Billing spikes tied to increased use of electronic medical and billing records.

The New York Times recently reported that “Medicare bills rise as records turn electronic”. Find the story here.

As reported, the issue is this: “When the federal government began providing billions of dollars in incentives to push hospitals and physicians to use electronic medical and billing records, the goal was not only to improve efficiency and patient safety, but also to reduce health care costs. …But, in reality, the move to electronic health records may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care.”

The article cites Medicare data to suggest that hospitals are using EHRs to exaggerate the scope of work that doctors provide, in an effort to increase their reimbursement rates. This practice, known as “upcoding” was also examined by the Center for Public Integrity earlier this month, focusing on hospital emergency room billing. Find that report here.

As reported, here are some of the data related to hospital billing: “Over all, hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010, the latest year for which data are available, compared with a 32 percent rise in hospitals that have not received any government incentives, according to the analysis by The Times.”

It’s also noted that the “most aggressive billing” can be found in practices and services specializing in family practice, internal medicine and emergency care, accounting for about 1,700 of the more than 440,000 doctors in the country – and according to the Inspector General of the Department of Health and Human Services, representing “as much as” $100 million in Medicare payments in 2010 alone. Find the IG report here.

As reported by Politico, the Department of Health and Human Services (HHS) and the Department of Justice (DOJ) have sent letters to five major hospital groups to warn against using EHRs to “game the system”. The letter stated that the government would “not tolerate health care fraud” and that “law enforcement will take appropriate steps to pursue health care providers who misuse electronic health records to bill for services never provided.”

But as reported by the Center for Public Integrity: “Dr. Donald Berwick, the immediate past administrator of the Centers for Medicare and Medicaid Services (CMS), which administers the Medicare program, said a small portion of the billing increase is likely caused by outright fraud, but in the majority of cases hospitals are legally boosting profits by targeting the vulnerabilities of Medicare’s payment system. “They are learning how to play the game,” Berwick said about the hospitals.”

In its story, “Hospitals: Feds share billing blame”, Politico reports that among the targeted groups, the Association of Academic Health Centers responded that the problem is that the government has failed to provide adequate guidelines on billing for some of the most common practices, even after requests have been made for such guidance – guidance hospitals have asked for.

Politico also reports that “Both the AHA and AAHC also complained about Medicare Recovery Audit contractors, which the Centers for Medicare & Medicaid Services hire to review billings. The so-called recovery audit contractors have long been accused of being overzealous, in part because they are paid a percentage of improper payments that they identify, even if those payments are reduced or overturned on appeal.”

The full story from Politico can be found here.

Answer this Question

How do you ensure patient privacy in the waiting room?

If you haven’t yet, you should check out NAHAM’s new Toolkit for Joint Commission surveys. The toolkit features a preparedness checklist and series of question sets – all organized around the disciplines NAHAM members all know and respect. NAHAM members may access the toolkit with their usernames and passwords from the NAHAM website.  Look for Government Relations on the sidebar and then click Joint Commission Survey Toolkit.

The toolkit looks not only at the requirements of positive patient identity, but also other aspects of the hospital experience that patient access managers can be responsible for – cultural competencies, patient privacy, infection, prevention and control, and environment of care… of course these sound familiar and drive much of our efforts to build knowledge and competencies for our staff, teams and colleagues.

The toolkit was developed and launched by a group of dedicated NAHAM members serving on the Policy Development and Government Relations Committee, but its success, and viability will depend on all NAHAM members. It will be NAHAM members who use the toolkit as a resource for ensuring a successful Joint Commission survey.  And it will be NAHAM members who contribute new checklist items, questions or question sets, and resources that others can use to strengthen their ability to ensure that the patient access management team in their facilities not only fulfill the expectations of a Joint Commission survey – but also contribute to our ability to meet the healthcare expectations of every patient we engage.

So, here’s this week’s question –

How do you ensure patient privacy in the waiting room?

Tell us what your specific protocols and safeguards and best practices are.

Send us any resources, guidance or educational material that can guide others relative to protecting patient privacy in the hospital setting.

You can also provide input when you are in the toolkit with an easy-to-use comment form.

Hospital Data Breach Tied to Two Employees: How common is this?

A July data breach at a Miami hospital was found, after investigation, to be due to two employees “inappropriately accessing” patient information. This information is according to a letter that The University of Miami Hospital sent to affected individuals.

