Studies Find High Rates Of Errors In Medical Billing

In 2013, the America Medical Association estimated that 7.1% of paid claims in 2013 contained an error and a 2014 NerdWallet study found mistakes in 49% of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75% or 80%.

To that end, experts suggest reviewing medical bills closely before paying them. "Don't pay it until you understand it," said Sara Taylor, health solutions and strategies manager for benefits administrator Aon Hewitt.

For some consumers, spotting and correcting medical billing problems is getting easier. A forthcoming Aon Hewitt survey of 800 large and mid-size employers found that 45 percent offer advocacy services to help workers manage their health-care benefits; 43 percent are considering adding those services within five years.

Often, billing errors result in an out-of-pocket cost that's bigger than expected, either from a charge that shouldn't be there or a coding error that affected how your insurer processed the claim. Or, a bill is sent before payment is received from an insurer.

For those patients who do not have access to health concierge and patient advocacy services, asking for an itemized detailed statement is the best option. For those patients who are facing a big or complex bill, hiring a billing advocate is a solution.

Typically, review of the bill is free, with the service taking a cut of whatever savings it successfully secures for you. (MBAA takes a 25 percent cut; CoPatient, 35 percent.) Outsourcing the process can also save you time spent trying to get the bill corrected.

However, waiting too long to pay (or officially dispute) a medical bill is not recommended. Some providers are fast to take action on unpaid balances — resulting in 20 percent of consumers having an unpaid medical debt on their credit report, according to a 2014 Consumer Financial Protection Bureau study. The average amount owed: $579.

The original article by Kelli Grant can be found at the following address: http://www.nbcnews.com/business/consumer/it-s-time-get-second-opinion-paying-medical-bill-n545626

Surprise Medical Bills Addressed in 2017 HHS Budget

For the uninsured, seeking medical treatment almost always results in a costly medical bill. But, over the past few years, it's become clear that even if you have health insurance in the U.S., you're still susceptible to receive pricey medical bills—many of which can be a complete surprise.

For the insured, an expensive bill is expected when one visits an out-of-network physician. Lately, bills have been popping up in the least expected places. For these patients, charges roll in even though they did research and, presumably, went to an in-network hospital or saw in-network physicians.

President Obama’s 2017 budget for HHS takes action to eliminate these surprise bills.

Embedded within the 2017 budget is a provision to “eliminate surprise out-of-network healthcare charges for privately insured patients.” The administration would try to solve the problem by requiring physicians who “regularly provide services in hospitals” to accept in-network rates, even if they aren't in the insurer's network. Hospitals would also have to “take reasonable steps” to ensure patients see in-network physicians.

Usually, patients face unexpected charges because of large payment disagreements between insurance companies and physicians. Physicians will refuse to participate in an insurer's network if they believe arguing insurers are low-balling them. But, insurers say doctors ask for unreasonably high rates. Hospitals and patients are often left in the middle. Under President Obama's 2017 budget, patients would be removed from the disputes, and physicians would have to cave to the insurers' rates.

However, American Medical Association President Dr. Steven Stack said last year that he didn't like any approach that would “coerce physicians through yet another way to not receive sufficient payment,” indicated that the budget proposal won’t be popular with physicians.

President Obama's budget for 2017 stands pretty much no chance of moving through Congress, but it does reveal the president's final priorities for his own and future administrations.

The original article by Bob Herman can be found at the following address: http://www.modernhealthcare.com/article/20160211/BLOG/160219975?utm_source=modernhealthcare&utm_medium=email&utm_content=20160211-BLOG-160219975&utm_campaign=am

Advance Life Support Measures Show No Benefit Over Basic Life Support Measures

Aaron E. Carroll discusses the negative health and economic impacts of using advanced life support measures in the following article, "Doing More for Patients Often Does No Good," featured in the New York Times.  Please share your thoughts as professionals on the impacts of these studies on medical billing and care provided. 

"Given the remarkable advances that have been made in the last 50 or so years in pharmaceuticals, medical devices and surgical procedures, it’s not a surprise that people want more, and more invasive, care than they have had in the past. Just as it’s hard to do nothing when you’re ill, it’s sometimes hard to do less than the maximum when there are different treatments to choose from.

Unfortunately, doing more often does no good. Sometimes, it even leads to harm.

In the United States, when it appears that someone might be in trouble, emergency medical services are dispatched. Many patients die from an out-of-hospital cardiac arrest, but steps taken out in the field can make a difference. Basic life support, the kind you might be taught in a CPR class — involving the use of bag valve masks, cardiopulmonary resuscitation and automated external defibrillators— can absolutely save a life.

