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Investors File Resolutions with Health Companies

Posted on December 7, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Seeking Compensation Transparency

By Staff Reporters

Thirty investors just filed shareholder resolutions involving 21 health companies asking them to publicly disclose the total compensation packages of their top executives.

Assessment

The investors are faith-based institutional shareholders who belong to the Interfaith Center on Corporate Responsibility.

http://www.fa-mag.com/green/news/4805-investors-file-resolutions-with-health-companies.html

Conclusion

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Filed under: Ethics, Health Insurance, Risk Management | 1 Comment »

About the Scribbos Secure Communication Platform

Posted on December 1, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

What it is – How it works

By Staff Reporters

Scribbos is a secure business communications solution that enables clients to easily and quickly send confidential messages or large files to colleagues, business partners or outsourced service providers.

Scribbos uses an intuitive email-like interface that provides secure communications whether sending a confidential message, or a file with sensitive or proprietary information. Additionally, as most financial and covered healthcare entities must comply with federal and industry regulations, Scribbos helps maintain compliance with all mandates whether corporate, federal or industry-specific [Sarbanes-Oxley and HIPAA, etc].

Several Industry Verticals

Scribbos offers four industry specific and scaleable verticals for healthcare, insurance, finance and professional services; all centers of focus for the ME-P subscriber. For example:

1. The financial vertical enables providers to securely send company financials, accounting reports, internal systems transfers, payments and remittances, etc.

2. The healthcare vertical enables providers to confidentially send personal healthcare information, claims adjudication, eligibility, billing information, insurance claims, X-rays, medical necessity documentation, PHR (Personal Health Records) and eMRs (Electronic Medical Records), etc

3. The insurance vertical enables providers to encrypt policy information, payments, enrollments and claims information, etc.

4. The professional vertical is ideal for healthcare attorneys.

Assessment

So give www.scribbos.com a click today, and tell us what you think?

Conclusion

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Filed under: Health Insurance, Health Law & Policy, Healthcare Finance, Information Technology, Insurance Matters | Tagged: EHRs, EMRs, HIPAA, Sar-Box, Sarbanes-Oxley, scribbos | Leave a comment »

Promoting the “Minimum Necessary” Rule

Posted on November 30, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding HIPAA Security Standards

By Richard J. Mata; MD, MS

www.HealthcareFinancials.com

One concept that is stressed by HIPAA is the “minimum necessary” rule, which states the minimum use of personal health information [PHI] that can be used to identify a person, such as a social security number, home address, or phone number. Only the essential elements are to be used in transferring information from the patient record to anyone else that needs this information. This is especially important when financial information is being addressed. Only the minimum codes necessary to determine the cost should be provided to the financial department. No other information should be accessed by that department. Many institutions have systems where a registration or accounting clerk can pull up as much information as a doctor or nurse, but this is now against HIPAA policy and subject to penalties. The “minimum necessary” rule is also changing the way software is set up and vendor access is provided.

Chain of Custody

Another challenging task is keeping up with the number of people who access PHI, because the privacy regulations allow a patient to receive an accounting of anyone who has accessed their information, both internally [within your hospital, Emerging Health Organization, or medical practice) and externally [such as through your business associates]. The patient has the right to know who in the lengthy data chain has seen their PHI. This sets up an audit challenge for the medical organization, especially if the accountability is programmed internally. When other business associates use this PHI without documenting access to a specific patient’s PHI, no one would be accountable for a breach in privacy.

Enter the Designated Record Set

One way to track access is through a designated record set, which contains medical or mixed billing records, and any other information that a physician and/or medical practice utilizes for making decisions about a patient. It is up to the hospital, EHO, medical practice, or healthcare organization to define which set of information comprises “protected health information” and which does not, though logically this should not differ from locale to locale.

Assessment

Overlaps from the privacy regulations that are also addressed in the security regulations are access controls, audit trails, policies on e-mail and fax transmissions, contingency planning, configuration management, entity and personal authentication, and network controls. For more information about the Security Standards final rule, reference the Federal Register.

Conclusion

In the age of Twitter, IMing, blogging and texting, some young doctors are forgetting the basic fundamentals of patient privacy. And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Filed under: Health Insurance, Health Law & Policy, Information Technology | Tagged: david marcinko, designated record set, EMRs, HIPAA, minimum necessary rule, PHI, Richard Mata | 1 Comment »

Diagnostic and Statistical Manual of Mental Disorders

Posted on November 29, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Coding Classification

By Staff Reporters

The classification and coding systems used by mental health insurers both diagnosis-related groups (DRGs) and current procedural terminology (CPT®) are still being defined through historical methodologies and are vague compared to the medical classification coding structure.

As an example, mental health insurers classify Tourette Syndrome (TS) as a “mental disorder.” In fact, TS is an inherited, neurobiological disorder, and both neurologists and psychiatrists treat TS with the same medications. If TS were reclassified under the medical coding structure, TS would not only receive potentially a better reimbursement but public perception of TS as a “mental disorder” would be changed.

The DSM-IV

The Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision), also known as the DSM-IV-TR, is a manual published by the American Psychiatric Association (APA) that includes all currently recognized mental health disorders. The coding system utilized by the DSM-IV is designed to correspond with codes from the International Classification of Diseases, commonly referred to as the ICD. Since early versions of the DSM did not correspond with ICD codes and updates of the publications for the ICD and the DSM are not simultaneous, some distinctions in the coding systems may still be present.

Assessment

For this reason, it is recommended that users of these manuals consult the appropriate reference when accessing diagnostic codes. For more information, contact the APA at (800) 368-5777.

Link: www.HealthcareFinancials.com

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Filed under: Career Development, Health Insurance, Healthcare Finance, Information Technology, Practice Management | Tagged: American Psychiatric Association, APA, billing codes, CPT, Diagnostic and Statistical Manual of Mental Disorders, DRG, DSM, DSM-IV, ICD, mental disorders, mental health | 1 Comment »

Thanksgiving “Food-for-Thought” on “Money Driven Medicine”

Posted on November 26, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

View the “Money-Driven Medicine” Video [A Free Streaming Download]

By Staff Reporters

During the month of November, Money-Driven Medicine will stream for free as part of the Watch-In! for America’s Health.

Based on Maggie Mahar’s Book

“Money-Driven Medicine” provides the essential analysis Americans need if they are to become knowledgeable participants in healthcare reform during these crucial days and in the years to come.

Assessment

Link: http://moneydrivenmedicine.org/watch-in

If you find this film to be a valuable tool, consider screening the DVD at your conference or professional event or in your community, association, school, workplace or place of worship.

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Filed under: Ethics, Health Economics, Health Insurance, Healthcare Finance, Op-Editorials, Videos | Tagged: Maggie Mahar, Money Driven Medicine, watch-in, www.moneydrivenmedicine.org | 1 Comment »

Joe Flowers New Healthcare Reform Strategy

Posted on November 19, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Selling Patients like Baseball Players – Seriously

By Staff Reporters

Here is a health care reform strategy that we have not heard of before. It was formulated by healthcare futurist Joe Flowers, and is reposted below for your review.

It first posits this question, and then gives a plausible answer, with unique new operational strategy.

Question

Why aren’t health plans more aggressive in promoting the long-term health of their members, like getting them to eat better, stop smoking, get a little exercise, and all that?

Answer

Because of health insurance industry “churn”

Strategy

Give Joe’s idea a read and tell us what you think?

http://www.thehealthcareblog.com/the_health_care_blog/2009/11/sell-patients-like-baseball-players-seriously-.html

More: www.imaginewhatif.com

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Filed under: Health Insurance, Managed Care, Op-Editorials | Tagged: Health Insurance, health plans, Joe Flowers, www.imaginewhatif.com | 2 Comments »

Don’t Tread on Me – Obama

Posted on November 12, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Bite Me – CMS

[By D. Kellus Pruitt; DDS]

Shy but proud Texas Dental Association leaders still direct employees to encourage members to volunteer for permanent, mandated National Provider Identifier numbers. Why? “Just ‘cause.”

As part of an agreement the TDA made with the state to help politicians out of a lawsuit they brought upon themselves for not providing adequate dental care for the poor in the state, TDA leaders followed someone’s bad advice to encourage Texas dentists to accept CHIP (Medicaid) – which requires dentists to have arbitrary 10 digit NPI numbers to participate.

Don’t get me wrong. I have the highest respect for dentists who treat the poor for pay that doesn’t even cover overhead. That is compassion to a fault – even before CMS investigators arrive with subpoenas based on vague, nuisance complaints from disappointed patients, disgruntled employees and hungry competitors. Getting even with rich, greedy, or otherwise mouthy dentists has never been easier because I’ve heard that CMS intends to investigate all complaints.

Yes, low pay is only part of the nasty package that TDA officials are officially discouraged from discussing with membership – even as they beg for us to sign up for CHIP and “do our part to return our debt to society by helping those who cannot care for themselves.” So who would dare question the reason for the faux sentiment expressed by a long string of TDA Presidents? That would be me.

There are simply so many other charitable ways of publicly and privately returning help to the community that don’t add to the risk of donating one’s skill. Even if one does not help local free clinics, how hard can it be to quietly give away care, Doc, in these hard times? It’s just between you and God anyway, isn’t it? One simply enters N/C in the fee column. Confidentially I sometimes get hugs that so far can be neither controlled nor taxed.

It appears to me that CMS is arguably more influential with TDA leaders than common TDA members like me. If I am correct, this means that dentistry is at risk of being overrun by authoritarian bureaucrats hired by ambitious politicians who often promise more than they can deliver before ducking accountability for earthly bad decisions. The business model even reminds me of the TDA’s.

So now that the TDA played its hand with regard to its fondness for BCBSTX and the NPI number, what does it mean for Texas dentists if Obama’s imminent “Public Plan Option” turns into “Medicaid for All” – as some naively hope and others justifiably fear? This week, the AMA gave its support to the Public Option. Will the ADA be next?

Dentistry unhurried is value-added service. One cannot get rich at it, but it’s an honorable living.

Regardless of whether you approve of my tactless vitriol or not, I have to say that when it comes down to feeding my family, even this special bastard could be silenced if there is no longer a market on the east side of Fort Worth for dentistry unhurried. Especially if it meant a monthly visit by CMS inspectors like Dr. Annie Bukacek is going through right now. Like me, she also gives her patients the time they deserve. But unlike me, she doesn’t have time to pick fights with shy bullies who hide behind employees.

I’ll get to the physician’s story in a moment. But first, just how important are secrets to the leaders of the nation’s preeminent non-profit dental organization? It’s important enough that many in the ADA House of Delegates want the power to mete out punishment to fellow officers who cannot keep their mouths shut. Some of those we elected even want to make the sanctions retroactive to deal with colleagues who have already broken the traditional unwritten good ol’ boy code of stoic conduct. At the same time, the TDA is begging dentists in the state to run for ADA office – starting on the local level. Why do you think dentists in Texas don’t want to get involved? Nobody accepts delivery from the cluetrain in Austin. It probably stops there at least a couple of times each week day.

I copied below three of the ADA Delegates’ referred resolutions from Judy Jakush’s November 2 ADANews article, “Delegates vote on Association business matters,”

http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=3821

1] Res. 70 states that if any member of the ADA, including delegation member, council, committee or task force member, or Board of Trustees member has been acknowledged as breaking the attorney-client privilege or executive session, that member is, at a minimum, barred from ever again participating in an attorney-client or executive session within the ADA. This shall include such acts which have been acknowledged as occurring prior to the enactment of this resolution.

2] Res. 67 would specify that candidates for elective or appointive officers may not have had any sanctions bestowed upon them by the Association. Also referred was Res. 67RC, which would direct that anyone found by the Committee on Credentials, Rules and Order to have violated his or her duties to the Association would be disqualified from holding elective or appointive office.

3] Res. 68 was referred to the Council on Ethics, Bylaws and Judicial Affairs for report to the 2010 House with recommendations for Bylaws changes. The proposal calls for CEBJA to review the Bylaws and craft language that would define the mechanism for sanctions up to and including removal from office of a delegation member or Board of Trustee member if there is found to be cause for removal as shall be defined. That cause, at a minimum, should include those causes as delineated currently for council members. Res. 68 also calls for a method for fair and impartial hearings to be recommended and the establishment of an authorized House committee that can be held on an ad interim basis between annual sessions of the House of Delegates with authority to determine and impose any such sanctions deemed appropriate.

Remember, the ADA is a non-profit, professional organization whose only purpose for existence is to serve dental patients through dentist members who support it with dues. When one reads these and other resolutions in Jakush’s article, it looks like ADA President Dr. Ron Tankersley is running the Pentagon. We’re only dentists for crying out loud!

Dr. Annie Bukacek’s 6-month battle with CMS

This morning I read what has turned out to be a popular article titled “Investigators descend on doctor,” written by Candace Chase, writing for the Daily Inter Lake which serves northwest Montana.

http://www.dailyinterlake.com/news/local_montana/article_d8cde54e-cc2d-11de-9ddd-001cc4c03286.html

“Dr. Annie Bukacek of Hosanna Health Care in Kalispell was surprised when a 30- to 40-foot-long command-post vehicle pulled up unannounced last week, along with a posse of state and federal health-care fraud investigators.”

“Bukacek points out that anyone – a disgruntled ex-employee or patient or someone who doesn’t like a physician’s looks or politics – could trigger an investigation and cost a physician as well as the government thousands of dollars.”

I wonder what would happen if a dentist openly taunts CMS leaders? As I previously mentioned, it is Dr. Bukacek who claims, “They said they have to followup every allegation made.”

When all American dentists are required to volunteer for NPI numbers and can no longer be legally paid in cash at the time of service, we’ll all be hung by an ADA-approved mistake of historic proportions. I suggest that ADA members take time right now to jot down names so that when judgment day inevitably arrives, one will be prepared to hold accountable the ADA employees who recommended the numbers. After reading how ADA leaders are hunkering down, it looks like going through employees will probably be the only way to touch the bosses they bravely try to shield.

Oh yeah. I posted the 5^th of almost 30 comments that so far follow Candace Chase’s provocative article:

“Dr. Annie Bukacek’s experience is why as a US citizen in the land of the free, I simply refuse to do business with the US government. Bite me, CMS. Did you hear me? I said bite me!”

Assessment

It’s not likely that I’ll regret those words because I am powerless to stop myself from typing them anyway.

Conclusion

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Filed under: "Doctors Only", Career Development, Health Insurance, Managed Care, Practice Management, Pruitt's Platform | Tagged: ADA, AMA, Annie Bukacek, BCBSTX, Candace Chase, CEBJA, CHIP, CMS, Darrell Pruitt, Hosanna Health Care Kalispell, Judy Jakush, National Provider Identification number, NPI, Ron Tankersley, Texas Dental Association | 2 Comments »

About Carena In-Home Medical Care

Posted on November 10, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

In-Home Medical Care Services for the Modern Era

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

We have written about the high cost, questionable quality and scheduling burden of emergency room visits on the Medical Executive-Post before. And, for some non-emergency or after-hours needs, the ER may possibly be one of the worst places to deliver medical care.

Enter Carena, Inc

Seattle-based Carena Inc. was founded in 2000 on the principle that expanding access to medical care improves outcomes and reduces costs. By providing around-the-clock medical care and education at a patient-identified time of need, Carena patients, clients and health plans are reported to experience lower costs while patients receive the right care – at the right time [www.CarenaMD.com].

A New [Old] Business Model

Carena is not an emergency room, not an urgent care center and not someplace patients go. This medical group delivers 24/7 house-calls both to render care and provide education for urgent medical needs.

House calls last as long as needed—often an hour—to make sure patients have the care and education needed to take control of their health.

The Carena model also offers medical care at the workplace enabling corporate clients to offer on-site care without the cost and space requirements of a typical employer-sponsored health clinic.

Home Visits in the Modern Era

Carena medical group physicians treat a wide range of urgent concerns. They carry an updated version of the traditional “doctor bag” filled with state-of-the art and portable instruments. For example, physicians have the equipment to suture minor cuts, deliver nebulizer treatments for asthma, or obtain lab samples. They run in-home rapid diagnostic tests for influenza, strep throat, and other medical issues. If X-rays or tests are needed, physicians coordinate scheduling and share results with patient PCPs. Electronic medical records are used throughout.

Always Open 24/7

Carena is always open. No waiting in the ER while doctors treat true emergencies. No wondering if other waiting patients are contagious.

Reduced Financial Shock.