The letter states that patient “face sheets”, containing basic patient information such as name, address, date of birth, insurance policy numbers, reason for visit, and partial social security numbers, may have been sold by the employees. The two employees in question have been terminated as a result of the incident. In the cases of patients on Medicare and Medicaid, social security numbers are used as the insurance policy number, and would therefore be fully written out on the patient face sheet, putting them in jeopardy.

As a precaution, the Hospital is providing all those affected with a 2 year subscription to a fraud monitoring service that will help detect possible misuse of personal information or identity theft. The hospital has also set up a website as a source of information and a toll free number for question that will be operating 7 days per week until December 5^th.

“The University of Miami Health System is cooperating fully with law enforcement, which continues to investigate this incident. We will continue to review our practices to determine what additional steps are necessary to avoid such incidents in the future,” The University wrote in the letter. “We apologize for any inconvenience this incident may have caused. We deeply appreciate being entrusted with your care, and we want to assure you that protecting patient information is a top priority for the University of Miami Health System.”

For more information, the letter can be viewed here.

Wonder how such data breaches happen?  In this case it involved employee theft.  In other cases it can involve theft of flash drives or laptops, and it can involve not only theft, but negligence or lack of appropriate safeguards and protocols. See what Health IT News calls “10 of the largest data breaches in 2012” here. 

Electronic Health Records Trial Proves Why it’s a Hot Industry

With the continued introduction of Electronic Health Records (EHRs) in hospitals and medical facilities, the ability to safeguard the information in EHRs (that providers and clinicians will need to have access to) has been a point of concern and challenge.  This week, however, a trial by both the Department of Veterans Affairs (VA) and the Department of Health and Human Services (HHS) showed that EHRs can be shared safely and securely.

Congressional Quarterly reported that the agencies showed through their trial that information can be shared between the agencies while protecting confidential information. Officials said that the HHS’ Substance Abuse and Mental Health Services Administration (SAMHSA) used new standards to securely send to the VA a mock patient’s substance abuse treatment records after electronically verifying that the mock patient had consented to the transmission.

Since the fictional case involved substance abuse treatment, an ailment that cannot be disclosed without patient consent, the trial added an additional test to prove that confirmation of electronic patient approval is possible.

“This project helps demonstrate that with proper standards in place, existing privacy laws and policies can be implemented appropriately in an electronic environment,” said Joy Pritts, chief privacy officer at the Office of the National Coordinator for Health Information Technology.

The use of EHRs by providers further cements what has already been identified as a hot industry. CNN Money and Fortune Magazine released an article on Tuesday that highlighted Electronic Medical Records Professional as a growth career.

The report pointed out that “just two years ago, about one in five hospitals used electronic health records. Thanks to an incentive program from the government, the number is growing fast: More than 3,600 hospitals (about 72%) received payments to transition to EHRs as of the end of July.” But much of the work remains to be done, and technicians are needed to input information and maintain systems.

Those with no prior knowledge may be required to go through an eight to 10 month training program by their employer. Those with a background in healthcare, however, may have an easier transition. The article, which can also be found in the September 24^th issue of Fortune Magazine can be found here. 

Automatic Spending Cuts will Reduce Provider Payments by $11 Billion

Last Friday, the Obama Administration released a long anticipated report that detailed specifics of the across-the-board spending cuts, known as sequestration, which could go into effect on January 2^nd.

The sequestration measures were passed as part of the Budget Control Act of 2011. At that time, the national debt was climbing and the federal government (and investors) was worried about defaulting on loans if Congress did not increase the debt ceiling. In a compromise between Democrats and Republicans in Congress, the Act agreed to raise the debt ceiling in return for the establishment of a bi-partisan debt reduction committee (known as the Super-Committee), and automatic budget cuts beginning in 2013 if no debt reduction legislation was passed. For more on the legislation, view the L.A. Times article here.

The Super-Committee met, worked, and disbanded, without an agreed-upon action plan endorsed by both parties, and last week, the Obama Administration released a report on what the automatic cuts would look like. While the cuts would affect the majority of federal agencies, certain programs like Medicare would be spared from massive funding cuts in favor of moderate and targeted cuts.

Medicare would not remain completely unaffected, however. The cuts to the program would be 2% overall, or about $11 billion, mostly to providers.  Kaiser Health News reports that hospitals would bear the largest share of the cuts. The Federal Hospital Insurance Trust Fund would be reduced by about $5.8 billion, while the National Institutes of Health would see a $2.5 billion reduction. The Centers for Disease Control and Prevention would face cuts of $490 million, and the Food and Drug administration would see reductions of about $318 million.

