Act now to get prebooking benefits for next influenza season
The 2016-2017 influenza season is winding down, and hopefully you have used up all your influenza vaccine supply. Right?
As a former office manager, I realize that answer is probably no, and you actually have a lot of leftovers. An essential part of running a medical practice is using your electronic health record or billing system to find the correct number. Determining the amount of flu vaccines you billed over the past two or three flu seasons should help you estimate the number you should order for the 2017-2018 season. Be sure to take into account if your patient panel has grown or decreased. Not only will you be better prepared for the next season but also you can take advantage now of the prebooking options offered by various vaccine manufacturers and distributors.
Prebooking is when you turn in your vaccine order for the upcoming flu season order in advance, typically by the end of March. Admittedly, it is difficult to manage this number effectively because you are doing it an average of five to six months ahead of when you will need the vaccine in your clinic. The manufacturers and distributors have programs available that can help you manage your inventory as well as keep your costs down. Some prebooking programs have matrixes to help determine the number of vaccines to order, staggered shipping, order forgiveness, and volume discounts. These factors can lead to diminished costs, which, of course, can lead to greater profit margins.
You are encouraged to contact the major manufacturers and distributors directly to see what their individual prebooking programs offer. These will vary based on your practice size, patient panels, and volume discounts. Here is contact information for some of the manufacturers:
• Sanofi Pasteur (www.VaccineShoppe.com) 800-822-2463
• GlaxoSmithKline (www.gskdirect.com) 866-475-8222
• Seqirus (www.flu.seqirus.com) 855-358-8966
• Protein Sciences (www.flublok.com) 203-686-0800
– Barbie Hays, CPC, CPMA, CPC-I, CEMC, Coding and Compliance Strategist for the American Academy of Family Physicians
Changes to renewing DEA registration for physicians
Update: After this blog item was originally posted, the DEA announced that it had reversed its decisions to eliminate a second registration renewal notice to prescribing physicians and eliminate the grace period for renewals after Jan. 1. Instead, the DEA said it would retain its current policies and procedures for renewing DEA registration although registrants will now receive the second renewal notification at the email address associated with their registration instead of through the mail.
There are many moving parts to practicing as a family physician and one of those is being able to prescribe needed medications for your patients. That depends on having a valid, current registration with the U.S. Drug Enforcement Administration (DEA).
The DEA recently announced significant changes to its registration renewal process. Effective Jan. 1, the DEA is eliminating the informal grace period that the agency had previously allowed for registrants to renew their registrations. The DEA will send only one renewal notice to each registrant’s “mail to” address approximately 65 days before the expiration date; DEA will provide no other reminders to renew the DEA registration.
The DEA also advises that physicians who fail to file a renewal application by midnight Eastern Standard Time of the expiration date will have their DEA number “retired” and have to apply for a new one. The agency also says after the expiration date physicians won’t be able to renew a DEA registration online and the DEA won’t accept paper renewal applications.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
How much can you charge patients for their health information?
The Office for Civil Rights (OCR) within the U.S. Department of Health and Human Services recently addressed patients’ rights to access their protected health information (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Much of the guidance focuses on the fees that a covered entity, such as your practice, may charge patients requesting copies of their own PHI.
According to OCR, you can charge patients for:
1. labor costs (including preparation of an explanation or summary when agreed to by the individual)
2. supply costs related to the creation of either the electronic or paper copy (e.g., paper, toner, CD, or USB drive)
3. postage costs when the individual requests the information be mailed
The OCR guidance indicates that permissible labor costs may include only the labor “for creating and delivering the electronic or paper copy in the form and format requested or agreed upon by the individual, once the PHI that is responsive to the request has been identified, retrieved, or collected, compiled and/or collated, and is ready to be copied.” (Emphasis added) That means you cannot charge for reviewing the request or searching for and retrieving the information.
The OCR also emphasizes that you may not charge individuals for system maintenance, data storage and maintenance, or the administrative costs associated with outsourcing your office’s response to requests for PHI. OCR further notes that if you use systems that allow individuals to access their PHI through electronic health record technology, you may not charge labor or supply costs.
The OCR guidance says that when calculating the fees you charge, they may reflect your actual costs, your average costs, or a flat fee. If using actual costs, they must be reasonable and calculated upon each request. OCR says that you can charge average costs as a standard rate (e.g., a per-page fee if you maintain the requested PHI in paper form and the individual requests a paper copy). The OCR adds that “per page fees are not permitted for paper or electronic copies of PHI maintained electronically.” Finally, you can charge a flat fee but only for electronic copies of electronically maintained PHI, and the flat fee cannot exceed $6.50.
