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Risk Assessment of Medical Practice Billing Companies

Posted on February 28, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Office of Inspector General

[By Pati Trites MPA, CHBC with Staff Reporters]

The Office of Inspector General [OIG] believes a medical billing company’s written policies and procedures, its educational program and its audit and investigation plans should take into consideration the particular statutes, rules and program instructions that apply to each function or department of the billing company.

Co-ordination Needed

Consequently, coordination between these functions is needed, with an emphasis on areas of special concern that have been identified by the OIG through its investigative and audit functions.

Furthermore, the OIG recommends that billing companies conduct a comprehensive self-administered risk analysis or contract for an independent risk analysis by experienced health care consulting professionals. This risk analysis should identify and rank the various compliance and business risks the company may experience in its daily operations.

Risk Analysis

Once completed, the risk analysis should serve as the basis for the written policies the billing company should develop. The OIG provides the following specific list of particular risk areas that should be addressed by billing companies. It should be noted that this list is not all-encompassing and the risk analysis completed as a result of the company’s audit may provide a more individualized roadmap. Nonetheless, this list is a compilation of several years of OIG audits, investigations and evaluations and should provide a solid starting point for a company’s initial effort.

Problem List

Among the risk areas the OIG has identified as particularly problematic are:

Billing for items or services not actually documented;
Unbundling;
Upcoding, such as, for example, “DRG creep;
Inappropriate balance billing;
Inadequate resolution of overpayments;
Lack of integrity in computer systems;
Computer software programs that encourage billing personnel to enter data in fields indicating services were rendered though not actually performed or documented;
Failure to maintain the confidentiality of information/records;
Knowing misuse of provider identification numbers, which results in improper billing;
Outpatient services rendered in connection with inpatient stays;
Duplicate billing in an attempt to gain duplicate payment;
Billing for discharge in lieu of transfer;
Failure to properly use modifiers;
Billing company incentives that violate the anti-kickback statute or other similar Federal or State statute or regulation;
Joint ventures;
Routine waiver of copayments and billing third-party insurance only; and
Discounts and professional courtesy.

Additional Risk Areas

The physician-executive should understand that a billing company’s prior history of noncompliance with applicable statutes, regulations and Federal health care program requirements may indicate additional types of risk areas where the billing company may be vulnerable and may require necessary policy measures to prevent avoidable recurrence.

Additional risk areas should be assessed by billing companies as well as incorporated into the written policies and procedures and training elements developed as part of their compliance programs.

Assessment

Billing companies that do not code bills should implement policies that require notification to the provider who is coding to implement and follow compliance safeguards with respect to documentation of services rendered.

Moreover, the OIG recommends that billing companies who do not code for their provider clients incorporate in their contractual agreements the provider’s acknowledgment and agreement to address the above coding compliance safeguards.

Conclusion

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Filed under: Career Development, Health Insurance, Health Law & Policy, Professional Liability, Risk Management | Tagged: ARs, CPT codes, DRG, healthcare fraud, medical billing firms, medical invoicing, OIG, Pati Trites | 7 Comments »

Political Primer on Healthcare Reconciliation

Posted on February 27, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

What it is – How it Works

By Staff Reporters

Several ME-P readers have contacted us for a definition of the term “reconciliation” and what it means in the current political debates and the recent Healthcare Summit in Washington, DC.

Definition,

According to Wikipedia, Reconciliation is a legislative process intended to allow consideration of a contentious budget bill without the threat of filibuster. Introduced in 1974, reconciliation limits debate and amendment, and therefore favors the majority party. Reconciliation also exists in the House of Representatives, but because the House regularly passes rules that constrain debate and amendment, the process has had a less significant impact on that body.

Healthcare Significance

“In 2009 the House and Senate each passed separate healthcare reform bills. The Senate bill passed only after all 60 members of the Democratic caucus voted for cloture to stop an attempted Republican filibuster. Negotiations to produce a compromise bill acceptable to majorities in both houses were thrown off track by Republican Scott Brown’s victory in the Massachusetts.