Funding for the new health law’s insurance exchange grants would also decrease by $66 million, while funding for the new health law’s prevention fund would drop by $76 million, according to a report funded by doctors, hospitals and nurses groups. In addition, the National Institutes of Health “would have to halt or curtail scientific research, including needed research into cancer and childhood diseases,” the report states.

Congress can still avoid sequestration measures by passing a debt reduction plan before the end of the year, but that will likely not happen until after the November elections. The can also avoid it by passing a bill that nullifies the measures.

The Senate is currently considering a Continuing Resolution (CR) that will fund the government from the beginning of the fiscal year on October 1^st, until the end of March. That CR, however, is separate from any sequestering. Come January 3^rd, sequestration measures go into effect, unless one of the actions above is taken. In a sense, the Budget Control Act ‘trumps’ any document that does not satisfy the debt reduction requirements. Normally sequestering would slash the funding levels put forth in the budget, but since the CR would be acting as the funding document, sequestration measures slash the funding amounts that are put forth in the CR.

You can see the Administration’s full (400 page) report here. You can also find Kaiser’s article here. 

Rate of Uninsured Americans Dropped in 2011

According to new census numbers released this week, Kaiser Health News is reporting that the number of people without health insurance fell last year, for the first time since 2007.

The percentage of Americans without health insurance last year was 15.7%, a 0.6% drop from 2010’s uninsured rate of 16.3%. The drop represents about 1.3 million less uninsured Americans, and puts the rate at the lowest percentage since 2009.

The drop in the uninsured was driven in part by a significant reduction among those aged 19 to 25, from 29.8 percent in 2010 to 27.7 percent in 2011, the Census Bureau said. The Obama administration’s health care law allowed families to keep adult children on their health plans until they turn 26.

The graphs by Kaiser Health News can be found here.

Medicare’s new Value Based Purchasing program: Enough to inspire hospital change?

October will mark the beginning of a new Medicare program that will withhold up to 1% of reimbursements due hospitals, and instead use the funds to reward hospitals based on their “patient experience” survey scores and adherence to certain clinical guidelines for providing care. The new Value-Based Purchasing program was passed as a part of the Healthcare Reform Act, and is designed with the intent in improving patient care. Kaiser Health news reported last week on what this may mean for hospitals. You can find the full article here.

Under the program, the 1 percent withheld, about $850 million in the first year, would be set aside into a ‘bonus pool’ and awarded to “hospitals that do better than average on a variety of measurements, or show the greatest improvement from the previous year.” The pool would increase to 2 percent of reimbursements in October of 2016.

The strategy shift, away from a model that “historically has paid hospitals and doctors based on the nature of services they provided to patients without taking into account how good a job they did”, is based on trial programs and studies that have been in the field for a number of years. The program also starts at the same time another provision of the Healthcare Reform Act which withholds reimbursements to hospitals with high readmission rates. NAHAM News reported on that program here.

Medicare hasn’t yet calculated how individual hospitals may be affected in the first year of the program, but a study published last week in the policy journal Health Affairs examined the program as if it had been in existence since 2009. According to the study, during that time “only 71 hospitals, or 2.4 percent of the total, would have earned bonuses of more than half a percent above the break-even point.”  The average bonus would have been just over $55,000. The study also estimated that “only 90 hospitals, or 2.4 percent, would have lost more than half a percent below what they would have received prior to the program.” The average loss would have been $125,000.

These modest numbers have some arguing that it may cost hospitals more to implement necessary changes than they would receive as a benefit from positive performance. Kaiser reports that a performance-based approach in the UK represents a much larger percentage of provider income.

Despite that, Nancy Foster, a vice president at the American Hospital Association, said the sizes of the bonuses are not as important as the signal the program sends "that these are important areas of quality and they’re worth the investment."

Medicare will be changing the measures in future years as well, for instance adding mortality rates for heart failure, heart attack and pneumonia patients in October 2013. 

Increasing Number of States Require Photo Identification for Voting

Controversy over photo identification has been in the news a lot recently, specifically in regard to laws passed by some states that require photo identification when voting. 

These laws, however, will have an effect outside the voting booth as well. Are you who you say you are?  Have you been here before?  Sound familiar?