Regardless of the fee method used, you must notify individuals in advance of any fees that could be charged for their requests for PHI at the time the details of the request are being arranged. Failure to provide such notice could potentially be a HIPAA violation.
If a patient requests that you send their PHI to a third party, you must treat that request the same under HIPAA as if the patient were requesting it be sent to them directly. However, if a third party initiates the request for PHI, the limitations on copying fees do not apply. So, you should ask whether the request was a direction from the patient or a request from a third party.
Finally, the OCR guidance discusses the relationship between HIPAA and state law. Specifically, when it comes to an individual's right to access his or her own PHI, HIPAA trumps state law if HIPAA provides individuals with greater access to their PHI. That means if your state law allows you to charge higher fees or to limit an individual’s access, HIPAA will preempt that state law.
Needless to say, now may be a good time to review your policies and procedures for granting access to individuals’ PHI, including whether and how you charge for copies of that information.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
MGMA-AMA encourage collaboration to solve health care challenges
Almost 350 physicians, practice administrators, and other health care leaders met in Colorado Springs, Colo., March 20-22 for the inaugural Collaborate in Practice Conference, sponsored by the Medical Group Management Association (MGMA) and the American Medical Association.
The event was billed as a way to help practices better handle the many challenges facing medicine through better teamwork, leadership, and collaboration among physicians, other clinicians, managers, and other partners.
Halee Fischer-Wright, MD, president and CEO of MGMA, said that health care can’t just confront change but needs to control it or, better yet, lead the way.
Breakout sessions focused on such topics as making team meetings more effective, refining and reinforcing your practice’s culture, finding ways to give patients more access so they don’t gravitate to other providers, and increasing physician engagement to fend off burnout.
Some takeaways from the sessions:
• 71 percent of malpractice suits are tied to miscommunication and poor physician-patient relationships. Practices should focus on fighting dysfunction within teams, defusing toxic relationships that can affect patient care, and create the kind of supportive environment where patients are more likely to share their own personal or social issues that could influence treatment. – Monica Broome, MD
• All team meetings should have a specific purpose and goal. Meetings are a vital sign for your organization, and useless or unsuccessful meetings may reflect a structural problem within the practice. – Steven Bromer, MD
• Practice administrators or physician leaders will have more success changing clinician behavior by appealing to their mastery, autonomy, and sense of purpose. Framing a change simply as a response to regulatory requirements is not helpful. – Stephen Beeson, MD
• To increase patient satisfaction, have nurses call patients the day after a visit, which can either make a satisfied patient even happier or give a dissatisfied patient a chance to complain before it becomes more work for the practice; take advantage of the perceived connection between cleanliness and good care by keeping your office clean; make sure the receptionist always makes eye contact with the patient upon entering; and try to give patients the appointment times they want so you don’t run the risk of the patient showing up late and throwing off your entire schedule. – William Faber, MD
• Leaders should not feel the need to be perfect in all facets of leadership. Instead, they should lead with their strengths, such as execution or motivation, and rely on their team to make up for their weaknesses. – Wayne Guerra, MD
• When done correctly, incorporating health care information technology into your practice can improve patient engagement, physician workflow, and, ultimately, physician happiness. Introduce technology innovations slowly, aim for short-term gains, but ultimately lay the groundwork for big wins down the road. – Lyle Berkowitz, MD
University of Florida department wins 2015 FPM Practice Improvement Award
The University of Florida Department of Community Health and Family Medicine has won this year’s Family Practice Management Award for Practice Improvement. The department was presented with the award Friday during the Society of Teachers of Family Medicine Conference on Practice Improvement being held in Dallas, Texas.
Former FPM Editorial Advisory Board member Kenny Lin MD, MPH, presented the award to the department’s program director, Peter Carek, MD.
The program was recognized for its inpatient readmission project that addressed high rates of readmission to the university hospital after discharge. A team that included family medicine physicians, emergency medicine physicians, pharmacists, nurses, social workers, and home health providers created and implemented a high-risk patient discharge plan.
During the 10 weeks before the project started, the family medicine inpatient service's readmission rate averaged 23 percent. For the 20 weeks following implementation of the project, the readmission rate decreased to 18 percent, an absolute reduction of 5 percent and a relative reduction of 22 percent.
– Lindsey Hoover, assistant managing editor, Family Practice Management.
CMC-Elizabeth Family Medicine wins 2014 FPM Practice Improvement Award
A North Carolina primary care clinic has won this year’s Family Practice Management Award for Practice Improvement.