Carena house calls are reported to costs about 30-35 percent less than a typical emergency room visit of about $1,500.

Another New Term

With apologies to my esteemed colleague Robert M. Wachter MD, the hospitalist guru at UCFS, Carena doctors are often called “housepitlists.”

Assessment

Carena is a medical company that provides a new model of health care delivery for innovative, self-insured companies. Internist Frances Gough MD is the Vice President of Product Development at Carena, Ted Conklin MD is the founder and Ralph C. Derrickson is President and CEO. Corporate clients for both Carena business models are Costco and the Microsoft Corporation of Redmond, WA.

Disclaimer

I own shares of MSFT common stock and am a professional member of MS-HUG.

Conclusion

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Filed under: Career Development, Health Economics, Health Insurance, Managed Care, Practice Management, Research & Development | Tagged: Carena, Dr. Marcinko, emergency room, ER, house calls, housepitalist, in home medical care, PCP, Robert Wachter | 1 Comment »

Allowable and Non-Allowable HSA Tax Expenditures

Posted on November 9, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding IRS Code 213[d]

[By Staff Reporters]

There have been thousands of legal cases involving the many nuances of what constitutes “medical care” for purposes of section 213(d) of the Internal Revenue Code. A determination of whether an expense is for “medical care” is based on all the relevant facts and circumstances. To be an expense for medical care, the expense has to be primarily for the prevention or alleviation of a physical or mental defect or illness. The determination often hangs on the word “primarily”.

Allowable Expenditures


Acupuncture	Alcoholism Treatment
Ambulance	Artificial Limb
Artificial Teeth	Bandages
Birth Control Pills (prescription)	Breast Reconstruction Surgery (mastectomy)
Car Special Hand Controls (disability)	Certain Capital Expenses (disabled)
Chiropractors	Christian Science Practitioners
COBRA premiums	Contact Lenses
Cosmetic Surgery (due to trauma or disease)	Crutches
Dental Treatment	Dermatologist
Diagnostic Devices	Disabled Dependent Care Expenses
Drug Addiction Treatment (inpatient)	Drugs (prescription)
Eyeglasses	Fertility Enhancement
Guide Dog	Gynecologist
Health Institute (if prescribed by physician)	H.M.O. (certain expenses)
Hearing Aids	Home Care
Hospital Services	Laboratory Fees
Lasik Surgery	Lead-Based Paint Removal
Learning Disability Fees (prescription)	Legal Fees (if for mental illness)
Life-Care Fees	Lodging (for out-patient treatment)
Long-Term Care (medical expenses)	Long-Term Care Insurance (up to allowable limits)
Meals (associated with receiving treatments)	Medical Conferences (for ill spouse/dependent)
Medicare Premiums	Medicare Deductibles
Nursing Care	Mentally Retarded (specialized homes)
Obstetrician	Nursing Homes
Operations – Surgical	Operating Room Costs
Optician	Ophthalmologist
Organ Transplant (including donor’s expenses)	Optometrist
Orthopedic Shoes	Orthodonture
Osteopath	Orthopedist
Over-the-Counter Medicines	Out-of-pocket expenses while enrolled in Medicare
Pediatrician	Oxygen and Equipment
Podiatrist	Personal Care Services (for chronically ill)
Prenatal Care	Post-Nasal Treatments
Prosthesis	Prescription Medicines
Psychiatric Care	PSA Test
Psychoanalysis	Psychiatrist
Psychologist	Psychoanalyst
Radium Treatment	Qualified Long-Term Care Services
Special Education for Children (ill or disabled)	Smoking Cessation Programs
Spinal Tests	Specialists
Sterilization	Splints
Telephones and Television for the Hearing	Surgeon
Therapy	Impaired
Treatment	Transportation Expenses for Health Care
Vitamins (if prescribed)	Vaccines
Wheelchair	Weight Loss Programs
X-Rays	Wig (hair loss from disease)

Non-Allowable Expenditures


Advance Payment for Future Medical Expenses	Athletic Club Membership
Automobile Insurance Premium	Babysitting (for healthy children)
Boarding School Fees	Bottled Water
Commuting Expenses for the Disabled	Controlled Substances
Cosmetics and Hygiene Products	Dancing Lessons
Diaper Service	Domestic Help
Electrolysis or Hair Removal	Funeral Expenses
Hair Transplant	Health Programs at Resorts, Health Clubs, & Gyms
Household Help	Illegal Operations and Treatments
Illegally Procured Drugs	Maternity Clothes
Medigap premiums	Nutritional Supplements
Premiums for Life or Disability Insurance	Premiums for Accident Insurance
Premiums for your HSA-qualified health plan	Scientology Counseling
Social Activities	Special Feeds/Beverages
Swimming Lessons	Teeth Whitening
Travel for General Health Improvement	Tuition in a Particular School for Problem Children

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: Accounting, Health Insurance, Taxation | Tagged: Healthcare Savings Account, HSA, Internal Revenue Code 213[d] | 10 Comments »

Uninsured and Eligible for Public Coverage

Posted on November 3, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Underlying Causes and Policy Solutions

Submitted Nancy Chockley
President and CEO
NIHCM Foundation www.nihcm.org

Policymakers working to reduce the number of persons without health insurance sometimes note the significant number of uninsured who are already eligible for public coverage but not enrolled. In this essay, Dr. Genevieve Kenney of the Urban Institute explores reasons behind this phenomenon and describes steps that can be taken to facilitate and encourage enrollment among eligible individuals. She stresses the importance of multi-faceted approaches that promote program awareness, simplify eligibility determination, and automate enrollment and renewal processes. As our country considers expansions in publicly funded coverage, these lessons should be top of mind in order to maximize program enrollment and reach as many uninsured people as possible.

Expert Voices

Other recent Expert Voices essays on health reform include:

Eric Jensen, Consultant, and Lenny Mendonca, McKinsey & Company, “Why America Spends More on Health Care” (November 2009)
Jonathan Gruber, PhD, Professor of Economics, Massachusetts Institute of Technology, “The Role of Individual Mandates in Health Reform” (January 2009).
Paul N. Van de Water, PhD, Senior Fellow, Center on Budget and Policy Priorities. “Scoring Health Legislation” (April 2009).

Assessment

I hope you enjoy reading this essay and the ones that follow.

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Sponsors Welcomed

And, credible sponsors and like-minded advertisers are always welcomed.

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Filed under: Alerts Sign-Up, Health Economics, Health Insurance, Research & Development | Tagged: Center on Budget and Policy Priorities, Eric Jensen, Genevieve Kenney, Jonathan Gruber, Lenny Mendonca, Nancy Chockley, NIHCM Foundation, Paul N. Van de Water, Urban Institute | 1 Comment »

Grading the Public Options That Already Exist

Posted on November 2, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding Existing Healthcare Plans

By Sabrina Shankman, www.ProPublica.org

October 28, 2009 12:27 pm EDT

What might a public health option look like in practice? One way to find out is to look at what’s already out there.

Link: http://www.propublica.org/ion/health-care-reform/item/grading-the-public-options-that-already-exist-1028

Assessment

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Sponsors Welcomed

And, credible sponsors and like-minded advertisers are always welcomed.

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Filed under: Career Development, Health Insurance, Military Medicine, Quality Initiatives | Tagged: Indian Health Services, Medicaid, medicare, ProPublica, public health options, Sabrina Shankman, Tri Care, VA | 1 Comment »

Why America Spends More on Healthcare

Posted on October 23, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

A McKinsey Global Institute Review

By Nancy Chockley; PhD
President & CEO
NIHCM Foundation

Path breaking work by the McKinsey Global Institute (MGI) shows that, relative to other peer countries from the Organization for Economic Cooperation and Development, the U.S. spends nearly $650 billion more on health care than would be expected after adjusting for cross-country differences in wealth. Fully two-thirds of this added spending occurs in the outpatient sector.

Out-Patient Services

The highly profitable nature of many outpatient services coupled with the incentives of a fee-for-service payment system are contributing to greater intensity of outpatient care and helping to fuel this spending. In this essay, “Why America Spends More on Health Care,” Eric Jensen and Lenny Mendonca describe MGI’s work to examine all sectors of the American health care system and identify factors responsible for the higher-than-expected spending.

More Examples

Other recent Expert Voices essays on health reform include:

Jonathan Gruber, PhD, Professor of Economics, Massachusetts Institute of Technology, “The Role of Individual Mandates in Health Reform” (January 2009).
Paul N. Van de Water, PhD, Senior Fellow, Center on Budget and Policy Priorities. “Scoring Health Legislation” (April 2009).
Mark Fendrick, MD, University of Michigan Medical Center and Michael Chernew, PhD, Harvard Medical School, June 2009. “Value Based Insurance Design” (June 2009).
I hope you enjoy reading this essay and those that follow.

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Sponsors Welcomed

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Filed under: Breaking News, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Op-Editorials, Research & Development | Tagged: Eric Jensen, Expert Voices, Harvard Medical School, Jonathan Gruber, Lenny Mendonca, Mark Fendrick, McKinsey Global Institute, Michael Chernew, Michigan Medical Center, MIT, Nancy Chockley, NIHCM, NIHCM Foundation, Paul N. Van de Water | 3 Comments »

Congressional Budget Office Healthcare Reports of Interest

Posted on October 18, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Ten [10] Aggregated CBO Reports

By Staff Reporters

Courtesy of Healthcare Town Hall:

Assessment

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Sponsors Welcomed

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Information Technology | Tagged: health information technology, health unsurance, healthcare costs, healthcare economics, healthcare reform, Healthcare Town Hall, ObamaCare, pharmaceutical pricing | 1 Comment »

Goals of Medical Performance Improvement

Posted on October 18, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding Best Clinical Practices

By Brent A. Metfessel; MD, MS

The major goals of medical performance improvement are twofold: First, for a particular practice pattern measure, the desire is to narrow the practice variation around the present health care mean. For instance, the spread of the distribution of a cost variance measure should decrease with process improvement. Second, clinical guideline-based “best practices” can be utilized to move the entire provider population mean toward better cost-efficiency and quality.

Best-Practices

Although best-practices may be guideline-based, they should be adapted to local considerations and evaluated periodically through actual outcomes analysis. Such outcomes measures may include:

Cost-efficiency improvement, showing a decrease in resource utilization.
An increase in the performance of preventive measures, such as childhood immunizations and various screening tests such as breast and cervical cancer screening. This may increase costs initially but will more than pay for itself through a decreased illness burden and cost in the future.
A decrease in episode length, usually implying a quicker resolution of symptoms.
A decrease in emergency room visits and unplanned hospital admissions.
A decrease in the rate of “sentinel events” such as status asthmaticus, hemorrhage during pregnancy, diabetic ketoacidosis, and ruptured appendix.

Many of these measures can be obtained using commonly available claims and administrative databases, although supplementation with clinical and functional status data will only increase the reliability and scope of outcomes analysis.

Assessment

In order to see significant performance improvement in response to quality improvement initiatives, one must be patient. Two to three years may be needed to see this improvement. Trending of measures helps analysts to determine whether such improvement is occurring. Trending of data, however, can be quite resource-intensive since there must be an adequate data set – usually requiring storage of data for several years of experience.

Conclusion

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Sponsors Welcomed

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Filed under: "Doctors Only", Career Development, Health Insurance, Managed Care, Practice Management, Quality Initiatives, Recommended Books | Tagged: Brent A. Metfessel, clinical medical guidelines, medical cost effectiveness, medical performance improvement, process improvement, sentinel events | 2 Comments »

Participating versus Non-Participating Doctors

Posted on October 15, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding Medicare Medical Payment Schemes

By Staff Reporters

www.HealthcareFinancials.com

As of 1992, Medicare invoices are paid per resource-based relative value unit (RBRVU), and according to the lesser of the actual billed charges or the fee schedule amount. But, there are two types of medical providers: 1. Doctors who accept Medicare assignment only bill the patient for the co-payment, which is usually 20%. 2. Doctors who do not accept Medicare assignment are offered a lower fee schedule of 95% of the approved schedule, which is a 115% maximum fee limit of the approved schedule.

Example:

A participating physician’s approved fee schedule charge of $100 would yield $80 from Medicare and $20 from the patient. A non-participating (Non-Par) doctor with charges of $200, and with an approved fee schedule of $100, would yield: $109.25 = (.95 X $100) X 1.15 entirely from the patient.

If the Non-Par doctor selects payment type on a case-by-case basis, Medicare will pay its portion of the bill directly to the physician, but the doctor must accept the Non-Par fee schedule.

Assessment

Continuing our example yields: (.8 X $95) plus the patient’s co-payment of (.2 X $95), OR $76 plus $19 = $95.00.

Conclusion

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Filed under: Health Economics, Health Insurance, Healthcare Finance | Tagged: medicare, medicare providers, non-participating medicare physician, Participating medicare physician, RBRVU, resource-based relative value unit | 1 Comment »

Become a Published Print Author with Us

Posted on October 13, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

The Business of Medical Practice [3^rd Edition]

By Hope Rachel Hetico RN, MHA, CMP™

[Managing Editor]

Dear Colleagues and ME-P Champions

As you may know, we are commencing work on the third edition of our best selling book: The Business of Medical Practice

TOC 1st: http://www.amazon.com/Business-Medical-Practice-Maximizing-Doctors/dp/0826113117/ref=sr_1_8?ie=UTF8&s=books&qid=1231111232&sr=1-8

TOC 2nd: http://www.springerpub.com/prod.aspx?prod_id=23759

Invitation to Contribute

Accordingly, we would be honored for you to consider contributing a new or revised chapter, in your area of expertise, for a low-effort but high-yield contribution. Our goal is to help physician colleagues and management executives benefit from nationally known experts, as an essential platform for their success in the healthcare industry. Many topics are still available: [health accounting; law, policy and administration; Medicare fraud and abuse; cloud computing; and finance and economics, etc].

Support Always Available

Editorial support is available, and you would enjoy increasing subject-matter notoriety, exposure and public relations in an erudite and credible fashion. As a reader, or preferably a subscriber to the ME-P, your synergy in this space may be ideal. Time line for submission of a 5,000-7,500 word chapter is ample, and in a prose writing style that is “wide, not deep.”

A Health 2.0 Initiative

And, be sure to address health 2.0 modernity. Update chapters from the second edition are also available.

Definition: https://healthcarefinancials.wordpress.com/2008/09/12/emerging-healthcare-20-initiatives

Assessment

Please contact me for more details [MarcinkoAdvisors@msn.com], if interested [770.448.0769]. A best selling-book is rare; while a third-edition volume even more so. Join us in this project. Regardless, we trust you will remain apostles of our core ME-P vision, “uniting medical mission and financial profit margin”, and promoting it whenever possible.

Front Matter Link: frontmatter1advancedbusinessmedicine

Channel Surfing the ME-P

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: "Advisors Only", "Doctors Only", Book Reviews, Breaking News, Career Development, Ethics, Experts Invited, Health Economics, Health Insurance, Healthcare Finance, iMBA, Inc., Information Technology, Managed Care, Media Mentions and PR, Practice Management, Professional Liability, Quality Initiatives, Recommended Books | Tagged: acountants, american medical writers association, authors, contributors, doctors, experts, JDs, journalists, lawyers, managers, MBAs, MDs, PhDs, publishers, writers | Leave a comment »

Health Insurance Prospective Payment System [HIPPS] Grouper Software and Documentation Codes

Posted on October 13, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Enter the CMPs

Understanding Home Health Prospective Payment System (HH PPS) Case-Mix Refinement Changes

[By Staff Reporters]

A few operational changes were made to the V-Code Table in the updated version of the ICD-9-CM Official Guidelines for Coding and Reporting, including:

HH PPS grouper software and documentation (effective October 1, 2006): Contains Version 1.06 of the home health PPS case mix grouper software codes, which accommodates changes in OASIS reporting requirements effective 10/1/2006. Also includes the grouper coding logic (pseudo-code), test records, and demonstration programs.
HH Consolidated Billing Master Code List: An Excel workbook file containing complete lists of all codes ever subject to consolidated billing provision of HH PPS. A master list worksheet shows the dates each code included and excluded from consolidated billing editing on claims, with associated CMS transmittal references. The master list also associates each code with any related predecessor and successor codes. Supplemental worksheets show the list of included codes for each CMS transmittal to date.

Example:

The national unadjusted (wage index) per-visit rate payments paid per code were: [a] home health aide $44.37; [b] medical social service $153.55; [c] occupational therapy $105.44; [d] skilled nursing care $95.79 and [e] speech pathology $113.81.

