With the alarming shortage of primary care physicians facing the United States, one has to wonder if Nurse Practitioners and PAs are going to represent the new Primary Care providers.  This is already one of the fastest growing segments of the healthcare industry and with the continuing shortage of family practice, internal medicine, and pediatricians, one can assume that it will not be changing anytime in the near future.

What is the answer to the shortage?  Well, some say more money but how much more and how do you force the commercial insurance industry to comply with standards adopted by Medicare.  There currently is no regulation specifically requiring commercial insurance companies to follow the guidelines produced by CMS.  So even if CMS does what many have suggested and increase the physician fee schedule for Medicare, what makes anyone believe that commercial insurance carriers are going to just fall in line.

I hope for the sake of our healthcare system that we come up with a solution fast or we are going to be in for a rude awakening as the wait times and locations continue to dwindle.

Paying for payment reform

The House-passed Medicare physician payment reform bill would cost the federal government an estimated $210 billion over 10 years. Nearly $260 billion in higher pay would go to physicians and health plans to treat seniors and military members over that time. But beneficiaries would make up roughly $50 billion of that through higher premiums.

Source: Congressional Budget Office Cost Estimate on H.R. 3961Medicare Physician Payment Reform Act of 2009, Nov. 4 (www.cbo.gov/showdoc.cfm?index=10704)

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Senate plan for reform

Senate Democratic leaders unveiled their version of a health system reform bill Nov. 18, and the full Senate will begin debating the measure when lawmakers return from their Thanksgiving break. The bill would extend coverage to an estimated 94% of Americans at a projected cost of $848 billion over 10 years. It also would cut the deficit by an estimated $127 billion in its first decade. It includes proposals for:

• State health insurance exchanges by 2014 that residents could use to obtain coverage.
• A public health insurance option that allows individual states to opt out of participation.
• A requirement that most individuals obtain coverage by 2014 or pay a penalty.
• Affordability credits for those earning up to 400% of the poverty level.
• Medicaid eligibility expansion to 133% of the poverty level.
• New health insurance coverage and market reforms.
• Replacement of the 21.2% Medicare physician fee cut in 2010 with a 0.5% increase.
• A 40% excise tax on “Cadillac” health plans, as well as additional fees on health plans, hospitals, and drug- and device-makers.
• Higher Medicare payroll taxes for higher-income workers.
• A 5% excise tax on voluntary cosmetic surgical and medical procedures.
• A Medicare ban on new physician-owned hospitals.
• An extension through 2014 of the Medicare Physician Quality Reporting Initiative.
• A new federal Center for Medicare and Medicaid Innovation to test alternative payment and delivery models.
• A national, voluntary Medicare payment bundling pilot program.

It also includes more help for Primary Care in the form of an additional 1% over GDP.  The House Medicare pay bill sets a new spending growth rate target for physician services that would be equal to the gross domestic product plus 1%. Preventive care and evaluation and management services would have a separate target of gross domestic product plus 2%, allowing primary care pay to increase at higher rates over time.

Source: The Patient Protection and Affordable Care Act

It is important to note that this bill is unlikely to pass the senate in its current format.  We should know what the Senate will do in the next couple of weeks as they should finish before the Christmas holidays.

Upgrading, replacing or adopting a practice management system can be difficult. Asking the right questions will ensure you get the right system.

By Emily Berry, amednews staff. Posted Nov. 2, 2009. Critiqued by Andrew Eriksen from http://FreeEMRsolution.com

A good practice management system should be like an oracle for your office. You should be able to ask, “Which patient is coming in next?” or “Who hasn’t paid their bill?” and get the right answer every time. This is true but the software is only as efficient as the employees using it.

Driven by federal incentives to adopt electronic medical record systems, even physicians who are happy with their practice management systems are wondering if it’s time to find new ones packaged with EMRs. The alternative is to pay thousands of dollars to have two vendors’ systems work together — an approach some practices may find worth the cost.  Interfaces are very dangerous so be very judicious about deciding what solution is best for your office.

“The push from the government with the funding that’s out there is driving a lot of energy in this space,” said Jared Peterson, executive vice president for ambulatory research at KLAS Research, a firm based in Orem, Utah, that rates medical software, vendors and medical equipment.

