You need not be tethered to the office due to HIPAA

Spending time with family and living life should not be sacrificed to HIPAA. That is, you can use your cell phone to communicate with your patients. And hopefully, you will from some scenic places, or while spending some quality family time.

HIPAA does not restrict you communications to encrypted emails, and landlines.

But you do have the continued obligations to implement technical, physical and administrative safeguards in using your cellphone as you do any other communication device.

So, if you're going to use your cell phone, be smart and safe about it.

Make sure your cell phone is password protected if it has patient information on it. This is especially true if your phone is linked to your EHR and practice management electronic systems.  If you’re going to end emails, you have to have the same encryption safeguards that you do with your office systems.

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Then makes sure you take steps to secure the phone physically. That has the locator functionally on in case you lose it. Control who you let use your phone. That is, don’t pass it to your teenager as an amusement device, or to call them friends.

And when you do speak with patients, its like the elevator at the hospitals – be cognizant of where you are when you do speak. Don’t carry on the call in a public place, find a corner or walk away from the crowd. And when speaking is cognizant of what you say, trying to avoid saying anything that could identify the patient, or publicly share sensitive personal health information.

A good practice is to tell your caller upfront that you are on a cell phone and ask if it is ok to continue the conversation, or if they would prefer to be re-contacted when you can get to a landline or more secure location. This lets them know where you are and lets them take part in the responsibility for the call.

Another responsibility that does not change is the obligation to document. So, check out the recording features of your phone, again, password protection is a must. After the call, record a simple reminder note that the call occurred, when, any medical advice is given, and on what basis you make it. And if you are committing to calling in a prescription, make sure you record it and call it in. You need not dictate a full not, that can wait till later, but you want enough to know what to enter into the patient’s medical record when you do.

So, get out of the office without being out of patient contact. Far better, of course, is if you have coverage so you can get out of the office and be out of patient contact for at least a little while.

Types of Denials - How to Get Paid

Claim denied and some reason code is given. Now you have to research what it means and what to do about it.  In too many cases, office staff puts these aside to work on later, and then that put aside, become pushed aside for other priorities, and becomes denied for lack of timely appeal.  Revenue loss.

Denials are very different from rejections, and staff needs to be able to read an understand the Explanation of Benefits (EOB) messages.  Rejections are errors in the data that was submitted, correct it, re-submit it and move on.  Practices should never let rejections become denials because they are not fixed and resubmitted timely.

Denials are another matter completely.  Here the payer is saying no – we won’t pay.

There are two basic reasons for denial – failure of the patient to be eligible for the services you provided, and failure of you to be authorized to provide the service that you provided.  These can only be fixed by an appeal.

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Denials for lack of patient eligibility means that the health plan is saying, not my responsibility. The problem is that you do not know what the plan is relying on when they say that because you only relied on the information that the patient gave you at time of service.  And here is the rub.  You may have even verified eligibility at the time of service, but low and behold, now they are saying that the patient was not eligible.  This is a fight you can’t win, and appealing will only result in further denials.

This is a problem you have to make the patients.  Bill them, pass on a copy of the denial and let them fight with their insurance company.  Hold them responsible, and if you have planned for such an event, you have taken a contingent credit card authorization to bill the card just for this type of possibility.  Bill the card, and your done.  Now if the insurance company relents based on the patient arguing with them, and you do get paid, promptly issue a credit to their card.  And be sure to keep the patient in the loop; advise them of the denial and the credit card billing and if paid, advise them of the credit being issued.

Denials for lack of authorization run the gambit of the lack of a referral for the procedure, to a requirement that you are “accredited” or certified” to provide a certain procedure or service.