Assessment

Link: http://www.cms.hhs.gov/homehealthpps/downloads/transitionepisodesqa.pdf

Link: http://www.cms.hhs.gov/HomeHealthPPS/downloads/GuidanceforHHAs_Posting_12-18-2007.pdf

Conclusion

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BLOG: www.MedicalExecutivePost.com

Filed under: "Doctors Only", Career Development, CMP Program, Health Insurance, Practice Management, Recommended Books | Tagged: CMS, HH Consolidated Billing Master Code List, HH PPS, HIPPS, Home Health Prospective Payment System, ICD-9-CM, medical billing, OASIS, V-codes | 3 Comments »

Healthcare Reform Articles from Kevin Pho MD

Posted on October 11, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Aggregating Content – Disseminating Knowledge

By Ann Miller; RN, MHA

[Executive Director]

Here are five interesting new articles on the healthcare reform debates from colleauge Kevin Pho, MD.

Kevin practices at the Nashua Medical Group near the Massachusetts border. He is board certified in internal medicine and provides both comprehensive adult and primary care services.

Related posts:

Give them a click, read em’ and comment now.

Assessment

Remember, how we put things together – sets us apart!

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Health Administration Terms: www.HealthDictionarySeries.com

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Filed under: Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Op-Editorials, Research & Development | Tagged: barack obama, DPM, Health Insurance, healthcare reform, kevin pho, Max Baucus, MD, pho, podiatrist, podiatry, primary care, Uwe Reinhardt | 1 Comment »

Essay on Individual Health Insurance Mandates

Posted on September 25, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

A White Paper by Jonathan Gruber; PhD

Submitted by Nancy Chockley; PhD

NIHCM: President and CEO

Dear Colleagues,

As health reform proposals become more concrete, there is renewed attention to the role of an individual mandate and issues of affordability. With this in mind, I am sending you NIHCM Foundation’s Expert Voices essay, “The Role of Individual Mandates in Health Reform” by Jonathan Gruber, PhD, Professor of Economics, at the Massachusetts Institute of Technology.

Assessment

In this essay Gruber explores the primary arguments for and against individual mandates and the challenges faced in their design and implementation. Then, pulling strongly from the Massachusetts experience, he examines evidence on the effectiveness of individual mandates in practice.

Conclusion

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Filed under: Alerts Sign-Up, Breaking News, Health Insurance, Healthcare Finance, Op-Editorials, Research & Development | 2 Comments »

Critical Expense Issues in Healthcare Reform

Posted on September 24, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

American Academy of Actuaries Report

By John Park

Health Care Analyst

Sherlock Company

jpark@sherlockco.com

ME-P Subscribers

Late last week, the American Academy of Actuaries released the attached paper discussing administrative functions and expenses. It is designed to provide an actuarial perspective relating to various components of comprehensive health care reform proposals.

Assessment

Sherlock Company benchmarks, as excerpted in the Plan Management Navigator, are cited in the paper and we thought you might find it of interest.

Link: American Academy Actuaries

Conclusion

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Filed under: Alerts Sign-Up, Breaking News, Health Economics, Health Insurance, Healthcare Finance, Managed Care, Research & Development | Tagged: American Academy of Actuaries, Healthcare Expenses, healthcare reform, John Park, Plan Management Navigator, Sherlock Company | 1 Comment »

On Increasing Price Transparency in Medicine

Posted on September 23, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

About NewChoiceHealth.com

By Staff Reporters

NewChoiceHealth, Inc. is an online comparison shopping marketplace built to provide healthcare consumers a way to save money. With NewChoiceHealth.com, consumers can easily locate medical facilities and compare medical procedure costs for services like MRIs, CT scans, mammograms, and more. Patients may shop nationwide, or right in their own local market from over 20,000 medical facilities for over 400 of the most commonly performed medical procedures.

Employer Portal

The site also features an employer portal to combat the rapidly escalating costs of healthcare. A Medical Cost Action Plan (mCAP) is reported to deliver an independent, unbiased, measurable plan which segments employer’s medical cost consumption categories into measurable Consumer Healthcare Efficiency Indices (CHEI) to deliver an actionable plan that reduces healthcare costs.

The Founder

CEO and Founder Brad Myers is a medical cost expert with 24 years of broad experience and extensive knowledge in medical cost informatics, healthcare insurance, managed care, clinical laboratory, and health and life insurance. His website message to ME-P readers, and others, is “shop & save!”

Assessment

Employee passion drives price transparency to healthcare consumers through the web site www.NewChoiceHealth.com Give it a click, for more information, and tell us what you think!

Conclusion

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Filed under: Accounting, Ethics, Health Economics, Health Insurance, Healthcare Finance, Information Technology, Managed Care | Tagged: Brad Myers, Consumer Healthcare Efficiency Indices, CT scans, healthcare price transparency, Medical Cost Action Plan, medical price transparency, MRIs, www.NewChoiceHealth.com | 4 Comments »

Understanding the Medicare Prospective Payment System

Posted on September 17, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Origins of Diagnostic Related Groups

By Dr. David Edward Marcinko; MBA, CMP™

[Editor-in-Chief]

The Medicare Prospective Payment System (PPS) was introduced by the federal government in October, 1 1983, as a way to change hospital behavior through financial incentives that encourage more cost-efficient management of medical care. Under PPS, hospitals are paid a pre-determined rate for each Medicare admission. Each patient was classified into a diagnosis-related group (DRG) on the basis of clinical information. Except for certain patients with exceptionally high costs (“outliers”), the hospital is paid a flat rate for the DRG, regardless of the actual services provided.

Enter the DRGs

Each Medicare patient is classified into a DRG according to information from the medical record that appears on the bill:

principal diagnosis (why the patient was admitted);
complications and co-morbidities (other secondary diagnoses);
surgical procedures;
age and patient gender; and
discharge disposition (routine, transferred, or expired).

Medical Records Documentation

Diagnoses and procedures must be documented by the attending physician in the patient’s medical record. They are then coded by hospital personnel using ICD-9-CM nomenclature. This is a numerical coding scheme of over 13,000 diagnoses and more than 5,000 procedures. The coding process is extremely important since it essentially determines what DRG will be assigned for a patient. Coding an incorrect principal diagnosis or failing to code a significant secondary diagnosis can dramatically affect reimbursement.

DRG Categories

Originally, there were more than 490 DRG categories defined by the Centers for Medicare and Medicaid Services (CMS, formerly known as the Health Care Financing Administration [HCFA]). Each category was designed to be “clinically coherent.” In other words, all patients assigned to a DRG are deemed to have a similar clinical condition. The PPS is based on paying the average cost for treating patients in the same DRG. Each year CMS makes technical adjustments to the DRG classification system that incorporates new technologies (e.g., laparoscopic procedures) and refines its use as a payment methodology. CMS also initiates changes to the ICD-9-CM coding scheme. The DRG assignment process is computerized in a program called the “grouper” that is used by hospitals and fiscal intermediaries. It was last significantly updated by CMS in 2006.

Assessment

Each year CMS also assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG with a weight of 2.0000, for example, means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average; and so on.

Conclusion

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Practice Management | Tagged: Centers for Medicare and Medicaid Services, CMS, david marcinko, diagnosis-related group, DRG, HCFA, ICD-10-CM, ICD-9-CM, medicare, Medicare Prospective Payment System, PPS | 7 Comments »

ME-P Thought-Leader [MD] in the News

Posted on September 16, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Brian J. Knabe MD of Savant Capital Management

By Max Alexander

Dow Jones Newswires; 212-416-2245

Lots of doctors get burnt out dealing with the business end of medicine. But Brian Knabe, a family practice physician in Rockford, Ill., had such a passion for crunching numbers that he became a financial planner.

Knabe, 42 years old, still sees patient’s two half-days a week. He also teaches residents for another half-day at the University of Illinois – College of Medicine.

Most of the week, he’s a certified financial planner with Savant Capital Management.

“I hear all the jokes,” says Knabe, “the most popular being some version of, ‘Hey I guess my portfolio’s doing so badly, they had to bring in the doctor.'”

When the laughter dies down – it doesn’t take long – people often ask what motivated him to transition from medicine into finance.

His short answer is what you’d expect from a wealth adviser: “I wanted to diversify my career.”

The long answer includes a lifelong passion for math that runs in the family. Knabe’s father and brother are both engineers, and the doctor himself majored in bioengineering at Marquette University. “In college, I loved calculus, statistics and differential equations,” he says.

Growing up in Rockford, his best friend was Brent Brodeski, a partner at Savant, and Knabe had been a client of the firm since 1995. “For years, I joked with Brian, ‘If you ever get bored with medicine, you can join us,'” says Brodeski. “Three years ago he called and said, ‘I’ll take you up on that.’ I was floored.”

Knabe wasn’t bored with medicine. “I love taking care of patients, and the intellectual stimulation of the field,” he says. “So I told the partners at Savant that I would only do this if they allowed me to continue practicing medicine part-time.” Meanwhile, he went back to Marquette and got his CFP credentials.

About half of Knabe’s financial clients are doctors, who appreciate his insider’s knowledge of their work and financial issues. Both fields involve privacy and trust, he notes, and both involve planning for the future. They also involve an element of uncertainty.

Sometimes his advice is specifically health-related.

“One client I was working with was a couple where the husband had a terminal illness,” recalls Knabe. “I worked closely with the family in planning living will issues and durable power of attorney for health care. I’ve helped other clients wade through health insurance and disability issues.”

Yes, financial clients do sometimes ask him for medical advice, but he stops them before they can unbutton their shirt.

“If they have a problem and need a diagnosis, I’ll tell them where to go to get a second opinion,” he says.

Link: http://online.wsj.com/article_email/BT-CO-20090914-711325-kIyVDAtMEM5TzEtNDIxMDQwWj.html

Managing Editor’s Note:

Dr. Knabe is also enrolled in the www.CertifiedMedicalPlanner.com program in health economics and medical practice management for financial advisors and healthcare consultants.

Conclusion

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Filed under: "Advisors Only", "Doctors Only", Breaking News, Career Development, CMP Program, Health Insurance, iMBA, Inc., Media Mentions and PR | Tagged: Brent Brodeski, Brian Knabe MD, certified financial planner, certified medical planner, CFP, CMP, CMP www.CertifiedMedicalPlanner.com, financial advisor, savant capital management | Leave a comment »

About Docs4PatientCare

Posted on September 16, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Politically Involved Physicians

By Staff Reporters

Docs4PatientCare is a grassroots organization of concerned physicians committed to the establishment of a health care system that preserves the sanctity of the doctor-patient relationship, promotes quality of care, supports affordable access to all Americans, and protects patients’ freedom of choice.

Mission

According to their website, Docs4PatientCare urges patients and physicians to get involved in the current healthcare debates in order to preserve the good qualities of our healthcare system, address the problems, while preventing their bureaucratic destruction.

Board Members

President: Hal Scherz, MD
Vice President: Fred Shessel, MD
Secretary: Tod Rubin, MD
Treasurer: Joanne Thurston CPA

Board of Directors

Scott Barbour, MD
Carl Capelouto, MD
Ron Anglade, MD
Terry Murphy, MD
Mike Koriwchak, MD
Barry Zisholtz, MD

Assessment

D4PC is a group of practicing physicians uniting to represent the interests and concerns of both patients and doctors in the healthcare reform debate. D4PC endorses the concept of needed healthcare reform, but recognizes it can only be accomplished by proceeding in a cautious and responsible manner. Their recommendations seek to enable them to reach this goal without requiring the nationalization of the entire American healthcare system.

But, should medical professionals be involved in such political organizations?

Link: http://docs4patientcare.org

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Are these sorts of organizations a form of self-aggrandizement; or not? Can you cite any others? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Filed under: Career Development, Ethics, Health Insurance, Health Law & Policy, Quality Initiatives | Tagged: Barry Zisholtz MD, Carl Capelouto, D4PC, Docs4PatientCare, Fred Shessel MD, Hal Scherz MD, healthcare reform, HR 3200, HR 3400, Joanne Thurston CPA, MD, Mike Koriwchak MD, ObamaCare, Ron Anglade MD, Scott Barbour MD, Terry Murphy MD, Tod Rubin MD | 1 Comment »

Off-Road Touring with Dr. Marcinko [Part VIII]

Posted on September 8, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Interview with David B. Lumsden; MD

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Dateline: Baltimore Maryland, August 10, 2009.

About David B. Lumsden MD

Dr. David Lumsden; MS, MA practices general orthopedic surgery and trauma as a board certified surgeon and partner with Orthopedic and Hand Surgery Associates in Baltimore, Maryland. He completed his training in community health at Towson State University, earned Master’s Degree in Anatomy / Neuroanatomy at University of Maryland/Baltimore and Exercise Physiology at University of Maryland, College Park. He is a graduate of Penn State University School of Medicine. Dr. Lumsden completed his internship and residency at Union Memorial Hospital with associative residency training at Johns Hopkins and the world renowned Shock Trauma Center at the University of Maryland, Baltimore City.

Our Brief Interview

When I caught up with David during a recent house-call visit, we discussed many things; especially the American Affordable Health Choices Act [HR-3200]. Unfortunately; I did not have my audio-recorder with me. So, here are a few points of interest about him that I jotted down, from memory, in my ever-present reporter’s notebook. No doubt, I missed many more:

He became a physician as a career change in mid-life.
He has read HR 3200 in its’ entirety.
He hired an attorney for HR 3200 interpretation and review.
He is for healthcare reform, but against HR 3200.
He is against a public health care plan.
He is against individual insurance mandates.
He does 10-12 house-calls every month.
He does not charge MC, MD or VA house-call patients; rarely bills them and/or accepts assignment without balance billing.
He regularly operates on same, under similar terms.
He does other pro-bono work.
He practices defensive medicine.
He is for tort reform.
He is not a member of the AMA with no plans to join.

Assessment

Review and vote for -or- against HR 3200 here: http://www.opencongress.org/bill/111-h3200/text

About Off Road with Dr. Marcinko

These sporadic off-road segments will continue through-out my 2009 summer promotional tour. Formal attendance increased toward the later part of the summer as the Obama Administration’s healthcare debates heated up. Our many local book stores and sponsors noted a spike in our CD and book sales, as well as interest in our online www.CertifiedMedicalPlanner.com program and premier quarterly guide: Healthcare Organizations [Journal of Financial Management Strategies] www.HealthcareFinancials.com

Part VII: https://healthcarefinancials.wordpress.com/2009/09/01/off-road-touring-with-dr-marcinko-part-vii/

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Filed under: Ethics, Health Insurance, Health Law & Policy, Sponsors, Touring with Marcinko | Tagged: American Affordable Health Choices Act, David Lumsden, david marcinko, healthcare reform, HR 3200, Obama care | 2 Comments »

Tightening Payment Rules for Non-Physicians

Posted on August 30, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding the Medicare “Incident To” Rules

By Staff Reporters

Under the “incident to” rules, Medicare Part B pays for some services that are billed by physicians, but performed by non-physicians. And, the Department of Health and Human Services [DHHS] and Office of Inspector General [OIG] says that some of these services might be used improperly.

Suggestions to CMS

The agency recommends the Centers for Medicare & Medicaid Services [CMS] perform the following:

Revise the “incident to” rule to require that physicians who bill Medicare, but don’t perform the services themselves, ensure that the services are provided by a licensed physician, or a non-physician with the necessary training, certification or licensure.
Require that physicians who use non-physician services identify this with a service code modifier on bills.
Take appropriate action to detect when physicians bill for “incident to” services that are not covered under the rule.

Assessment

In the current healthcare reform environment, Medicare services by non-physicians are coming under increased scrutiny. And, the OIG is finding that the “incident to” rule is allowing medical care to be provided by non-physicians who may lack the necessary qualifications. This may be a healthcare financial, insurance and quality breach. So, don’t let this trap “bite” you.

Source: HHS Office of Inspector General (www.oig.hhs.gov/oei/reports/oei-09-06-00430.pdf)

Conclusion

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Filed under: Health Insurance, Health Law & Policy, Healthcare Finance, Research & Development | Tagged: "incident to" rules, Centers for Medicare & Medicaid Services, CMS, Department of Health and Human Services, DHHS, HHS, medicare, Medicare Part B, non-physician providers, Office of Inspector General, OIG | Leave a comment »

BCBS-TX Reverses NPI Policy

Posted on August 24, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Victory at Last

[By Darrell K. Pruitt; DDS]

Every now and then, I enjoy little victories. My war with BCBS-TX started when they began declining to pay their clients’ claims if they originated in my office. Since I’m not a HIPAA-covered entity, I didn’t volunteer for an arbitrary National Provider Identification number.