After Brown’s victory, the Democratic caucus no longer had enough votes to stop a Senate filibuster of the compromise bill. An alternative plan was for the House to pass the Senate bill verbatim, and for each house to pass another bill that would embody the compromises agreed to in the negotiations. This separate piece of legislation, which might possibly include a public option, would require use of the reconciliation procedure in the Senate.”

Of Minutia

No matter whether the House votes on reconciliation or the Senate bill first, the Speaker can ensure that the health care bill is signed into law before reconciliation. (The dirty little secret of Congress is that even if the House votes to pass the Senate health care bill tomorrow, the Speaker has unilateral power to hold that bill at her desk until January 3rd of next year before sending it to the President and starting the 10-day Constitutional veto clock).

Assessment

The Republican leader in the Senate, Mitch McConnell, said: “Using reconciliation would be an acknowledgment that there is bipartisan opposition to their bill, another in a series of backroom deals, and the clearest signal yet that they’ve decided to completely ignore the American people.” according to the New York Times, February 19, 2010.

Other opponents of Democratic legislative initiatives in the 111th Congress began to refer to reconciliation as the “nuclear option, although that term had previously been used to refer only to a majoritarian procedure to effect a formal change in Senate rules.

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Note: Cloture is the only procedure by which the Senate can vote to place a time limit on consideration of a bill or other matter, and thereby overcome a filibuster. Under the cloture rule (Rule XXII), the Senate may limit consideration of a pending matter to 30 additional hours, but only by vote of three-fifths of the full Senate, normally 60 votes.

Conclusion

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Filed under: Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: cloture, fillibuster, healthcare reform, Healthcare Summit, obama, reconciliation, Scott Brown | 7 Comments »

Reality TV or Healthcare Summit?

Posted on February 25, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Preparing for the Debate and a TV Audience

By Staff Reporters

In convening today’s bipartisan health session, President Obama is angling to recreate the kind of spontaneous, unscripted debate that gave him a decided advantage when he took questions on live television at a House Republican retreat in Baltimore Maryland, last month.

Link: http://www.nytimes.com/2010/02/25/health/policy/25summit.html?ref=health

[picapp align=”none” wrap=”false” link=”term=healthcare+summit&iid=5340228″ src=”3/c/1/8/Members_Of_White_56fc.jpg?adImageId=10712340&imageId=5340228″ width=”380″ height=”527″ /]

Assessment

Or, will the meeting be like the summer’s flu summit; much ado about nothing?

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Watch, listen and tell us what you think about the President’s ideas; new innovations or more of the same? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too.

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The Almost Brand New Obama Healthcare Reform Proposal [Again]!

Posted on February 23, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Fallback Version Now More Likely than Ever

By Staff Reporters

President Barack Obama put forward a nearly $1 trillion, 10-year healthcare reform bill compromise yesterday that would allow the government to deny or roll back egregious insurance premium increases that infuriate consumers. Of course, all ME-P readers are aware of the recent Wellpoint scenario, and Anthem rate increases at such an inauspicious time. Nevertheless, it is unlikely that such sweeping political legislation can pass.

Bi-Partisan Opposition Brewing

Most political pundits view Republicans as opposing the new Obama plan along with some Democrats who previously supported healthcare reform and are having second thoughts in an election year. And so, after a year in pursuit, Obama may still have to settle for a crippled fallback version of what once was his top domestic priority.

Assessment

Feel free to review the attached summary report [The President’s Proposal – February 22, 2010 – Puts American families and small business owners in control of their own health care].

This revised Obama health plan costs $1 trillion. No public option is proposed to cover 31 million uninsured, or limit health insurance rate hikes.

