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Health Plan Management Navigator

Posted on July 11, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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July 2010 Edition

By Erin Sawchuk

Dear ME-P Readers

Please find attached the early July 2010 Edition of our health Plan Management Navigator. In this month’s edition, we suggest an approach to quantifying best practice of administrative activities of health plans. Determining best practice for health plans is a knotty problem because of the complexity of the product and because some of what makes for best practice cannot be captured in the current year’s administrative expense line. We offer a solution that we hope to implement but we would be grateful for any insights you wish to share on this matter.

Financial and Operating Results

Navigator also summarizes some of the May financial and operating results of health plans reporting in our Dashboard. Operating earnings are weak on soft revenues and compressing margins. Enrollment trends in Medicare, Medicaid and ASO products are relative bright spots. Plans are adapting by reducing staffing ratios.

Link: Early July 2010 Navigator[1]

Web Casts

Please save 2:00 on July 16, and 2:00 on August 5 for two important web conferences. The first will summarize the results of this year’s SEER benchmarks for Independent / Provider-Sponsored plans. The second will summarize this year’s SEER benchmarks for Blue Cross Blue Shield Plans.

The Plan Management Navigators containing the respective peer group data will be sent to you a day or so before the web conference. There is no charge to participate, but we would be grateful if you would let us know in advance. Please reply back to me.

Assessment

Erin Sawchuk [Sherlock Company]

P.O. Box 413

Gwynedd, PA 19436

www.sherlockco.com

215-628-2289 – Phone

Conclusion

Feel free to comment and 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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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Filed under: Career Development, Health Economics, Health Insurance, Healthcare Finance, Monthly Reports, Research & Development | Tagged: ASO, Blue Cross Blue Shield Plans, Erin Sawchuk, Medicaid, medicare, Plan Management Navigator, SEER, Sherlock Company | Leave a comment »

The PPACA and Physician’s Ability to Bill

Posted on July 9, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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Failure of Physician Referral Sources to Enroll in Medicare’s Provider Enrollment, Chain and Ownership System [PECOS] May Affect their Ability to Bill

By Garfunkel Wild, PC

In response to, among other things, the Patient Protection and Affordable Care Act that was signed into law earlier this year, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule on May 5, 2010 that requires all:

Physicians [1] and non-physician practitioners [2] who order or refer Medicare beneficiaries for, or furnish Medicare beneficiaries with, Part B covered items and services; and
Physicians who certify home health services be enrolled in PECOS as of July 6, 2010 in order for the billing provider to receive payment for the ordered, referred, or furnished items or services under Medicare Part B (and, in the case of home health services, Part A). Some of the types of claims that will be affected by this new rule include:
Claims from laboratories for ordered tests;
Claims from imaging centers for ordered imaging procedures;
Claims from suppliers of DMEPOS for ordered DMEPOS;
Certification for Part A and Part B covered home health services; and
Claims from specialists or specialty groups for referred services (including, but not limited to, physical therapy services).

In addition to prohibiting payment for these services, the interim final rule also requires that the teaching physician — NOT the intern or resident — be identified on the claim for Part B services as the referring or ordering physician whenever an intern or resident orders or refers. This is also effective as of July 6, 2010.

Assessment Therefore, all providers who bill for ordered, referred, or furnished items or services that are payable under Medicare Part B (and home health care providers who bill for Part A and/or Part B covered services) should check the “Ordering and Referring Report” maintained by CMS to confirm whether the ordering or referring provider has an enrollment record in PECOS before submitting a claim as of July 6, 2010.

This Report can be viewed at: www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp.

If the ordering or referring provider is not listed on the Report, there is confusion as to whether billing providers are entitled to submit claims for items and services ordered or referred by such providers. While CMS has acknowledged that some providers have encountered problems getting their information into PECOS and announced that, for the time being, it will not implement changes that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved by July 6, 2010, CMS has expressly declined to delay implementation of the interim final rule as of the date of this Alert.

References [1] This includes a doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry, and doctor of chiropractic medicine.

Conclusion

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, subscribe to the ME-P. It is fast, free and secure.

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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FINANCE:Financial Planning for Physicians and Advisors
INSURANCE:Risk Management and Insurance Strategies for Physicians and Advisors

Filed under: "Doctors Only", Breaking News, Health Economics, Practice Management | Tagged: Centers for Medicare and Medicaid Services, CMS, DMEPOS, medicare, Patient Protection and Affordable Care Act, PECOS, PPACA | Leave a comment »

Customer Service in Medicare and Medicaid Plans

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

June Edition of Plan Management Navigator

By Erin Sawchuk

erinsawchuk@sherlockco.com

Please find attached by the link below, the June 2010 Edition of Plan Management Navigator. In this month’s edition, we estimate the strength of cost drivers for “Customer Services in Medicare and Medicaid Plans.”

We quantify the relationships of customer services costs to simple algebraic and other operational metrics within the Customer Services function. We also identify and test some of the potential interrelationships between customer services costs and other functions for Medicare and Medicaid Plans. This analysis draws on data from the 2009 Sherlock Expense Evaluation Report.

Benchmarks

Also included in this analysis is an update on our progress on our various benchmarking universes. Participation is up this year, we think due to public policy changes and economic weakness. While benchmarks for Independent / Provider-Sponsored plans will be published shortly, please let us know if you are interested in joining our 2010 Medicare, Medicaid or TPA universes.

Link: Navigator June 2010[1]

Assessment

Finally, we summarize the operating and financial trends identified in our recent Dashboard.

Sherlock Company

P.O. Box 413

Gwynedd, PA 19436

www.sherlockco.com

215-628-2289

Conclusion

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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Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Sponsors Welcomed: Credible sponsors and like-minded advertisers are always welcomed.

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Alerts Sign-Up, Career Development, Health Economics, Health Insurance, Practice Management, Research & Development | Tagged: Erin Sawchuck, Medicaid, medicare, Plan Management Navigator, Sherlock Company, Sherlock Expense Evaluation Report, TPA | 4 Comments »

The DDS / Doctor [Salesman] will See [Up-Sell] you Now

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

Blurring the Line between Medical Professionalism … and Mercantilism

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Concerns and complaints about pushy dentists are apparently becoming more numerous among consumers, as elective cosmetic treatments and marginally effective tests and modalities are increasingly available from the same providers that patients formerly turned to for unbiased dental advice and oral healthcare. All for a price!

http://www.msnbc.msn.com/id/37198272/ns/health-oral_health

So, enter the cosmetic [rank-and-file] dentists and the elective renaissance of the profession – at least economically. An entire industry has even sprung up teaching dentists how to sell various products, and up-sell related services and procedures.

[picapp align=”none” wrap=”false” link=”term=dentists&iid=166771″ src=”0163/1731b859-b744-4a0e-b055-a9e985ad8673.jpg?adImageId=12959860&imageId=166771″ width=”372″ height=”459″ /]

Root-Cause [pun intended]

Why is this happening? Economics of course! Dental profession success in eradicating cavities, caries and other common mouth disorders – which used to comprise 80% of dental procedures and income – is now a two-edge sword working against their financial self interests … damn!

In fact, I recall about three decades ago when the situation first became acute, as more than a few of our nation’s dental schools closed for lack of interest in matriculation. Right here in Atlanta, the prestigious Emory University School of Dentistry closed its doors while I myself was a patient there; and employed as a surgical resident at a nearby acute care hospital. Contemporaneous cocktail party talk and medical gossip centered on the “death of dentistry” as I exhaled a sigh of relief at my career choice.

Going forward, years later, far too many managed care contracts reimbursed so poorly that they became a loss-leader [access portal to a patient population] for dental practitioners. In other worlds, lose money or break-even on the covered services contract, but profit handsomely by offering [pushing] non-covered services to cohort contract members … and their sphere of influence.

One Word from Mrs. Robinson – Plastics

Plastic surgeons, of course, are still the doctors most commonly associated with non-covered and purely cosmetic and elective treatments such as Botox injections, facelifts and tummy tucks. But, similar elective procedures — which generally aren’t covered by insurance — are being offered by a wide variety of medical specialists.

For example, many dermatologists, who treat patients for skin cancer and other diseases, also promote treatments to smooth wrinkles, lighten age spots and remove hair. Otolarnygologists, who care for patients with conditions of the ear, nose and throat, commonly perform nose jobs, brow lifts and eyelid surgery. And, podiatrists, who are often experts at foot reconstructive, diabetic and ankle surgery, sell shoes, shoe-inserts, laser beam treatments for fungus toenails and various cosmetic and prosthetic devices for deformed toenails and crooked digits.

Medicare Limits – Privates Don’t

At least Medicare requires an ABN [advanced beneficiary notice] for non-covered medical services, and limits non-participating doctors to 115% of the Medicare fee schedule for all providers. Increasingly, some private health plans are doing and proposing, same.

Practice Management Guru

Now, I have no issue with efficient medical practice management operations, for any specialty. In this era of managed care and health 2.0, governmental intervention is onerous, competition is fierce and patient empowerment is reversing the aging command-control medical establishment. Nor, do I have a problem with offering the entire range of therapeutic and/or elective options to any patient. This is a “good – better – best” elective marketing concept.

In fact, the third edition of our best-selling book, the Business of Medical Practice [Transformational Health 2.0 Skills for Doctors] will soon be released this autumn www.BusinessofMedicalPractice.com. In it, we seek to educate doctors about modern business, management and economics practices; as well as the emerging participatory health 2.0 philosophy and information technology skills. Our goal is enhancing the survival potential of the independent practicing medical professional.

But, the ever expanding menu of treatment options – promoted by a trusted medical professional – should include procedural risks and complications, period of recovery and alternatives, including benign neglect [watchful waiting], marginal benefit and marginal utility, as well as price transparency.

Call this new-wave litany, a type of “informed patient business consent”.

[picapp align=”none” wrap=”false” link=”term=doctor+money&iid=182012″ src=”0178/66353b45-9776-48b9-9bdd-2993a48f32bf.jpg?adImageId=12959922&imageId=182012″ width=”372″ height=”459″ /]

Aphorisms of the Past

Over the years, we have heard phrases like the following from all sorts of independent specialists. I know I have, and so have you. Many are the butt of “insider” jokes:

MD: I’m sure that appendix is hot – I have a car payment to make

DPM: Even the normal foot can be surgically improved

DO: Now, I can bill like a real MD

DDS: We can straighten out – the straightest teeth

DC: I’ll crack your back in only forty sessions … and I finance

But, these are aphorisms of the last-generation. Today we are responsible adults. Let’s grow up and become medical professionals and “DOCTORS” again … not healthcare merchants, sales sharks or equipment shills that offer strategic competitive advantages; but not real patient benefits.