Advanced life support, usually requiring a trained paramedic, involves much more. Trained providers may put in endotracheal breathing tubes; start intravenous lines; deliver sophisticated cardiac drugs; and defibrillate patients manually.

We’ve assumed, for the most part, that advanced life support is better than basic life support — so much so that in most areas where both options are available, advanced life support is almost always used. But a recent study in JAMA Internal Medicine brings this assumption into question. Researchers examined Medicare patients who were billed for either advanced life support or basic life support before admission to the hospital from 2009 through most of 2011. They looked at how often patients survived to hospital discharge, and then months later.

What they found was that about 13 percent of patients who received basic life support survived and were discharged versus 9 percent of patients who received advanced life support. More patients who received basic life support lived for 90 days after discharge, too (8 percent versus 5 percent). Basic life support patients also had better neurological outcomes.

Now, of course, this is not a randomized controlled trial. It’s possible that sicker patients received advanced life support and that people who didn’t appear as sick received basic life support. But the authors called all of the state agencies, and they reported that this can’t really happen. After all, a 911 dispatcher can’t tell if it’s a “mild” or “severe” heart attack from a third party on the phone with no medical training. Dispatchers send out advanced life support if it’s available, and basic life support if it’s not.

It’s also possible that there could be differences in bystander CPR administration until help arrives. But the authors attempted to control for that, too. They conducted a number of sensitivity analyses, and in none of them did advanced life support outperform basic life support.

It would also be easier to dismiss this finding if it weren’t corroborated in many other studies. In 2004, results from the Ontario Prehospital Advanced Life Support Study were published in the New England Journal of Medicine. This was a multicenter controlled trial in 17 cities in Canada comparing advanced life support with basic life support. They found that if an instance of cardiac arrest were witnessed by a bystander, the chance of survival significantly improved. They also found that CPR administered by bystanders improved survival, and so did rapid defibrillation. These are all components of basic life support. The addition of advanced life support, however, made no difference in survival.

A 2007 study conducted in Taipei also found that advanced life support did not improve survival to discharge. Even the main components of advanced life support have failed to show results in studies. A 2008 systematic review showed no efficacy for emergency intubation. A 2010 cohort study found advanced airway methods — basically, putting in an airway tube rather than using a bag mask — to be associated with decreased survival compared with basic life support methods, as did a 2013 study in Japan.

A 2012 JAMA study found that the use of epinephrine was associated with worse outcomes, and a 2008 New England Journal of Medicine study found that adding vasopressin (another drug that, likeepinephrine, constricts blood vessels to raise blood pressure) didn’t improve things. A randomized controlled trial of these drugs, published in 2009 in JAMA, found that their use didn’t improve survival either.

The evidence is compelling. Advanced life support does not seem to provide any benefits in the randomized controlled trials, and it’s often associated with worse outcomes in the cohort studies. How can this be so? Some theorize that the things that work have already been incorporated into basic life support. All that the advanced life support may be doing is slowing things down in the field, distracting people from the useful basic life support measures, and delaying the time until a patient can get to the hospital.

It’s hard not to do more if we can, though. We see this in all sorts of areas of care. A few months ago, a study was published in JAMA that examined the outcomes of women with stage 0-III unilateral breast cancer who underwent breast conserving surgery with radiation compared with those who had a unilateral mastectomy and those who had a bilateral prophylactic mastectomy. The 10-year survival differences between the groups were negligible. Breast conservation therapy is more tolerable, is much less invasive and costs less.Continue reading the main story

In fact, breast conservation therapy has become a “standard of excellence” in breast cancer care. But a study published even more recently showed that from 1998 through 2011, the odds of a woman eligible for breast conservation therapy receiving a mastectomy increased. Rates of bilateral mastectomy went up over this time period as well, from 2 percent in 1998 to 11 percent in 2011.

And based on the data from many randomized controlled trials, we know that women who have radiation therapy for early breast cancer do well with less of it. The use of “hypofractionated” whole breast irradiation, which consists of fewer treatments with higher levels of radiation, has been shown to be equally effective for women without any excess side effects. It’s cheaper, easier and just as good. Hypofractionated whole breast radiation has been endorsed by the American Society for Radiation Oncology for women who satisfy certain criteria since 2011.

But a study published a month ago that looked at the use of radiationin women with early stage breast cancer found that in 2013, only about a third of women who qualified for hypofractionated radiation therapy were getting it. The rest got more, but not better, care.