Experts say there’s no right answer on whether to buy an EMR bundled with a new practice management system or to pay to have the two systems interfaced. But there are key considerations.  There is a right answer for each practice but there is not a universal solution.  You have to spend the necessary time in determining, to the best of your ability, what is best for your office.

“As physicians and practice administrators seek EMRs, they may also recognize their practice management system is not able to give them the reporting they need to truly manage their practice efficiently and effectively,” said Cindy Dunn, RN, a senior consultant for the Medical Group Management Assn.  This is a good point and goes back to ensuring that your foundation is stable enough to support the addition of an interfaced EMR product.

Peterson estimated that about half of physician practices buying EMRs intend to keep their practice management systems. About 75% of those end up changing their minds and opting for a package deal. A lack of knowledge among practice managers is the only reason there are so many that initially opt for the interfaced solution.  An integrated solution is far more stable and efficient in 9/10 cases.  You also have to look at who is responsible in an interfaced solution when there are problems with data integration or system work flows.  It is common that each company blames it on the other which makes it difficult to reach solutions.

But a package deal isn’t always best, said Chicago-based practice management consultant Karen Zupko. “One of the biggest mistakes I think people make is on this very subject. The practice management system may be superb, but the EMR that company has designed [has] a really strong primary care flavor, and if you’re an orthopedic surgeon, that’s going to drive you nuts.” You must do plenty of demos and learn what works for your practice and work-flow.

Defining practice management system needs

Brandon Betancourt is practice manager for Salud Pediatrics in Algonquin, Ill., where his wife, Joanna Betancourt, MD, and another physician see 30 to 40 patients a day. Betancourt evaluates practice management systems on whether they can tell him what he needs without complicated queries or hassles. “I’m really into analysis and running numbers. In this system, what kind of pushed me was the reporting capabilities.”

Experts say Betancourt was right to define what’s needed and ask if the system can deliver. If multiple people use the system, each should write down what he or she wants, Dunn said. The final purchase should reflect those needs.

All systems should be able to schedule patient visits and submit claims. And robust, user-friendly reporting distinguishes a great practice management system from a so-so system. “You cannot make any decisions in a practice without data,” Dunn said. “You have to have data, and it’s difficult in many systems to get data out of it.”

A good system should be able to run reports easily, meaning you shouldn’t have to program in data or know complicated command language. This includes “lag reports” that will show the time between date of service, date a claim was submitted and date it was paid, and denial analyses that will help identify problems that lead to claims getting rejected. A good system also should allow patient preregistration, including eligibility checks on insurance coverage, Dunn said.

A basic practice management system should allow electronic claim submissions. But not every system does it the same way. Typically, those claims go through a clearinghouse; a vendor may require a certain one be used, or charge for claims submitted directly to payers. You need to know applicable restrictions and fees, Dunn said.

Some systems will help fix errors in claims to make sure what’s submitted to insurers is “clean,” expediting payment, Peterson said.

A suberb system should allow you to auto post remits, customize your dashboard based on the user, import fee schedules from excel, electronically submit secondary claims, integrate with patient statement companies, and allow you to custom build reports based on your needs.  These reports should be available immediately and should only be available to specific users as defined by the administrator.

Developing seamless EMR communication

If you opt to keep your current practice management system, you should know if adopting a new EMR will require you or your staff to enter the same information twice.  Technically, not ture.  HL7 compliant EMR/PM programs or even most custom built interfaces will transfer the data between the two programs but there can be a delay or unwanted manipulation of data during the transfer.  Double data entry is not as common these days because of the advancements in the programming of these interfaces.

Look for “bidirectional interface,” Dunn advised, so if you change a patient’s phone number in the practice management system, that change will show up automatically in the EMR, and vice versa. Beyond the time wasted, entering information twice doubles the risk of an error, Dunn said.

But vendors can charge $10,000 to $50,000 to make their EMR talk to your practice management system or vice versa, so you need to decide if that cost is worth it.

