ICD-10 goes into effect. As a further “insurance plan” against money loss, I recommend communicating with your biggest payers and trying to negotiate a worst-case scenario cash flow plan. You must be careful when broaching this topic. I suggest being fully transparent about your approach to ICD-10 implementation, showing the payer that you’ve done your due diligence. This could involve sharing your risk assessment, project plan for mitigating any anticipated risks, training programs for clinicians and coders and governance structure for the implementation.

Once payers understand that you’ve done everything you can to prepare, they may be open to discussing a short-term, emergency payment arrangement based on historical information about service volumes. I firmly believe that setting up this type of back-up plan can help your organization ensure adequate cash flow for a period of time as you work through unexpected issues with the new code set.

Although October 2014 may seem like a long way off, it will be here before we know it. Most of the organizations I work with are making steady progress toward implementing the new code set, having completed an impact assessment and project plan. However, I have noticed that organizations often underestimate the need to consider the potential cash flow impacts of the switch. Taking the time to understand and prepare for changes in cash flow can help your organization put mitigation strategies in place to support a smoother transition with limited disruptions.

Brad Boyd is vice president of sales and marketing for Culbert Healthcare Solutions.

News 6/27/13

Humana earns the top spot in athenahealth’s 2013 PayerView Report, which ranks health insurers based on claims-payment data. Other highlights from the report:

• Medicaid continues to underperform on key metrics, such as days in A/R
• Many payers performed worse than the 95 percent benefit accuracy, including six payers that returned correct co-pay information less than 50 percent of the time
• Payers still require enrollment by fax or mail for 65 percent of transactions.

The seven-provider Athens Bone and Joint Orthopedic Clinic (GA) selects simplifyMD’s EHR.

Financial management issues are the most challenging difficulties facing group practice executives, according to an MGMA member survey. Specific concerns include managing rising operating costs, preparing for potential cuts in reimbursement rates, and navigating transformative federal policies. Implementing an EHR is considered less of a challenge than a year ago, but optimizing an existing EHR has become a more pressing concern.

Orion Healthcorp., a provider of medical billing and coding for physician offices, names Dale Brinkman (Western Skies Billing Service) CEO and promotes Joseph Seale from COO to president.

UCSF Dermatopathology and Oral Pathology Service selects McKesson to provide revenue management services for its eight-physician group.

Kareo reports that one-third of the 4,000 providers signed up for its EHR have moved from another EHR system.

Consumer Reports publishes an excellent overview of the PCMH model that should be a must-read for anyone wanting to understand the why and how of this emerging care model. The article outlines what a PCMH is, how it is run, how it can reduce costs, and how it benefits patients. The use of “smart medical records” is recommended to facilitate preventative care,  improve provider-patient and provider-provider communications, and manage the coordinated care process. If you work for a vendor serving the ambulatory physician market, it’s worth the read. If nothing else, you will seem really smart at your next company cocktail party.

A Maine newspaper profiles Michael Clark, MD, owner of Lifespan Family Healthcare Center, which is part of the PCMH Pilot Program. Clark believes the success of the PCMH is dependent on modern technology, including EMRs that are available to both providers and patients:

Electronic medical records allow for easier tracking of complex medical problems, help to prevent medication prescription errors, provide automatic reminders for overdue care, flag critical lab values and improve coordination among different specialists and healthcare facilities. Equally important, patients have the same access to all of their records as providers.

E-mail Inga.

News 6/25/13

From Sleepless: “Re: Priorities. The customer should be the priority, but you know how people are programmed to cater to doctors’ schedules and timelines. It is as though we are living in the 1950’s. I also find it offensive when I call the doc office or pharmacy and get the recording that says doctors press 1 and the rest of you press 2.” Apparently I am not the only one who is annoyed by office staff that seem to believe their doctor’s time is more valuable than mine. As another reader pointed out, the staff’s priority should be to assist, “the one with cash in their hand.”

eClinicalWorks has signed up 1,000 providers to its RCM during the first six months of 2013 and is projected to reach $100 million in revenues by 2015. eCW offers the service for 2.9 percent of monthly collected revenues and includes EHR.