The reasons for this are varied. With respect to the radiation therapy, it’s hard not to lay some of the blame on economics. After all, in a fee-for-service system, more visits and more treatments mean more money. Research shows that twice as many women want hypofractionated radiation therapy as want conventional therapy, but only half of radiation oncologists offer it.

But it’s not all money. It’s also probably fear. Many radiation oncologists are concerned that doing fewer treatments will lead to worse outcomes. That’s most likely the concern of women who choose much more invasive surgery than necessary as well.

It’s certainly the rationale for why advanced life support is so prevalent. The Ontario Prehospital Advanced Life Support Trial was supposed to be a randomized controlled trial, but the paramedicsevidently refused to do it because they felt that holding back advanced life support was unethical. This was in spite of the lack of evidence that it was effective.

More is expensive. More sometimes does no good. Sometimes, more is even harmful. When our policies and care ignore these facts, we all suffer."

Negative Consequences Abound When Nonprofits Hospitals Sue Poorest Patients

Nonprofit hospitals receive a tax-exempt status based on their work to serve the poor by addressing their medical needs. However, the medical billing practices of hospitals was recently called into question by a Consumer Financial Protection Bureau report. The report examined medical debt in this country and found that 1 in 5 consumers, or 43 million individuals, have a negative mark on their credit report from a medical debt. The debt collections practices employed by hospitals raise several concerns including releasing private medical information covered by HIPAA to outside parties not involved in treatment, unfair billing practices that disproportionately impact low-income patients, a failure to provide and educate patients on available aid, the need for aid to retroactively cover eligible medical costs, and the legality of nonprofit hospitals suing their poorest patients. 

A recent NPR story highlighted the issues that arise for low-income patients when nonprofit hospitals sue for unpaid medical bills. In addition to the aribtrarily higher prices many low-income patients are charged for medical treatment, the debts associated with their medical care negatively impact nearly every area of their lives. Medical debts reported to credit agencies lower credit scores which in turn, raises the prices for many basic needs such as car insurance, mortgages, credit cards, and loans. Additionally, some employers examine the credit report in the hiring process and a low credit score or history of medical debt may negatively impact an individual's chance to get a job because they are viewed as irresponsible or the employer feels they will not be reliable due to the medical issues insinuated in the report. 

Hospitals are turning to the courts to recover these inflated debts from their low-income patients. When the hospitals are successful they may be able to recover the debt, in addition to court costs, debt collection administration fees, and interest by garnishing the low-income individual's wages. This practice creates a cycle of poverty that is nearly impossible to escape and discourages individuals from receiving medical care. It particularly provides a disincentive for low-income individuals to receive preventative care, which would be beneficial to all parties involved. 

Reform is imperative. Hospitals and health access managers must be diligent in educating patients about aid, prudently billing, and limiting the debts that move to collection agencies. 

Resources to help those with medical debt may be found at the following websites:

• Legal Aid
• Families USA
• National Consumer Law Center
• USA.Gov

CMS Boosts Coverage for Telehealth

The Centers for Medicare & Medicaid Services released new rules that significantly broaden coverage for chronic care telehealth services.The rulemaking changes are inside the 1,185-page document detailing Medicare payments to physicians and other providers. The new rules also include seven new covered procedure codes for telehealth, including annual wellness visits, psychotherapy services, and prolonged services at physicians' offices.

Health Leaders Media reports, "The American Telemedicine Association, which had sought the expanded coverage for five years, notes that among the rules are provisions that will pay for remote chronic care management using the new current procedural terminology (CPT) code 99490, with a monthly unadjusted, non-facility fee of $42.60.

"For us, it was more important to begin to specifically address chronic care," says Gary Capistrant, senior director of public policy at ATA. "The combination of the chronic care management code and being able to use it in conjunction with monitoring of those chronic conditions is a big step forward and a very substantial change for Medicare." Capistrant says the new rules also represent an acknowledgement by CMS that reimbursing for chronic care could prove to be cost effective.

"It's an important policy move. Whether it is sufficient, time will tell, but it is certainly a step in the right direction and an important initiative," he says. "There has been a lot of focus on primary care, even with the Medicare population. That may be the 80% of the people but it is only 20% of the problem. There's an increasing emphasis on looking at the 80% of the problem that is 20% of the people, and that is chronic and specialty care. They understand that the government is spending a huge amount for chronic care conditions and that there is a value managing those to reduce the overall expenditures."

ICD-10 Transition Date Finalized for October 2015

The Centers for Medicare and Medicaid Services announced last week that the final deadline to comply with the ICD-10 implementation requirement is October 1, 2015. The tenth edition of the International Classification of Diseases is widely viewed as a significant change in the way claims that are submitted to Medicare and private insurance payers are classified. 