Your office should build a matrix of all the plans that you participate with, and which of those plans, or products of those plans require pre-authorizations, referrals, or accreditations/certifications. And if you are adding a new service, especially a piece of technology, don’t believe the salesman that tells you that you will get paid by everyone for using it.  Make sure you verify with the health plans directly. (Or better yet, make the salesman guarantee his words with consequences)

If you are a specialist then there is a likelihood that at least some of your pay sources will require prior authorizations or referrals.  Best to know beforehand.  And never let the patient dismiss your request for a referral with the promise that they will get it later.  Get it before services are rendered.  Two ways (1) invite them to all their primary care physicians and ask that it be immediately faxed, and (2) invite them to sign a waiver that if they do not get the referral, or it is invalid, or if they claim it is not needed, they will take personal financial responsibility and pay the bill, in full.  And get that contingent credit card.

If your practice includes ancillary technology, such as imaging services, be sure to verify that if you provide them to your patients they will be covered by the payers.  Imaging services, in particular, are increasingly coming under the egis of specifically contracted subnetworks, and if allowed by practitioners, only if they are “accredited or certified” to provide.  

And always monitor your denials.  Not only do you want to appeal anything where the payer has its facts wrong, you want to bill out to the patient when appropriate, you also want to learn from one denial to avoid it reoccurrence.  Too many offices only react after hundreds, or perhaps thousands of dollars are lost to the same denial reason, repeated and repeated.

Benchmarking Your Practice

So how is your practice doing?  A simple question, but to answer you have to ask a question; compared to what?  Well, let’s compare it with some recent information that MAGMA published about physician-owned vs hospital-owned medical practices.  Some striking differences.  For almost every benchmark the physician-owned practice performed better than the hospital owned practice. 

From MGMAs Data Drive 2017 Cost and Revenue

• Median total gross charges $1,876,174 $1,208,258
• Median adjusted FFS charges $1,033,830 $588,007
• Median Total A/R per FTE physician $169,281 $111,514
• Median days adjusted FFS in A/R 62.19 66.45
• Median gross FFS collection percent 53.90% 46.90%
• Median adjusted FFS collection percent 99.02% 96.75%
• Median bad debt due to FFS activity $19,612 $21,875

Data such as this can be used to benchmark your own practice, and answer the question, how’s your practice doing? 

Start with adjusted gross charges, which is what your charges are after adjusting for contractual allowances, you might even call this your actual billings.  How is the performance of the physicians in your practice in comparison?  This is a measure of your physician performance, the volume, and complexity of the patients seen.

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If your charges are less than the benchmark, you might want to take a look at the services you provide and determine if you are capturing all charges from your medical records.  An integrated EHR-PMS system should sweep the services form the medical record to the billings to capture everything.  Some studies say that upwards of 7% of all services performed and documented in the medical record are not transferred to billing.  

This is also a measure of how busy your physicians are.  How is their schedule?  Gaps in the appointment book mean lost revenue.  Are the gaps no-shows, or lost volume?  

From here the benchmarks are measures of your office staff performance.
Accounts receivable is money that has been billed but remains outstanding.  What is happening in your practice?  Ideally, you should be billing daily so that cash flow is maximized.  And your office should be aggressively pursuing claims with insurance companies older than 30 days since most states have regulations that call for physician claims to be acted on within 30 days of receipt by the insurance company.

The next big issue in accounts receivable is patient collections.  Balances due from patients.  What is your policy on collecting at the time of service?  Do you take credit cards as a contingent payment to be charged when the insurance company settles and advises the balance due?  If not, consider.  Otherwise, you will need to work on your collection practices at the front desk.

Private physician-owned practices are doing a better job in collecting funds due with 99% of FFS payments being collected.  How are you doing in comparison?
And when it comes to the ultimate bad debt, those charges that you are unable to collect, less than $20,000 a year is the benchmark.  Better still, if you are requiring a contingent credit card, you can often bring that balance even lower.

No benchmark is perfect for your practice, but if you don’t have anything to compare with you really don’t have a handle on your own performance, and where there are opportunities for improvement.

How to Increase Your Practice Income through Referrals

Patients follow your advice for continued medical care needs.  Its not just anecdotal information any longer. The National Bureau of Economic Research studies the impact of physician recommendations, price and geography on a patient’s choice of provider, and their conclusion – what you say matters.