Peterson said it’s that choice — to enter data twice or pay to make the systems talk — that pushes many physicians toward a single vendor. Larger practices are less likely to replace an old system if it’s working well and customized to the group’s needs, since training everyone on both an EMR and new practice management system may be as expensive as paying the interface fee. Much more expensive in practices with more than 5 physicians.  The short term costs are not what should push you in one direction or another.  You need to look at it more from a productivity standpoint and long term viability.

If you keep your practice management system or buy one from a vendor different from the one that sold you your EMR, Dunn advised, “make sure the two vendors will talk to each other — you don’t want to be stuck in the middle.”

Finding a good vendor

Dunn said there are several ways to evaluate a vendor, but you must take time to do the research.

First, do not assume having a “certified” system means that your vendor is a good choice. Certification doesn’t “rate whether the vendor provides good support, or is financially viable, and those are things you’re going to take care of and take responsibility for,” Dunn said. Agreed, certified vendors only means it has a stamp of approval from an organization that does not have a clue what your practice needs.  I like to think back to Farley’s guarantee sales pitch in Tommy Boy…

Find out if the company hosts an annual user group meeting, she said. If possible, attend that meeting to hear customers’ gripes.

Dealing with only a company’s sales staff does not tell you about vendor support, said Jennifer O’Brien, executive director for Arkansas Specialty Orthopaedics, a 22-doctor practice in Little Rock, Ark. She suggested judging by numbers — finding out how many clients the support team handles gives you an idea of their responsiveness. You should also find out where the support is based as some companies have moved phone support overseas, this is terrible on many levels.  Tell them that you would like to visit the support center and actually do it if you are serious about software.

Betancourt chose his practice management vendor first based on how well it would work with the practice’s EMR, then for its pediatric-specific customization. “I never bought it when [other vendors] told me, ‘We can customize it,’ ” he said.

The system he ultimately chose offers tools that made sense for the group, something experts said can be helpful, but isn’t a necessity for every specialty. And there are trade-offs. “The challenge is a lot of those specialty-specific vendors [are] not huge vendors, and there is risk going with a small vendor,” Peterson said.

Budgeting time and money

Key to planning adoption of a new system is realizing that the outlay of time and money isn’t going to stop after a few months.

Dunn said you still must replace computers every three years on average, and you may have to pay for new software user licenses if your practice grows. If you upgrade either your EMR or practice management system and they are from different vendors, you might have to pay the interface fee again.

Spending enough implementation time is key. “Bringing on either a practice management software system for the first time or a new practice management system probably requires at least twice as much preparation, planning, piloting and training than you think it does,” O’Brien said.  Understanding the Implementation time frame is key to having realistic expectations.  Additional information here: http://freeemrsolution.com/selecting-and-implementing-emr/5-pillars-emr-ehr-successful-implementation/

She started working as a practice management consultant after seeing firsthand the problems a practice can have returning to a previous system. Be ready to troubleshoot nontechnical problems, such as how the system affects practice flow and morale, she said.

“The skills of the manager in managing people, developing them to their highest level of performance, is as important as knowing the system and what it can do for you,” O’Brien said.

The print version of this content appeared in the Nov 9, 2009 issue of American Medical News.

Additional Questions to ask and consider before selecting an EMR/PM system can be found here:  http://freeemrsolution.com/questions-before-selection/

Two primary care clinics will close as part of 93 layoffs announced Nov. 11 by the Jackson Health System in Miami.

The closures and layoffs, scheduled to occur in January 2010, come as the county-run hospital system has tried to cut a $168 million budget shortfall. The system previously was able to cut $61.7 million. But it said it also needs to close the primary care clinics, as well as a liver transplant unit, a heart-and-lung transplant unit, a wound care unit and a mental health unit.

Attempts to convert the primary care clinics into federally qualified health centers were not successful, according to Jackson officials.

The system did not disclose if any doctors would be laid off. Jackson Health uses a combination of doctors affiliated with the University of Miami Miller School of Medicine as well as its own employed physicians.

Jackson began hiring its own doctors and expanding its services several years ago when the University of Miami, which had used Jackson Memorial Hospital as its teaching facility, considered getting its own facility. In 2007 the university bought Cedars Medical Center, across the street from Jackson.

While University of Miami doctors continued to work at Jackson, tensions between the two sides began running higher, culminating in a Nov. 2 summit in which school officials criticized the quality of doctors that Jackson was hiring and the hospital system’s expansion strategy.