These changes enable providers to coordinate patients care over distance and time, improve the accuracy of patient records with more detailed patient history coding, and reduce fraudulent claims. CMS also believes that the ICD-10's granular classifications will improve the data and analytics related to public health research, surveillance, and reporting. The more specific classifications found in ICD-10 represent, in part, the evolution of diagnosis and the modern developments in medicine and medical technology used to treat patients. 

CMS released an online resource designed to help providers in small practices make a timely transition to ICD-10. The "Road to 10" is an online resource available here. The  Road to 10 breaks allows providers to select a profile based on their expertise that is specifically tailored to each speciality's common codes, clinical documentation procedures, and clinical scenarios. Additionally, the Road to 10 gives users the opportunity to create an ICD implementation action plan specifically suited to the needs of their small practices. 

Proposed Medicare Rule Leaves Hospitals Concerned About Financial Impact

The Centers for Medicare & Medicaid proposed a rule on Wednesday that makes changes to several aspects of the  Medicare payment program. The proposals were part of a wide-ranging, 1,600-plus-page proposed rule issued by the CMS outlining Medicare payment and policy changes for hospitals in 2015. A final rule is scheduled to be published August 1. The policies would be effective October 1.

Under the proposed rule the payments for inpatient treatment at acute-care hospitals will decrease by $241 million in fiscal year 2015. The proposed rule would affect over 3,000 hospitals nationwide.  In addition, the CMS proposes increasing Medicare payments to long-term-care hospitals by 0.8% in 2015, a bump of $44 million. The change in payment methodology would affect 435 facilities. Under the proposed payment rule, hospitals that successfully participate in Medicare’s quality reporting system and meet the criteria for the meaningful use of health information technology will see a payment bump of 1.3%. However, because of the penalties meted out to the hospitals that don’t, the CMS is projecting an overall reduction in payments.

Notice to Patients Required for Outpatient Facility Fees

The Connecticut House of Representatives responded on Wednesday to medical billing concerns patients expressed over undisclosed and unexpected facility fees by unanimously passing a bill that requires notice. Many patients expressed that the additional charges were a surprise when they received their bill. The legislation now moves to the state Senate for a vote.

The charges, often referred to as "facility fees" are charged to patients by medical offices that are owned by hospitals for outpatient care. These fees are separate from doctor fees. Facility fees range from several hundred to thousands of dollars.

The bill to require notice to patients about fees possible extra charges for outpatient care at medical offices owned by hospitals. The bill specifically requires that patients with scheduled appointments at medical offices where facility fees are charged receive notice about the fees in plain language before they receive treatments scheduled so long as the appointment is scheduled at least 10 days in advance. If the exact nature of the services or insurance coverage is unknown the patients would be provided with an estimate based on typical charges at the facility. Notice for patients receiving emergency care would need to be delivered as soon as practicable after the patient is stabilized. The bill does not impact the offices' ability to charge facility fees.

Other provisions in the bill are include requirements that the office prominently displays that the facility is connected to a hospital, what hospital the office is affiliated with, and states that the patient may be incur higher charges than if they were treated at a facility that isn't hospital-based.

ICD-10 Deadline Delay Slows Medical Billing Conversion

Medical billing codes are used by doctors, hospitals, and health insurance companies to track each patient procedure and ensure that the doctors are paid. The ICD-9 code has been in place since the 1970s. The ICD-9 was scheduled to be replaced with ICD-10 by October 2014. 

The conversion would add tens of thousands of unique codes to the medical billing structure, an increase to roughly 72,000 codes in ICD-10 from about 4,000 codes in ICD-9. Advocates for ICD-10 argue that the new coding system is necessary to modernize the billing code to capture the variety of medical treatments available now that did not exist in the 19070s.  Additionally, they argue that a more detailed code will allow for more precise medical research and data collection. 

Despite the benefits of moving to an ICD-10 medical billing system, the transition over the last five years has been difficult. In order for the transition to be smooth and successful all parties need to switch to the ICD-10 codes at the same time. Many smaller practices were not able to dedicate the training time and resources to complete the transition by October of this year. 

However, larger facilities, hospitals, and insurance companies with more resources were able to dedicate time and money to implementation measures and preparation. In fact, many have spent millions to train staff on the new ICD-10 billing codes. These facilities were relying on the statements by Health and Human Services representatives made as late as February 2014 that explained the October compliance date was firm. Questions remain about the implementation of ICD-10 at these facilities and whether these employees will need to be re-trained as the adjusted ICD-10 deadline nears.