Link: summary-presidents-proposal

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Be sure to take a read and tell us what you think of the new Obama health plan proposal. And, then vote:

VOTE: https://healthcarefinancials.wordpress.com/2009/12/17/vote-on-healthcare-reform/

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Health Care and the Economy

Posted on February 22, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

The National Governors Association Meeting

By Staff Reporters

The National Governors Association (NGA)—a bipartisan organization of the nation’s governors—promotes visionary state leadership, shares best practices and speaks with a unified voice on national policy.

Healthcare Politics

The nation’s governors gathered this weekend to address critical issues, including health care reform and the economy. The Governors met with President Obama, members of the Administration, business executives and other experts for discussions on a host of issues and challenges facing states.

Opening Session

This 2010 winter meeting began with a robust opening plenary session highlighting the role states can play in improving health care delivery systems to provide cost-efficient and effective health care to all Americans.

http://www.nga.org/portal/site/nga/menuitem.b14a675ba7f89cf9e8ebb856a11010a0

Conclusion

And so, your thoughts and comments on this ME-P are appreciated; especially our colleague Somnath Basu, PhD. Be sure to visit and watch the online video discussions, as well.

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Filed under: Breaking News, Career Development, Health Economics, Health Insurance, Health Law & Policy | Tagged: CMS, Health Economics, Health Insurance, healthcare, healthcare financing, healthcare reform, National Governors Association, obama | 2 Comments »

Save Fewer Lives or Save Lives More Efficiently?

Posted on February 15, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

An Economics Argument

By Austin Frakt PhD

The Incidental Economist

Originally Posted: 14 Feb 2010 03:58 AM PST

Let’s say the cost per saved life due to providing an additional individual with health insurance is X dollars (Tyler Cowen says X = $9 million; I say that’s an overestimate). If one thinks X is too high, what’s the right policy response? One answer is to extend insurance to fewer people. The other is to try to reduce the cost of care so that X is lower.

The Differential

There is a huge difference between these two responses. I won’t go into all of them now. One important difference I want to highlight is that if we simply reduce the number who will become insured then the rest of us are still left paying exorbitant health care costs. Thus, two problems remain, many are left uninsured and health care costs are still too high.

Cost Reductions

On the other hand, if the policy response is to reduce the cost of care then we all win. More of the uninsured can be insured for some level of funding and the rest of us can benefit from lower health care costs. That’s a double victory.

Assessment

That health reform is too expensive is not a good argument for doing less of it*. It is an argument to do more. The provision of health care will not become more efficient under the status quo. And, the status quo (with perhaps minor tweaks to it) is what we will get if health reform does not pass this year. But, if reform does pass it sets the stage for more reforms, and ones that focus on costs.

*Note: I’m not saying I think it is too expensive. But if you do think it is I do not find that a convincing argument not to do it.

Link: http://theincidentaleconomist.com/save-fewer-lives-or-save-lives-more-efficiently/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+TheIncidentalEconomist+%28The+Incidental+Economist+%28Posts%29%29

Conclusion

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Filed under: Health Economics, Health Insurance | 1 Comment »

On the Elimination of Medicare Consultation Codes

Posted on February 8, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Is it Budget Neutral?

By Brian J. Knabe MD, CFP, CMP

http://www.CertifiedMedicalPlanner.org

The New Year 2010 has brought some changes in the Medicare Physicians Fee Schedule. For many specialists, the most significant change is the elimination of consultation codes, 99241-99245 in the outpatient setting and 99251-99255 for inpatient care. Physicians can still provide consultations and bill for these services – using codes for routine new or established patient visits (99201-99205 and 99211-99215).

Reported Revenue Neutrality

It has been reported that this change has been made in a revenue neutral manner. Reimbursement for all E/M codes has been increased in order to make up for the removal of consultation codes. The increase is approximately 6% in the outpatient setting and about 2% for inpatient codes.

Of Averages and Outliers

The result of these changes might be revenue neutral overall, but the outlier effect on many specialties and individual physicians can be significant. Specialists who obtain most of their income from procedures will see less of an effect on their income. This includes dermatologists, surgeons, and gastroenterologists. Less procedurally-oriented specialists, particularly those who rely upon Medicare as a primary payor, are seeing the most significant effect. For example, neurologists and hematologists will likely see double-digit declines in revenue.