The behemoth insurance company not only successfully drove away some of my long term patients, but their clever policy blocked my access to their pool of clients who were led to believe their dental insurance was good everywhere – until my office manager had to tell them otherwise. BCBSTX is a sleazy company simply because it lies to its clients as policy.

Successful Claims

In the last two weeks, my office manager has successfully filed a couple of claims and it appears that unless payment is blocked in the next day or so, BCBSTX no longer requires Texas dentists to have NPI numbers.

Asessment

That’s nice, but I want more. I want the state CHIP program to drop its NPI requirement as well. Why limit access to dental care to the poor because of a number that only helps insurers. I’m just getting started, Texas.

Conclusion

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Filed under: Health Insurance, Health Law & Policy, Information Technology, Managed Care, Pruitt's Platform | Tagged: BCBSTX, Darrell Pruitt, DDS, dentists, health insurance claims, HIPAA, National Provider Identification number, NPI, Texas CHIP | 3 Comments »

Understanding Deviations in Medical Billing

Posted on August 21, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Appreciating Normative Comparisons

[By Patricia A. Trites; MPA, CHBC, CPC, CHCC, CHCO ]

Deviation in medical billing can be detected through utilization data that insurance companies produce on all providers that submit a claim for payment of services.

Insurance companies track utilization through a variety of parameters, including CPT codes, ICD-9-CM, or number of referrals. Different programs utilize certain benchmarks to trigger a review.

Example

For example, a physician who sees patients in the office from 8:00 a.m. until 8:00 p.m., seven days a week and has the highest billing amounts in the region can be subjected to a review. This doctor’s activities would be scrutinized. The utilization review department would probably flag this doctor’s provider number and request more information on a sampling of his or her claims, based on the volume.

Utilization Review

Some utilization review activities may occur due to the type of services that a doctor may offer. For example, if a cardiologist should suddenly start billing for a large number of incision and drainages of abscesses, this might trigger a review, since that might not be a typical scope of service for this doctor in this locality. The same could be said for a pathologist, triggering a review due to the high volume of wound care or ulcer debridement.

Audit Trigger Thresholds Vary

Thresholds vary from locale to locale regarding what triggers an audit. There are consultants who have suggested querying the local carrier for provider specific information regarding utilization activity to compare against community performance. Some Carrier Advisory Committee (CAC) representatives have indicated that this may bring undesirable attention from the Medicare program and trigger an audit. Consult professional associations. and, if possible; local CAC representatives to obtain most current information in your area.

Conclusion

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Filed under: Health Insurance, Managed Care, Practice Management, Risk Management | Tagged: billing compliance, Carrier Advisory Committee, CPT codes, fraud and aubuse, ICD-9-CM, medical audit triggers, medical billing, medical utilization review, Medicare audits, Medicare Carrier Advisory Committee, Medicare compliance, Patricia Trites | 2 Comments »

ME-P Healthcare Reform Survey?

Posted on August 18, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Off-Road Touring with Dr. Marcinko [Part V]

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

About Marquette, Michigan

As our ME-P readers are aware, Marquette Michigan has a population of 20,714, and is the UP’s largest community. In addition to being a population center, it serves as the regional center for education, health care, and outdoor recreation. This regional draw is particularly evident due to Northern Michigan University and Marquette General Hospital [MGH]. Naturally, during my recent tour there, I was able to visit both small and large medical practices, clinics and hospitals. Everywhere, the topic of conversation was the Obama Administration’s vision of domestic healthcare reform. And so, after unofficially asking local residents on their feelings in the matter, we are pleased to offer this survey to all readers and subscribers to our Medical-Executive Post.

About Off Road with Dr. Marcinko

These sporadic off-road segments will continue through-out my 2009 summer promotional tour. On the one hand, formal attendance at several engagements was a bit sparse because of the death of several recent celebrities and entertainer types. On the other hand, local book stores and sponsors noted a spike in our CD and book sales, as well as interest in our online www.CertifiedMedicalPlanner.com program and premier quarterly guide: Healthcare Organizations [Journal of Financial Management Strategies] www.HealthcareFinancials.com

Part IV: https://healthcarefinancials.wordpress.com/2009/08/13/off-road-touring-with-dr-marcinko-part-iv/

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Filed under: Drugs and Pharma, Health Economics, Health Insurance, Information Technology, Managed Care, Professional Liability, Quality Initiatives, Surveys and Voting, Voting Polls | Tagged: CDHCP, consumer directed healthcare plans, EHRs, electronc medical records, EMRs, healthcare reform, HSAs, malpratice tort reform, medical records, MSAs, national health care, obama, pharmaceutical pricing, single payer, socialized medicine | 1 Comment »

Kelly Mclendon RHIA censors D. Kellus Pruitt DDS

Posted on August 16, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

By Darrell K. Pruitt; DDS

Dateline: 8.15.09

Dear Kelly Mclendon, Registered Health Information Administrator

You are beginning to make me feel insulted, and I will not have that. I just noticed that the last two comments I submitted to your Website, www.spacecoastmedicine.com, on August 9 and 10, are still “awaiting moderation.”

http://www.spacecoastmedicine.com/2009/08/electronic-records-for-all-patients-mandated-by-2014.html#comment-89

(For clarity, the comments which scared Mr. Mclendon are copied below)

Over five days have passed, and I want you, your readers and my readers to know that I spent a lot of time preparing those two pieces exclusively for you at your invitation for comments. You are as sincere as I am, aren’t you?

When I’ve caught others in the squeeze you might be experiencing, several have pleaded that the censorship was an innocent oversight, and did the right thing immediately by posting everything I send them (include this comment, please). And then again, there are a few slow-learning, command-and-control types who think they cam still somehow control the content of their Websites. Like you, Kelly, an anonymous dentalblogs.com editor whom I call “Nancy” by default, also informed me that my comments were awaiting indefinite moderation. What a foolish, rookie mistake that proved to be. For example, if you google “dentalblogs.com,” my article “Dentalblogs.com hates D. Kellus Pruitt DDS” is their 4^th hit. It seems to be very popular.

How’s this for the title of a comment that should make it to your first page by Monday: “Kelly Mclendon RHIA censors D. Kellus Pruitt DDS”? Please, no phone calls.

D. Kellus Pruitt; DDS

Dateline 8.9.09

I’m sure physicians’ businesses are no different than dentists’ when it comes to the liability of data breaches – especially considering the giddy, mindless momentum of HITECH-empowered HIPAA. If a computer is stolen in a burglary, compromised by a dishonest employee who sells IDs on the side, or otherwise hacked, and the dentist reports the tragedy according to the letter of the law, it inevitably means bankruptcy even before the feel-good fines are levied by HHS (HIPAA) and the FTC (Red Flags Rule) for not having required irrelevant documentation of administrative trivia in order. What were our lawmakers thinking?

I guess the HIPAA blunder proves that when politicians, insurers and healthcare IT entrepreneurs get together in vendor clubs like CCHIT, the only government-approved eHR certification authority, they can mandate damn well any law that suits their needs.

Allscripts CEO Glen Tullman, who is an influential friend of Barack Obama as well as a Trustee of CCHIT told Bloomberg.com reporter Alex Nussbaum in an interview almost a year ago that providers should make the financial commitment “to ensure that doctors have some skin in the game.”

Glen Tullman is only one reason our nation’s healthcare IT industry stinks from the top down.

D. Kellus Pruitt; DDS

Dateline: 8.10.09

Thank you, Kelly Mclendon, for providing a rare venue to possibly clear up a few items of uncertainty about eHRs in dentistry. First of all, if a technological advancement such as eDRs does not pay for itself, even with government subsidies, who pays for it? That seems like a quick way to increase the costs of dental care – and for what? How do dental patients benefit from expensive HIT solutions when the telephone, fax machine and US Mail serve us fine?

Digitalization of records offers no benefits to dental patients. Only stakeholders who would grab our patients’ money benefit from HIT. Everyone else loses. Trusting, naive dental patients lose the most.

Electronic dental records are expensive hazards. If you can think of a lame reason for them, please let me hear it. You can bet I’ve crushed it before. I’ve been down this road with others many, many times.

Within a week, the government will price computerization smooth out of dentistry. Over 90% of dentists have patient identities on their computers today. If HIPAA is enforced, with or without the Red Flags Rule, I predict that less than half of the nation’s dentists will be computerized a year from now.

As for your argument that eHRs somehow provide up-to-date and otherwise superior medical histories for dental patients, think about this: If someone changes a paper medical history, it leaves a paper trail. If an insurance thief alters allergies on a digital record to suit his or her own needs, nobody in the emergency room can tell. Whoever said “Paper kills,” lied. It is a catchy PR pitch, though.

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Filed under: Ethics, Health Insurance, Information Technology, Managed Care, Op-Editorials, Practice Management, Pruitt's Platform | Tagged: Alex Nussbaum, Allscripts, Bloomberg.com, CCHIT, Darrell Pruitt, DDS, dental records, Dentalblogs.com, DMD, EHRs, electronic dental records, EMRs, FTC, Glen Tullman, Health I.T., healthcare information technology, HHS, HIPAA, HITECH, IT, kelly McLendon, obama, red flag rules, Registered Health Information Administrator, RHIA, www.spacecoastmedicine.com | 12 Comments »

Health Plan Management Navigator

Posted on August 16, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

August 2009 Edition

By Douglas B. Sherlock; CFA, MBA

Linked below is the August 2009 edition of Plan Management Navigator. In this month’s edition, we update readers on the results for the Blue Cross Blue Shield universe, and provide product breakouts, summary functional area breakouts as well as expense trends. Cost increases are lower this year than last, though higher if product mix is considered. Twenty-two Blue Cross Blue Shield Plans serving 31.3 million members participated in this year’s benchmarking study. Growth in Information Systems and Medical Management costs explained more than 40% of the total increase.

Link: Navigator August 09

Sherlock Expense Evaluation Report

This analysis is based on materials from our Sherlock Expense Evaluation Report (SEER) for Blue Cross Blue Shield Plans. Additional information about SEER is available at http://www.sherlockco.com/seer.shtml or by contacting us.

Assessment

In coming weeks, Plan Management Navigator will summarize other results of this year’s performance benchmarking studies. We expect to publish Medicare and Medicaid editions in late August or early September. Independent / Provider-Sponsored plan results were published two weeks ago in Plan Management Navigator and the associated presentation and transcript are found at http://www.sherlockco.com/

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Tell us what you think. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Filed under: Accounting, Breaking News, Career Development, Health Economics, Health Insurance, Healthcare Finance, Information Technology, Managed Care, Monthly Reports, Op-Editorials, Research & Development, Sponsors | Tagged: Blue Cross, Blue Shield, Douglas B. Sherlock, health costs, Health Plan Management Navigator, medical cost accounting, medical management, Sherlock Company, Sherlock Expense Evaluation Report | 1 Comment »

BCBS-TX Must Talk to D. Kellus Pruitt DDS

Posted on August 14, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Do My Manners Bother Anyone?

[By Darrell K. Pruitt; DDS ]

I posted this on the Dallas Morning News Website in response to an article about BCBSTX downsizing due to the economy.

http://economywatchblog.dallasnews.com/archives/2009/08/health-care-losing-jobs.html

Dear Jason Roberson – Reporter – The Dallas Morning News

As a dentist on the east side of Fort Worth whose patients have been harmed by BCBSTX, I say the fewer clients BCBSTX has, the safer Texans are. Changing dentists causes fillings.

Of HIPAA and the NPI Number

It wouldn’t surprise me that until about now, you and most of your readers have never heard of the HIPAA-mandated National Provider Identifier (NPI) number. And it probably doesn’t make much sense to you when I say that it is BCBSTX policy not to process their clients’ dental claims if they come from a dentist who doesn’t have an NPI number, like me. BCBSTX’s horrible policy has not only decreased my number of new patients, but the arbitrary rule also caused a couple of dozen of my long-term patients – who were perfectly satisfied in the comfortable dental home I provided them – to leave me for dentists with NPI numbers. Please note that the 10 digit identification number does nothing improve the quality of care. It only benefits BCBSTX. And did I mention that changing dentists causes fillings?

Not Accepting Assignment

Even in these tough economic times, I choose to no longer accept BCBSTX. My ethics-based decision hurts me financially, but that is how much I sincerely despise BCBSTX for its NPI policy. Unless Texas Health CEO Doug Hawthorne or a spokeswoman for BCBSTX like Margaret Jarvis or Ross Blackstone mans up to their deception really soon, I hope to help the wheels fall off of BCBSTX as an example to other insensitive CEOs who harm my patients by selling their clueless bosses discount dental plans with no quality control. Special bastards like me proudly volunteer to clean up the neighborhood, just for grins. As a matter of fact, a few sports fans and I are hoping one of the recently laid off BCBSTX employees is named Wilma, who on May 1, 2008 was known as an “overall supervisor” for BCBSTX in the dental claims department. I’m certain that CEO Hawthorne knows her. Then again, it wouldn’t surprise me to learn that he is unconcerned about dentistry.

A Pubic Invitation

I am publicly inviting Wilma to come forward – even as whistleblower if she still has her job – and share with us the motivation behind the alleged lies she told me during our conversation. Even now, as I listen to our recording, I consider it an entertaining and educational conversation between two people who both know a BCBSTX overall supervisor who brought talking points to an argument. Nevertheless, even while trapped between honesty and her job, Wilma proved to be a devoted employee – willing to risk her own reputation for her boss. The way she sticks with defending a defenseless policy, at times it sounds like the NPI number actually makes sense to her. Then you think, “Surely she is smarter than that.”

Assessment

I know that coming at the end of one of the strangest comments you have ever attracted, it is appropriately ballsy that I say that there’s a new sheriff in town, Jason. And disrespect around my niche is no longer tolerated if I have anything to do with it. I’ll shoot holes in BCBSTX to help it crash sooner if it will cause fewer Texans experience unnecessary dentistry. How important to one’s oral and systemic health is continuity of care when virtually all oral problems are caused by neglect? Is BCBSTX dental insurance worth the hidden price? Thank you for the opportunity to air out my opinion.

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Filed under: Career Development, Health Insurance, Information Technology, Managed Care, Op-Editorials, Pruitt's Platform | Tagged: BCBSTX, Dallas Morning News, Darrell Pruitt, Darrell Pruitt DDS, DDS, dentist, DMD, Doug Hawthorne, Fort Worth, HIPAA, Jason Roberson, Margaret Jarvis, National Provider Identifier, NPI Number, Ross Blackstone | 6 Comments »

ADA President and Broken Promises

Posted on August 11, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

The Future President

By Darrell K. Puritt; DDS

The election for a future ADA president occurs the first week in October in Hawaii at the 2009 annual meeting. A couple of days ago, the ADA News Online posted the ADA President-elect candidates’ statements.

http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=3133

All three sound like they support meaningful dialogue with membership: Candidate Dr. Raymond Gist says one of his goals is: “To protect and preserve ownership of the intellectual property of the ADA while demonstrating transparency and fostering an understanding of how our system works.” Candidate Dr. William Glecos says “My first goal will be to coordinate and improve our communication efforts within the ADA. To make sure we are engaging all our members and imparting a sense of connection and transparency.” Candidate Dr. Marie Schweinebraten says “… communication, internal and external, must be improved to respond in today’s world … barriers must be eliminated to allow member input and volunteer involvement when solving specific issues.” I’ve seen candidates use these same buzzwords before, but not mean them. Dentistry is being severely threatened right now, and I’m too young to retire. So I want to see a future leader confident enough to walk through fire with me on behalf of my patients.

Promises from ADA President-elect candidates have been very disappointing so far. Past President Dr. Mark Feldman, President Dr. John Findley and President-elect Dr. Ron Tankersley each promised “transparency.” Feldman and Findley broke their promises very early, and so far, Tankersley has done no better. Nine months ago I invited Dr. Tankersley to a conversation about the future of electronic dental records and he chose to insult me with silence rather than respond. I took it personally, Ron, and I’ll never forget it. Because all three of these presidents are simply rude people, it wouldn’t bother me to never ask any of them for friendship.