Congress Passes Bill to Delay Medicare Reimbursement Cuts

On Monday evening the Senate passed and President Obama signed the Protecting Access to Medicare Act of 2014 (H.R. 4302) into law. This marks the 17th time Congress delayed the cuts to physician reimbursements established with the Sustainable Growth Rate under Medicare. The bill delays a 24% cut to the payments.

The Senate passed the bill with a 64-35 vote the evening the cuts were to go into effect at midnight. The Senate vote was preceded by the House passing the bill with a rare voice vote last week.  Both chambers moved quickly to pass this bill after it became obvious no agreement would be reached on how to pay for the permanent 'doc fix' bills.  

The Sustainable Growth Grate (SGR) was created in 1997 by Congress as a mechanism for tracking the payments with economic growth. The SGR became a problem within a few years as increases in healthcare costs substantially outpaced economic growth. This development resulted in the creation of a multi-billion dollar shortfall for the funding of Medicare payments to physicians. 

Members on both sides of the aisle and in both Chambers spoke about the need to permanently fix the SGR. However, they recognized the immediate need to prevent the delay's expiration and prioritized this temporary patch over a lengthy negotiation process to pass a  permanent fix that would result in the expiration of the SGR delay. 

Bill to Delay ICD-10 and Sustainable Growth Rate Patch Passes House

Advocates on behalf of hospitals and practitioners were optimistic about the likelihood of a permanent 'fix' to the Sustainable Growth Rate for Medicare's physician reimbursement system. Members in both the House and the Senate introduced bills this session that would repeal the Sustainable Growth Rate in Medicare's physician payment formula. 

In a surprise development today the House passed the Protecting Access to Medicare Act of 2014, H.R. 4302, by voice vote. This bill does not provide a permanent fix, only a one year patch to the Sustainable Growth Rate. The legislation, sponsored by Rep. Pitts of Pennsylvania, did not extend a fix for the SGR to physician-owned hospitals. Insiders agree that the cost of longer term bipartisan bills with permanent fixes to SGR were tabled because the parties were not able to agree on how to pay for the costs--about $140 billion over a 10 year period.  

Many on the hill expect the Senate to move this bill to a vote tonight. Speaker Harry Reid is said to be working on a deal to bring the bill to the floor. However, Senator Wyden is said to be pushing back on passing a bill with only a short term fix. Stakeholders following SGR legislation believe that if a temporary fix is passed the Congress will feel less pressure, and efforts to pass a permanent fix this year will fade into the background. 

The Protecting Access to Medicare Act of 2014 also contains a provision to delay the ICD-10 meaningful use requirements until October 2015. CMS Administrator Marilyn Tavenner has repeatedly stated that the agency was not going to extend the ICD-10 meaningful use requirements. Many eligible practitioners and hospitals are concerned about being able to meet the deadline and have publicly appealed to the agency and Congress to extend the compliance deadline. 

CMS Issues Guidance on Stage 2 Meaningful Use Hardship Exceptions

The Centers for Medicare and Medicaid Services (CMS) issued guidance on qualifying for the hardship exception from Stage 2 meaningful use requirements under the federal electronic health record incentive payment program. CMS has been under pressure by stakeholders and lawmakers alike to provide clarification about how to apply and what conditions qualified hospitals and eligible professionals for a hardship exemption

The guidance explains that CMS may grant hospitals and eligible professionals the hardship exception and grant an extension for meeting the Stage 2 meaningful use requirements if their electronic health record (EHR) vendor is at fault for their failure to meet the deadline. This expands on previous statements by CMS Administrator Marilyn Tavenner that the applications for exceptions would be evaluated on a case-by-case basis. 

The guidance specifically states that providers may apply for hardship exceptions if the "EHR vendor was unable to obtain 2014 certification" or the hospital or eligible professional "was unable to implement meaningful use due to 2014 EHR certification delays." If approved, the hardship exception is valid for a single payment year. In the event the application for exception is denied hospitals and eligible professionals may not appeal the decision and any denial is considered final.

The hardship exception application for hospitals is available here.

The hardship exception application for eligible professionals is available here. 

CMS Looks to Limit Estate Recovery Actions for New Medicaid Recipients

Commentators on both sides of the Affordable Care Act (ACA) debate have pointed out that lower-income Americans may be deterred from enrolling in the expanded Medicaid program because of the currently estate recovery actions are allowed. An estate recovery action is a legal collection method that allow states to recover the amount of payments for long-term Medicaid services from patients after their death to repay the state for the cost of their medical care. 