Assessment

The old practice management business adage of yesteryear – to work longer hours, see more patients quicker, up-sell marginally effective procedures, or do more treatments in order to realize more income – will not necessarily hold true in the modern era.

http://www.washingtonpost.com/wp-dyn/content/article/2010/05/17/AR2010051703034.html

According to colleague, financial advisor and ME-P thought leader Brian J. Knabe MD – a primary care physician and current www.CertifiedMedicalPlanner.com matriculant – and textbook chapter 27 co-author on physician compensation and salary:

In the environment of Healthcare 2.0, those doctors who embrace efficiency, innovation and appropriate business models will be better positioned to optimize their incomes.

http://businessofmedicalpractice.com/chapter-27-salary-compensation-2/

Conclusion

Comments from our dental – and other – physician readers are requested. And, so are your general or specific thoughts on this ME-P. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe. It is fast, free and secure.

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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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Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: "Doctors Only", CMP Program, Ethics, Op-Editorials, Quality Initiatives | Tagged: ABN, DDS, DMD, DO, DPM, MD, medicare, osteopaths, Otolarnygologists, podiatrists, Practice Management, www.BusinessofMedicalPractice.com, www.certifiedmedicalplanner.com, www.healthcarefinancials.com, www.healthdictionaryseries.com, www.medicalbussinessadvisors.com | 2 Comments »

Late April 2010 Edition of Plan Management Navigator

Posted on May 1, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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On Medicare and Medicaid Plan Processing Costs

By Erin Sawchuk

Dear ME-P Readers

Please find attached the late April 2010 Edition of Plan Management Navigator.

Medicare and Medicaid Plans

In this month’s edition, we identify and test some of the potential interrelationships between claims processing costs and other functions for Medicare and Medicaid Plans. This analysis draws on data from the 2009 Sherlock Expense Evaluation Report.

Bench Mark Updates

Also included in this analysis is an update on our progress on our various benchmarking universes. Participation is up this year, we think due to public policy changes and economic weakness.

Link: Navigator Late April 2010[1]

Assessment

Please let us know if you are interested in joining our Medicare, Medicaid or TPA universes.

Sherlock Company

P.O. Box 413

Gwynedd, PA 19436

www.sherlockco.com

215-628-2289 – Phone

erinsawchuk@sherlockco.com

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Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Sponsors Welcomed

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

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Alerts Sign-Up, Breaking News, Career Development, Health Economics, Managed Care, Sponsors | Tagged: Douglas Sherlock CFA, Erin Sawchuk, Medicaid, medicare, Plan Management Navigator, Sherlock Expense Evaluation Report | 1 Comment »

On Medicare and Medicaid Cost Drivers

Posted on April 29, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

The Health Plan Management Navigator

By Douglas B. Sherlock; CFA

Dear ME-P Readers

Please find attached below the Mid April 2010 Edition of Plan Management Navigator.

In this month’s edition, we estimate the strength of cost drivers for claims processing in Medicare and Medicaid plans. We quantify the relationships of claims processing to simple algebraic expressions and operational metrics within the Claim and Encounter Capture and Adjudication function.

Assessment

Also included in this analysis is an update on our progress on our various benchmarking universes. Participation is up this year, we think due to public policy changes and economic weakness. Please let us know if you are interested in joining our Medicare, Medicaid or TPA universes.

Erin Sawchuk

Sherlock Company

P.O. Box 413

Gwynedd, PA 19436

www.sherlockco.com

215-628-2289 – Phone

erinsawchuk@sherlockco.com

Conclusion

Link: Navigator Mid April 2010

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Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Sponsors Welcomed

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

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Alerts Sign-Up, Health Economics, Health Insurance, Healthcare Finance | Tagged: Douglas B. Sherlock CFA, Erin Sawchuk, Health Economics, health plans, Medicaid, medicare, Plan Management Navigator, Sherlock Company | 4 Comments »

Donald M. Berwick MD to Head CMS?

Posted on April 13, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Obama Selects Health Policy Scholar as the Director for Medicare and Medicaid

By Staff Reporters

President Obama has named Dr. Donald M. Berwick, an iconoclastic scholar of health policy, to run Medicare and Medicaid, the programs that serve nearly one-third of all Americans.

Assessment

New York Times: http://www.nytimes.com/2010/03/28/health/policy/28health.html?scp=1&sq=Berwick&st=cse:

Berwick on: “Reducing the Harm from Medical Care” http://www.nihcm.org/pdf/ExpertVoices_Berwick_HR_final.pdf

Berwick on: “Curing Health Care”

http://www.amazon.com/Curing-Health-Care-Strategies-Improvement/dp/0787964522/ref=sr_1_1?ie=UTF8&s=books&qid=1271007422&sr=1-1

Wachter on: “Is Don Berwick the One”

http://community.the-hospitalist.org/blogs/wachters_world/archive/2010/03/26/is-don-berwick-the-one.aspx

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Is this the right man for the job? 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.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Subscribe Now: Did you like this Medical Executive-Post, or find it helpful, interesting and informative? Want to get the latest ME-Ps delivered to your email box each morning? Just subscribe using the link below. You can unsubscribe at any time. Security is assured.

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Sponsors Welcomed

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Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Alerts Sign-Up, Book Reviews, Breaking News, Health Insurance, Health Law & Policy | Tagged: CMS, Donald M. Berwick, Medicaid, medicare, obama | 13 Comments »

Update on Medicaid and Medicare Advantage Plans

Posted on April 9, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

The Impact of Health Care Reform

[By Christopher de Garay]

Please find attached below, the Early April 2010 edition of Plan Management Navigator.
Link: Navigator April 2010

Review

In this month’s edition, we review how health care reform will impact the top line of plans offering government managed care programs such as Medicare Advantage and Medicaid. Combined with new minimum health benefit ratios, these pressures will force health plans to look at their administrative expenses. In the next several issues of Navigator, we will look at specific operational metrics and their impact on functional areas such as claims processing.

2010 Benchmark Studies

This edition of Navigator also summarizes the timing for the 2010 benchmarking studies, which includes a new Third-Party Administrator universe.

Christopher de Garay
Senior Health Care Analyst
Sherlock Company
www.sherlockco.com
215-628-2289 Phone
215-542-0690 Fax
cgaray@sherlockco.com
P.O. Box 413
Gwynedd, PA 19436

Editor’s

If your plan would like to consider participation, we invite you to give Chris a call at 215-628-2289 or email him at sherlock@sherlockco.com.

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

Filed under: Alerts Sign-Up, Health Economics, Health Insurance, Managed Care, Research & Development | Tagged: Christopher de Garay, DHHS, Managed Care, Medicaid, medicare, Medicare Advantage, Sherlock Company, TPA | 12 Comments »

Events-Planner: March 2010

Posted on March 1, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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Events-Planner: MARCH 2010

By Staff Writers

“Keeping track of important health economics and financial industry meetings, conferences and summits”

Welcome to this issue of the Medical Executive-Post and our Events-Planner. It contains the latest information on conferences, news, and relevant resources in healthcare finance, economics, research and development, business management, pharmaceutical pricing, and physician/entity reimbursement! Watch for a new Events-Planner each month.

First, a little about us! The Medical Executive-Post is still a relative newcomer. But today, we have almost 17,500 visitors and readers each month from all over the country, in addition to our growing subscriber base. We have been a successful collaborative effort, thanks to your contributions. As a result, we are adding new resources daily. And, we hope the website continues to provide the best place to go for journals, books, conferences, educational resources, tools, and other things you need to establish the value your healthcare consulting and financial advisory intervention. And so, enjoy the Medical Executive-Post and our monthly Events-Planner with our compliments.

A Look Ahead this Month

March 1: Print Edition Healthcare Journalism: If you would like to “step-up-your-game” and be considered as a peer-reviewed contributor to the third print edition of: The Business of Medical Practice [Health 2.0 Profit Maximizing Techniques for Savvy Doctors]; contact Ann at: MarcinkoAdvisors@msn.com. There are several chapter topics still available. Now, the important dates:

March 1-4: HIMSS-10 Conference, Atlanta, GA
March 4-5: Medicare RAC Summit, Washington, DC
March 6-9: BISA Annual Convention, Westin Diplomat, Hollywood, FLA
March 7-9: ABA Wealth Management and Trust Conference, Biltmore, AZ
March 11: Health Plan Innovations Conference, Orlando, FLA
March 13: AORN Congress, Denver, CO
March 14: Health Facility Planning, San Diego, CA
March 25: World Healthcare Congress on HI-TECH, Washington, DC
March 29: HIT and the Future of Managed Care Industry Forum, NY

Please send in your meetings and dates for listing in the next issue of our ME-P Events-Planner: MarcinkoAdvisors@msn.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Subscribe Now: Did you like this Medical Executive-Post, or find it helpful, interesting and informative? Want to get the latest E-Ps delivered to your email box each morning? Just subscribe using the link below. It’s free. You can unsubscribe at any time. Security is assured.

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Filed under: Experts Invited | Tagged: AORN, BISA, Events-Planner, HI-TECH, HIMSS, HIT, Managed Care, medicare, RAC Summit | Leave a comment »

About the County Health Rankings Project

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

Mobilizing Action Toward Community Health

By Staff Reporters

The County Health Rankings projects aims to demonstrate that where we live matters to our health.

For example, the health of a community depends on many different factors – ranging from individual health behaviors, education and jobs, to quality of health care, to the environment. This first-of-its-kind collection of 50 reports – one per state – is reported to help community leaders see that where we live, learn, work, and play influences how healthy we are and how long we live.

And – perhaps ever more importantly, the type and quality of the medical care we receive.

A Collaborative

The Robert Wood Johnson Foundation is collaborating with the University of Wisconsin Population Health Institute to develop rankings for each state’s counties. This model has been used to rank the health of counties in Wisconsin for the past six years.

Mobilizing Action Toward Community Health

The County Health Rankings are a key component of the Mobilizing Action Toward Community Health (MATCH) project. MATCH is a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

The Website

The project’s web site provides access to the 50 state reports, ranking each county within the 50 states according to its health outcomes and the multiple health factors that determine a county’s health. Each county receives a summary rank for its health outcomes and health factors and also for the four different types of health factors: health behaviors, clinical care, social and economic factors, and the physical environment. Each county can also drill down to see specific county-level data (as well as state benchmarks) for the measures upon which the rankings are based.