So do you think our fresh leaders are any more sincere about transparency with membership? Or are they also hoping to be safely elected. This could be an opportunity for one or more of the three to break loose and be counted as a brave leader… or not. Let me show you what Feldman, Findley and Tankersley have gotten us into. Below is a list of duties expected of dentists with NPI numbers that came out today on ANCO Online. If any of you three candidates have the courage to respond to my challenging comments about what I consider to be a perfect example of a renegade department, jump right in. Concerned members need to be warned about the courage we can count on. If you cannot defend the Department of Dental Informatics, just say so. We’ll all be better off. And on truth, we can build. What an opportunity for you! I bet one could easily gain the delegates’ attention by doing the right thing, even if it is unpopular at first to those who may have helped you to power.

Responding to this article in a respectful, professional way could be just what it takes to get a person elected to the highest position in the American Dental Association. That’s what you intensely want, isn’t it? You just have to recognize what I am spelling out for you, Raymond, William and Marie. Just look at the growing discontent with the ADA on the Internet. Whoever is the first to show sincerity and courage, will become a hero to those of us who feel betrayed by those we once trusted. Victory will never be easier. I’ve had a look around. Believe me when I tell you that things are soo bad that even I could be a contender. Don’t make me run for the job.

Here is the first issue for discussion if you are interested: For dentists who were persuaded by the ADA Department of Dental Informatics to quickly volunteer for the 10 digit identifying number, let me ask you this: If you had been told what ADA employees are paid to tell you, which you can read below, would you have applied for an NPI number? And if you were forced to apply for a number by a managed care contract with BCBSTX, Delta Dental or other discount dentistry broker, would that be considered an unfair business practice?

Let’s look at fairness: Who does the NPI number help? Dental patients or BCBSTX? Or perhaps the ADA? We were told again and again in ADA News Online articles written by Arlene Furlong that the best reason for the NPI number was convenience. She said office managers would love it because it would replace numerous identification numbers. When one reads the list of NPI obligations a dentist volunteers their office manager for, all those other numbers don’t seem so bad after all. Why was HIPAA so important that the ADA Department of Dental Informatics forced employees under its supervision to intentionally mislead membership? Does the ADA work for dentists and their patients or for CMS? There you go, Dr. Raymond Gist, Dr. William Glecos and Dr. Marie Schweinebraten. It’s your turn now. If you have the guts to step up to a challenge, it could pay off big. Besides, even if you get elected without first responding to my concerns doesn’t mean you’ll get rid of me. Oh heaven’s no.

D. Kellus Pruitt; DDS

http://anco- .blogspot.com/2009/08/asco-coa-cms-palmettoj1mac-news.html

**** CMS NEWS ****

This message is for health care providers, particularly physicians and other practitioners, who have obtained National Provider Identifiers (NPIs) and have records in the National Plan and Provider Enumeration System (NPPES). The Centers for Medicare & Medicaid Services (CMS) recommends that each health care provider, including individual physicians and non-physician practitioners: · Secure and maintain their own NPPES account information (i.e., User ID, Password, and Secret Question/Answer) for safety and accessibility purposes. Health care providers should maintain the confidentiality of their User ID, password, and Secret Question/Answer in order to protect their NPPES information from unauthorized access. Reset their NPPES passwords at least once a year.

See the NPPES Application Help page at https://nppes.cms.hhs.gov/NPPES/Help.do and select the ‘Reset Password Page’ for applicable rules. Those rules indicate the length, format, content and requirements of NPPES passwords. Review their NPPES records in order to ensure that the information reflects current and correct information. Covered health care providers are required to update their NPPES information within 30 days of the effective date of the change.

Viewing NPPES Information Health care providers, including physicians and non-physician practitioners, can view their NPPES information in one of two ways: (1) By accessing the NPPES record at https://nppes.cms.hhs.gov/NPPES/Welcome.do and following the NPI hyperlink and selecting Login. The user will be prompted to enter the User ID and password that he/she previously created. If the health care provider has forgotten the password, enter the User ID and click the “Reset Forgotten Password” button to navigate to the Reset Password Page. If the health care provider enters an incorrect User ID and Password combination three times, the User ID will be disabled. Please contact the NPI Enumerator at 1-800-465-3203 if the account is disabled or if the health care provider has forgotten the User ID. OR (2) By accessing the NPI Registry at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.

The NPI Registry gives the health care provider an online view of Freedom of Information Act (FOIA)-disclosable NPPES data. The health care provider can search for its information using the name or NPI as the criterion. Information regarding NPPES data that are FOIA-disclosable can be found at http://www.cms.hhs.gov/NationalProvIdentStand/ by selecting ‘Data Dissemination’. Please note: Business Mailing Address and Business Practice location information (full address and corresponding telephone numbers) are key data elements that are FOIA-disclosable.

Health care providers should not report their residential address unless it is their Business Mailing Address or Business Practice location. The NPPES data appearing on the NPI Registry cannot be deleted; however, it can be updated or changed. Updating NPPES Information Health care providers, including physicians and non-physician practitioners, can correct, add, or delete information in their NPPES records by accessing their NPPES records at https://nppes.cms.hhs.gov/NPPES/Welcome.do and following the NPI hyperlink and selecting Login. The user will be prompted to enter the User ID and password that he/she previously created.

Please note: Required information cannot be deleted from an NPPES record; however, required information can be changed/updated to ensure that NPPES captures the correct information. Certain information is inaccessible via the web, thus requiring the change/update to be made via paper application. The paper NPI Application/Update Form (CMS-10114) can be downloaded and printed at http://www.cms.hhs.gov/cmsforms/downloads/CMS10114.pdf.

Deactivating the NPI Health care providers, including physicians and non-physician practitioners, can deactivate their NPIs if the NPIs are no longer required or needed. Reasons for deactivation include retirement, business dissolved, or death of the health care provider. A request for deactivation must be submitted via paper application. The paper NPI Application/Update Form (CMS-10114) can be downloaded and printed at http://www.cms.hhs.gov/cmsforms/downloads/CMS10114.pdf.

Health care providers should review the instructions located on the application regarding deactivations in order to properly complete the deactivation request. The Power of Attorney or Executor of the Will may complete the application for deactivation due to death of the health care provider.

Need More Information?

Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Visit CMS’ dedicated NPI web page at www.cms.hhs.gov/NationalProvIdentStand for additional NPI information.

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Filed under: Career Development, Ethics, Health Insurance, Health Law & Policy, Information Technology, Managed Care, Op-Editorials, Practice Management, Pruitt's Platform | Tagged: ADA, American Dental Associaion, ANCO, Arlene Furlong, BCBSTX, Darrell Pruitt, DDS, delta dental, Department of Dental Informatics, DMD, doctoroogle.com, HIPAA, john findley, Marie Schweinebraten, mark feldman, NPI, NPPES, OSHA, Raymond Gist, Ron Tankersley, William Glecos | 8 Comments »

Dictionary of Health Insurance and Managed Care

Posted on August 8, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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Filed under: Book Reviews, Career Development, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, iMBA, Inc., Managed Care, Practice Management, Recommended Books, Sponsors | Tagged: CPAs, david marcinko, doctors, financial advisors, health information technology, Health Insurance, healthare reform, HIT, hope hetico, INSURANCE COMPANIES, IT, Managed Care, MEDICAL PROVIDERS, nurses, obama, patients, PAYERS, physicians, www.healthdictionaryseries.com | 1 Comment »

Journal of the American Dental Association [Letter to the Editor]

Posted on July 28, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

ADA Image Tarnished?

[By Darrell K. Pruitt; DDS]

Dear Editor,

This is a sincere letter which I am sure you will agree should be published in the October 2009 edition of the JADA. Today is July 19, 2009. I am allowing for the six weeks minimum time it requires for letters to appear in print following their selection for publication. It will be posted on the Internet immediately. In spite of this, I trust you will eventually agree to publish it in spite of your archaic rules. Otherwise, by November, history could show that the editor of the JADA arguably denied representation of dental patients’ interests at a most critical time in the history of the profession. That would be regrettable for your own professional reputation as well as for the JADA’s. As an ADA member, if my concerns are ignored, I will hold you publicly accountable for an explanation for a long time.

Public Laundry

From now on, we will agree to wash our laundry in public because otherwise it doesn’t always come clean. You can call the pressure I bring unprofessional if you want, but following the ADA News’ public exhibition of their shoddy ethics this week, it would be foolish to use my methods as an excuse to deny my access to membership. As I am certain you are aware, there were three revisions of “ADA/idm to phase out service” on ADA News Online (7/10, 7/13 and 7/16). I not only welcome a wide-open public discussion about ethics in journalism with representatives of the JADA, but I encourage it. We both know that the ADA needs clean laundry now more than ever before in its history.

ADA Business Enterprises, Inc.

For members who haven’t heard, the 2 ½ year old joint venture of our ADA Business Enterprises, Inc. (ADABEI) with Intelligent Dental Marketing – a Utah-based private business – fell apart in late spring of this year. Months later, our ADA leaders are still less than transparent with membership about what went wrong. I’ve been in business long enough to know that if mistakes by employees are not revealed and discussed, they are bound to happen again and again. And, it’s not like the leaders of the ADA were not warned. They just didn’t take heed. By late 2007, many knowledgeable people involved in the dental industry easily recognized the faults in the partnership between our non-profit professional organization and a for-profit Utah advertising company. In hindsight, anyone can see that ADA/IDM’s slogan, “Image is everything,” clearly betrays an attitude inconsistent with both the mission of the ADA and the Hippocratic Oath. Nevertheless, even the spirit of the slogan was regretfully adopted by the leaders of the ADA’s Business Enterprises, Inc. Now it is the image of the entire ADA that is suffering the damage.

ADABEI

I personally began questioning the accountability of the tricky ADA/IDM business model over two years ago when the profits from ADABEI had officials excited about avoiding the need to raise membership dues last year. Not unexpectedly, in the atmosphere of euphoria, nobody in Chicago wanted to acknowledge the concerns of a handful of alert members. We were cast aside as troublemakers. So how critical is the risk? With massive, unprecedented health care legislation imminent, this is the worst time imaginable for our stoic, image-conscious officers to lead us to nation-wide embarrassment.

Following the Money

The surrender to such temptations for leaders of non-profit organizations is not unprecedented. Do you know why the dues for the American Association of Retired People (AARP) have been kept so low? Not unlike the ADA, the non-profit AARP reaps profits from insurance policies and other products that its leaders sell to membership – even using misleading ads in AARP dues-supported publications. However, unlike dues money, vendor “kickbacks” don’t depend on accountability to members. A few years ago, the profits derived from agreements with vendors predictably became the lifeblood for AARP’s self-perpetuating bureaucracy – eventually influencing their lobbying efforts. Since non-profits like the AARP and the ADA are traditionally respected by lawmakers who like huge campaign donations, a non-profit entity’s lobbyists can be tempted to quietly represent vendors’ interests at members’ expense. Sometimes they get caught.

Lost Confidence

Almost a year ago, the AARP lost valuable member confidence when the organization was forced to suspend sales of “limited benefit” health plans backed by UnitedHealth Group (of Ingenix fame). Sen. Chuck Grassley said the plans which leave policyholders vulnerable to tens of thousands of dollars in costs were sold by the AARP to naïve and trusting members using misleading marketing tricks – not unlike those used in the ADA’s promotion of ADA/IDM. Sen. Grassley sent a detailed letter to CEO Bill Novelli demanding answers to questions about health insurance plans promoted to over a million dues-paying AARP members. Grassley told USA Today reporter Julie Appleby that “Insurance is supposed to limit your exposure to the potentially high cost of a serious illness and these plans do the opposite.” (Nov 7 2008).

http://www.usatoday.com/news/health/2008-11-07-aarp-insurance_N.htm

Is AARP-level accountability as good as it gets?

I say no. Attention ADA members – It is my opinion that our leaders are losing the control of our professional organization. The recent failure of ADA/IDM isn’t the first glaring sign of trouble in Headquarters. Over a year ago, the executive director, Dr. James Bramson, was suddenly fired with no explanation. In fact, then President Dr. Mark Feldman commanded that the reasons for the firing will not be disclosed. Obediently, ADA leaders have so far maintained firm control of the top secret information which if released could somehow endanger dental patients (?). Because Bramson’s severance pay came from my dues and not out of Dr. Feldman’s pocket, I think I deserve to know more details. Otherwise, this mistake could happen again and again.

The ADA/IDM disaster is also not the only ADABEI embarrassment I see on the horizon. It is my opinion that CareCredit is also showing signs of silent desperation. On July 9, the officials of the wholly-owned ADA subsidiary purchased an ad on dentalblogs.com titled “Press Release: CareCredit Adds 24-Month, No-Interest [sic] Payment Plan” (no byline).

http://www.dentalblogs.com/archives/administrator/press-release-carecredit-adds-24-month-no-interst-payment-plan/

Even though I approve of the benevolence in the idea of extending credit to those with worsening dental problems – especially during these hard financial times for patients – the anonymous CareCredit (ADA) representative who posted the ad failed to respond to my timely and important question: “If the Red Flags Rule is not delayed for the third time in three weeks, how will it affect those who offer Care Credit?”

Assessment

Nor did he or she respond to my follow up response on July 13. “On July 9 at 4:54 pm, I submitted a sincere question concerning how the Red Flags Rules will affect ADA members who sign up for CareCredit. Instead of posting it with the promise of an answer, you regretfully chose to censor an ADA member. Today, July 13, I have a second and third question: Why did you ignore my first one and who is your boss?”

Conclusion

So far, I’m still waiting for responses to all three questions. I trust you will treat my concerns with more respect, Editor.

Conclusion

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Filed under: Breaking News, Career Development, Ethics, Health Insurance, Managed Care, Op-Editorials, Pruitt's Platform, Research & Development | Tagged: AARP, ADA, ADA Business Enterprises, ADA News, ADA News Online, ADA/IDM, ADABEI, American Association of Retired People, American Dental Association, Bill Novelli, CareCredit, Chuck Grassley, Darell Pruitt, DDS, denturist, DMD, Dr. James Bramson, Dr. Mark Feldman, Hippocratic Oath, Inc., Ingenix, Intelligent Dental Marketing, JADA, Journal American Dental Association, Julie Appleby, LD, red flags, red flags dentistry, UHG, UnitedHealth Group, USA Today | 4 Comments »

Off-Road Touring with Dr. Marcinko [Part I]

Posted on July 20, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

“Using-Up” Health Insurance

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Dateline: June 18-19th, 2009

I flew into Marquette Michigan last night on a puddle jumper from Chicago, Illinois. Marquette will be the home base on my current book promotion and public/private speaking tour. This second leg of our trip, from Atlanta, was delayed for mechanical reasons. So, rather than follow directions from American Airlines regarding new arrangements, and rushing to wait in a long line of humanity for a new boarding pass on a much later flight, I simply called the travel assistance number on my cell phone. We were re-routed by computer from American, to a Delta Airlines flight, that caused no additional time lag as we later learned the other passengers boarded their American flight three hours late. Many of the elderly and slower moving folks even missed connecting flights which necessitated overnight hotel stays, in some cases.

THINK: outside the box independently, and don’t follow directions mindlessly.

About Marquette, Michigan

The City of Marquette is located in the central region of Michigan’s Upper Peninsula. With a population of 20,714, it is the UP’s largest community. In addition to being a population center, it serves as the regional center for education, health care, recreation, and retail. This regional draw is particularly evident due to Northern Michigan University and Marquette General Hospital, both of which are located in the City of Marquette. Of course, I visited both.

Quality Healthcare for the Upper Peninsula

So, the next morning I called some friends who suggested we head over to the Marquette Upper Peninsula Healthcare Network System, on Washington Street, for an unplanned and unofficial stop on our current “signing and opining” tour. It seemed very busy for a Friday morning; so we gathered some colleagues and ambled over to Viering’s Restaurant where we discussed the local economy, current state of the healthcare industry and the Obama Administration’s ideas for healthcare reform. When I expressed my surprise at the number of patients in the clinic waiting room areas, I was informed that an unexpected corporate layoff resulted in patients “wanting to use their health insurance, before being RIFed [Reduced-in-Force].” Now, as a doctor, and insurance agent, I find this attitude both very strange; yet not uncommon.

“Using-Up” Health Insurance

I can honestly say that after more than three-decades in the business, I have never heard a single soon-to-be unemployed client say,” I need to use up my life insurance”, or “auto insurance”, or “homeowner’s insurance”, etc. So, what gives with health insurance?