This practice stems from a 1993 federal law that requires states to recoup the costs spent on long-term Medicaid services from the estates of deceased recipients. The 1993 law also gives states the option of recovering all Medicaid costs incurred from the age of 55 until death, even if they are not related to long-term care. In practice this often results in states placing a lien on the deceased's home after being notified of the death. However, states generally try not to collect the debt immediately in instances where a surviving spouse or dependent is living in the home. 

Last week the Centers for Medicare and Medicaid Services (CMS) issued a letter to state medicaid directors providing guidance that seek to limit estate recovery actions for Medicaid recipients that qualify under the ACA's Medicaid expansion program. While the letter does not compel states to follow the conditions set forth in the letter, experts say it will likely serve as a deterrent for states considering estate recovery actions against expanded Medicaid recipients. 


More discussion on Medicaid Estate Recovery and the CMS letter can be found at the following sources:

•  Asbury Park Press, Feds: Don't try to bill new Medicaid recipients after their death.
• National Senior Citizens Law Center, MAGI Medicaid and Estate Recovery: CMS Issues State Medicaid Director Letter.
• Modern Healthcare, Reform Update: Medicaid estate-recovery law may hamper enrollment efforts.

Patient Identification and Matching Report Released by ONC

The Office of the National Coordinator for Health Information Technology (ONC) released the final version of the Patient Identification and Matching Report. The report evaluated best practices and current trends in using electronic health record systems to accurately identify patients and exchange information between providers, patients, and caregivers. Mistakes in properly identifying patient health records put patient safety at risk and has resulted in too many patient deaths. 

The drafting process for the report included an industry environmental scan with input from stakeholders at meetings, on calls, and requests for submitted comments and recommendations. NAHAM was an active participant throughout the drafting process and provided recommendations focused on improving patient safety that are featured in the report. NAHAM's recommendations can be found on page 76 of the report. 

The report resulted in 10 findings that ONC will use as they move forward with the process of improving electronic health record systems and patient matching to improve patient safety.The findings are below.

Findings

1. Standardized patient identifying attributes should be required in the relevant exchange transactions. 

2. Any changes to patient data attributes in exchange transactions should be coordinated with organizations working on parallel efforts to standardize healthcare transactions. 

3. Certification criteria should be introduced that require certified EHR technology (CEHRT) to capture the data attributes that would be required in the standardized patient identifying attributes.

4. The ability of additional, non-traditional data attributes to improve patient matching should be studied. 

5. Certification criteria should not be created for patient matching algorithms or require organizations to utilize a specific type of algorithm. 

6. Certification criteria that requires CEHRT that performs patient matching to demonstrate the ability to generate and provide to end users reports that detail potential duplicate patient records should be considered. 

7. Build on the initial best practices that emerged during the environmental scan by convening industry stakeholders to consider a more formal structure for establishing best practices for the matching process and data governance. 

8. Work with the industry to develop best practices and policies to encourage consumers to keep their information current and accurate. 

9. Work with healthcare professional associations and the Safety Assurance Factors for EHR Resilience (SAFER) Guide initiative to develop and disseminate education and training materials detail best practices for accurately capturing and consistently verifying patient data attributes. 

10. Continue collaborating with federal agencies and the industry on improving patient identification and matching processes. 

No Extension for ICD-10 Implementation

Marilyn Tavenner, Administrator for the Centers of Medicare & Medicaid Services, announced today that there will be no extension of the October 1, compliance deadline for the nationwide conversion to the ICD-10 diagnostic and procedural codes. Speaking at the Healthcare Information and Management Systems Society convention in Orlando, Florida, Tavenner also explained that CMS was not changing compliance requirements for Stage 2 despite extensive pressure on the agency. 

Stage 2 of the electronic health record incentive payment program requires providers to electronically exchange healthcare records with each other to improve the interoperability of CMS' value-based payment programs. Eligible hospitals must commence 90 consecutive days of meeting the meaningful-use criteria on schedule. The starting date for most hospitals was October 1, 2013. However eligible professionals and physicians which operate on a fiscal year must begin compliance on April 1 or July 1, 2014. 

CMS will consider extensions on a case-by-case basis for providers and health IT vendors to obtain a "hardship exemption" that will extend the deadline for that facility. Tavenner does not expect the exemptions to delay full Stage 2 implementation by 2015. 