National Public Radio (NPR) ran a story earlier this year analyzing a study from the Brennan Center for Justice at New York University’s School of Law. The study, “Voting Law Changes in 2012,” looked at the population of U.S. citizens that do not currently have identification to use for voting. The NPR article can be found here.  The study can be found here.

The study indicates that going into the 2012 elections, millions of Americans will find that since they last voted, and for many that would be 2008, there are new barriers that could prevent them from voting.  At least thirty-four states introduced legislation that would require voters to show photo identification in order to vote. Photo ID bills were signed into law in seven states: Alabama, Kansas, Rhode Island, South Carolina, Tennessee, Texas, and Wisconsin. By contrast, before the 2011 legislative session, only two states had ever imposed strict photo ID requirements.

The study also shows that 89% of the U.S. population has some form of photo ID, while the remaining 11%, about 3.2 million people, do not. The majority of the 11% without ID fall into one of four categories: the elderly, minorities, the poor and young adults aged 18 to 24. The Brennan Center estimates that 18 percent of all seniors and 25 percent of African-Americans don't have picture IDs.

Here’s how NPR reports it: 

Many people have multiple forms of identification, including those that display their pictures — like employee badges or credit and debit cards. But states with strict voter ID laws require people to have certain photo IDs issued by governments…That typically means driver's licenses. But many seniors and many poor people don't drive... And many young adults, especially those in college, don't yet have licenses…A good number of these people, particularly seniors, function well with the IDs they have long had — such as Medicaid cards, Social Security cards or bank cards.

Not to worry.  If you really need a photo ID, NPR reports that many states offer non-driver IDs that can be displayed when voting, often provided by motor vehicle agencies.

But here is an interesting Catch-22: “to get an ID, you need an ID”.

In most states with voter ID laws, citizens must present birth certificates to obtain new photo IDs.  OK.  If a state does have a person's birth certificate, they often must present a photo ID to obtain a copy.  Oh.  NPR continues its reporting based on the focus on these laws and the impact they have on individuals who find they may not be able to vote.  

Shift to the healthcare setting and the Kaiser Family Foundation (KFF), in a report, “characteristics of Frequent Emergency Department Users” (found here), stated that about 20% of “high emergency department users” are 65 and older, and 37% of emergency department patients are poor and near poor. This reflects a significant part of the population that is unlikely to have a photo ID.

NAHAM News will continue to monitor these state ID laws, but we also welcome your feedback.

If you are in a state that recently passed a voter ID law, are you seeing an increase of patients with photo identification?

Are you confident in the source of non-drive photo IDs?

What about the elderly or poor – do they tend not to have photo IDs?

Changes to 2012 Medicare Therapy Cap Take Effect on October 1

The Centers for Medicare and Medicaid Services (CMS) have provided guidance to the changes in this year’s therapy services beginning October 1, 2012.  The 1997 Balanced Budget Act established financial limitations on outpatient therapy services in all settings except outpatient hospital.  Some exceptions to these limitations were enacted by the 2005 Deficit Reduction Act, and these have been extended several times, most recently by the Middle Class Tax Relief and Job Creation Act of 2012. 

The full report from CMS can be found here with a CMS summary here.

For 2012, the therapy caps are set at $1880 for physical therapy and speech language pathology services, and a separate $1880 cap on occupational services, if those services are provided on an outpatient basis in a non-hospital setting. Suppliers and providers have been, and can continue to use the KX modifier to request an exception to the therapy caps on claims that are over these amounts. The use of the KX modifier indicates that the services are reasonable and necessary and there is documentation of medical necessity in the patient’s medical record.

Beginning on October 1, 2012, and continuing through December 31, 2012, there will be two new therapy services thresholds of $3700 per year: one annual threshold each for 1) Occupational Therapy (OT) services,  and 2) Physical Therapy (PT) services and Speech-Language Pathology (SLP) services combined. Per-beneficiary services above these thresholds will require mandatory medical review.

It is important to note that, although the therapy caps are only applicable to hospitals for services provided on or after October 1, 2012, claims paid for outpatient therapy services since January 1, 2012, will be included in the caps accrual totals in applying the caps after October 1, 2012.

Additionally, beginning October 1, 2012, the National Provider Identifier (NPI) of the physician (or Non-Physician Practitioner (NPP) where applicable) certifying the therapy plan of care must be reported.   NPPs who can certify the therapy plan of care include nurse practitioners, physician assistants and clinical nurse specialists.