The Ratings and Rankings

It is hoped that the Rankings will serve as a real “call to action” for state and local health departments to develop broad-based solutions in their community so all residents can be healthy. The Rankings team works with health departments to help take advantage of the discussions and opportunities that will arise from the release of the Rankings.

But, efforts must also be made to mobilize community leaders outside the public health sector to take action and invest in programs and policy changes that address barriers to good health and help residents lead healthier lives. This includes education officials; elected and appointed officials, including mayors, governors, health commissioners, city/county councils, legislators, and staff; businesses and employers; the health care sector, and others.

Assessment

The founders believe that the County Health Rankings web site will serve as a corner stone of the project, a place where people from all these sectors can find Rankings data, as well as action steps and the latest news about the multiple factors that determine our health.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Give em’ a click and tell us what you think: http://www.countyhealthrankings.org How similar, or dissimilar, is the 20 year old Dartmouth Atlas Project that has documented glaring variations in how medical resources are distributed and used in the United States. The DAP uses Medicare data to provide comprehensive information and analysis about national, regional, and local markets, as well as individual hospitals and their affiliated physicians? http://www.dartmouthatlas.org

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Hayes Announces Appointment of Dr. Susan Levine

Posted on February 18, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Medicare Evidence Development and Coverage Advisory Committee

By Karen Matthias
Lansdale, PA—February 12, 2010

Hayes, Inc., the nation’s leading health technology research and consulting company, today announced that Susan A. Levine, DVM, MS, PhD, Vice President of Health Technology Research and Consulting, has joined the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC).

The MEDCAC was established in 1998 to provide independent guidance and expert advice to the Centers for Medicare & Medicaid Services (CMS) on specific clinical topics. Dr Levine will serve a two-year term beginning January 1, 2010.

About MEDCAC

MEDCAC is utilized by CMS to supplement its own research and allow for additional expert and public input on coverage topics, including those that are highly complex or have a major potential impact on the health of beneficiaries and/or the Medicare program itself. The MEDCAC reviews and evaluates medical literature and technology assessments to determine reasonable and necessary applications of medical services and technology. Advisory in nature, MEDCAC provides an unbiased, external evaluation of the strength of available evidence in a public forum. The committee also provides expert clinical and technical review regarding conclusions about the net health outcomes of a technology under consideration.

Interview

MEDCAC members are valued for their background, education, and expertise in a wide variety of scientific, clinical and other related fields. “I am honored to be invited to work with this prestigious group of professionals,” says Dr Levine. “In order to improve the quality of healthcare in the United States, decisions about policy, coverage, utilization, and personal healthcare must be grounded in scientific evidence.”

Dr Levine has extensive experience in health technology assessment, clinical trial methodology and data analysis, and comparative effectiveness reviews, and has held a senior management position at Hayes, Inc. for the past 13 years.

Previous Career

Before joining Hayes, Dr Levine earned a PhD in Pharmacology and Doctor of Veterinary Medicine degree from Cornell University, and completed a surgical residency at the University of Wisconsin, School of Veterinary Medicine. She has held faculty appointments at the University of Wisconsin-Madison, Johns Hopkins University School of Medicine, and Mayo Graduate School of Medicine.

Assessment

The Committee provides independent, expert advice to CMS in a public forum.

Video: http://www.hayesinc.com/hayes/hayes_analytics/analytics-video/

Conclusion

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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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Product Details

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Words of a Healthcare Reform Philosopher

Posted on February 2, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

The Lady Speaks

By Staff Reporters

Healthcare reform insights from America’s leading contemporary philosopher, Stefani Germanotta (a.k.a. Lady Gaga).

I want your ugly. I want your disease.
I want your everything, as long as it’s free!

Conclusion

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Do Prices Drive Regional Medicare Spending Variations?

Posted on January 31, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

A New Study Says – Apparently Not

By ME-P Staff Reporters

Per capita Medicare spending is more than twice as high in NewYork City and Miami than in places like Salem, Oregon.

How muchof these differences can be explained by Medicare’s payingmore to compensate for the higher cost of goods and servicesin such areas?

The Study

According to Daniel J. Gottlieb, Weiping Zhou, Yunjie Song, Kathryn Gilman Andrews, Jonathan S. Skinner and Jason M. Sutherland – not much!

The Answer

The authors analyzed Medicarespending after adjusting for local price differences in 306Hospital Referral Regions. The price-adjustment analysis resultedin less variation in what Medicare pays regionally, but notmuch.

The findings suggest that utilization—not localprice differences—drives Medicare regional payment variations,along with special payments for medical education and care forthe poor.

Assessment

http://content.healthaffairs.org/cgi/content/full/hlthaff.2009.0609v1

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Off Road Touring in Boston with Dr. Marcinko

Posted on December 31, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

How Doctors Get Paid

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Just before the Christmas Holidays, I flew up to Boston at the invitation of a pharmaceutical company to lead a managerial workshop entitled: “How Doctors Get Paid” [Treatment is only the beginning in the Changing Billing and Medical Reimbursement Climate].

Our goal was to inform drug representatives, and their regional managers, what value added information physician offices might expect from the pharmaceutical industry of the future.

Topics of Discussion

The two hour interactive workshop included team projects, flip chart exercises, a mock role-playing session and the customary [hopefully energetic] ppt presentation. Other topics of discussion included:

Health insurance payment evolution
Collapse of Medicare
Rise of managed care
Medical records documentation
ICD-9 and 10, HCPCS, DRGs and CPT® coding
ABNs, super-bills and HCFA 150 forms
Billing methodologies
Healthcare fraud, abuse and related policies
Capitation, HSAs, concierge medicine and RACs
Futuristic health 2.0 payment mechanisms, and more.

Assessment

Rest assured; these folks were a very knowledgeable and aggressive group; not like your father’s “detail men” of yore! They seek to … talk the talk, and walk the walk, of the Health 2.0 era.

Many thanks again to Helen, and Jon D, for the invite.

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Filed under: "Doctors Only", Drugs and Pharma, Health Economics, Managed Care, Media Mentions and PR, Practice Management, Sponsors, Touring with Marcinko | Tagged: ABNs, concierge medicine, CPT codes, HCFA 1500, health abuse, health fraud, HSA, ICD-10, ICD-9, Managed Care, medicare, super bill | 3 Comments »

Defining “Provider” for Medicare Incentive Payments?

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

Ask a Medical Practice Management Advisor

Staff Reporters

HR 1 of ARRA states:

“The term ‘health care provider’ includes a hospital, skilled nursing facility, nursing facility, home health entity or other long term care facility, health care clinic, community mental health center (as defined in section 1913(b)(1)), renal dialysis facility, blood center, ambulatory surgical center described in section 1833(i) of the Social Security Act, emergency medical services provider, Federally qualified health center, group practice, a pharmacist, a pharmacy, a laboratory, a physician (as defined in section 1861(r) of the Social Security Act), a practitioner (as described in section 1842(b)(18)(C) of the Social Security Act).”

For Ambulatory Surgery Center’s

HR 1 of ARRA includes ASCs in the definition of “provider” (see above), but the CMS seems to indicate otherwise CMS’s site.

For Pharmacists

HR 1 of ARRA includes pharmacists and pharmacies as “providers.” New information on phamacists’ eligibility for IT loans was recently announced – see the Healthcare IT News coverage on this.

Assessment

What was missed; please advise?

Conclusion

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Filed under: "Ask-an-Advisor", Health Law & Policy, Information Technology, Practice Management | Tagged: ARRA, HITECH, MC, medicare, Social security act | 1 Comment »

To Par or Not to Par? [The Critical Question for 2010]

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

About the Medicare HIT 1115 Project

By Ann Miller; RN, MHA

[Executive-Director]

At least one iconoclastic physician, ME-P thought-leader Al Borges MD, has asked that all doctors unite and participate in this year’s Medicare “HIT 1115 Project”; now in-process.

The November 15, 2009 Project

November 15, 2009 began the 6-week time period during which all medical providers can switch Medicare participation. If all physicians become “non-participating” or simply “opt-out,” then lawmakers and their lobbyists may take notice that doctors are fed-up with government intrusion into physician affairs!

Assessment

More: http://www.hcplive.com/technology/blogs/The_HIT_Realist/1269/HIT_1115_project

Cast Your Ballot – Send a Messsage

After reading the above op-ed piece, and a month into the project, please cast your VOTE:

About Dr. Borges

Alberto Borges, MD, is in private practice and is an assistant clinical professor of medicine at The George Washington University School of Medicine and Health Sciences in Washington, DC.

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Filed under: Breaking News, Career Development, Information Technology, Practice Management, Surveys and Voting, Voting Polls | Tagged: Alberto Borges MD, medicare, Non-Par, Par | 2 Comments »

Understanding the Healthcare Fraud and Abuse Control Program

Posted on December 4, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

A Joint Project Between the OIG and DOJ

By Patricia Trites; MPA, CHBC, CPC

The Healthcare Fraud and Abuse Control (HCFAC) program is a joint project between the Office of Inspector General [OIG] and the Department of Justice (DOJ).

Functions

The primary functions are to coordinate federal, state, and local enforcement in controlling healthcare fraud, and to conduct investigations relating to delivery and payment of healthcare services, and oversee Medicare and Medicaid exclusions, civil money penalties, and the anti-kickback law. The program is also designed to provide opinions, alerts, and a means for reporting and disclosing final adverse actions against healthcare providers.

HIPAA Policies

HIPAA established the Health Care Fraud and Abuse Control Account within the Medicare Part A Trust Fund and funds DOJ and DHHS activities for operation of the HCFAC. In addition to federal appropriations, the fund receives a portion of funds collected from healthcare fraud and abuse penalties and fines. HIPAA also authorizes funds from general revenues for the Federal Bureau of Investigation (FBI) to combat healthcare fraud and abuse.

Assessment

Anti-fraud and abuse provisions were also included in the Balanced Budget Act of 1997 and the Deficit Reduction Act [DRA] of 2005, and annotated and

Conclusion

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Filed under: Career Development, Health Law & Policy, Healthcare Finance, Professional Liability | Tagged: anti-kickback, BBA, david marcinko, DOJ, DRA, FBi, HCFAC, healthcare abuse, healthcare fraud, HIPAA, Medicaid, medicare, OIG, Patricia Trites, Stark, www.healthcarefinancials.com | 17 Comments »

Part D Payer Shares of Prescriptions Dispensed Rise

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

Increase for Eight Major Drug Classes

[By Staff Reporters]

The shares of all prescriptions dispensed covered by Medicare Part D rose by at least three percentage points, between midyear 2007 and midyear 2009, in each of eight major drug classes profiled.