Overwhelmingly, patients sought services from the providers, physician, hospital, ancillary, based on the recommendation of their physician irrespective of price, or geographic differential.  Transparency, the doctor next door, the big bill board, the advertising, the bottom line is that patient’s trust their physician.  While the reality is that not everyone will follow your recommendations, but the majority will.

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This means you have power of the purse, power to influence the economics of others.

The only way that you can use this information is to understand what your referral pattern means to others.  You probably already know what it means to clinical labs that grovel (and at times to too far) in seeking your specimens, but have you thought about your impact on others? The specialist, the hospital?

The best way to understand your role in others income is to measure it, that is estimate it.  Turn to your EHR/PMS to see what reports it is capable of running.  If your system can, take a periodic run of your referrals, and where they go.  Not its not going to be in your system, but you can estimate the economic value of your referrals in a crude way, by assigning a dollar value to an office visit and if to a proceduralist, an estimated value of their work, surgery, colonoscopy, etc.  Need a data source, you google Fair Health and see what the rates are on the average for these services. For hospitalizations, just use the average of $10,000, which is the average for a hospital stay in the US.

The value of this information is to understand the economic power that you and your referral pattern command.  Not that its your money, but your decisions mean income to others.

Now with this information consider if the revenue you are producing for others is being respected by them. 

For example, if you continually make referrals to Dr X and he never sends you a consultation report, then perhaps for the betterment of your patients, you should consider another physician to receive your largesse. Similarly, if there is a receiver of the bulk of your referrals, that makes your life more difficult by not taking patients with insurance A, again consider a conversation about it with them, and after they balk at accommodating your patients, slip into the conversation the estimated value of your referrals, if not the dollars the number of cases referred. A reminder may be even necessary to the physician when their office staff won’t accommodate a patient of yours that is in more immediate need of their services.

Specialists, with few exceptions (Allergy, dermatology ophthalmology) are largely in the wholesale business, that is their business is based on referrals, from you and from other referral sources.  While the specialist may command a certain higher stature by virtue of their specialty, they are dependent on your referral for survival.  This means that you have the clout to impact their responsiveness to you and your patients. 

Don’t be afraid to use it.

Retroactive recoveries – you do have protections

There is little more infuriating for a physician than to have provided services, in good faith, billed the patient’s insurance company, and gotten paid for those services to now receive a letter claiming that the payment was in error, and demanding its return.  The physician is left to chase the patient or swallow the loss.  And these letters come out of the blue and may come months, even years after services were rendered and paid.

If you are practicing in New York, or in any state with regulatory protections there is an end to this madness.  In New York physician rights when it comes to insurance companies and HMOs can be found In Insurance law section 3217-b, 3224-a, 4325, 4803 and Public Health law sections 4403, 4406-c, and 4406-d.

When it comes to those recovery demands, the first thing to look at is the date of payment you received on the claim.  The regulations prohibit recoveries more than 24 months after the date you received payment.

This is important to know because as an executive of United once said when challenged why they were sending letters seeking recoveries that were older than 24 months, “Just because we can’t offset the claims, does not mean that we cannot ask for the money back.  Physicians are expected to know their contract and the regulations”.  In other words, there is nothing that stops a payer form asking for the money back, and if you do not know this regulation, you or your staff may be intimidated by the official-sounding letter into dashing off a payment to the insurer.

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In addition, these official letters even when within the recovery window, cannot be mysterious. Under NYS regulation, other than the recovery of duplicative payments, HMOs and insurance companies must give physician 30 days’ notice before engaging in overpayment recovery efforts – like off-setting current claims for the alleged overpayment.  And the letters must include the patient’s name, service date, payment amount, the proposed adjustment, and a reasonably specific explanation of the proposed adjustment.  If the recovery demand does not include the foregoing, send back their letter with a cover letter that says that you dispute this recovery pending the receipt of information consistent with NYS regulations.  And if they press on without responding, send their letter as a complaint to the NYS Department of Financial Services (NYS Insurance Department) or the applicable state regulatory agency.

This will not only get the regulators to ask the plan to explain but will cost the plan money to respond to the regulators, always a good thing.