Meanwhile, Jackson leaders accused the university of sending private insurance patients to Cedars and the poor and uninsured to Jackson.

The Jackson system is funded by property and sales taxes, both of which, the hospital said, have dropped considerably over the past few years because of the economic recession and the rapid drop in the area’s land values. The recession also has brought increased demand from uninsured patients.

Closing the clinic and other units will not be enough to fill the rest of the budget gap, so hospital executives are still looking for more areas to cut.

The employee cutbacks were announced in a year that already has seen a large number of mass layoffs at hospitals. As of Sept. 30, the Bureau of Labor Statistics said there had been 127 layoffs involving 50 or more employees. That already exceeds the 112 mass layoffs for all of 2008, and nearly double the 67 for 2007.

Is anyone else confused at the position of the American Medical Association regarding ObamaCare?  It would seem as though they are a very poor representation of their members.  But the fact is that the recent house bill has thrown huge incentives at Physicians by doing away with the SGR (Sustainable Growth Rate Formula) which was due to give physicians a 21.5% decrease in Medicare payments in January.  It has been coming up with decreases every year for the past 4-5 years but every year it is stopped by the AMA or other lobbyists.  Anyone practicing Medicine knows that the Medicare reimbursements are barely enough to cover the costs of doing business so any cut to Medicare would be far felt.  The doing away of the SGR is a big win for the AMA so it does not surprise anyone when they offer their support.  The House bill also contains an allocated 5% increase to primary care physicians(Finally) which has been needed for a long time.

The problem with the AMA’s support is that the Bill still is devasting to our national deficit and long term sustainability.  With a Medicare system that has been operating in the Red for years, how can we expect the government not to come up with a balance that debt in the coming years.  What you will have is a healthcare system revolving around the government.  40% Medicare, 60% obamacare.  The House bill does provide some serious incentives but you have to question the naked man who offers you his coat.

There are many physicians out there wondering what is going on withe proposed health plans and how any of them will affect them.  Internal Medicine physicians, Family Practice Doctors, Pediatricians, and Hospitalists seem to have the most at stake in this evolving health plan.

Primary Care physicians are already in high demand and the country has been facing a shortage of doctors providing general care for many years.  This is only going to get worse as their pay continues to lessen and demand continues to increase.  You are seeing more and more urgent care facilities because Emergency doctors and other practitioners are leaving their traditional practices behind and seeing patients on a cash basis thus circumventing the insurance red tape(for the most part).  This is very attractive for many reasons but once everyone has insurance, will this model remain.

You have to ask yourself what will happen to the system when people are given health insurance.  Health insurance that has not costed them anything therefore how much could they possibly care about protecting the system.  There is not an easy answer or an answer that everyone will be happy with.

The following tasks will improve the cash flow of your business:

• Obtaining the correct demographics, insurance information and eligibility for a patient at the front desk is key for efficient claims processing and will reduce denials for timely-filing issues.

• Tracking no-show patients as well as contacting patients for follow-up visits and/or procedures that they did not previously schedule will increase patient volume and revenue.

• Encounter Forms should be reviewed and updated on an annual basis due to the numerous ICD-9-CM diagnosis codes and CPT procedure code changes that occur. Removing deleted codes and adding new codes for the current year will ensure that claims won’t be denied for non-valid code submission. Paying close attention to the addition of 4th and 5th digits for more specificity of diagnosis codes will reduce claim denials and support medical necessity along with your documentation for higher-level Evaluation and Management (E/M) services and/or procedures.

• Obtaining an independent review of your coding and documentation should address many areas that could affect your revenue. In addition to determining if the provider’s documentation is supporting the procedure codes being billed, it can also uncover charges not being billed.

• Be certain that you are utilizing appropriate modifiers and reviewing the Correct Coding Initiative (CCI) edits to ensure you’re capturing all billable items.

• Review your current fee schedules, reimbursement schedules and Explanation of Benefits (EOB’s) for incorrect reimbursement and/or downcoding.

• Proactively negotiate your managed care contracts.

• Improve the effectiveness of your collection process. Set up timings for follow-up and utilize the appropriate number of staff.