Assessment

The largest percentage increases over this period were in the osteoporosis (to 26.9% in 2009 from 20.5% in 2007) and anti-platelet (to 28.4% from 22.5%) markets as of September 9, 2009.

Conclusion

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Filed under: Drugs and Pharma, Health Economics, Managed Care | Tagged: medicare, Medicare Part D, Part D | 6 Comments »

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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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 »

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 »

Take the Healthcare Leadership Survey

Posted on October 4, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Tracking Claims, Real-World Solutions

Staff Reporters

Dear Subscribers

Next year is the deadline for all Medicare healthcare providers to enroll in the Recovery Audit Contractor program. Due to national implementation, the market has become flooded with products to track claims, provide easy audit solutions, as well as aggregate data to predict which claims are at risk for recoupment.

And so, we have been asked to help facilitate this survey.

Past Surveys

According to our past survey, over 90 percent of respondents listed claim denials as a major problem for them. The editorial staff of Healthcare Reimbursement Monitor wants to know what steps your organization is taking to ensure the protection of claims through our latest query Healthcare Leadership Survey: Tracking Claims, Real-World Solutions

Assessment

What impact has the RAC program had on your organization? Are claims tracking software a necessity for today’s healthcare business? What type of claims solution does your organization need?

The Survey

Please take a quick moment to complete the short survey to allow your colleagues insight into best practices and solutions you have experienced, or to warn the community of which tools are simply excess. Share your experiences with the community by participating in the survey.

Link: www.themcic.com/claims.htm

Sincerely
Healthcare Reimbursement Monitor
Health Resources Publishing
1913 Atlantic Avenue, Suite 200, Manasquan, NJ 08736
phone: 800-516-4343
fax: 888-329-6242

Assessment

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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 »

The Largest Purchaser of Domestic Healthcare?

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

It’s the Government – Silly

By Ann Miller; RN, MHA

[Executive Director]

By far, our federal government is the largest purchaser of healthcare services, according to Robert James Cimasi MHA, AVA, CMP™ of Health Capital Consultants, in St. Louis, MO; and many others.

Obama Care

Although the government faces immense pressure to control healthcare costs, especially during the current HR 3200-3400 debates, it also faces pressure to expend additional funds in order to achieve its ostensible primary mission in its involvement in healthcare, i.e., to expand and improve public health.

Federal Payment Schemes

In many ways the government has led the way for cost control through its development of resource-based reimbursement, prospective payment systems, budget limitations and other payment schemes. However, its conflicting goals have led it to approach these controls in a hesitant and piecemeal manner rather than effecting bold, comprehensive reforms.

Consider, for example, the lack of government intervention in the face of mounting pressure to remove some of the barriers preventing a reduction in US pharmaceutical costs.

Assessment

Today, most experts agree that Uncle Sam pays for at least 51% of domestic healthcare when Medicare, Medicaid, SHIPS, the VA, Indian and Prison Healthcare Systems are considered. In fact, according to our Publisher-in-Chief, Dr. David Edward Marcinko; MBA:

‘We already have a single payer health system in this country, but most folks just don’t realize it.”

Conclusion

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Filed under: Drugs and Pharma, Health Economics, Managed Care, Military Medicine, Op-Editorials | Tagged: david marcinko, healthcare reform, HR 3200, HR 3400, Indian Health Services, Managed Care, Medicaid, medicare, Obama care, Prison Healthcare, prospective payment systems, resource-based reimbursement, robert james cimasi, SHIPs, VA System | 7 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 »

Henry Louis Gehrig, eMRs and Healthcare Reform

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

What’s the “Iron Horse” Got to Do with Health IT?

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

According to UPI reports from Charlestown, WVa on August 24 2009, at least 1,200 veterans across the country were mistakenly told by the Veterans Administration [VA] that they suffered from a fatal neurological disorder.

Link: http://www.msnbc.msn.com/id/32541579/ns/health-health_care/

Panicked Veterans

One of the leaders of a Gulf War veterans group is reported to have said that panicked veterans from the states of Alabama, Florida, Kansas, North Carolina, West Virginia and Wyoming contacted the group about the error. Denise Nichols, the vice president of the National Gulf War Resource Center, reportedly blamed a “coding error” for the mistake. In medicine, we call this a “false positive.”

About Henry Louis “Lou” Gehrig

Henry Louis “Lou” Gehrig (June 19, 1903 – June 2, 1941), born Ludwig Heinrich Gehrig, was an American baseball player in the 1920s and 1930s; chiefly remembered for his prowess as a hitter, the longevity of his consecutive games played record and the pathos of his tearful farewell from baseball at age 36, when he was stricken with a fatal disease. Of course, Gehrig was known as the “The Iron Horse” for his durability. Yet, the irony is that Amyotrophic Lateral Sclerosis [ALS], or Lou Gehrig’s disease [sometimes also called Maladie de Charcot] is progressive and fatal. Lou died in 1941 after developing the illness. Will the same death-spiral happen to eHRs and Obama care?

Link: http://www.lougehrig.com

Assessment

Having rotated through the VA system as a young medical student back-in-the-day, I have never been a fan. It smacked of socialized medicine and government plutocracy, and was never a leading-edge example of domestic healthcare, in my informed opinion. Recent HIPAA administrative, security, IT and clinical medical errors are well known. So, to blame the mix-up on an insurance billing and “coding error” seems somewhat disingenuous. Especially now, at a time when eMRs and the Obama Administration’s healthcare reform itself is being vigorously debated by the citizenry. I mean, are there no human checks and balances? Would there be any human intervention if a public healthcare policy was adopted?

Of course, we have written about military medicine previously on this Medical Executive-Post, and devoted an entire channel to it. And, I do realize that more than fifty percent of us receive similar governmental care in some form, or another [Medicare, Medicaid, CHIPS, the Indian and Prison Healthcare Systems, etc].

Link: https://healthcarefinancials.wordpress.com/category/military-medicine/

Nevertheless, shall we give a new moniker to this mistake? How about “Lou Gehrig’s coding error”, and document it in our www.HealthDictionarySeries.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Is it even fair to relate this “isolated incident” to the current healthcare reform debate, the eMR conundrum and/or similar discussions on health Information Technology [IT]? 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: Breaking News, Ethics, Health Law & Policy, Information Technology, Military Medicine, Op-Editorials, Touring with Marcinko | Tagged: ALS, amyotrophic lateral sclerosis, CHIPS, CMS, david marcinko, Denise Nichols, EHRs, EMRs, health information technology, healthcare reform, HIPAA, Indian Health Service, Iron Horse, IT, Lou Gehrig, Medicaid, medicare, National Gulf War Resource Center, nationalized medicine, obama, Obama Health, Prison Health Service, public health plan, socialized medicine, VA, Veterans Administration | 1 Comment »

Medicare Scam Alert Notice

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

Fearing Medicare Payment Gaps

By Staff Reporters

June 18, 2009

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

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

Medicare Contractors

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

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

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

Conclusion

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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 »

Essay of Atul Gawande MD in the New Yorker

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

The McAllen Redux

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

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

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

Commentary

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

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

Assessment

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

Conclusion

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

Government-Enabled Patient “Bounty Hunters”

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

Spider Webbing Technology May Trip-Up Miscreant Doctors

By Dr. David Edward Marcinko; MBA CMP™

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

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

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

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

Real Health Fraud Exists

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

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

Assessment

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

Conclusion

Of course, your thoughts and comments on this Medical Executive-Post are appreciated. Do you feel like the hunter; or the hunted? Tell us what you think? Do you ever – or never – fear the spider? 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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For details about how to report an abuse, see www.usdoj.gov/oig/FOIA/hotline.htm.

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

On Growing Tensions in Healthcare Services Markets

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

Stressors Affecting all Stakeholders

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

http://www.HealthCapital.com

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

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

Assessment

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

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

Medical Coding and Billing Vocabulary

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

Basic HIT Nomenclature and HIPAA

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

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

Diseases

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

Procedures

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

Pharmaceuticals

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

Assessment

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

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

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

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

Conclusion

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

Interview with Jack Levy of Securebill, Inc

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

President – Securebill, Inc

What: An Interview and Special Report Exclusively Prepared for the ME-P
Who: Mr. Jack Levy, CISSP [President – Securebill, Inc]
Topic: Physician Selection of eHRs
Reporter: Amaury Cifuentes; CFP®
Where: Internet Ether

Although skeptics of eHRs abound, President Barack H. Obama’s signing of the American Recovery and Reinvestment Act [ARRA] of 2009 has created a massive push for their implementation. The Act provides $19.2 billion, including $17.2 billion for financial incentives to be administered by Medicare and Medicaid. This assistance of up to $40 to $65 thousand per eligible physician, and up to $11 million per hospital, begins in 2011.

Link: https://medicalexecutivepost.com/wp-content/uploads/2009/05/jack-levy-interview.pdf

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Filed under: Breaking News, Career Development, Information Technology, Interviews, Practice Management | Tagged: Amaury Cifuentes, American Recovery and Reinvestment Act, ARRA, CISSP, EHRs, electronic medical records, EMRs, HITECH, Jack Levy, Medicaid, medicare, obama, Securebill | 1 Comment »

Understanding Periodic or New Employee Practice Compliance Audits

Posted on May 22, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Perform and Improve as Needed

By Patricia Trites MPA, CHBC; with Staff Reporters

www.HealthcareFinancials.com

There are several types of compliance audits that a medical practice, clinic or healthcare organization might need to perform. The starting point, discussed elsewhere on this ME-P, is to obtain a baseline audit. The next step is periodic audits or reviews that are performed after information is obtained from the baseline audit.

Periodic Audits

Periodic audits are performed on an on-going basis. Depending on the volume of billing, these may occur weekly for a large multi-specialty ambulatory clinic to quarterly for a small medical practice. These periodic audits can be random or scheduled. Sometimes in the process of seeing how things run, a surprise review can be informative to staff and practitioners.

New Employee Audits

New employees require regular training and reviews until there is confidence in their capabilities. Background checks are often helpful to find out whether there are any potential conflicts. In hospitals, health plan offices, surgery centers, and other regulated facilities, background checks are a normal part of the credentialing process. This process typically includes Medicare violations, which would show up on the National Practitioner Data Bank report. However, independent medical practices do not have access to this type of information and may have to rely on other organizations to obtain the information. The OIG and the General Services Administration both maintain a database of excluded persons and entities that can be accessed through the Internet. As part of the organization’s initial and periodic audits, queries of these two databases should be performed for all employees and independent contractors (like locum tenens physicians). Failure to do so can put the practice at risk of large civil money penalties ($10,000 for each occurrence) and liability for refunds of all claims the excluded individual had part in providing or billing.