Health Insurance IS Different

Insurance of all types is sold to economically protect against catastrophic events like pre-mature death, auto accidents, or home destruction. But life insurance doesn’t pay for non-lethal issues; auto insurance doesn’t pay for new tires, tune-ups or oil changes; and home owner’s insurance doesn’t pay for regular upkeep and maintenance, etc. So, why do some patients believe that health insurance necessarily needs to be used-up? Were they not healthy before the lay-off announcement; or did they suddenly become ill, thereafter? What do you think? Is this just a local phenomenon, or would it be [is it] pandemic in any community given the same or similar circumstances?

Assessment

For me, this scenario clearly demonstrates two things. First, that Health Insurance is thought of as a personal right and/or corporate fringe-benefit; rather than true financial indemnification. Second, it demonstrates the ability of patients to think ahead; unlike the airline customers on my initial trip here. So, if patients can be forward thinking about their health insurance needs, why don’t they think ahead about their personal health care needs? Why don’t more of us exercise regularly, watch our blood pressure and weight, and/or avoid drugs, alcohol and promiscuous sex, etc. If we can monitor and pay for routine auto and home maintenance ourselves; why not our routine health needs? Isn’t good health our most important personal asset? Aren’t we worth it? Do we really want to abrogate our very lives to others? Do we want to concede our responsibilities to a third party, ie, a national [single-payer] governmental controlled healthcare? Those patients wanting to “use their health insurance”, before unemployment, certainly seem to think so.

About Off Road with Dr. Marcinko

These sporadic off-road segments will continue through-out my 2009 summer promotional tour. On the one hand, formal attendance at several engagements was initially a bit sparse because of the death of several recent celebrities and entertainer types. On the other hand, local book stores and sponsors noted a spike in our CD and book sales, as well as interest in our online www.CertifiedMedicalPlanner.com program and premier quarterly guide: Healthcare Organizations [Journal of Financial Management Strategies] www.HealthcareFinancials.com

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Filed under: Health Economics, Health Insurance, iMBA, Inc., Marketing & Advertising, Media Mentions and PR, Op-Editorials, Sponsors, Touring with Marcinko | Tagged: American Airlines, auto insurance, certified medical planner, CMP, david marcinko, Delta Airlines, doctor, Health Insurance, healthcare, healthcare reform, insurance agent, marquette general hospital, marquette MI, Marquette Upper Peninsula Healthcare System, Michigan, Northern Michigan University, obama, RIF, Upper Peninsula, Viering’s Restaurant, www.certifiedmedicalplanner.com | 1 Comment »

Medicare Scam Alert Notice

Posted on July 17, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Fearing Medicare Payment Gaps

By Staff Reporters

June 18, 2009

The Centers for Medicare and Medicaid Services (CMS) issued the following “Scam Alert Notice”

“CMS has become aware of a scam where perpetrators are sending faxes to physician offices posing as the Medicare carrier or Medicare Administrative Contractor (MAC). The fax instructs physician staff to respond to a questionnaire to provide an account information update within 48 hours in order to prevent a gap in Medicare payments. The fax may have the CMS logo and/or the contractor logo to enhance the appearance of authenticity.”

Medicare Contractors

Furthermore, CMS said that “Medicare FFS providers, including physicians, non-physician practitioners, should be wary of this type of request. If you receive a request for information in the manner described above, please check with your contractor before submitting any information. Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov website” found at:

Link: http://www.cms.hhs.gov/MLNGenInfo/

Link: http://www.cms.hhs.gov/MedicareProviderSupEnroll.

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Filed under: Alerts Sign-Up, Breaking News, Career Development, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Research & Development | Tagged: CMS, CMS Scam Alert Notice, FFS, MAC, MC, medicare, Medicare Administrative Contractor, Medicare FFS, medicare paymenhjt gaps, Medicare Scam Alerts | Leave a comment »

Janis Oshensky Lobbies Congress – Not Dentists

Posted on July 16, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Show Me the Math

By Darrell K. Pruitt; DDS

I have noted here far too many times how it disappoints me that Delta Dental Plans Association vice president Janis Oshensky repeatedly chooses to turn to politicians rather than discuss Delta Dental’s arguably egregious and harmful policies with me, a dentist. I intend to put a stop to such disrespect one PR expert at a time if necessary.

Long ago I warned Oshensky that if she didn’t talk to me, she should probably just shut up in order to preserve what’s left of her Internet reputation. Since by posting her Letter to the Editor on POLITICO.com today, she obviously ignored my advice, this highly critical comment will reliably join three others of mine on her first page soon enough. Her employer is sacrificing her like a pawn.

The following comment is the one I posted on POLITICO.com in response to Oshensky’s letter. It might just help the vice president to finally come to a decision on this issue one way or the other. Either way, marketplace conversation like this cannot help but lead to safer air for the community … My pleasure.

http://www.politico.com/news/stories/0709/24873.html

Dear POLITICO.com Editor:

This comment and subsequent invitation to Janis Oshensky is in response to the Delta Dental Plans Association vice president’s July 14, 2009 letter to you. Her letter is the most recent message she successfully sent Congress using a political news Website. Even though Ms. Oshensky holds the position of VP of dental relations as well as public policy, she has avoided answering this dentist’s questions about Delta Dental’s policies for months. If Ms. Oshensky is willing to do so, I would love for her to join me in discussion of Delta Dental’s taxation subsidy right here on POLITICO.com so that our lawmakers can witness a more balanced view of the issues.

Hello – It’s Me

Hello. My name is D. Kellus; Pruitt DDS, and I’m a practicing dentist in Fort Worth, Texas. It is my professional opinion that my patients are harmed by the policies of managed care dental plans like that sold by DDPA because there is no accountability to their clients or dentists. There is barely any accountability to those who select and pay for Delta’s products – dental patients’ naive bosses.

Like virtually every US citizen, your readers probably couldn’t care less about the dental industry. It is precisely because dentistry has been uninteresting for decades that make the microcosm of health care incredibly interesting to me. Let me uncover for your appreciation the event horizon in dental history. You could learn about more than just dentistry.

If left to natural forces of human nature, what happens to value when there is no accountability? For example, what do the 1975 East German Trabant and the 1979 Ford Pinto have in common? By popular vote, those products not only represent the two worst automobiles ever made, but the state shielded both manufacturers from accountability to consumers. Poor quality happens.

Oshensky argues against the taxation of managed care dental benefits like those sold to employers by Delta Dental. Let me offer that if Delta’s product were taxed like income, its value would quickly dive below the market threshold that attracts purchasers’ consideration.

Allow Me to Show-You the Math

Recently, Delta Dental of Michigan lost the accounts of thousands of GM retirees when their group dental benefits were cut in bankruptcy negotiations with UAW. Suddenly, Delta found itself forced to market their product to individuals who for once have the choice to keep their money. Faced with true competition for healthcare dollars, Delta leaders desperately cobbled together individual policies for the retirees who want to continue with their coverage. Even though Delta did everything possible to lower the cost of their coverage, the cheapest of the plans they offered still runs about $30 per person per month, and covers only 50% of everything, including preventive. So for premiums of $360 per year plus half the preferred providers’ 20% to 30% discounted fees, is this a bargain for Michigan retirees?

Free Markets

In my free-market, fee-for-service practice, if a patient comes in for two cleanings and routine x-rays during a year, 100% of my bill is $208. This is the market price in my neighborhood that is continually challenged by lively competition with other dentists for new patients who may not even have dental benefits. Those customers pay in full at the time of visit, just like most people whose bosses purchased Delta Dental Plans.

Value Comparisons

So let’s compare value of Delta Dental’s product with cash. If I were a Delta Dental preferred provider, my fee of $208, less Delta’s 25% discount would be $156. Never mind that my wife has problems with my 70% cut in pay, let’s move on.

The patient’s half of the $156 I earned is $78. $360 + $78 = $438. So for one uneventful year of discounted dental services with a dentist chosen from a list of names, a patient can expect to spend more than twice as much than if they paid the free-market price at the point of service.

Assessment

Not only is that hardly a bargain, but it is my opinion that managed care dentistry is dentistry by the lowest bidder with no quality control. That should be enough meat to get this conversation rolling. Now it’s your turn Ms. Oshensky. I think you have to admit that you’ve got holes to mend in the dental relations part of your job.

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Filed under: "Doctors Only", Career Development, Ethics, Health Insurance, Managed Care, Practice Management, Pruitt's Platform | Tagged: ADA, Darrell Pruitt, DDPA, DDS, delta dental, Delta Dental Michigan, dentists, DMD, GM, HMO, Janis Oshensky, managed dental care, POLITICO, PPO, UAW | 3 Comments »

Health Plan Management Navigator

Posted on July 15, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

July 2009 Edition

By Douglas B. Sherlock; CFA, MBA

Attached below, find the July 2009 Edition of Plan Management Navigator. In this month’s edition, we summarize the results of Independent / Provider-Sponsored Healthcare Plans. The 16 plans collectively serve 5.7 million members and are leaders in their communities.

Link: Navigator_07-09

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Managed Care, Monthly Reports, Research & Development | Tagged: douglas sherlock, Health Insurance, health plan, healthcare plans, managed care plans, Plan Management Navigator, Sherlock Company | 1 Comment »

ADA / IDM Breakup – You Heard it Here First

Posted on July 14, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Will CareCredit be the Next ADA Subsidiary to Fail?

I saw a warning sign last week.

By Darrell K. Pruitt; DDS

My aggressive writing hobby has understandably brought me in hard contact with public relations people whose job is to insulate good ol’ boys from accountability – even if it means taking hits for the team and staining their reputations. Let’s face the fact we all of us involved in public relations know but don’t dare discuss: Depending on the ethics of one’s employer, PR professionals are sometimes used up like expendable pawns. And avoiding bylines for press releases no longer shields anyone from accountability.

I often silently stalk PR employees (Gasp!) on the Internet who work for sleazy companies just to better understand them. I’ve discovered that it is not hard to find and exploit the weaknesses of those whose heart isn’t behind selling their employer’s product. Sometimes all it takes is a fistful of transparency to cause defenseless representatives to completely shut up, and that alone makes our neighborhood safer. Committee-approved methods of evasion are as simple-minded as committees, so it doesn’t take long to figure them out – exposing the shameful ethics of those who sign off on the use of lame, institutional trickery.

For example, here’s a very popular, traditional PR trick: If a huge business entity such as the ADA has bad news they can no longer keep secret from customers, professional PR-types will advise their bosses to post bad news on a Friday to soften the blow. When traditional leaders find that they can no longer sidestep accountability, delaying accountability until a busy news day is the next best thing one can purchase. Even though the tricks seem simple, there are people who study evasion science as part of obtaining a degree in marketing.

So how good is the ADA’s PR team? How much time did ADA members’ employees buy for leaders before they had to quietly acknowledge an expensive failure?

On July 10, a Friday, “ADA/idm to phase out service” was posted on ADA News Online without a byline. (Another PR trick: When the ADA posts an orphan without a name, it means someone is ashamed of the bastard.)

http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=3655

“ADA Business Enterprises, Inc. (ADABEI), a wholly owned ADA subsidiary, announced today that ADA Intelligent Dental Marketing (ADAidm) of Salt Lake City, one of its joint venture companies, is no longer able to provide marketing services to its customers due to significant production and operational difficulties.”

Now the ADA must refund money to members in a depressed market. Could this embarrassment for our professional organization have been quietly avoided instead of delayed and magnified? I personally started seeing clues of CEO Trajan King’s reticence long ago, and warned ADA leaders in Chicago about my concerns. Nobody ever responded to my numerous, sincere warnings.

These are highly critical times on Capitol Hill and our patients trust us to represent their welfare. Dentists are their last hope, because there is nobody else who cares. Practicing dentists are solely responsible for assuring the benevolence of our niche market, and we are losing control publicly. Disasters like the ADA/IDM make the ADA look foolish to Congress, and word gets around fast on the Internet.

This morning, I read an article posted on The NY Times titled “Study Measures the Chatter of the News Cycle, “ written by Steve Lohr.

http://www.nytimes.com/2009/07/13/technology/internet/13influence.html?_r=1

Researchers at Cornell used powerful computers and sophisticated algorithms to accomplish an unprecedented analysis of news articles and comments on the Web during the 2008 presidential campaign. They studied the characteristics of the news cycle by scanning 1.6 million mainstream media sites and blogs for repeated phrases and tracking the history of their appearances.

Lohr writes: “The researchers’ data points to an evolving model of news media. While most news flowed from the traditional media to the blogs, the study found that 3.5 percent of story lines originated in the blogs and later made their way to traditional media.”

The study also shows that traditional news outlets are still quicker than blogs by 2.5 hours. I should now point out that the Cornell study was performed using data from very popular, huge news items collected during a presidential election – not hidden, niche news like dentistry’s.

If you are involved in the dental industry, where are you more likely to read time-sensitive news about our profession first? In an ADA publication, or from D. Kellus Pruitt; DDS?

Whereas traditional media is 2.5 hours quicker with popular topics, I scooped traditional ADA News Online by three weeks when I posted “ADA/idm – A bad union after all?” on the PennWell forum.

http://community.pennwelldentalgroup.com/forum/topics/adaidm-a-bad-union-after-all

So what about the warning sign I saw concerning CareCredit – a wholly-owned subsidiary of the ADA?

When Trajan King, former CEO of the defunct ADA/IDM partnership refused to acknowledge my questions, I immediately suspected something was terribly wrong with the union of my non-profit professional organization and his for-profit Utah advertisement company. Six months later, my fears were confirmed. Now then, I hope it grabs someone’s attention that I see the same warning signs coming from the ADA’s CareCredit business. Note this date: July 13, 2009.

On Thursday, July 9, CareCredit purchased a press release on dentalblogs.com: “CareCredit Adds 24-Month, No-Interst [sic] Payment Plan” (no byline).

http://www.dentalblogs.com

Since dental problems only get worse, I consider the idea of extending credit to dental patients is a benevolent thought during these hard financial times. I also say that the offer appears to have been put together out of generosity and not greed like the ADA/IDM disaster. However, at 4:54 pm on the same day that CareCredit’s press release was posted, I submitted a difficult question for the anonymous author of the piece who works PR for CareCredit – and is an ADA employee.

“If the Red Flags Rule is not delayed for the third time in three weeks, how will it affect those who offer Care Credit?”

I was given the hopeful response “Your comment is awaiting moderation,” but days later there is no sign that my question is being considered at all. Please, oh please ask yourself: What could CareCredit leaders be hiding and how much will it end up costing ADA membership?

I will not be ignored by anyone. Today, I submitted two follow-up questions on dentalblogs.com. I considered warning the anonymous moderator that this is being simulposted on other blogs, as well as described on Twitter, but then I thought, why spoil the fun? Let the leaders of the ADA Business Enterprises, Inc. (ADABEI) get word of my e-Attack from their colleagues. Won’t they be surprised!

Oh, and for those who are wondering what happened to ADA/IDM CEO Trajan King – he quit.

Dear Dentalblogs.com moderator:

On July 9 at 4:54 pm, I submitted a sincere question concerning how the Red Flags Rule will affect ADA members who sign up for CareCredit. Instead of posting it with the promise of an answer, you regretfully chose to censor an ADA member. Today, July 13, I have a second and third question: Why did you ignore my first one and who is your boss?

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Filed under: "Doctors Only", Breaking News, Career Development, Ethics, Health Insurance, Information Technology, Marketing & Advertising, Media Mentions and PR, Pruitt's Platform, Research & Development | Tagged: ADA, ADA Business Enterprises, ADA/IDM, ADABEI, American Dental Association, CareCredit, Darrell Pruitt, dentists, IDM, Intellignet Dental Marketing, red flag rules, Steve Lohr, Trajan King | 12 Comments »

Essay of Atul Gawande MD in the New Yorker

Posted on July 9, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

The McAllen Redux

We urge all ME-P subscribers and followers to read Atul Gawande’s piece in the New Yorker that appeared as an essay on McAllen, Texas – the little Texas town with the dubious honor of being one of the most expensive health care markets in the country, today.

Link: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

As Dr. Gawande noted, in 2006, Medicare spent about $15,000 per enrollee there – close to twice the national average, and three thousand dollars more per person than McAllen’s per capita income of $12,000.

Commentary

Then, take at look at the comment by OMB Director Peter R. Orszag, posted on Thursday, June 4th, 2009 at 10:50 am; entitled the McAllen Redux

http://www.whitehouse.gov/omb/blog/09/06/04/McAllenRedux/

Assessment

Who says bloggers, and citizen journalists, get no respect?