Timing is Crucial for Effective ICD-10 Education

The ICD-10 billing code system will expand the number of billing codes in the ICD-9 from 18,004 to 155,000 codes. This change will take place by October 1, 2014. The expanded codes create a need for the biller to have a more in-depth understanding of the medical conditions and diseases to accurately bill the patient. If billers are untrained or improperly trained it will create havoc for practices. Practices across the country are wrestling with the questions of 'when' and 'how' to train employees.

Several training methods are available. The depth of the training ranges from self-paced online modules to certification courses that require dozens of hours of in-person instruction. With the huge increase in individual codes and variety of training programs many administrators are left scratching their heads at the decision of how to train their staff. There seems to be a consensus that an online training module provides the flexibility and informational value that best suits the educational needs of many practices. 

Experts recommend that the training material used is centered around billing codes most commonly used in the practice. For example, the employees of a cardiologist practice should focus their training on the medical billing codes for heart-related disease and conditions. 

The experts also suggested that practices begin training now by assessing how well the staff works with ICD-9. The practice should address any bad practices and frequent problems before moving to the more complex ICD-10 system. 

Many experts suggest waiting to train employees until about three months before the transition to ICD-10 to avoid workers forgetting how to use the new coding system since they will be still be interacting with the older system daily.

CMS Extends Medicare EHR Meaningful Use Attestation Deadline to March 31, 2014

The Centers for Medicare and Medicaid Services announced an extension for some participants in the Medicare Electronic Health Records meaningful use attestation deadline. The extension did not retroactively change any requirement for the date the criteria must have been met, it merely extended the deadlines for data submission for some physicians, eligible professionals and hospitals. The deadline extensions do not apply to the Medicaid portion of the Electronic Health Records incentive payment program. The Medicaid incentive payment program does not incorporate penalties.

Both the Medicare and Medicaid Electronic Health Records incentive payment programs were created in the American Recovery and Reinvestment Act of 2009. The programs have a significant impact with payments thus far in the amount of over $19 billion to more than 320,000 physicians and other professionals and 4,400 hospitals.  


Physician and Eligible Professional Extension

The Centers for Medicare and Medicaid Services (CMS) extended the deadline for eligible professionals to attest to Electronic Health Records (EHR) meaningful use in 2013. Physicians and eligible professionals will now have until 11:59p.m. on March 31, 2014 to submit their performance data. The new deadline, extended from February 28, 2014, does not change the requirement that the criteria for meaningful use must have been met by the end of the reporting period for the incentive payments, December 31, 2013. 

A CMS press release explained that this extension would allow more time for providers to submit their meaningful-use data, receive an incentive payment for the 2013 year and avoid the 1% penalty 2015 payment adjustment. 

EPs attesting for the Medicaid program or Physicians Quality Reporting Systems incentive pilot program did not receive an extension and must complete the attestation requirements by the original deadline. 


Hospital Extension

CMS is also offering what the agency is calling a "one-time" extension to hospitals "that may have experienced difficulty attesting" by the November 31, 2013 Medicare meaningful use attestation deadline. To be eligible to participate in the deadline extension hospitals must contact CMS by 11:59p.m March 15, 2014 for assistance. 

This extension will allow eligible hospitals to receive incentive payments under the program and avoid the price adjustments effective in 2015. 

Like the extension for physicians, the extension for hospitals does not change the deadline for the date the meaningful use criteria must have been met. The implementation deadline for the hospitals program, which operates on the fiscal year, was September 30, 2013. 


Resources
A Modern Healthcare article discussing the extension is available here.

A Medscape article discussing the extension and incentive payments is available here. 

A FierceHealthIT article discussing industry representative opinions on the extension is available here. 

A user guide for eligible professionals on meaningful use attestation is available here. 

A user guide for eligible hospitals on meaningful use attestation is available here.

The EHR Information Center is Open Monday-Friday from 8:30a.m.-5:30p.m. EST. The toll-free number to reach the center for assistance with meaningful use attestation is 1-888-734-6433. 

CMS' Two-Midnight Rule: Who Must Sign Off?

The Centers for Medicare and Medicaid Services (CMS) announced a clarification to the ‘Two-Midnight Rule’ this week that a physician must sign off on the admitting paperwork for Medicare beneficiaries. CMS published the two-midnight policy in an effort to explain when a Medicare beneficiary may qualify for overnight care versus outpatient care. This distinction is important to hospitals because the payment to the hospital is higher for overnight stays than for outpatient care. The rule initially established that a physician must have good reason to believe that a patient will require two nights in the hospital to qualify for the higher hospital rate from Medicare.