Assessment

Additional audits can be performed whenever new employees are added, or if there are complaints or issues that arise in the course of business; prn.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated? What interesting, informative or strange tidbits have you uncovered in your auditing processes?

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Filed under: "Doctors Only", Career Development, Ethics, Managed Care, Practice Management, Risk Management | Tagged: audits, baseline audit, compliance, david marcinko, GSA, HMO, hope hetico, locum tenens, medicare, Medicare Advantage, Medicare audits, medicare billing, Medicare compliance audit, medicare compliance audits, Medicare HMOs, Medicare plans, National Practitioner Data Bank, new employee audit, OIG, Patricia Trites, www.healthcarefinancials.com, www.healthdictionaryseries.com | Leave a comment »

Physician [Fee] Schedule Augmentation

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

Organizing and Analyzing Financial Data

[By Christy Clodwick; MHA]

After all medical practice management data has been gathered, organize it onto a spreadsheet or chart. This analysis report will help to determine the codes and/or health plans that should be targeted for process improvement.

Focus … Focus … Focus

The focus should be on the highest volume and dollar value codes. Does this mean patients with unusual conditions or low dollar value codes are not treated? Hopefully it will not; but it will push this process forward and the practice will see the greatest benefit from these categories. When you review the report and find that a fee is being paid at a much lower rate, this would be indicative of a necessary negotiation with the payer for an increase for that procedure. Most health plans are committed to preventing disease. Maybe, but they are still actually aimed at treating diseases; not preventing them. If this is true of many payers then they should be willing to provide the incentives for those services to be carried out. You will find that some payers’ fee schedules are very much out of line with a percentage of Medicare payments, therefore the practice administrator should focus on those payers and bring evidence of the inadequacies to their attention.

The Specialists

Specialists are, for the most part, paid at a higher rate than primary care physicians not usually for the same service! And, with GPs as gatekeepers, the specialty doc incomes may have actually decreased in some instances, while the GPs may have increased. There was a time when Medicare had two conversion factors, and this was the result. This inequity could also be used as a tool for better reimbursement rates.

Finalizing the Fee and Revenue Analysis

When the final preparations of the fee analysis have been completed, it is time to react to the results of the findings. There are several options to choose from when it has been determined that a health plans fee schedule is not in tune with the practice’s financial growth. The practice should act on these results as soon as they are discovered, to avoid the loss of any more revenue.

No longer Accepting Health Plans

During the analysis phase, you may determine that a health plan’s payment levels are extremely low. You will have to determine whether the plan is worth negotiating or the practice administrator should consider dropping out of the plan altogether at the end of the contract period. It will have to be carefully determined by the local market. If the practice is in a highly competitive market, this process should not be considered as first choice. However, if the market is very slim, the health care purchaser will be responsible for complaining to the health insurance plan provider that there is simply not enough physician coverage for their employees for the area. This could be a very effective way to force a negotiation with the health care company. If this were the case, the area would have less managed care and more MC/MD.

Not Accepting New Patients from Low Paying Health Plans

One option would be to not accept any more patients from the health plan that is reimbursing the practice with low rates. Although this may initially lower your patient count, over time the practice will benefit from new patients with health plans that have a better reimbursement policy. Include snapshot of what the final analysis or report should look like and the details of what it should include. This can be used in any specialty to assist in putting together the individual practice analysis to achieve the same results. But is it noble or ethical? What about any willing provider laws?

The Future for Health Care Reimbursement

The health care purchasers who pay most of the bills, such as employers and the government, will soon be challenging the annual increase and the overall cost of health care. The cost increases of the hospital and pharmacy sectors of healthcare are far higher than that of the physician. However, the pressure for cost containment is being felt across the board. This will eventually depress future reimbursement for all healthcare providers. In the future it will be hard for practices to keep up with the demands of labor, malpractice and supply cost increase. All medical providers need to plan for this future paradigm. To offset this trend, physicians will need to get the most out of the work that they are doing today as well as look to new revenue generating procedures for their practice that will be cheaper and more convenient to the patient.

Process Improvement

The biggest benefits will come from continually improving the process of the daily operations of the practice, as well as ensuring accurate diagnostic coding. This will enable a practice to keep up with charge capturing through the explanation of benefits (EOB) when the charge has been processed and paid by the health insurance provider. When this process identifies that there is room for negotiation, the provider should proceed for a better reimbursement rate. If the provider is in a dominant market, the payers will be more likely to issue sweeping fee increases and so can you give me an example of this ever happening? By completing a Practice Fee Analysis, any practice should be able to use this tool to demonstrate the inequities and negotiate a better reimbursement rate for the practice.

Assessment

The first step in the negotiation process would be to contact a representative of the health insurance company that is in question. If you can produce compelling evidence to the representative, the negotiation process should be the next meeting. These folks may be fired if they do what you suggest, too frequently. Continually updating the practice fee schedule will help the practice stay on top of the contracts that it practices under. Practices that present a well-documented argument may (almost never) be rewarded with positive payer response. Again, proper planning will make for great future performance in any health care practice.

Conclusion

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Negotiating Physician Fee Schedules

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

Better Data for Improved Fixed Compensation

[By Christy Clodwick; MHA]

[By Dr. David E. Marcinko MBA]

It is known that most health plans operate with fixed fee schedules. While these fee schedules have little or nothing to do with RBRVS, and most are based on a percentage of what Medicare pays, the question is: “are they tied to levels that are more than 3 or 4 years old?” Physicians who have no negotiating tools or a plan in place, and who question the methodology that the payers are using, are (too casual-left) with a ‘take it or leave it’ response from the health insurance provider.

Gathering the Data

A good solid foundation of data is necessary to negotiate better reimbursement rates successfully. The practice administrator or accountant (not 1 in 100 accountants can actually do this) should have this information readily available, especially if the office has an automated billing system.

Steps to Preparing a Fee Analysis

First and foremost, the medical management team in charge of this project will need to determine the most commonly used CPT® codes for the practice. The bulk of primary care or family practice physician fees should be derived from the revenue of the office visit, hospital and preventive medicine codes. This in turn may limit the number of codes for the study. The frequency of each CPT code should be listed over a 12 month period. If applicable, laboratory fees should also be included to see if there are fluctuating reimbursement schemes for these services. The codes on the list should account for at least 75% of the total practice charges.

Determining Top Payers and Reimbursement by Payer

It is known that Medicare and Medicaid use established fee schedules and do not negotiate, therefore the focus should be on the other major payers that make up the bulk of the reimbursement. In this process, make sure that the payers in the report are the practice’s top payers. The practice administrator will also need to determine the reimbursement for each code that is sent to the various payers’ list in the report. The administrator or team leader (the average GP has 3-4 employees, so I don’t think there would be a team leader, here). For this project we can use the Explanation of Benefits EOB that is received from each payer that has been selected for the report. When including this data, make sure the allowed amount, not the paid amount, is referenced. After this information has been gathered, each payer’s reimbursement rate will need to be calculated as a percentage of Medicare’s reimbursement rate. Medicare’s current rates for any geographical area can be found through the “Medicare Physician Fee Schedule Look-up” tool at:

Link: https://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?p_sid=1reSKuxj

This site also provides a reference to Relative Value Unit, (RVU) that Medicare assigns to each code.

RVU Conversion Factors

It is important for the practice administrator or manager to understand the RVU conversion factors and how they work, simply because most payers are in the beginning stages of using this method. To calculate a payment for service you multiply a particular CPT Code by the Medicare conversion factor for that code. For an example we will use the code 99214 – office visit. The Relative Value Unit for that Code is 2.2. The Medicare conversion factor for the same code is $37.34. The calculation would result in a rate of $82.15. Geographical adjustments must be taken into account when performing these calculations. The next step in this process would be to review the fees for each code listed in the report. Calculate each fee as a percentage of Medicare’s rates. You will find different statistics for each payer.

Apply the Rules and Process

Follow these basic rules when applying this new process:

First, if the charges are being reimbursed at 100%, the fee may be too low. At this point, raising the fee for that code would be acceptable (Usually not the case). Next, If several fees are in this category, the practice should just set all its fees to a percentage of Medicare reimbursement across the board, such as 125 percent (many managed care plans pay at less than MC, i.e., 80% MC). Finally, a tiered fee schedule would be applicable if the payers seem to pay more for certain procedures or diagnostic studies. That would set evaluation and management codes at 125 percent of Medicare reimbursement while charging 150 of Medicare reimbursement for other procedures and diagnostic tests.

Assessment

The medical practice administrator should make sure that, no matter which fee schedule is best suited for the practice, it is updated annually to prevent loss of any increases that may occur per payer.

Conclusion

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Long-Term Care Insurance

Posted on May 5, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

A Review for Doctors and Advisors

By Gary A. Cook; MSFS, CLU, ChFC, LUTC, RHU, CFP®, CMP™ (Hon)

Long-term care (LTC) insurance is considered one of the newest forms of personal coverage insurance. LTC insurance is designed to transfer the financial risk associated with the inability to care for oneself because of a prolonged illness, disability, or the effects of old age. In particular, it is designed to insure against the financial cost of an extended stay in a nursing home, assisted living facility, Adult Day Care Center, hospice or home health care. It has been estimated that two out of every five Americans now over the age of 65 will spend time in a nursing home. As life expectancy increases, so does the potential need for LTC. One unfortunate consequence of being the “new kid on the block” is the lack of actuarial data specifically collected for this style of policy. This results in policy premiums being underpriced to sustain the claims currently being experienced. During the first half of 2003, at least three insurance companies stopped writing these policies because of their losses. Those insurers remaining in this market are expected to increase premiums quickly. Unless these policies can be profitable for the company, their future will be an uncertain one.

Medicare

Any discussion of LTC must begin with an understanding of what Medicare is designed to cover. Currently, the only nursing home care that Medicare covers is skilled nursing care and it must be provided in a Medicare-certified skilled nursing facility. Custodial care is not covered. Most LTC policies have been designed with these types of coverage, or the lack thereof, in mind. To qualify for Medicare Skilled Nursing Care, an individual must meet the following conditions:

Be hospitalized for at least three days within the 30 days preceding the nursing home admission;
Be admitted for the same medical condition which required the hospitalization; and
The skilled nursing home care must be deemed rehabilitative.