Private Payers

While private payers have not yet adopted these changes, billing codes must be adjusted when filing a claim with a commercial insurer when Medicare is the secondary insurer. If a consultation code is used in these instances, the primary payer will pay their portion of the bill, but Medicare will deny secondary coverage. There is no indication yet that commercial insurers are dropping the consultation codes altogether, but if history is any indication, they will likely eventually follow the lead of Medicare.

Assessment

Physicians can take certain measures to decrease the impact of these changes on their revenue stream. It is increasingly important to understand how the complexity of a patient visit affects the appropriate level to be billed. Prolonged service codes are also available (99356 and 99357) to enable physicians to bill appropriately for more complex and time-consuming evaluations.

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
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Dictionary of Health Economics and Finance
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Product Details

Filed under: Health Insurance, Health Law & Policy, Practice Management | Tagged: brian knabe, CPT codes, EM codes, medical billing codes, medicare, physician fee schedules | 5 Comments »

The Scott Brown versus Healthcare Reform Poll

Posted on January 20, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

The Sott Brown Opinion Poll

By Staff Writers

In what some pundits are calling the “Boston Massacre” in liberal Massachusetts, Republican Scott Brown rode a wave of voter anger to win the US Senate seat held by the late Edward M. Kennedy for nearly half a century, leaving President Barack Obama’s health care overhaul in doubt and marring the end of his first year in office.

Our ME-P Audience

As a financial advisor, we know you are aware of the rise in healthcare stocks yesterday. And, as a medical executive or healthcare professional, we know you have been against the public option, and healthcare reform, in its current version. The AMA is not your friend – nor does it represent you.

The Question Is?

And so, do you believe that last Tuesday’s Republican victory in Massachusetts means the current Democratic health care bill will not be on the President’s desk in 2010?

Please VOTE:

Filed under: Health Insurance, Health Law & Policy, Surveys and Voting, Voting Polls | Tagged: AMA, Edward Kennedy, FA, financial advisor, healthcare reform, obama, public option, Scott Brown, Ted Kennedy | 4 Comments »

Healthcare Reform and the US Constitution

Posted on January 17, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Consider this Proposed 28^th Amendment

Submitted by Cecelia T. Perez; RN

Author Unknown

For too long we have been too complacent about the workings of Congress. Many citizens have no idea that Congress members can retire with the same pay after only one term, that they didn’t pay into Social Security, and that they specifically exempted themselves from many of the laws they have passed (such as being exempt from any fear of prosecution for sexual harassment); while ordinary citizens must live under those laws.

The Healthcare Reform Exemption

The latest is to exempt themselves from the Healthcare Reform that is being considered … in all of its forms. Somehow, that doesn’t seem logical. We do not have an elite class that is above the law. I truly don’t care if they are Democrat, Republican, Independent or whatever. The self-serving must stop. This is a good way to do that. It is an idea whose time has come.

Proposed 28th Amendment to the United States Constitution:

“Congress shall make no law that applies to the citizens of the United States that does not apply equally to the Senators and Representatives; and, Congress shall make no law that applies to the Senators and Representatives that does not apply equally to the citizens of the United States.”

Assessment

Each person contact a minimum of twenty people on their address list, in turn ask each of those to do likewise. Then in three days, all people in The United States of America will have the Message. We ask you to pass this idea to your friends for their consideration.

Channel Surfing

Have you visited our other topic channels? Established to facilitate idea exchange and link our community together, the value of these topics is dependent upon your input. Please take a minute to visit. And, to prevent that annoying spam, we ask that you register.