Carolina Medical Center-Elizabeth Family Medicine, based in Charlotte, was named winner Friday during the Society of Teachers of Family Medicine Conference on Practice Improvement being held in Tampa, Fla.
FPM Medical Editor Kenneth Adler, MD, MMM, presented the award to the clinic’s medical director, M. Quentin Fité, MD.
The clinic was recognized for using LEAN efficiency principles over several years to dramatically improve patient satisfaction scores, appropriate care metrics, patient visits, and overhead costs, as well as standardize clinic processes and make more choices based on data rather than gut decisions.
LEAN, first developed by automobile manufacturers, is a systemic approach to improving efficiency by eliminating waste and understanding what parts of the operation create value for the patients and staff.
CMC-Elizabeth Family Medicine is part of the Carolinas HealthCare System and primary ambulatory clinic for CMC’s family medicine residency program. The clinic handles about 25,000 patient visits a year with more than half of its payer mix made up of Medicare and Medicaid patients.
Survey shows practices spending more for business staff
Physicians are spending more for staff that support the business side of their practices, according to a new survey.
Respondents reported a 4.6 percent increase in spending compared with last year on total business operations staff for each full-time equivalent (FTE) physician. The Medical Group Management Association’s (MGMA) 2014 Cost Survey said multispecialty practices spent a median of $52,009 per FTE on business operations staff. That includes general administration, information technology, accounting, and managed care administrative employees.
Family physicians spent a median of $32,772 per FTE. That's a 17 percent increase from the previous year, but MGMA cautioned that only a third of family physicians taking the survey provided information on this question. The organization noted that business administrative staff costs for family physicians rose 4.59 percent between 2009-2013.
MGMA didn’t ascribe a specific reason for the increases, crediting everything from practices simply wanting to make themselves more efficient and business savvy to offices reacting to regulatory changes in the medical and insurance communities.
The survey involved 2,518 medical groups across the country, including 475 family medicine practices.
Survey: Average family physician wait times are more than two weeks
The average wait time for a patient wanting to get an appointment with his or her family physician has dipped slightly from two years ago, a new study says. But patients are still having to wait two weeks or longer.
Health care consulting firm Merritt Hawkins, in a new report, says its survey of family physician offices in 15 U.S. metropolitan areas found an average appointment wait time of 19.5 days in 2013. By comparison, average appointment wait time was 20.3 days in 2009.
However, the researchers noted that average wait times equaled or exceeded 14 days in 10 of the 15 markets last year. In 2009, only eight markets equaled or exceeded the two-week mark.
The company surveyed almost 1,400 offices across the 15 metro areas in family medicine and four other specialties. Researchers considered family medicine essentially flat. Cardiologists (16.8 days) and dermatologists (28.8 days) saw their wait times increase while obstetricians/gynecologists (17.3 days) and orthopedists (9.9 days) saw a decrease.
Overall, the average wait time to see a physician across all specialties and markets decreased from 20.4 days in 2009 to 18.5 days in 2013.
Despite the decline, Merritt Hawkins warned that physicians unable to see patients within 14 days are likely busy and need the help of other physicians or advanced practitioners to handle the overflow.
The survey also found that the overall average acceptance of Medicaid patients has declined in the 15 markets over the past four years, falling to 45.7 percent in 2013, compared with 55.4 percent in 2009. An average of 76 percent of practices in the 15 markets accepted Medicare in 2013. Merritt Hawkins didn't survey for Medicare in its 2009 survey.
If you're looking for ways to get more patients into your practice faster, you can check out articles in Family Practice Management's Access to Care topic collection.
New year, new insurance verification reminders
It is the beginning of the new year, which means patients may be walking into your office with new health insurance.
Some may have gotten new employer-based insurance as many companies hold open enrollment in the fall and the plans become effective on Jan. 1. But this year will also feature a number of patients who have purchased insurance through a state or federal health insurance exchange, made possible under the Affordable Care Act. In any case, you should verify your patients' insurance status when they show up in your office to avoid potential problems getting paid after they leave.
The insurance exchanges are expected to provide new coverage to more than a million people. In many cases, this will be the first insurance these patients have had in years. Many will also have signed up for their plan within the past few days and either may not have received their card yet or may be unaware they need to carry their insurance information.
How do you verify their coverage?
If the marketplace in your state is run by the federal government, call the customer service line for the patient’s plan. A list of all plans and their customer service numbers can be found in a database on the Healthcare.gov website. A fact sheet for using the database is also available online. If you can’t find the number, you can also call the Marketplace Call Center (1-800-318-2596).