Once these requirements are met, Medicare will pay 100 percent of the costs for the first 20 days. Medicare covers days 21 to 100 along with a daily co-payment, which is indexed annually. After the initial 100 days, there is no additional Medicare coverage. Medicare Home Health Services cover part-time or intermittent skilled nursing care, physical therapy, medical supplies and some rehabilitative equipment. These are generally paid for in full and do not require a hospital stay prior to home health service coverage.

Critical LTC Policy Features

According to the U.S. Department of Health and Human Services and the Health Insurance Association of America, there are seven features that should always be included in a good long LTC policy:

Guaranteed renewable (as long as premiums are paid, the policy cannot be canceled).
Covers all levels of nursing care (skilled, intermediate and custodial care).
Premiums remain level (individual premiums cannot be raised due to health or age, but can be raised only if all other LTC policies as a group are increased).
Benefits never reduced.
Offers inflation protection.
Full coverage for Alzheimer’s Disease (earlier contracts tried to eliminate this coverage).
Waiver of premium (during a claim period, further premium payments will not be required).

In addition, there are another seven features considered to be worthwhile and are included in the better LTC policies:

Home health care benefits
Adult day care and hospice care
Assisted living facility care
No prior hospital stay required
Optional elimination periods
Premium discounts when both spouses are covered
Medicare approval not a prerequisite for coverage.

ADLs

Most LTC policies provide benefits for covered insured’s with a cognitive impairment or the inability to perform a specified number of Activities of Daily Living (ADLs). These ADLs generally include those listed below and the inability to perform two of six is generally sufficient to file a claim:

1. Bathing: Washing oneself in either a tub or shower, or by sponge bath, and includes the task the getting into and out of the tub or shower without hands-on assistance of another person.

2. Dressing: Putting on or taking off all necessary and appropriate items of clothing and/or any necessary braces or artificial limbs without hands-on assistance of another person.

3. Toileting: Getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene without hands-on assistance of another person.

4. Transferring: Moving in and out of a bed, chair or wheelchair without hands-on assistance of another person.

5. Eating: The ability to get nourishment into the body without hands-on assistance of another person once it has been prepared and made available.

6. Continence: The ability to voluntarily maintain control of bowel and/or bladder function, or in the event of incontinence, the ability to maintain a reasonable level of personal hygiene without hands-on assistance of another person.

Other Issues

Another issue concerning ADLs is whether the covered insured requires “hands-on” assistance or merely needs someone to “stand-by” in the event of difficulty. Obviously, LTC policies that read the latter are considered more liberal.

Long-Term Care Taxation

Some LTC policies have been designed to meet the required provisions of the Kassenbaum-Kennedy health reform bill, passed in 1996, and subsequently are “Tax Qualified Policies”. Insured’s who own policies meeting the requirements are permitted to tax deduct some of the policy’s premium, based on age, income and the amount of total itemized medical expenses. The major benefit of the tax-qualified LTC policy is that the benefit, when received, is not considered taxable income. There are several initiatives in Congress, however, which would expand and simplify these deductibility rules.

Assessment

Regardless, the medical professional or financial advisor [FA] should investigate the opportunity afforded them through their current form of business, or client use, for any purchase of a LTC policy. And, small businesses may be permitted to deduct LTC premiums on a discriminatory basis.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. What have we missed, and who might wish to update this post?

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Selecting an Assisted-Living Facility

Posted on May 4, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Checklist for Financial Planners

[By Staff Reporters]

Thousands of boarding homes cater to the elderly. Their operators promise to provide at least a place to sleep and food to eat. Beyond that, the services and assistance offered will vary from facility to facility. This checklist will help the financial planner or his or her client find a facility that is appropriate in all respects to the client’s resources and needs. Unlike nursing homes, assisted-living facilities often operate without any scrutiny from public agencies. Furthermore, Medicaid often will not be a source of funds.

The Checklist

The items the financial planner and client should consider when selecting a facility are listed below.

1. Determine the client’s willingness to live in a group environment.

2. Avoid unlicensed facilities, particularly if Medicaid-provided services may be needed in the future.

3. Review the facility’s inspection report.

4. Review the facility’s service contract and house rules. Look for answers to the following questions:

a. Where will the resident live?

Are there any types of ownership rights?

What flexibility is there with respect to furnishings?

Will the same unit be available after a hospital stay?

b. What meals are included?

Will the facility provide appropriate meals and a special diet?

c. What form of transportation does the resident currently use?

What transportation is provided by the facility?

Can residents shop, dine, attend services or visit doctors?

d. What help does the facility provide during a medical emergency?

What type of staff training is provided or required? Is there 24- hour-a-day staffing?

e. What provisions are there for privacy? When are rooms cleaned and when can staff access the rooms?

f. What is the basic cost and what are the costs for extras?

What is included in each?

What provisions for fee increases are there?

g. Can a resident see his or her own doctor?

Does the facility offer transportation for appointments?

h. Who’s in charge of administering and scheduling medication?

Can medication and other supplies be purchased at the facility?

i. What happens if the resident’s health begins to fail?

Does the facility provide additional services to help with ADLs?

j. What is the procedure for transfers from one unit to another?

Does the resident have any opportunity to express an opinion?

k. What’s required if a contract is terminated by facility or resident?

What is the provision with respect to refunded fees?

Is there a required minimum stay?

Assessment

What have we missed?

Conclusion

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Advisor’s Checklist for Physicians Seeking Insurance

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

Background, Education, and Certifications

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

The following are sample questions and information gathered for Professional Liability Coverage

The Checklist

**Medical specialty information by percentage of practice.

**Information on medical education, including information on medical school, internship information, residency information, and fellowship information, if any.

**Information on medical experience, including information on military discharge (DD214), public health service, moonlighting, ‘locum tenens’, and private practice information. Have dates and locations available. Other information includes:

Information on completed continuing education hours in the past two years.
Publications, speeches, instruction, etc.
Information on medical licenses, including state, license number, expiration dates, and current status.
Information on board certifications.
The above information may be contained in a Curriculum Vita, if you have one.
On an “as applicable” basis:
Complete details including dates and outcomes of any board certification revocations or suspensions, license revocations or suspensions, alcohol or drug addictions and treatments, criminal or sexual misconduct charges, or Medicare or Medicaid charges.
Previous Insurance Information
Insurance history, including the name, policy number, whether the coverage form was occurrence or claims made, policy period, limits of liability, deductible amount, and prior acts date, for your current carrier, and your first, second, third, and fourth prior carrier, if applicable.
Information on any insurance company cancellations or non-renewals.
If your current policy is a claims-made policy, whether you are obtaining tail coverage from your current insurance company.
Copies of prior policies, if available.

Current Medical Practice Information

Information on supervision and employment of residents, physician assistants, nurse practitioners, CRNAs, nurse midwives and other physicians;
Information on networks or managed care organizations associated with (IPA, PHO, MSO, etc.), including group name, type of organization, and relationship;
Information on other contractual relationships other than PPOs, HMOs, IPA, etc;
Full information on all hospital privileges, including hospital name, location, and type of privilege.
Information on any suspension, denial, revocation, restriction, or other sanctioning of hospital privileges.

Classification and Specialty Identification

Full information on procedures performed, including details of surgeries, average number of patients seen weekly, specialty practice areas, etc.

Prior Claims History (if any)

For each claim, patient’s name; date of occurrence; insurance carrier; location of occurrence; date claim was reported; date claim was closed (if applicable); copies of subpoenas, pleadings, or judgments; amount reserved on your behalf; and amount paid on your behalf. Provide as complete a description of the allegations as possible.

Important Note

This checklist is provided as a guide to assist the Healthcare Professional in gathering the information that insurance companies typically request. Discuss this checklist with your agent to identify additional information as needed.

Assessment

The author has been an expert medical witness in both state and federal court. He is also a former licensed insurance agent and certified financial planner.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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Understanding the Emergency Medical Treatment and Active Labor Act

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

An Important and Contemporary Issue – Once Again

[By Patricia Trites; MPA, CHBC, CMP™ (Hon) with Staff Reporters]

The Emergency Medical Treatment and Active Labor Act (EMTALA) is receiving increasing scrutiny from prosecutors during these times of financials stress and credit tightening. The statute is intended to ensure that all patients who come to the emergency department of a hospital receive care, regardless of their insurance or ability to pay. Both hospitals and physicians need to work together to ensure compliance with the provisions of this law.

Triad of Requirements

EMTALA imposes three fundamental requirements upon hospitals that participate in the Medicare program with regard to patients requesting emergency care.

First, the hospital must conduct an appropriate medical screening examination to determine if an emergency medical condition exists.

Second, if the hospital determines that an emergency medical condition exists, it must either provide the treatment necessary to stabilize the emergency medical condition or comply with the statute’s requirements to affect a proper transfer of a patient whose condition has not been stabilized. A hospital is considered to have met this second requirement if an individual refuses the hospital’s offer of additional examination or treatment, or refuses to consent to a transfer, after having been informed of the risks and benefits of treatment.

Third, EMTALA’s requirement is activated if an individual’s emergency medical condition has not been stabilized.

Hospital Transfers

A hospital may not transfer an individual with an unstable emergency medical condition unless:

(1) the individual or his or her representative makes a written request for transfer to another medical facility after being informed of the risk of transfer and the transferring hospital’s obligation under the statute to provide additional examination or treatment;

(2) a physician has signed a certification summarizing the medical risks and benefits of a transfer and certifying that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the transfer outweigh the increased risks; or

(3) a qualified medical person signs the certification after the physician, in consultation with the qualified medical person, has made the determination that the benefits of transfer outweigh the increased risks, if a physician is not physically present when the transfer decision is made. The physician must later countersign the certification.

On-Call Responsibilities

One area of particular concern is physician on-call responsibilities. Physician practices whose members serve as on-call hospital emergency room physicians are advised to familiarize themselves with the hospital’s policies regarding on-call physicians. This can be done by reviewing the medical staff bylaws or policies and procedures of the hospital that must define the responsibility of on-call physicians to respond to, examine, and treat patients with emergency medical conditions. Physicians should also be aware of the requirement that, when medically indicated, on-call physicians must generally come to the hospital to examine the patient. Patients may be sent to see the on-call physician at a hospital-owned contiguous or on-campus facility to conduct or complete the medical screening examination due to the following reasons:

all persons with the same medical condition are moved to this location;
there is a bona fide medical reason to move the patient;
qualified medical personnel accompany the patient; and
teaching physicians may participate.