The combination of all the tasks mentioned in this article will lead to an increase in the cash flow of your healthcare business.

Most medical practices have heard of AAPC or the American Academy of Professional Coders, the question remains what certification if any is the best for your practice?  As you may already know, the certification can make a bad employee good but can make a good employee better.  Having a certificate does nothing for an individual that does not stay current with ever changing coding rules and procedures.  It also does not give the employee a better work ethic or attitude.

The most frustrating thing for me as a former Medical Practice Administrator is a biller or coder with a poor attitude.  I understand that many billers lack the desire or skills to interact with employees and patients on a daily basis but this was unacceptable in my practice.  I would rather have a coding specialist that has a positive attitude and is willing to do what is necessary to improve OUR practice, even if that means they have to do some AR follow-up.  The one thing that I have noticed with Certification is that it adds a level of confidence or arrogance to a coder that is not sometimes not present when the certification is not present.  Having a coding certificate does less for your practice than it does for your employee and that is a fact.  Certification is in no way a bad thing but you have to be prepared to pay more and may have to worry about losing them to another organizaton.  From a coders perspective, obtaining certification does add value and increase your knowledge which is always the ultimate goal.

From a practice’s perspective a good coder does not need some letters behind their name to make them a better coder.  The question is really concerning whether or not they are actually coding correctly.  And know that just because they are certified, that does not mean that they are actually coding correctly or within compliance.  If you are unsure of your coders ability then it would be wise to have an outside company perform a coding audit to ensure their competence.

There are many choices out there for Elecrtonic Medical Records and we know how difficult it is to select one.  We recommend that you demo many products before ever selecting one.

Preliminary Steps to Implementing Electronic Medical Records:

• Find out about regional incentives available for implementing EMR
• Purchase or lease high quality printer/scanner that can easily scan documents to a computer in your office or your server
• Test the computer literacy of your nursing staff as they will be needed to document H&P or Vitals in the EMR
• Decide on either tablet pcs or computers in every exam room and the nurses station
• Look into leasing/purchasing options for computer equipment if your current computers are outdated
• Evaluate your own desires for a .net/asp or internally hosted application
• Determine current cost savings with implementing EMR.  Things to consider- More accurate coding, chart prep savings, staff hours reduction(10% after 6 months), transcription cost savings, etc…
• Determine variable costs increase with the implementation of Electronic Medical Records- Productivity drop during transition, licensing fees, support costs, computer maintenance costs, purchase/lease costs for additional computers, training costs, scanner costs, etc….

Top Things to Consider:

• Ease of Use-Directly effects your productivity and therefore your bottom line.  Don’t expect to be more productive for at least 6 months
• Must interface very well with your Practice Management Software and be easy for your nurses to learn
• Costs-Affordability
• CCHIT Certified-make sure program will qualify for rebates
• Functionality for your specialty
• Lab Interface
• Medicare E-Prescribe

Check with the specialists at http://FreeEMRSolutions.com or email emrhelp@primarycaremedicalbilling.com.

We also recommend you speak with one of the executives at Physicians World Online as they can help you select an appropriate program.  aeriksen@pwomail.com

7 Step AR Recovery Process:

This plans takes for granted that you have adequate staff and sufficient practice management software. If you do not have these things we recommend that you contact the experts at Physicians World Online for a free consultation. info@physicianworldonline.com

1. VERIFY PATIENT INSURANCE ELIGIBILITY( this and accurate demographics are a must for collecting Insurance and Patient AR)

2. Evaluate Insurance Contracts to ensure they adhere to current CPT guidelines.

3. Adjust your charges with a consistent formula based on a percentage of Medicare.(This allows for an accurate gross and net collection percentage)

4. Scrub your claim and use a coder with knowledge of your specialty to ensure proper modifiers and diagnosis codes are appended.

5. Submit claim electronically to decrease the payment cycle of claim.

6. Do not wait to receive something in the mail, call when the claim is older than the contract allows.(Medicare 20 days, BCBS and other commercial carriers is usually 30 days)

7. BE PERSISTENT and don’t let them get away without paying you. Call and send documentation if required. Make sure to write down patterns with denied claims and send supporting documentation with original claim if needed.