Now most letters will be about another payer being primary.  Don’t fight it, just bill the primary insurance company, which they should be identifying, and send back to the requesting plan a letter that you have billed the alleged primary and will repay them when and if the alleged primary makes payment.  When that insurer pays, refund the requesting company.  If they deny, just send the requestor a copay of the denial, with a note that they are responsible. (It's not your job to debate insurance coverage).

If the recovery demand is for any other reason, check out their reasoning.  If they are right, then refund, if they are questionable, or you can’t determine from their letter, send back a letter saying you dispute their request until you see…..whatever information you need to confirm the correctness of their representation.

One little problem with all of the above is that it does not apply to governmental programs, or to self-insured plans.  However, you will not readily know if the recovery is on behalf of a self-insured plan, so follow the same guidance.  Even if you end up owing the money, better to make the plan work for the money, rather than readily surrender your earned dollars.

Quickly evaluate an EHR

Quickly and easily evaluate an EHR, any Electronic Health Record, by asking how it supports you with the following functionality. Quickly get focused on what matters and use the expertise of others to assess the system.

Interoperability:  

Does it share well with others?  In today’s practice environment, no man (or woman) is an island.  They can’t be for the sake of their own practice, and for the care of their patients.  Data, which is information for billing and clinical care must be able to flow back and forth between an increasing number of parties.  

Can the EHR share with such diverse systems as Health Information Exchanges (HIE), pharmacies, payers, radiology/imaging services, referring physician, cancer and immunization registries, as well as other disease state registries, hospital networks, as well as the electronic devices increasingly being added to an office?

Today’s EHR must be interoperable, able to share two ways with others. The world of healthcare treatment and reimbursement is increasingly interdependent, and if you are not part of this sharing world with data, you will not only lose out on patient information that could impact the care you render, but also be excluded from even participating in some of the new, and increasingly complex reimbursed offerings.

Ease of use: 

Technology can be hard.  How easy is it to actually use? Does the Electronic Health Record allow for customization of your template for documenting a patient visit, or do you have to twist yourself into a pretzel to document? How flexible is it to follow your usual patient flow, enabling you to truly personalize your operations?

Optimization of your workflow:  

While mirroring your patient flow may be necessary for comfort in transitioning to a system, dashboards that let you monitor your operation and reporting capabilities are necessary to allow you improve your practice. Doing is the status quo, improving is the way to make your practice a success. If an EHR does not contribute to practice improvement across its entire operation, from productivity to revenue to improving the quality of the services you provide, the EHR is not contributing to making yours a better practice.

Patient engagement: 

How does the Electronic Health Record enable you to engage patients? Yes, a patient portal, but what does it allow you to do with your patients that increases satisfaction, service quality and reduce your operating costs?  

Needed is the ability of your patients to securely request appointments and refills online, receive test results as they become available, utilize educational material and update their health status, history, demographics, and insurance information while subscribing to valuable electronic tools and services.

KLAS Rating: 

KLAS Research is an accurate, honest and impartial research on the software and services used by providers and payers worldwide. 

Their extensive research and evaluation process provides an objective review of EHRs and related software. 

You need to ask; “How does KLAS rank you?” to every EHR you might be considering.  The extensiveness of KLAS ranking which takes into consideration actual user experiences is in-depth due diligence. 

Choose the EHR that is right for you, but make sure it is highly ranked by KLAS at a minimum.

All About MIPS: How to Prepare for this Reporting Period

Are you prepared for MIPS? As the deadline to collect data is approaching, it is time for providers to get serious about documentation to avoid penalties. MIPS reporting can be stressful, confusing, and haphazard if you are not prepared. However, in order to avoid penalties and maximize incentives, it is important to assess how you have fared. While you may require special assistance in the form of CureMD’s MIPS consultancy services to properly equip you with a penalty protection plan and help you understand how to maximize your returns, CureMD can simplify the technicalities for you. Enhance your understanding of eligibility, scoring, performance thresholds, and alternative payment models here. Get More Information on MIPS Reporting 2017