If your state has its own health insurance exchange, you'll need to contact its customer service line. To find the website for your state exchange, select the name of your state in the box at the left hand side of the Healthcare.gov website.
To help both those patients who are new to insurance and your practice, remind them to retain all paperwork they receive from their doctor's appointments, pharmacy visits, and other treatment in case their insurer needs to see it or to support a claim. It may also help to remind them to bring their new insurance card with them to the office. If they don’t have a card, they can contact their plan to get a card.
All patients have until March 31 to sign up for non-employer based coverage to avoid penalties under the Affordable Care Act. They can go to HealthCare.gov to sign up for a plan and apply for financial assistance. Additional fact sheets or educational material for your patients are available through the Centers for Medicare and Medicaid Services website.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Standards for streamlining physician payment coming Jan. 1
Beginning Jan. 1, 2014, family physicians and all other entities covered by HIPAA must comply with operating rules regarding electronic funds transfer (EFT) and electronic remittance advice (ERA).
These rules, called for under the Affordable Care Act, require health insurers to standardize business practices for EFT and ERA, and they will make it possible for medical practices to automate the time-consuming process of manually matching payments from insurers with claims that have been submitted. That, in turn, should help reduce administrative hassles and paperwork burdens and free up time to spend with patients.
The Centers for Medicare & Medicaid Services estimates that approximately one-third of claim payments across the industry currently are transferred electronically, and insurers’ reliance on EFT is expected to increase. Medicare rules already require physicians who are new to the program or who update their enrollment information to be paid via EFT.
The operating rules were established by the Council for Affordable Quality Healthcare's (CAQH) Committee on Operating Rules for Information Exchange (CORE). To ensure that physicians are prepared to meet their deadline obligations, CAQH and CORE already have begun to roll out a series of online resources. Physicians should check the CAQH website regularly to read updated fact sheets about the rules, access helpful tools, and sign up for educational sessions and webinars that will assist in compliance preparations.
Free toolkits from the American Medical Association (AMA) can also help physicians take advantage of the changes. The AMA toolkits on EFT and ERA include informative sections on getting started with electronic transactions, key questions to ask vendors, guidance about information technology solutions, and an outline of the rules and standards for electronic transactions.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Survey: PCMH model generates more costs and revenues than regular practices
The cost of operating a medical practice under the patient-centered medical home (PCMH) model is higher per patient than it is for a regular practice, although revenues also rise.
Those are some of the takeaways from a review of primary care cost data released this week by trade organization MGMA-ACMPE.
Surveying 969 primary care practice groups, the researchers found that the median operating cost per patient for PCMH practices was $245.79 in 2012, compared with $177.11 for non-PCMH practices. That figure includes total operating and non-physician provider expenses.
Much of the added expense is from the additional care coordinators and other support staff required under the PCMH model. According to the survey, PCMH practices had a median of 29 full-time equivalent (FTE) support staff members per 10,000 patients last year, compared with 18.5 FTEs per 10,000 patients in non-PCMH practices.
The researchers added that while costs were up, the PCMH model practices also tended to generate more revenue per patient, helping offset the added cost. Surveyed PCMH practices reported last year generating a median of $379.37 per patient, compared with $248.15 in non-PCMH practices.
No shows = lost revenue
Medical practices average a 5 to 7 percent no-show rate, according to the Medical Group Management Association (MGMA). No-show appointments are a reality of every medical practice. While you may not be able to eliminate them, there are ways to reduce no-shows and the negative effect they have on your practice.
Maintain patient access. The longer you require a patient to wait to be seen, the more likely they will find care from another provider, especially if it is something they need to be seen for right away such as an ear infection or strep throat. In these cases many patients do not call to cancel the future appointment with you, they just don’t show up as they have received care somewhere else.
Make sure you have assigned acute appointment slots in your schedule every day to see these patients the same day they call. Seeing just one more patient per day can accumulate into a large amount of additional revenue each year. According to Michael O'Connell's MGMA Connexion article, "10 ways to manage better during difficult financial times," adding just one more patient to your schedule each day can add $25,000 to the annual bottom line for primary care (estimating $100 for a new patient visit).
Remind patients. Remind patients that they have an appointment with your practice. Assign staff to remind patients at least 48 hours in advance of their appointment or consider using an automated appointment reminder service if it makes financial sense for your practice.