Channel Surfing the ME-P

Conclusion

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Sherlock Expense Evaluation Report [SEER]

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

ADVERTISEMENT

Plan Management Navigator

By Marco Georeno

Ph: 215-628-2289

Please find attached the April 2009 edition of Plan Management Navigator. In it we provide an update on the timing of the Blue Cross Blue Shield universe and the Independent / Provider-Sponsored editions of the Sherlock Expense Evaluation Report (SEER). In addition, we expect to circulate the benchmarking surveys for the Medicaid and Medicare universes on or about June 1st, for completion by July 20^th, 2009.

Benchmarking Studies

If you are interested in participating in our benchmarking studies please contact us as soon as possible. Additional information about SEER is available at www.sherlockco.com/seer.shtml or by contacting Doug Sherlock (sherlock@sherlockco.com).

Best Practices for the Healthcare Enterprise

We also endeavor to provide an enterprise view of best practice. Best practice is typically considered to be the most efficient way of achieving a desired outcome. We believe that the best way of determining the best practice in its most practical application is to start with an overall objective and weigh all particular practices in light of how they contribute to that overall objective.

In that vein, over the next several months, Sherlock Company will be offering web conferences focused on best practices. The first conference will address activities within Customer Services, as well as activities or effects in other functional areas. This web conference will be held on Wednesday May 20th at 2:30 PM, Eastern Time. The costs will be $225. Participation is free of charge to health plans participating in our 2009 benchmarking studies. If you are interested in participating, please email Erin Sawchuk (erinsawchuk@sherlockco.com) or call at 215-628-2289.

Assessment

This edition of Navigator also discusses the latest private health plan Dashboard results for the trailing three months ended January 31, 2009.

Link: navigator

Sincerely,
Sherlock Company

Marco Georeno – Analyst
mgeoreno@sherlockco.com

Fax: 215-542-0690

Conclusion

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Alternative Design Options for a Public Health Plan

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

New Lewin Group Report Examines Potential Impact

[By Staff Reporters]

April 6, 2009

FALLS CHURCH, VA – The Lewin Group released a report titled “The Cost and Coverage Impacts of a Public Plan: Alternative Design Options.” The report examines potential impacts that a “public health plan” might have in competing for enrollment with the private insurance industry.

Healthcare Reform

As ME-P readers are aware, a public plan is currently being considered in a number of health reform proposals being considered by President Obama and the US Congress. This analysis enhances prior work done by The Lewin Group of the major party presidential candidate’s health reform proposals, during the 2008 campaign, as well as more recent analyses of the Congressional plans now being considered. The report estimates the impact on cost and coverage based on different levels of eligibility and reimbursement rates.

Key Findings Review

According to The Health Care Blog writer Robert Laszewski, key study findings include:

If Medicare payment levels are used in the public plan, premiums would be up to 30 percent less than premiums for comparable private coverage. On average, the monthly premium in the public plan for a typical benefits package would be $761 per family compared with an average of $970 per family in the private market for the same coverage.
If as the President proposed, eligibility is limited to only small employers, individuals and the self-employed, public plan enrollment would reach 42.9 million people. The number of people with private coverage would fall by 32.0 million people. If private payer reimbursement levels are used by the public plan, enrollment would be lower, with only 10.4 million people switching to the public plan from private insurance.
If the public plan is opened to all employers as proposed by former Senators Clinton and Edwards, at Medicare payment levels we estimate that about 131.2 million people would enroll in the public plan. The number of people with private health insurance would decline by 119.1 million people. This would be a two-thirds reduction in the number of people with private coverage (currently 170 million people). Here again, if the higher private payer levels are used, enrollment in private insurance would decline by only 12.5 million people.
Assuming Medicare reimbursement rates and eligibility for all individuals and employers, provider net income would decline under this public plan proposal, even after accounting for reduced uncompensated care and increased utilization for the newly insured. Net hospital revenues would fall by $36 billion (4.6 percent), and physician net income would fall by $33 billion (6.8 percent). If eligibility is restricted to individuals and small firms, net hospital revenues would actually increase by $11.3 billion due to the increase in newly insured individuals. But net physician incomes would decline by $3.0 billion.

Assessment

Full report: lewin-report

Conclusion

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More about Healthcare Organizations [Financial Management Strategies]

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

Our Print-Journal Preface

By Hope Rachel Hetico; RN, MHA, CMP™

As Managing Editor of a two volume – 1,200 pages – premium quarterly print journal, I am often asked about our Preface.

A Two-Volume Guide

As so, our hope is that Healthcare Organizations: [Financial Management Strategies] will shape the hospital management landscape by following three important principles.

What it is – How it works

1. First, we have assembled a world-class editorial advisory board and independent team of contributors and asked them to draw on their experience in economic thought leadership and managerial decision making in the healthcare industrial complex. Like many readers, each struggles mightily with the decreasing revenues, increasing costs, and high consumer expectations in today’s competitive healthcare marketplace. Yet, their practical experience and applied operating vision is a source of objective information, informed opinion, and crucial information for this manual and its quarterly updates.

2. Second, our writing style allows us to condense a great deal of information into each quarterly issue. We integrate prose, applications and regulatory perspectives with real-world case models, as well as charts, tables, diagrams, sample contracts, and checklists. The result is a comprehensive oeuvre of financial management and operation strategies, vital to all healthcare facility administrators, comptrollers, physician-executives, and consulting business advisors.

3. Third, as editors, we prefer engaged readers who demand compelling content. According to conventional wisdom, printed manuals like this one should be a relic of the past, from an era before instant messaging and high-speed connectivity. Our experience shows just the opposite. Applied healthcare economics and management literature has grown exponentially in the past decade and the plethora of Internet information makes updates that sort through the clutter and provide strategic analysis all the more valuable. Oh, it should provide some personality and wit, too! Don’t forget, beneath the spreadsheets, profit and loss statements, and financial models are patients, colleagues and investors who depend on you.

www.HealthcareFinancials.com

Assessment

Rest assured, Healthcare Organizations: [Financial Management Strategies] will become an important peer-reviewed vehicle for the advancement of working knowledge and the dissemination of research information and best practices in our field. In the years ahead, we trust these principles will enhance utility and add value to your subscription. Most importantly, we hope to increase your return on investment [ROI] in some small increment.

Visit and Order Now

Specialty Technical Publishers

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Blaine, WA 98230

1-800-251-0381

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Conclusion

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Doctors Preventing Medical Identity Theft

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

More on the “Red Flag” Rules

[Staff Reporters]

According to MedicalNews, Inc and Lynne Jeter, the Medicare “Red-Flag” rules are set to take affect on May 1, 2009.

Three Categories

And, according to David Williams, CPA, FHFMA, a healthcare partner for HORNE in Jackson, Mississippi, the Red Flag guidelines for hospitals, clinics and medical practices can be broken down into three categories.

1. Red Flags that definitely apply to healthcare:

Documents provided for identification appear altered or forged.
Photographs or a physical description on file are not consistent with the appearance of the patient.
Other inconsistent information identifies the patient.
Inconsistent signatures are on file.
Patient forms or applications appear forged, altered, or destroyed and re-assembled.

2. Red Flags that may apply to healthcare:

Statements sent to the patient – or guarantor – that is returned as un-deliverable despite ongoing transactions on active records.

3. Red Flags that most likely do not apply to healthcare:

A fraud alert is included with a consumer report.
A consumer reporting agency provides notice of a credit freeze in response to a request for a consumer report, a notice of address discrepancy, and/or unusual credit activity.
Financial institutions and creditors use challenge questions that the person opening the covered account cannot answer with readily available information.
A request is made for new, additional or replacement cards or the addition of authorized users on the account shortly after a change of address request.
A new revolving credit account is used in a manner commonly associated with known patterns of fraud patterns.
The use of a covered account is inconsistent with established patterns of activity on the account.
There is unexplained usage of a covered account that has been inactive for a reasonably lengthy period of time.

Assessment

Link: http://www.medicalnewsinc.com/news.php?viewStory=222

Conclusion

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Hospital Non-Profit Care and Community Benefits

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

The IRS Sounds-Off

Staff Reporters

According to the Internal Revenue Service [IRS], a survey of nearly 500 not-for-profit hospitals in 2006 revealed that 9 percent total revenues were dedicated to community benefit. The just finalized 2006 report warned that attempts to set a percentage threshold for determining compliance may have a

“disproportionate impact on hospitals, depending upon their size, where they are located their community benefit mix, and other hospital and community demographics.”

Link: http://greisguide.com/?p=1059

Definition

The current “community benefit” standard was established by the IRS in 1969 in Revenue Ruling 69-545. The standard sets out factors to be considered in measuring community benefit, including: (i) a board made up of a broad base of community members; (ii) an open medical staff; (iii) participation in Medicare and Medicaid; (iv) application of surplus funds toward improving facilities, equipment, patient care, medical training, research, and education; and (v) a full-time emergency room open to all regardless of ability to pay (the emergency room standard applies differently to tax-exempt Long Term and Acute Care Hospitals [LTACH] that do not maintain a full array of emergency department services). Under the current community benefit standard, individual hospitals are given flexibility to determine what services will-best serve their communities.

www.HealthDictionarySeries.com

Assessment

Some pundits suggest that if Congress doesn’t establish new charity care requirements, the IRS should revert to its community benefit standard last in force in 1969.

Interim Report: http://greisguide.com/wp-content/uploads/2009/02/eo_interim_hospital_report_072007.pdf

Conclusion

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Filed under: Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Quality Initiatives | Tagged: community benefit, congress, IRS, LTACH, Medicaid, medicare, non-profit hospitals, not-for-profit hospitals, Revenue Ruling 69-545, www.healthdictionaryseries.com | 8 Comments »

Defining Current Procedural Terminology [CPT®] Codes

Posted on April 4, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

What they are – How they work

By Staff Reporters

The American Medical Association’s Physicians’ Current Procedural Terminology® is contained in the CPT user guide. The maintenance of these codes is the responsibility of the American Medical Association with consultation from the AMA CPT Editorial Panel, Advisory Committee, and the AMA CPT Health Care Professionals Advisory Committee. Procedure codes in the CPT user guide are reviewed and revised annually. The Health Care Financing Administration’s – now CMS – Common Procedure Coding System [HCPCS] lists three levels:

Level I National Codes

CPT codes are five-character, all numeric configurations (e.g., 99215). Contact the American Medical Association to obtain a current copy of the CPT® Users Manual.