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Filed under: Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Op-Editorials | Tagged: congress, healthcare reform, public option, social security, US Constitution | 2 Comments »

Around the Healthcare Financial Blog-O-Sphere

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

News and Economics Updates in Thirty Minutes or Less

By Staff Reporters

1. Unions pressure Democrats on health insurance tax
Associated Press via Google, December 10, 2009

2. Is there a doctor in the corporation? Maybe soon
Reuters, December 9, 2009

3. Sebelius Statement on Benefits of Health Insurance Reform for Businesses
HHS Press Release, December 3, 2009

4. Majority of employers would reduce health benefits to avoid proposed excise tax
Mercer Press Release, December 3, 2009

5. U.S. unemployed face higher healthcare premiums
Reuters, December 2, 2009

6. Public support for health-care reform is high, but some CFOs take a different view
CFO.com, December 1, 2009

7. Survey: Growing worker stress seen in benefits use
Associated Press via Google, November 30, 2009

8. Employers Play Dr. Mom to Limit Swine Flu Impact
Associated Press via Google, November 30, 2009

9. Health Care Savings Could Start in the Cafeteria
The New York Times, November 28, 2009

10. Ford, GM Face $2.5 Billion First VEBA Bill
Workforce Management, November 24, 2009

11. Plan credits healthy habits – Employer cuts costs by allowing workers to ‘earn’ lower rates
Business Insurance, November 23, 2009

12. Health Care: GE Gets Radical
Business Week, November 19, 2009

Conclusion

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Filed under: Breaking News, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Monthly Reports | Tagged: Health Insurance, healthcare business, healthcare economics, Healthcare Finance | 4 Comments »

Take the ICD-10 Survey Poll

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

ICD-10 Survey Poll

By Ann Miller; RN, MHA

[Executive Director]

The Department of Health and Human Services [DHHS] recently released the final rule for implementing the ICD-10 [International Classification of Diseases] CM [Clinical Modification] and ICD10-PCS [Procedure Coding System] insurance coding initiatives.

Shifting Deadlnes

The compliance deadline was shifted from October 1, 2011; as proposed in the original rule; to October 1, 2013. And so, how prepared are you for the transition to ICD-10?

Please VOTE:

Filed under: "Doctors Only", Health Insurance, Research & Development, Voting Polls | Tagged: CM, CMS, DHSS, ICD-10, ICD-9 | 7 Comments »

Kathleen Sebelius Please Pay Attention to Dr. Darrell Pruitt

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

Deferred Investment [An Incentive to Access]

By D. Kellus Pruitt; DDS

On Friday, the editor of the Chicago Dental Society’s [CDS] blog “Open Wide” posted a progressive, brief article titled, “State of Illinois offers incentive for dentists to treat Medicaid patients” (no byline).

http://chicagodentalsociety.blogspot.com/2009/12/state-of-illinois-offers-incentive-for.html

CDS says that last week, Governor Pat Quinn signed a law which allows Illinois dentists who treat Medicaid patients to accept payment deposited into a tax deferred investment portfolio instead of the traditional delayed, unpredictable payments that offer no tax advantages – only headaches.

Illinois Governor Quinn is a vast improvement over his predecessor. What was his name? He’s gone on to become a TV personality …. Oh yeah. Blagojevich!

I don’t know about you, but for me, Quinn’s incentive to access could offer not only more relief for those who cannot afford dental care in Texas, but it could also be a more or less painless way for dentists to fund IRAs – rather than having to do it at the last minute like I’ll do in a few months – just like every year. Instead of having an IRA hanging over my head, all I would have to do is donate my skills to help a few more people every now and then. That’s noble, charitable duty, friends – even with the Quinn incentive.

I especially respect current Medicaid dentists who work for nothing at all on the more profitable days.

To HHS Secretary Kathleen Sebelius

Pay attention. You only think you run the show.

The nations’ dentists you need aren’t being paid what they deserve, yet they put up with expensive and threatening CMS bureaucracy and struggle on – simply because they wish to ease suffering everyone else chooses to ignore.

Medicare dentists are American heroes to be sure. But let me warn you, Ms. Sebelius, they will turn on you hard and cold if you try to push them around. It’s time that you welcome real dentists to the bargaining table instead of ambitious ADA-approved stakeholders. You need us more than we need you, Ms. Sebelius. Forget the ADA. That is a foundation on which we can build … or not.