Require appointment confirmations when appropriate. Long appointments such as procedures or complete physicals take up a lot of time on a physician’s schedule. For these types of encounters you may want to require that the patient confirms the appointment with you. Confirming long appointments can prevent huge gaps that can have a negative effect on your day. Confirmations can be done using automated reminder systems or personally asking patients to call back to confirm the appointment rather than leaving a message and hoping they received it.
Manage chronic offenders. Identify the patients who chronically miss appointments. Place a note in the patient’s record for the schedulers to see during the scheduling process. If a chronic no-show patient requests an appointment, try double-booking them with a quick visit or give them an appointment at the end of the day where the missed appointment will not disrupt patient flow.
Dismiss chronic offenders from your practice. Patients that repeatedly no-show for appointments can be terminated from your patient panel. Develop a policy for your practice to dismiss these patients and be consistent with every patient. For example, allowing a specific number of no-shows prior to dismissal gives the patient an opportunity to accidentally miss appointments before being terminated from the practice. Three missed appointments prior to termination is a reasonable policy to put in place.
Consider charging no-show fees. If you have tried other methods to decrease your no-show rates and are not seeing results, you may want to implement a policy to charge a fee for patients that do not show up for appointments to recoup some of that lost revenue.
There are some important aspects to consider before moving forward with a no-show fee policy:
- Some payers allow charges for no-shows. Is your office capable of tracking who can and cannot be charged the no-show fee?
- What is your patient population like? Can the average patient afford to pay the fee for a no-show appointment? Will they ignore these charges and make it difficult for you to collect the fee? You don’t want the implementation of a no-show policy to lead to a more complicated problem of collecting the fees from your patients.
- Will the amount of the fee charged compensate for the amount of time it takes to bill and collect from no-show patients, or will you be losing money on this effort?
- Your patients may seek care from another physician. If the patient does not approve of the no-show fee, they may leave your practice voluntarily and you could lose that patient and the revenue of future visits.
How do you keep no-shows from ruining your day in your medical practice? Click on “Comments,” below, and share your ideas and best practices.
–Renae Moch, MBA, CMPE, Practice Management Strategist for the American Academy of Family Physicians
Is your practice "wholly owned" or "wholly operated"?
Recently I listened to a Medicare contractor's teleconference regarding the three-day payment rule that applies to services provided by an entity that is wholly owned or wholly operated by a hospital. In a nutshell, this rule bundles the technical component of the payment for all outpatient diagnostic services (e.g., lab, ECG) and the practice expense components for other related outpatient services (e.g., evaluation and management, or E/M, services) into the payment for a hospital stay that begins within three days of the outpatient service. The good news is that this applies only to physicians whose practice is wholly owned or wholly operated by a hospital that is paid under the Inpatient Prospective Payment System (IPPS). A shorter one-day rule applies to practices wholly owned or wholly operated by psychiatric hospitals and units, inpatient rehabilitation hospitals and units, long-term care hospitals, children’s hospitals, and cancer hospitals. The rules do not apply if your practice is owned by a health system that also owns hospitals or if a hospital is only one of the owners of your practice.
If your practice is not owned or operated by a hospital, the rest of this entry does not apply to you, but reading it may make you feel a little less hassled.
If you are unsure whether your practice is wholly owned or wholly operated by a hospital, it is important that you determine whether the rule applies to you and if so, how your practice and the hospital will work together to identify admissions and related outpatients services. The Center for Medicare & Medicaid Services (CMS) has published a memo of frequently asked questions that can help you determine if your practice is subject to the rule and also explains how hospitals must work with their wholly owned or wholly operated practices to comply with this rule.
Some key points regarding this rule are:
It applies to Medicare Part B claims of wholly owned or wholly operated practices.
It applies only to claims that are submitted using place of service 11, 12, or 32. It does not apply when professional and facility charges are separately billed (e.g., place of service 22.)
Practices subject to this rule must hold Medicare and Railroad Medicare claims for at least 72 hours prior to billing for the hospital to determine if a related admission has occurred. However, all services provided in the office on the date of admission will be considered related to the admission.
Medicare will pay only the professional component for services that have professional and technical components and the facility rate for other services such as evaluation and management services.
As of July 1, 2012, modifier PD ("Diagnostic or related nondiagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within three days or one day") must be appended to the codes for services that are subject to the rule.
Services that the hospital determines are not diagnostic or not related to the inpatient stay are not subject to the rule. (Practices should keep record of the rationale for why the service is unrelated to the admission.)
It is up to your practice to work with the hospital to determine if and how any lost revenue for the practice is offset by the hospital. How's that for administrative simplification? (No answer required.)
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