The clarification requires physicians to sign off on the admitting paperwork for Medicare beneficiaries before the patient is discharged. By signing the admitting paperwork the physicians are accepting responsibility for the determination that there is good reason the patient will require two nights in the hospital. Medicare's recovery auditors will not audit inpatient claims under the two-midnight rule until after Sept. 30, 2014.  

A hospital may still comply with the regulation if a non-physician staffer writes the admitting order into the medical record, even if the recording staffer does not have the independent authority to admit a patient. However, in all cases the physician must sign the admitting paperwork prior to the patient's release. 

For example, a hospital will be in compliance with the regulation if a nurse documents a physician's verbal order to admit a patient in the medical record if the physician signs the decision before the patient leaves the hospital. Similarly, residents, physician assistants and nurse practitioners may write the inpatient admitting order as a proxy for a physician so long as the physician signs the order before the patient is discharged. In every case the physician's signature represents that she approves and accepts responsibility for the admission decision.

Hospitals may still be compensated in cases when a doctor later refuses to sign the admitting order.  However, they will be compensated at outpatient rates. The hospitals must send the bills through Medicare's Part B system for outpatient care.  


CMS' Two-Midnight Policy can be found here. 

"Balance Billing" from In-Network Hospitals Leaves Patients Shocked

In emergent situations paperwork is often the last thing on a patient's mind. Patients that have the wherewithal to remember to choose an in-network hospital to avoid large bills for treatment assume that they may be treated by any physician in the hospital and their insurance will cover the treatment. Unfortunately, many find out this is not true several weeks later with the arrival of a hefty "balance bill."

Balance billing is a common practice that bills the patient for the remainder of the cost of treatment that the insurance refused to pay because the treating physician was not out-of-network, even though she practices at a hospital that was in-network.

These unexpected bills can have huge consequences on patients and their families. NBC 5, in Texas, recently ran a story about Melinda Allen, a patient at the Texas Harris Methodist Hospital emergency room. Allen woke up on a Saturday with intense abdominal pain. She had her husband take her a hospital she knew was in-network. Several tests later Allen was diagnosed with an ovarian tumor large enough to require surgery.

The billing was less straightforward than her treatment plan. Allen paid nearly $5,000 out-of-pocket for her treatment, in addition to her $1,500 monthly premium. Allen assumed her insurance would cover the rest since she was treated at an in-network hospital. Allen was shocked when she later received a bill for nearly $700. 

The amount of the bill Allen received  was the balance left over from the price of the treatment charged by the emergency room doctor and the price her insurance company felt was appropriate. 

This practice leaves the patient to sort out the claim with their insurance company. "People are really vulnerable when they go into an emergency room," Stacey Pogue of the Center for Public Policy Priorities explained. "It's unfortunate, again, that we're put in that position because insurance companies and doctors can't decide what is appropriate reimbursement."

In situations like Allen's where does the blame fall? Allen chose an in-network hospital. Physicians, by law, are not allowed to ask about insurance and must treat all patients regardless of their ability to pay. Should the in-take process include a list of in-network and out-of-network physicians? 

Hidden Costs of Duplicate Patient Records

A recent article by Patricia Consolver, Minimizing Duplicate Patient Records to Maximize Cash Flow, highlighted the relationship between a reduction in duplicate patient records and increases in revenue cycle efficiency. A 2008 RAND Corporation study found that the average duplicate patient record is 8 percent. In addition to the inherent risks to patient safety, duplicate and incorrect patient identifications have the potential to impair downstream financial activities such as delayed payments, appeals, and denials. 

The costs associated with duplicate records also include instances of repetitious lab and diagnostic tests that were performed, but documented in a duplicate record. Insurance companies often deny claims for repetitive tests. This results in care that the hospital will not be reimbursed for and cannot collect. 

Texas Health Resources, a 13-hospital system that serves over 1 million patients per year, implemented a four-step process during the transition to EHRs that resulted in a duplicate patient record rate of 0.36 percent. 

The Four-Step Process

1. Scrubbing the existing MPI
2. Identifying and selecting the correct patient records
3. Educating key stakeholders on avoiding duplicate creation
4. Monitoring performance

Education was necessary to ensure the EHR did not devolve to the state of MPI's duplicate records. Texas Health Resources education efforts were focused on both registration and medical record department employees. These courses emphasized the importance of using a full, legal name and the ways that duplicate records affect downstream activities in several areas of the hospital's operations. Data integrity teams were created to monitor the records and focus new education efforts on common mistakes that needed to be corrected. 

The implementation of similar systems is being evaluated at hospitals across the country as Meaningful Use requirements become effective.