And this is for my stunned dentist colleagues in Texas who cross the street to ignore grandiose special bastards like me. Most of you detest the messy stuff I drag around, but nevertheless can’t stop watching from a safe distance. Rather than get your own hands messy, most of you simply pay the TDA to quietly and ineffectively hide or delay huge approaching problems. So what’s the trade-off? To remain “In the Loop,” you must obediently take up your differences with leadership in the approved, professional manner through designated ADA representatives. And. that’s so cute.

Now that you read about Quinn’s incentive, don’t you also hope that a TDA committee has already approved a draft of a deferred investment proposal to be offered to state lawmakers as soon as possible? After all, similar plans are already being tried in not only Illinois, but in four other states as well: Louisiana, Florida, Mississippi and Arkansas.

Hope as we may, nimrods, I fear those in Austin who should be paying attention to legislative opportunities such as this only heard about Quinn’s incentive to access law a minute or so ago at best.

Of Face Book Accounts

Both the TDA and the ADA desperately need functional Facebook accounts like Chicago Dental Society’s. By the way, it is the CDS which will be hosting their annual mid-winter dental conference in Chicago – reliably a tremendous meeting. This year it is Thursday-Saturday, Feb. 25-27, 2010 in the McCormick Place West Building.

http://www.cds.org/mwm_2010/

The TDA’s Facebook Wall is pristine white and graffiti-ready, and the spray paint is free to any artist who walks by. Not unexpectedly, it’s a mess. Nobody is joining, and whoever is in charge of managing the site is busy deleting unacceptable comments from a jerk who has no respect for anyone. (It’s not me). The TDA Facebook is in trouble, and it has been suggested that it should be shut down. It is indeed an embarrassment.

Assessment

Here’s something we’ll all laugh about later: The one dentist in Texas who could have sent the rogue artist on down the road (me), was kicked off for badmouthing BCBSTX and the NPI number as well as 13 other listed allegations, including posting pornography. I’ll let the TDA Director of Membership explain that and the other allegations if you are curious. I was not provided access to the evidence on which the sudden and uncontestable revocation of my TDA benefit was based. But there’s still hope because a friend of mine resented the way I was treated and complained to the TDA using the approved channels. That was 2 months ago. I wonder how well that one is progressing from the Austin City dump.

The ADA Facebook is no better. Over 1600 fans have piled up at the door waiting for the ADA’s grand opening, yet nothing is happening. What do you think is going on there?

If you’ve missed hearing from me for the last 2 weeks and have an inquisitive mind, I’ve been pursuing answers for such questions about ADA and TDA transparency on Twitter. They call me Proots.

Conclusion

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Filed under: Breaking News, Funding Basics, Health Insurance, Health Law & Policy, Pruitt's Platform | Tagged: ADA, BCBSTX, Blagojevich, Chicago Dental Society, CMS, Darrell Pruitt, DDS, dentists, IRAs, Kathleen Sebelius, Medicaid, NPI, Pat Quinn, Proots, TDA, Texas Dental Association, twitter | 10 Comments »

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

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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?

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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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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:

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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

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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

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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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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

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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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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.

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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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Health Administration Terms: www.HealthDictionarySeries.com

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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

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Has anyone been bitten by the ‘incident to” rules? 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: 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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FINANCE:Financial Planning for Physicians and Advisors
INSURANCE:Risk Management and Insurance Strategies for Physicians and Advisors

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.

Conclusion

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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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Sponsors Welcomed

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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.

Conclusion

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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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Health care is the most rapidly changing domestic industry. The revolution occurring in health insurance and managed care delivery is particularly fast. Some might even suggest these machinations were malignant, as many industry segments, professionals, and patients suffer because of them. And so, because knowledge is power in times of great flux, codified information protects all people from physical, as well as economic harm.

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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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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 »

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