Level II National Codes

The HCPCS Level II National codes are contained in the HCPCS user’s guide and are published in the Federal Register. The maintenance of these codes is the responsibility of the Health Care Financing Administration [CMS]. Procedure codes in the HCPCS user guide are reviewed and revised annually. HCPCS codes are five characters with one alpha and four numeric configurations (e.g., A0042). Contact any publishing company that provides medical coding reference books to obtain a current copy of the current HCPCS User Manual.

Level III Medicare Local Codes*

Historically, local Medicare carriers developed local procedure codes which were published in the local Medicare Newsletters. The maintenance of these codes was the responsibility of the local Medicare carrier. Medicare local procedure codes were all five-character configurations with the following alpha/numeric configuration: one alpha, (W, X, Y or Z) with four numeric configurations (e.g., Y5523); and two alphas, (W, X, Y or Z) same character with three numeric identifiers (e.g., XX001). Contact your local Medicare carriers to obtain their Medicare Newsletters.

* Note: Due to HIPAA (Health Insurance Portability and Accountability Act) requirements, Medicare Local codes and the Office of Medicare Assistance Program Unique [OMAPU] codes were replaced with national standard procedure codes.

Assessment

For more terminology information, please refer to the Dictionary of Health Economics and Finance.

Conclusion

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Medicare and Medicaid Health IT Network Proposal

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

Governmental Initiative for the Elderly and Poor

By Staff Reporters

According to Nancy Ferris of Government Health IT, on Mar 18, 2009, a rapid learning health information data network could close some gaps in medical knowledge and cut costs for Medicare and Medicaid recipients.

A Congressional Letter

In a letter to Congress, a group of health policy experts urged creation of a network to share information on Medicare and Medicaid patients in order to improve treatment received. In particular, Lynn Etheredge, one signatory of the letter, wants information to be shared on “dual eligible’s”. This term is defined as low income, elderly patients who receive money for medical care from both Medicare [Federal] and Medicaid [State] sources.

www.HealthDictionarySeries.com

According to Etheredge, there are 7 million such dually-eligible patients in the US, which represents 40 percent of Medicaid spending, and 25 percent of Medicare spending. Etheredge and the others suggest that a network backed by government policy would hasten treatments for everyone.

Assessment

Others who signed the letter include Kenneth Kizer, who created the health-records system for the Department of Veteran Affairs; Commonwealth Fund President Karen Davis; National Quality Forum [NQF] President and CEO Janet Corrigan and National Committee for Quality Assurance [NCQA] President Margaret O’Kane.

Link: http://govhealthit.com/articles/2009/03/18/network-for-data-on-medicaid-medicare-patients.aspx

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. One conclusion of this letter was that“[Researchers] spend way too much time simply acquiring data.” Do you agree, why or why not? Please opine. Will networked eHRs, eMRs and eDRs really save money and time; or cost money and time? Can they be inter-operable and connected on a nationally networked basis that is cost-effective, secure and available to all providers? What about CCHIT, and other vendors?

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Frank Gehry, Health Reform and the Cleveland Clinic

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

Las Vegas Hospital Uses Celebrity Architecture to Fight Disease?

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

According to the Las Vegas Sun Newspaper on March 2, 2009, the Cleveland Clinic is the newest top-tier player in Sin-City with an emerging health care system that will shake up the status quo, supposedly creating a multitude of direct and residual benefits for patients throughout the region.

Lou Ruvo Center for Brain Health

In its role as partner with the Cleveland Clinic’s Lou Ruvo Center for Brain Health, the hospital — ranked fourth best nationally by U.S. News & World Report — is projected to influence medical care in Nevada on the strength of its immense organization. And, it is being designed by, none other than esteemed architect, Frank Gehry.

A Huge Project

And, if you believe numerous websites, the behemoth project will include office towers, a park, a 60-story tower for jewelry trading, a hotel conceived by celebrity chef Charlie Palmer, thousands of apartments and a $360 million performing arts center. Of course, in typically flamboyant Gehry fashion, the highly embellished main facility is said to model curvy metallic shapes and “folds of the brain.” Other nescient drawings of the Ruvo Center show it divided in two sections. Offices and examination rooms will be housed in stacked rectangular blocks set slightly off kilter, like a fortress wall built by children.

The Architect

Gehry used this method to design his world famous Guggenheim Museum in Bilbao, Spain (1997) and his Peter B. Lewis Building for the Weatherhead School of Management at Case Western Reserve University in 2002. His style is well known.

Misplaced Priorities

But, with an estimated 40 million uninsured citizens, one only can wonder if this facility could have been built more cost effectively and/or more utilitarian?

Assessment

Moreover, some Clevelanders are grumbling about the clinic’s involvement in such a glamorous project far away, and imagine that the project will drain local resources just as sun-parched Western states have fantasized about tapping the Great Lakes.

Industry Indignation Index: 70

Conclusion

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The No Insurance Club

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

Emerging Pre-Paid Cash-Based Medicine

By Bob Grove

Healthcare in America is in Turmoil. The No Insurance Club [NIC] feels private contracts may be the solution. More and more Americans are going without healthcare especially preventative healthcare. The reasons – costs are too high, patients can’t get accepted due to a pre-existing condition, companies are cutting back on benefits, people have been laid off from work; and the list goes on.

Governmental Solutions

What’s being done to improve healthcare? Barack Obama and the Government want more control and regulation and the system seems to be leaning toward socialized care. Private insurance companies continue to increase premiums, which prices healthcare out of reach for the average American. Employers can no longer float the cost of insurance so they pass it on to their employees. Patients aren’t the only ones being affected by the current state of healthcare. More and more doctors are going out of business and hospitals are cutting back due to escalating costs and payment defaults.

Private Solutions

The current remedy; Americans are taking out private major medical policies for catastrophic events with high-deductibles [MSA/HSAs] to keep monthly premiums down, or are turning to Medicaid, mini retail-clinics at grocery stores/pharmacies, and emergency room visits for common illnesses.

Innovative Solutions

What about prevention and maintenance? More than 90 percent of health related issues can be taken care of with preventative care and maintenance but only a small percentage of Americans currently enjoy the benefit of preventative healthcare.

The No Insurance Club

The NIC has come up with a fresh look at healthcare by offering an affordable alternative to traditional insurance options.

NIC Benefits and Features

The No Insurance Club connects patients with participating board certified physicians that will treat and care for preventative healthcare needs for a one-time prepaid annual membership fee:

NIC patients make a one-time annual payment that is typically less than a one-month premium with traditional insurance.
Patients receive up to 12 office visits per year that also include immunizations, $4 or less in-office prescriptions, and additional services including blood tests.
No deductible, no co-pays, no premiums.
No surprise bills to patients.
Viable alternative to COBRA for employees laid off from work.
Low cost option for the self-employed.

Assessment

What’s in it for the doctors? How about no insurance clerks, no need to snail mail medical insurance claims or use expensive electronic claims submission clearinghouse services, no bad debts or bad expense write-offs, no ARs; and fast cash!

Link: http://www.noinsuranceclub.com/

I would be happy to speak with and connect ME-P readers, participating doctors and even patients for interviews to learn more about the NIC network and its benefits.

Bob Grove

Wild West PR

(801) 651-0290

bob@wildwestpr.com

Conclusion

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Maintenance of Medical Board Certification

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

Status Growing in Importance – or Sham

Dr. David Edward Marcinko; MBA, CMP™

And Staff Reporters

Increasingly, efforts to boost quality and gain better value from the world’s most costly healthcare system are including attention to Maintenance of Board Certification [BOBC], a little-understood but rigorous process by which physicians maintain board certification status and then keep it.

Hillary-Care Redeux

Back in the day, circa late 1970s – early 1980s, medical board certification was indeed a rigorous process; and still is to a very large extent. For example, Democratic presidential candidate Hillary Rodham Clinton, in laying out the quality portion of her three-part healthcare reform plan last year, specifically touted these programs as a key step in enhancing quality. From the presidential campaign trail to hospital and health plan board rooms, Board Certification and the Maintenance of Board Certification is a growing force in the industry.

But, is maintaining recertification status another matter of true quality import?

Major Health Plans On-Board

Several of the nation’s biggest health plans—including Aetna, Cigna, Humana, UnitedHealth Group and national and regional Blue Cross and Blue Shield organizations—are embracing Maintenance of Certification as part of their recognition and reward programs. Physicians who do not participate are not highlighted in plan directories and miss out on higher plan reimbursements.

Yet, why do we have “red flag” issues, “never-events” policies and/or the rise of “checklist-medicine” for risk reduction if these continuing education programs are so effective?

Allow me to cite the raging over-treatment epidemic, especially in specialties like arthroscopic orthopedics, radiology imaging [CT and MRI scans] and invasive cardiology, etc. Not to mention recent, and not so recent, Institute of Medicine [IOM] quality chasm reports for in-hospital patient deaths, complications and infections, etc.

Assessment

Of course, savvy hospital administrators and physician executives, of all stripes, are examining ways to use elements of board certification maintenance to respond to the Joint Commission’s new requirements for physician credentialing and privileging. Furthermore, the National Quality Forum [NQF] and the AQA quality alliance will be considering Maintenance of Certification for quality measurement endorsement.

Source: Cary Sennett and Christine Cassel, Modern Healthcare

Joint Commission Relevance in Modernity

But, is the Joint Commission itself even as relevant today, as in the past? Or – is its [political, quality and economic] status, might and swagger being reduced in favor of modern new-wave insights from health 2.0 collaboration activities and emerging formal organizations like DNV Healthcare Inc., a division of the Norwegian company.

As subscribers and Medical Executive-Post readers are aware, Det Norske Veritas [DNV] has recently been charged with immediately determining if hospitals are in compliance with the Medicare Conditions of Participation [COP]. The company’s authority to accredit hospitals runs through September 26, 2012. DNV joins the American Osteopathic Association [AOA] as the only other national hospital accrediting agency approved by the Centers for Medicare and Medicaid Servicers [CMS].

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Is medical board certification and maintenance status of real value – or just fluff – much like the continuing education and licensure requirements of insurance agents, stock-brokers and financial advisors, etc? Is it less for medical education – and more for liability risk reduction – or PR – you decide?

Disclosure: I am a reformed insurance agent, stock-broker, board certified quality review physician and Certified Financial Planner®.

Speaker:If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Physician Advisors: www.CertifiedMedicalPlanner.org

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Filed under: "Doctors Only", Career Development, Health Law & Policy, Managed Care, Op-Editorials, Quality Initiatives, Research & Development, Risk Management | Tagged: ADA, AMA, AOA, APMA, AQA, COP, david marcinko, Det Norske Veritas, DNV, IOM, Joint Commission, medicare, NQF | 3 Comments »

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