Georgia Governor Nathan Deal announces that athenahealth will expand into Atlanta, bring 500 new jobs, and make an $10.8 million investment in the Ponce City Market area.

An American Medical News article discusses ways that practices can use patient data from EHRs to  impact the way care is delivered and identify improvements on the business side. For example, EHRs help practices identify patients in need of preventative care, facilitate the management of chronic care cases, and monitor outcomes. To improve population health, experts recommend using Meaningful Use measurements as a guide and selecting target measures from the 64 included in Stage 2.

The AMA votes to lobby CMS for a two-year grace period to avoid complying with the ICD-10 transition, despite the announcement last week by ONC head Farzad Mostashari, MD that there will be no additional ICD-10 delays.

A CMS study concludes that adoption of EHRs in community practices doesn’t necessarily decrease costs, but can facilitate either increases or decreases in costs depending on how the EHR is used and the context in which it is used.

E-mail Inga.

DOCtalk by Dr. Gregg 6/22/13

In the Kingdom of Happy Healthcare

Once upon a time, in a land far, far away, Eric Henry Roberts V went looking for a wife. Since he was the prince of the entire Kingdom of Happy Healthcare, he knew he would be able to find a wonderful wife. What woman wouldn’t want to marry the handsome prince and share this wonderful kingdom from atop EHR Mountain within the glorious walls of EHR Castle, the grandest castle in all the land?

EHR Castle had been built by Eric’s great, great grandfather who was known as Pen. He ruled at a time when the land was rife with outlaws and hooligans. At that time, the kingdom was a vast jungle. It was divided into many small lands ruled by warlords and chieftains. None of them spoke in person with the others and they rarely shared. They were the kings of their parts of the jungle and, by a long-held and poorly understood tradition, they all wrote decrees to each other on parchment. Thus, they were known as the “Paper Lions.”

The Paper Lions’ paper decrees had many problems. They were, by tradition, the only way the various tribal leaders spoke with the nearby leaders, discussing treaties and the like, but they were often more trouble than treaty. Their papers were often lost, hard to read, or so poorly written that many a war was started over the years simply due to poor communication.

Pen was one of the Paper Lions, but he developed a bigger vision than his fellow chieftains. He saw the value of working more cooperatively with others outside of his clan. He knew that resources abounded in other areas of the jungle that he could not access. He knew, too, that he held riches within his domain that others would want. He was the first to step away from the Paper Lions and develop a new way of connecting with his fellow warlords. He developed “The Talk.”

Pen figured out a clever way to make messages between tribes more reliable. He strung a network of wires running through the jungle from tribe to tribe. They put their decrees and other inter-tribe messages into little holders and sent them careening through the trees on these long wire pathways. Messages got to where they were intended. Plus, he developed a standard message format that all tribe leaders agreed to use to insure that everyone could read and understand the messages. The fellow chieftains dubbed this system “The Talk.”

The Talk worked. As tribes communicated more effectively, barriers between them fell. They worked together more. They eventually grew together, taming their vast jungle and joining forces under the wise leadership of Pen.

Pen was crowned king of the entire land of Happy Healthcare and adopted the kingly name, Eric Henry Roberts. All the generations since have proudly carried the E.H.R. (version II, II,IV, etc.) moniker.

Now Eric Henry Roberts V needed a wife. The word went out and many a comely woman aspired to his attentions. However, just as he was setting his sights upon the loveliest and gentlest among them, the Kingdom of Happy Healthcare was attacked by neighboring enemies. The attack was fierce and all of Prince Eric’s advisors beseeched him to use his Solomon-esque skills to assuage the enemy. Eric knew what he had to do.

The marauders were from the Land of Efficient Healthcare; they had long argued with their Happy Healthcare neighbors to the north. Eric knew that the ruler of their enemy was a good woman, though she had grown up indoctrinated with family values, values that included a longstanding feud mindset with the Kingdom of Happy Healthcare. No one even remembered what had started the feud, but it has burned ever more hotly through the years as Eric’s predecessors had driven the improvements and camaraderie within their kingdom. Now they had invaded. They were envious of what the E.H.R.s had built.