Conclusion

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Filed under: Alerts Sign-Up, Breaking News, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Media Mentions and PR, Practice Management, Quality Initiatives | Tagged: Atul Gawabde, CMS, Health Insurance, McAllen Redux, McAllen Texas, medicare, New Yorker, OMB, Peter R. Orszag | 6 Comments »

Concierge Medicine and the “Zombie” Medical Practices

Posted on July 7, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Continued Growth of Boutique Medical Practices Today

[By Dr. David Edward Marcinko; MBA CMP™]

The boutique, or direct reimbursement, or cash based medicine, or concierge medical practice business model requires an annual fee for personalized treatment that includes amenities far beyond those offered in the typical practice, or suggested by physician medical unions. Patients pay annual out-of-pocket fees for top tier service, but also use traditional health insurance to cover allowable expenses, such as inpatient hospital stays, outpatient diagnostics and care, and basic tests and physician exams. Typical annual fees can range from $1,500 to $ 5,000 per patient, to family fees that top $25,000 a year, or more. The concept, initially developed for busy corporate executives, has now made its way to others desiring such service.

A Higher Level of Care

Medical providers get to provide a much higher level of care and get to know their patients as they enjoy the incentive to spend appropriate time with them, and over time, get to know them within their unique social/cultural context as well (hence the house calls become important). Patients enjoy the access, the attentiveness, and are willing to spend cash to have the type of unhurried, contemplative time with physicians that is required to develop a trusted relationship and deliver high quality care. The financial remuneration potential is compelling as well.

Now, let us compare and contrast various parameters of traditional medical practice [third party reimbursement] with the same parameters of so-called “new-wave” concierge medicine. Then, let the next-generation of doctors decide.

Current Traditional Model

patients seen at 15-20 min increments
2,000 – 3,000 patients
Paperwork, administrative burdens, frustrations, and lack coordinated care
Impersonal experience (long waits, un-intelligible interactions with health care system)
Average Salary = $150,000-250,000

Concierge Practice Model Potential

direct relationship with patients
300-500 patients
$1,500 – $3,000 access/retainer fee
Reduced overhead, positive interactions, care coordination and increased quality
Personalized experience (reduced headaches and paperwork with transparent pricing)
24/7 access, same day appointments with multiple other amenities
Average Salary = $100,000 – $500,000

Enter the Franchisors

Concierge medical practices can be developed organically, or use a franchise business model [personal communication, Suzanne R. Dewey, Forté Partners, LLC, Williamstown, MA]. Examples of franchisors include:

Elite Health: http://elitehealth.com
Health Advocate: http://healthadvocate.com National organization with over 4,300 client relationships.
MD2 International: http://www.md2.com/home.php
MDVIP: http://www.mdvip.com
ModernMed: http://www.modernmed.com

Opponents and Pessimists

There have been plenty of opponents, within medicine and outside, to the idea of concierge practices almost from the first day. For example,

”The state of Washington’s insurance commissioner attacked the concept of practices offering all the primary care patients needed for a prepaid fee or retainer, arguing that such practices amounted to the business of underwriting health insurance. He said that the practices would have to meet all the regulatory requirements for such an insurance business, including establishing capital reserves and maintaining loss reserves for the payment of claims. It didn’t work, and besides, few concierge practices offer free traditional medical care once retainers are paid–most concierge physician’s bill insurance plans for all the services covered under their patients’ coverage. The Medicare folks chimed in and managed to drive one physician out of business, arguing that he had tried to charge Medicare patients an extra $600 a year for services already covered by Medicare, hence he was guilty of illegal “balance billing.” Rather than fight Medicare over the issue, the doctor gave up and closed his practice. [C. Davis, “Big Problems for Medicare and Concierge Medicine,” Sierra Sacramento Valley Medicine, 55:3, May/June, 2004 (www.ssvms.org)]”

Attacking ME?

Objections to concierge medicine focus on both its causes and its effects, and some critics have even attack me, personally. For example, just look what “they” said in the online journal: “Health Care Strategic Management.”

”Many critics argue that concierge medicine merely reflects physician greed and unconcern over the needs of the community. Indeed, a recent book by David Marcinko, Business of Medical Practice [Advanced Profit Maximization Techniques for Savvy Doctors], includes a chapter on “The Case for Concierge Medicine” (Ch. 24) as one of the ways ‘savvy’ physicians can maximize their profit, as if that is what medicine is all about. While the image of physicians may retain some Marcus Welby elements of their rushing to the hospital or a patient’s home in the middle of the night, most physicians would rather stay home and leave the job to someone else, it is argued”.

Nicht Schadenfreude

Just think! My mother always feared I’d be a no-body. Good publicity – bad publicity – just spell the name correctly. Schadenfreude may be defined as a “largely unanticipated delight in the suffering of another which is cognized as trivial “ and I take no delight in the slow collapse of traditional medical practice models; or the economic, professional or personal pain of colleagues. But, I also often tell my critics – and clients – that although it’s awfully nice to be altruistic; I am always mindful of the competitive business adage: “no margin-no mission.” And, in as much as this attack was written in July 2005, I can only wonder if I was prescient, or just lucky? With all due respect, I believe it was the former, rather than the later. Why so? Well, just consider how fast www.ChoiceMed.com is growing. This stuff is not rocket-science.

www.MedicalBusinessAdvisors.com

About Concierge Choice Physicians

Concierge Choice Physicians: http://choice.md is a national organization offering a hybrid business model. Physicians divide their practice between a traditional practice and a retainer practice. The retainer practice is limited to approximately 150 patients. A typical concierge practitioner may have 300-500 patients, while the norm for a traditionalist is about 2,000-3,000 patients.

Assessment – Whither the “Zombies”

I, also ruefully wonder how many “zombie” medical practices [practitioners] are out there? You know the kind – a medical practice with neither a good/bad balance sheet. One with only subsistence level operating performance; a practice that is not growing organically or thru merger activity. It is just barely existing as the doctor-in-charge slowly, agonizingly, milks it to death; or retires, whichever comes first.

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***

Filed under: Career Development, CMP Program, Ethics, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Practice Management, Professional Liability, Research & Development, Risk Management, Sponsors | Tagged: boutique medical practice, Business Medical Practice, c Davis, cash based medicine, choice.md, ChoiceMed, concierge medicine, david marcinko, direct reimbursement medicine, elite health, health advocate, Health Care Strategic Management, MD2 International, MDVIP, ModernMed, zombie medical practices | 11 Comments »

Blue Cross/Blue Shield of Texas on Facebook

Posted on July 6, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Let’s Have Some Fun!

[By Darrell K. Pruitt; DDS]

Hello, sports fans. Have you missed me? It’s been about five days since I posted a comment that didn’t follow an article authored by someone else.

My last one was “Pruitt’s Platform – Introduction to an Adventure.” It’s unusual for me to go so long between posting stand-alone pieces, but after putting that title to my introduction, and compounding the challenge by promising to never push out bland stuff, I set my standard high. It took me a few days, but I finally found a deserving old target on a brand new venue that I think will hold your interest. BCBSTX and I have an intense history, so I assume they charged someone anonymous and shy to follow everything I write. I welcome you, whoever you are. Yea, you. The one hiding in the dark corner, justifiably afraid to utter a peep. Keep your pointed head down, friend, and try not to wet your nice pants.

BCBSTX, you should be disappointed to learn that I found your Facebook account. Even for a fat dinosaur, you are an especially thick and slow-moving easy target. I recommend you just surrender now to transparency and start the confessions and reparations before the lawsuits become huge and the lawyers profit more from your collapse than the Texan dental patients you’ve harmed. Let me remind you that the repeal of the McCarran-Ferguson Act is just around the corner, and we all know about the rumor (started by me) that there are attorneys across the nation just waiting to file class-action lawsuits against BCBS for unfair business practices, including restraint of trade for using the NPI number to drive satisfied patients from dental homes they preferred. Finally, BCBSTX will be subject to the same anti-trust laws as the doctors they fear, and I am here to make sure BCBSTX feels the pain. Look what happened to Dell Computer when that huge dinosaur was surrounded by Jeff Jarvis and Dell Hell. The game I’m playing with you is a more nimble, improved variation of Dell Hell, using fewer vulgar words.

You should know by now you are too fat and too slow to hide from me and the sports fans I bring. Nevertheless, I am always fair in telling my targets my goals before I go on to accomplish them. Here is what I am going to do to you, BCBSTX: I intend to pull your anonymous, unaccountable butt out into the wide open for everyone to see – especially the lawmakers you lobby and support with generous donations. Did you know that there is a rumor (also started by me) that some of those same lawmakers you consider friends are aware of most of what I write on the same day I post it? The transparency I bring will eventually trap and crush you, BCBSTX. Or, you can immediately come out and meet me for an open discussion about the inevitable reformation of dental insurance in Texas – putting humble, obedient bureaucrats with names under the direct control of dentists and patients. And of course, it is understood that in order to save Texas citizens millions of dollars in healthcare expense, there will be drastic downsizing of BCBSTX Dental, just like Delta Dental and ADA/IDM are experiencing right now. That means no more bonuses and no more frivolous pursuits like publishing, printing and mailing to Texas dentists those expensive self-serving brochures joyfully titled “NPI Times.” I suggest you get your resumes in order, BCBSTX employees. I’m very good at having my way with archaic business models. Others I have attacked, such as ADA/IDM and Delta Dental, are clearly failing. Coincidence? Perhaps you’d like to tell yourself that when I undermine your support every time you come up for air. Why not send out your sharpest PR specialists? Oh please, would you? Also, equip them with committee-approved talking points that I’ll hang around their necks for a long time.

When I discovered that BCBSTX had a Twitter account, I started asking anonymous employees of BCBSTX about their new NPI number requirement for processing dental claims – even for dentists who have no contractual relationship with the company. But rather than answer a dentist’s questions about their dental policy (incredibly stupid, BCBSTX), the leaders of the command and control company who can no longer command or control their own socks, responded by blocking me from following them. That was irresponsible, childish behavior from one of the largest and most powerful dental insurance companies in the state. Shouldn’t it be important for BCBSTX to respect dentists who must deal with their cumbersome rules?

At a time when managed care dental companies like BCBSTX are lobbying Congress hard to preserve their taxation subsidy, I think it is important for lawmakers to recognize that these huge stakeholders neglect the welfare of those they serve: the principles – dentists and their patients. We are your constituents who count, Congress. Not discount dentistry brokers whose products will not sell in the free market without mandates and taxpayer assistance – simply because they are lousy products.

If BCBSTX had not opened a Facebook account, I would not have opened one myself. I discovered my fat, defenseless opponent when I googlesearched “BCBSTX” the other day. On their first page was the link “What is the NPI number of BCBSTX? – Facebook.” It features a client’s naïve, insignificant question about the NPI number, and it opened the door for my informed, significant one which I copied below, as well as posted on Twitter.

http://www.facebook.com/topic.php?uid=93487018652&topic=8926

By the way, I was disappointed to see that my comment “BCBS-TX Dental Insurance is Rude to everyone,” which I posted on the Medical Executive-Post over three months ago, was no longer on BCBSTX’s first page. It was their third hit for weeks. But since I hadn’t given the comment a bump lately, it has dropped down to the bottom of their second page. Can’t have that! If you don’t mind, please click once or more on the following link and stay there a few minutes. That way, it will push the blunt criticism back up onto BCBSTX’s first page and will once again warn potential clients of BCBSTX’s poor business ethics. If you’re going to be there anyway, why not go ahead and read the sucker? You could find it interesting. Lots of people do.

https://healthcarefinancials.wordpress.com/2009/03/27/bcbs-tx-dental-insurance-is-rude-to-everyone/

As I wrap up this comment, I’ll share with you with the question I left BCBSTX on Facebook almost 6 hours ago concerning their NPI policy. I don’t think Facebook was a good idea for BCBSTX leaders. Sit back and watch me get someone fired today.

Dear BCBSTX:

I would like to point out to readers more information about the NPI number which you are not likely to share. If you have BCBSTX dental insurance, and your dentist does not have an NPI number, BCBSTX will not process your dental claim and the premiums you will have paid to BCBSTX will become unearned profit for BCBSTX.

Is that true, BCBS-TX? Yes or no?

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Filed under: Career Development, Health Insurance, Information Technology, Pruitt's Platform | Tagged: ADA, ADA/IDN, BCBS, BCBSTX, Darrell Pruitt, DDS, Dell, delta dental, dentist, Facebook, Jeff Jarvis, McCarran-Fergusan Act, NPI, NPI Number, twitter | 19 Comments »

Government-Enabled Patient “Bounty Hunters”

Posted on June 30, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Spider Webbing Technology May Trip-Up Miscreant Doctors

By Dr. David Edward Marcinko; MBA CMP™

Under the Health Insurance Portability Accountability Act (HIPAA), the U. S. Department of Health and Human Service (HHS) have operated an “Incentive Program for Fraud and Abuse Information.”

In this program, HHS pays $100 – $1,000 to Medicare recipients who report abuse in the program.

To assist patients in spotting fraud, HHS has published examples of potential fraud, which include:

medical services not provided;
duplicated services or procedures;
more expenses, services, or procedures claimed for than provided (upcoding/billing);
misused Medicare cards and numbers;
medical telemarketing scams; and
no-medical necessity.

Real Health Fraud Exists

There is no question that real fraud exists. The Office of Inspector General of HHS saved American taxpayers a record $32 billion in 2006, according to Inspector General Glenn A. Fine.Savings were achieved through an intensive and continuing crackdown on waste, fraud, and abuse in Medicare and over 300 other HHS programs. To discourage flagrant allegations, regulations require that reported information directly contribute to monetary recovery for activities not already under investigation. For the DRA in 2009, this includes the following:

promoting state False Claims Acts (section 6032);
enhancing the Fair and Accurate Credit Transaction Act, with “red flags” (PL 108-159); see http://www.gpo.gov/fdsys/pkg/PLAW-108publ159/content-detail.html
employee education about false claims recovery (section 6033);
augmenting the Medicaid Integrity Program (section 6034);
enhancing third party recovery (section 6035); and
“mining” medical claims for potential fraud with the help of sophisticated computer technology algorithms – called “spider-webbing” – which locate a common insurance claim denominator and then follow the thread throughout claims review. Indicators of possible fraud include doctors charging more than peers; providers who administer more tests or procedures per patient; providers who conduct medically “unlikely” procedures; providers who bill for more expensive procedures and equipment when there are cheaper options; and patients who travel long distances for treatment.

Assessment

CMS and private companies are able to save far more money by detecting fraud before claims are paid than recovering the money after the fact. And so, a further erosion of patient confidence can be expected as CMS, and private insurers, assume the “bounty hunter” view of healthcare providers.

Conclusion

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Filed under: "Doctors Only", Career Development, Ethics, Health Insurance, iMBA, Inc., Information Technology | Tagged: CMS, david marcinko, DRA, Fair and Accurate Credit Transaction Act, false claims act, fragmented billing, Glen A. Fine, healthcare abuse, healthcare fraud, HIPAA, HSS, Incentive Program for Fraud and Abuse Information, Medicaid Integrity Program, medical claims mining, medicare, medicare cliams mining, spider webbing, unbundled medical billing, unbundling, www.healthcarefinancials.com | 5 Comments »

On Growing Tensions in Healthcare Services Markets

Posted on June 21, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Stressors Affecting all Stakeholders

[By Robert James Cimsai; MHA, AVA, ASA, CMP™]

http://www.HealthCapital.com

The changes in reimbursement for Medicare services through the introduction of prospective payment systems and physician reimbursement cuts for professional services, as well as the increased focus on patient quality and transparency initiatives and health 2.0 collaboration have forced healthcare providers to look for more efficient ways to provide services, as well as additional sources of revenue and margin-producing business.

Additionally, with the rise of corporate healthcare provider networks and health systems, together with rising healthcare costs, competition among providers has become prevalent in the healthcare industry.

Assessment

Strict control of reimbursement costs from payers and consistent decreases in physician professional component fee reimbursement yields; reduction in traditional hospital inpatient use; and higher costs of capital have all contributed to the trend of physician investment in outpatient (and inpatient) specialty provider enterprises [ASCs, specialty hospitals and clinics, etc] , which often compete with general acute care community hospital providers.