Eric also knew that the Queen of the Land of Efficient Healthcare had accomplished many of the same feats he and his forebears had; she had banded together disparate tribes within their land and brought peaceful coexistence and prosperity through cooperation and enhanced inter-tribal communication.

He also knew she had an exquisite daughter.

Prince Eric sent a special envoy to Queen Eleanor. The envoy rode non-stop to deliver the message. Eric had used the same message protocol that his great, great grandfather had established years ago with the warlords. His hope was that the message clarity would insure accurate communications between the leaders, just as it had done so many years ago.

This fact was not lost on Queen Eleanor. She understood and she accepted Prince Eric’s proposal; she dispatched her beautiful daughter the very next day.

Queen Eleanor’s daughter arrived in the Kingdom of Happy Healthcare within a fortnight. She dutifully married the handsome Prince Eric the very next day. The warring nations were now joined by royal matrimony and peace was declared.

As the newlyweds retired to the royal bedchambers on their honeymoon night, they noticed that the maidservants had arranged the boudoir with all of the new couple’s personalized accoutrements. One among them stood out to both Eric and his lovely new bride: monogrammed pillow cases with the initials “E.H.R.” on them.

The new bride looked surprised and apologized to her new husband, “My lord, I most humbly beg your forgiveness. My servants have snubbed thee and for that I beg thy mercy.”

Eric was perplexed. “Why sayeth thou so, dear wife?” he asked.

“My ladies in waiting have placed only my pillows upon our bridal bed. They have neglected your royal highness’ seal,” she replied.

Said Eric, “But, dear bride, these are my marks. I fear they have neglected thine.”

Suddenly, as the awareness dawned upon him, Eric realized he knew not the full name of his betrothed. “Beloved,” he asked, “pray, tell me thy fullest name.”

“Why, Eleanor Hermione Rothwell, of course. The same as my mother, and her mother before her, and her mother before her,” she answered. “It is a proud maternal tradition of our land.”

“Aw,” said the goodly prince. “Now ‘tis clear. I see we are both well represented in our chambers as I am Eric Henry Roberts V. The royal ‘E.H.R.’ monograms connect us both.“

Eleanor smiled when Eric then strode toward her with a knowing (and not exactly royal) twinkle in his eye and said, “Let us now connect two lands, two peoples, and two E.H.R.s!”

The moral of the story? When EHRs connect, Happy and Efficient Healthcare finally get it on!

From the trenches…

“To the royal guards of this realm, we are all victims in-waiting.” – Cheshire Cat

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

News 6/20/13

From Guppy: “Re: KLAS scores. KLAS always seems to hand-pick the largest vendors as winners. It was interesting to look at the data you reported because it would appear that a number of the small, specialty-specific vendors do a much better job at usability than the big fish – shocking!”  “Usability” is not necessarily the same thing as customer satisfaction, which is the metric KLAS is measuring. Regardless, the KLAS scores always stir up plenty of controversy. At least in the ambulatory EMR segment, several of the smaller vendors did quite well, including PCC, SRS, and Sevocity.

The 110-provider Oregon Medical Group will implement Phytel’s Outreach, Insight, and Coordinate modules for population health management.

Technology could improve treatment outcomes for children with chronic illnesses, according to a report from Boston Children’s Hospital and the Verizon Foundation. The white paper stresses the need for technology that improves coordination among members of the care team; improves care management by providing appropriate data required for decision-making; facilitates the education of care team members on available resources; and incents providers to adopt technology that focuses on the patient and family rather than a traditional physician-centric model.

CMS publishes updated 2014 clinical quality measures for EPs, which are categorized based on the agency’s priorities for patient and family engagement, patient safety, care coordination, population health, efficient use of resources, and clinical effectiveness.

Yesterday I stopped by my optometrist’s office to pick up some contacts. While the tech was hunting for my order, he took a phone call. As I became increasingly impatient for him to get off the phone and finish helping me, another employee explained that the tech was talking to the doctor. When I finally walked out the door, I wondered to myself who should have been the tech’s priority: the customer/patient or the doctor?  Anyone?

Robert M. Wah, MD, the ONC’s first deputy national coordinator and a retired Navy captain, is named president-elect of the AMA.

E-mail Inga.