Conclusion

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Filed under: Career Development, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Practice Management | Tagged: health 2.0, health 2.0 collaboration, healthcare competition, HMO, IPA, Managed Care, MC, medicare, next generation healthcare, participatory medicine, PPO, PPS, prospective payment system, Robert Cimasi, www.healthcarefinancials.com | 6 Comments »

GM Bankruptcy Hits Delta Dental Hard

Posted on June 17, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

United Auto Workers Retirees Lose Benefits

[By Darrell K. Pruitt; DDS]

It’s no longer just the recent rash of bad PR on the Internet that has some Delta Dental employees worried about losing their jobs. Okemos, Michigan, home to Delta Dental of Michigan is downstream from GM. If Delta employees are laid off because of decreased sales of benefits packages, Okemos will lose even more of its disappearing tax base. And, this week we learn that United Auto Workers [UAW] retirees will lose their Delta dental benefits in GM’s bankruptcy.

The Michigan Messenger

I discovered a short article today on the Michigan Messenger Website, written by Ed Brayton, titled “GM’s UAW retirees to lose Delta Dental coverage.” Brayton closes with a sad lament: “It was only last November that Tim Daman, a Lansing Regional Chamber of Commerce vice president, declared that with the office expansion, 2008 was ‘really Delta’s year.’ It appears that 2009 will not be.” Less than a year before Daman’s optimistic comment, Delta Dental announced that it was expanding its existing office space by 25,000 square-feet including 20,000 for a new data center. It’s unfortunate that the squandered money wasn’t spent on GM retirees’ teeth before they lost their dental insurance. Is it any wonder that Americans pay so much for so little healthcare?

Eyeing the Situation

And, what was Delta planning to do with that much data space anyway? Are Delta’s computers that huge, or was someone anticipating that future claims processing will require lots of soon to be unemployed Okemos citizens? I think if Colombo, a detective played by Peter Falk in a TV show long ago, were to cast his good eye on this situation with Delta Dental, he would see something odd about risking so much healthcare money on “data” rather than rewarding bonuses to executives who managed to save those huge amounts of money on payments to dentists. He’d scratch his head with the same hand holding a cigar, and say something like, “If Delta was willing to invest that much into say, a data mining project; they must have been planning on saving even more money on dental care for GM retirees somehow. Where was that money going to come from?

Public Relations Perspective

Ari Adler, the same Delta PR employee who a few months ago publicly announced that Delta Dental guarantees its dentistry, offered prepared statements about the bad news for Delta, but would not comment on how this enormous loss in business might ultimately change the company’s plans. He was only allowed to offer that the company is “studying the impact of this situation on the organization.” He assured Brayton that the building is going up as planned. I hope Delta doesn’t back out of its guarantees on fillings. That would be especially cruel to GM retirees.

More: GM’s UAW Retirees to Lose Delta Dental Coverage

Dental provider plans to offer special options for retirees, whose coverage could end as early as next month

By Ed Brayton 6/8/09 12:11 PM

http://michiganmessenger.com/20507/gms-uaw-retirees-to-lose-delta-dental-coverage

Assessment

It’s a real puzzler, Columbo. But, I’d bet you could figure it out by the end of the show. Peter Falk and family, I wish you the best.

Managing Editor’s Note: Dr. Dave Marcinko our publisher will be on a book and speaking tour in Michigan, and the Upper Peninsula later this month. He will be “signing and opining” – “preaching and teaching” to all ME-P advocates and others who attend. So, be sure to stop by any venue, and say hello. And, we will report back on his trip later this summer.

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Conclusion

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Filed under: Alerts Sign-Up, Breaking News, Career Development, Events-Planner, Health Insurance, Interviews, Managed Care, Marketing & Advertising, Media Mentions and PR, Practice Management, Research & Development, Sponsors | Tagged: Ari Adler, book tour, Darrell Pruitt, david marcinko, Delta Dental Michigan, dental insurance, Ed Brayton, General Motors, GM, GM bankruptcy, healthcare benefits, Lansing, Michigan Messenger, Okemos, Tim Daman, UAW, United Auto Workers | 8 Comments »

Medical Coding and Billing Vocabulary

Posted on June 11, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Basic HIT Nomenclature and HIPAA

[By Richard J. Mata; MD, MIS, CMP™ [Hon]

For the Health Information Technology [HIT] department of a hospital, clinic or medical practice and its coders, the following medical vocabularies are mandated by the Health Insurance Portability and Accountability Act [HIPAA].

Diseases

For diseases: the 9th or 10th International Classification of Diseases (ICD) Clinical Modification should be used. ICD9-CM is maintained by the Centers for Disease Control National Center for Health Statistics, while ICD-10 is maintained by the World Health Organization.

Procedures

For medical procedures: a combination of ICD-9-CM, Current Procedural Terminology maintained by the American Medical Association, the Current Dental Terminology maintained by the American Dental Association, and Healthcare Common Procedure Coding System (HCPCS) maintained by CMS, which is also used for medical devices.

Pharmaceuticals

For drugs: these should be coded according to their National Drug Code classification.

Assessment

“A recent change to Medicare policy made by the Centers for Medicare & Medicaid Services (CMS) helps ensure claims processing isn’t delayed when the only missing information on the CMS-1490S form is the provider or supplier’s National Provider Identifier (NPI).

CMS Transmittal 1747, Change Request 6434, issued May 22, notifies A/B Medicare Administrative Contractors (MAC) and carriers of editorial changes to Medicare policy in Pub. 100-04, Medicare Claims Processing Manual, chapter 1 regarding the monitoring of claims submission violations and the handling of incomplete or invalid claims.

In either case, as stated in the transmittal, “If the beneficiary furnishes all other information but fails to supply the provider or supplier’s NPI, the contractor shall not return the claim but rather look up the provider or supplier’s NPI using the NPI registry.”

http://www.aapc.com/news/index.php/2009/06/missing-npi-no-reason-to-deny-says-cms/

Conclusion

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Filed under: Glossary Terms, Health Insurance, Information Technology, Practice Management, Research & Development | Tagged: ADA, AMA, CDC, CDT, Centers for Disease Control National Center for Health Statistics, CMS, CPT, current dental terminology, current procedural terminology, david marcinko, HCPCS, Healthcare Common Procedure Coding System, HIPAA, hope hetico, ICD-10, ICD-9, international classification of diseases, IT, MAC, medicare, National Drug Code, National Provider Identifier, NPI, Richard Mata, WHO | 2 Comments »

Why Coding Professionals?

Posted on June 7, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

More on the NPI, the AAPC, Censorship and Quality Health Care

By Darrell K. Pruitt; DDS

For those who have been following me recently on Twitter (Proots), you know that unlike me, John Hamm has not yet been kicked off of DrBicuspid, and is awaiting a response from Dr. David J. Pettigrew – a dental coding expert with 14 years of experience as Chief Dental Officer for BCBS of New Jersey. I can only shadow the conversation because, as I said, I was kicked off.

Through John Hamm, I sent word to Dr. Pettigrew that he should just shut up and not enter into a discussion about the NPI number. Pettigrew told Johnhamm that I should come onto the DrBicuspid forum and say that in front of everyone. Of course, I am unable to do that because as shameful as it is to my family, I am still banned from posting anything on DrBicuspid.

For real-time developments concerning Dr. Pettigrew’s public defense of the NPI number, it would be better to follow that chunk of drama on Twitter or DrBicuspid. I’ve got other things cooking here. Can you smell it yet?

As you can see, sports fans, I have had Internet contact with a new class of fat, slow-moving healthcare IT stakeholders, and I haven’t been building long-term relationships fortified by good will – if you know what I mean. 14 years of employment at BCBS of New Jersey fails to impress me much.

American Academy of Professional Coders

Those who have studied alphanumeric science have a national organization called the American Academy of Professional Coders [AAPC] which represents business consultants in a growing healthcare niche. Most are employed by providers who are too busy actually performing healthcare to play games with insurance companies for the money owed them. Like SEO professionals who know gimmicks to increase a client’s page rank in relation to competitors, or perhaps a bolus of bad news from a special bastard, professional coders maximize providers’ profits by keeping on top of the ever-changing hoops involved in paying doctors almost all that is owed them following a shorter than average delay.

ICD-10 is Coming

Learning coding is job security these days because in a few years the mandated ICD-10 codes will force even dental offices to hire IT staff, which also cuts down on the nation’s unemployment. I’ve taken a peek at the ICD-10, and it makes the ICD-9 look like simple algebra. I’d stick with well-trained coding professionals. They’ll cost more but you do want to approach making a profit, don’t you?

Of Censorship

I submitted the following stinker to be posted on the AAPC Website. To their credit, it was posted almost immediately. That could be a good sign … OOPS! Several minutes later it went back under moderation. I think someone is having problems with it. You’ll have to read it to understand why. It’s tricky to let go of, yet if it remains posted, it looks like a concession. Some poor slob in the AAPC is in a bad position. I hope you are enjoying this as much as I am.

-Darrell

CMS Transmittal 1747, Change Request 6434, issued May 22, notifies A/B Medicare Administrative Contractors (MAC) and carriers of editorial changes to Medicare policy in Pub. 100-04, Medicare Claims Processing Manual, chapter 1 regarding the monitoring of claims submission violations and the handling of incomplete or invalid claims.

http://www.aapc.com/news/index.php/2009/06/missing-npi-no-reason-to-deny-says-cms/

“How does an NPI number improve patient care?”

By D. Kellus Pruitt DDS – posted on AAPC Website, 6.4.09

I see that nobody from the American Academy of Professional Coders has yet attempted to answer my question. Some visitors to the AAPC Website who have followed the comments to the article “Missing NPI Won’t Delay Processing – CMS” (no byline) may think the lack of an answer is odd – that is if they happen to notice. The novice professional coder who still does not know much about HIPAA could easily assume that since the article itself is almost a week old, the lack of a response to my question is nothing more than the natural fading of interest. At some point, people logically move on to newer posts and other parts of their lives.

But I know a secret.

Based on nothing more than glaring silence from anonymous officials of AAPC, I know that my question of whether the NPI number improves care did not go unnoticed by a few knowledgeable and sharp individuals. They know enough not to touch a transparently trick question. The answer of course is:

The NPI number does nothing to improve patient care (Gasp!)

There’s more. Five years ago informatics experts (coders), promised that the ten digit identification number for providers will speed payments lightning fast. When is the last time you heard that fib? I cannot fault abundant optimism, AAPC, but by now you are surely aware that physicians have had to wait for a year or more for payment because of foul-ups at NPPES. Some have had to take out loans to pay the salaries of coding professionals and other new IT members of their staffs.

Improving Healthcare?

And as far as “improving” patient care? That would be worse than a fib. That would be called a harmful lie that upsets me in a very personal way. I know where it is documented that dental patients have been forced to leave dentists they preferred simply because one-third of the dentists in Texas do not have NPI numbers. BCBSTX requires that their clients only see dentists who have the numbers. Otherwise, the client has to pay their dental bill in full and BCBSTX isn’t even obligated to refund the employer the insurance premium. Yet BCBSTX sales reps tell these employers that their employees can see any Texas dentist they choose.

I’m sorry. Sometimes I ramble.

To keep it fair, I will ask if there is anyone who would like to point out the benefits of the NPI number. Your AAPC members and many others, including enthusiastic newbie coders, are interested in hearing from leaders of the organization. Many careers are built upon the complexities caused by digitalization and informatics. I don’t blame you for the complications. After all, you don’t make the rules – you just get along with them really well. It’s like our unavoidably complicated tax code and accountants. Accountants call themselves professionals. So why the hell shouldn’t you?

The Medical Executive-Post

Let me say that I am grateful that you believe enough in transparency that this comment remains posted. It wouldn’t surprise me if someone briefly considered deleting it until they discovered that it will be on the PennWell forum and probably on the Medical Executive-Post anyway. And of course, we can all see that you chose the honorable thing to do.

NPI Fallacy

The NPI fallacy reminds me of a scene in the Mike Judge movie “Idiocracy,” when a character 500 years in the future named Frito is asked why fields are fruitlessly irrigated with a politically-correct brand of green colored sports drink instead of water. Frito, who got his law degree from Costco, doesn’t even have to suffer minimal thought before he quickly repeats what he’s heard so many times, “’Cause it’s got ‘lectrolytes.”

Grnerod finds it incredible that I don’t have an NPI number. “How on earth are you billing and getting paid without an NPI?”

I told him (?) that I don’t work if I don’t get paid. Call me an old school radical.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. What are your feelings on the NPI situation? Does it really improve health care, or not? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Filed under: Glossary Terms, Health Economics, Health Insurance, Information Technology, Op-Editorials, Practice Worth | Tagged: A/B Medicare Administrative Contractors (MAC), AAPC, ADA, AMA, American Academy of Professional Coders, BCBS New Jersey, BCBS New York, CMS, CMS Transmittal 1747 Change Request 6434, CMS-1490S, CPT codes, Darrell Pruitt, david marcinko, Dr. David J. Pettigrew, DrBicuspid, ICD-10, ICD-9, John Hamm, medical billers, medical coders, Medicare Claims Processing Manual, National Provider Identifier, NPI, NPI Number, Proots, Pub. 100-04 | Leave a comment »

The Power of “ME Inc” for Physicians

Posted on June 3, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Embracing a New Competitive Practice Culture

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

There are more than 900,000 physicians in the United States. Yet, the brutal supply/demand/demographic calculus of the matter is that there are just too many aging patients chasing too few doctors. Compensation and reimbursement is plummeting as Uncle Sam becomes the payer-of-choice for more than 52% of us. And, the government as payer will likely increase with the Obama Administration. So, going forward, it is not difficult to imagine the following four rules for a new-wave competitive medical care culture for all physicians.

[A] Rule No. 1

Forget about large office suites, surgery centers, fancy equipment and the bricks and mortar that comprised traditional medical practices. One doctor with a great idea, good bedside manner or competitive advantage, can outfox a slew of CPAs, while still serving the public and making money. It’s a unit-of-one healthcare economy where “ME Inc.”, is the standard and physicians must maneuver for advantages that boost their standing and credibility among patients and payers. Examples include patient satisfaction surveys, the rise of evidence-based medicine; outcomes research analysis, concierge medicine, direct reimbursement payment plans, and economic credentialing; etc.

[B] Rule No. 2

Challenge conventional wisdom, think outside the traditional payer box, recapture your dreams and ambitions, disregard conventional gurus and work harder – and smarter – than you have ever worked before. Remember the old saying, “if everyone is thinking alike, then nobody is thinking”. Do insurance panel members think rationally or react irrationally?

However, you should realize the power of networking, vertical integration and the establishment of virtual medical practices, which come together to treat a patient, and then disband when a successful outcome achieved. Job security in this structure is achieved with successful outcomes, and perhaps not necessarily a degree in the near future. Medical futurists even presume the establishment of virtual medical schools and hospitals, where students and doctors learn and practice their art on cyber-entities that look and feel like real patients, but are generated electronically through the wonders of virtual reality units.

www.HealthcareFinancials.com

[C] Rule No 3

Differentiate yourself among your medical peers. Do or learn something new and unknown by your competitors. Market your accomplishments and let the world know. Be a non-conformist. The conformity of health insurance plans are an operational standard and a straitjacket on creativity. Doctors should create and innovate, not blindly follow entrenched medical society leaders into oblivion. Seek, and practice, health 2.0 collaboration with all stakeholders.

[D] Rule No 4

Realize that the present situation is not necessarily the future. Attempt to see the future and discern your place in it. Master the art of the quick change and fast but informed decision making. Do what you love, disregard what you don’t, and let the fates have their way with you. Then, decide for yourself if health plans adhere to any of the above rules?

Assessment

Regardless of the future de facto business model of the learned profession of medicine, current practice models are no longer the structure of choice. Rather, a more laissez-faire and highly competitive business model should be pursued. Physicians have been slow to accept this philosophy. Remember, as a physician, if you merely want a static job with promised security, pledged retirement benefits, limited goals and structured regulations; join a health plan panel and become their laborer.

However, if you desire more, such as the possibility of a dynamic career, the unlimited security of your brainpower, non-defined retirement contributions, infinite potential with rules you can create along the way; incorporate the power of ME, Inc., in everything you do. Remain a competitive professional and be a physician ... Get fly!

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Filed under: Career Development, Ethics, Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, iMBA, Inc., Managed Care, Practice Management | Tagged: Comparative Medical Effectiveness, competition, concierge medicine, CPAs, david marcinko, direct reimbursement, healthcare competition, outcomes research, physician economic credentialing | 3 Comments »

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