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Every Hospital and Provider Needs to Understand the Mais Decision

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Last month, on November 7, 2014, the WUSB 90.1 radio show, The Business of Healthcare with host Susan Montana, featured guest Laura J. Lowenstein, Esq.
The interview and discussion was based on Laura’s article posted on her website with the title “Every Hospital and Provider Needs to Understand the Mais Decision”

LISTEN to the Radio Program on archive:

Be sure you don’t miss the next radio show that is all about “The Business of Healthcare” with host Susan Montana on 90.1 fm WUSB

Podcast: Play in new window | Download

Ebola was MORE than a Healthcare Crisis!

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How important are solid policies and procedures, including clinical best practices? This is something that became very popular in the news with the identification of three cases of Ebola here in the US. But it’s also something that I’ve encountered personally over the summer as my mother had her knees replaced, my brother experienced a cardiac scare, and I prepared for a procedure.

While you probably don’t have to worry about contracting the Ebola virus in your office, the situation in Texas demonstrates that you never know when you’ll be hit with an unexpected crisis.  How will you and your staff respond?
I received this link from one of my nursing friends. It’s an inside story from some registered nurses at Texas Health Presbyterian Hospital in Dallas who have familiarity with what occurred at the hospital following the positive Ebola infection of first the late Thomas Eric Duncan and then a registered nurse who cared for him Nina Pham.

We now know many more details of the Ebola story, but just because it’s out of the news doesn’t mean the headaches are over for that Texas hospital, or any other health providers who may find themselves in a crisis situation.
It has served as a wake up call to many that usable Policies and Procedures are not just a binder full of papers that sits on a shelf.
Another situation that occurred for me personally, that demonstrated the importance and efficacy of documentation, policy & procedure, and overall public and provider information regarding best practices in health care was when my brother experienced chest pains on the train. He recognized them, his seat companion responded appropriately when he noticed, the taxi driver who overheard him telling his wife he was experiencing chest pains sped his way to the hospital, and when he presented in the ER, as soon as he uttered the words ‘chest pain’ he was whisked off, stripped of his shirt, hooked up to an EKG and given an aspirin.
My mother had her knee replaced and every person on the medical team, from the surgeons to the housekeeping staff were obsessed with avoiding falls. Every piece of equipment, cleaning supplies, warnings, patient and staff awareness was riveted on making sure the patient didn’t fall and screw up that new knee.
I’m having a procedure done next week as an outpatient. One of the biggest risks identified has been infection, so there are many different protocols to follow to minimize the chance of infection.
We can extend this now to the recent Ebola hysteria. I’ve said this before – there is no doubt about it – I think if you had asked anyone where Ebola was likely to show up they’d say NY or CA. I highly doubt ANYONE would have expected it to show up in the middle of TX.

I was at Peconic Bay Medical Center recently, and they had a guard with a questionnaire at the front doors with big signs to attempt to identify anyone who may need medical screening for Ebola. So the message is getting across, and these best practice protocols are being put in place. 

The doctor in NY who was diagnosed was identified immediately because the best practice for Doctor’s Without Borders is to make sure health care workers who return from an Ebola area take their temperatures twice a day until they are past the incubation period. As a result, this doctor was identified, isolated and treated very quickly.
In the meantime, each one of us has an exponentially higher chance of dying from a bad egg/chicken (salmonella) or the flu or in a motor vehicle accident than even contracting Ebola, much less dying from it.
There is never a good time for developing protocols and documentation and delivering training. And 99% of the time, you’ll be fine. It’s that time when you really need it that people will start criticizing, condemning and blaming (and of course, since this is the good old US of A, lining up the lawsuits) YOU for NOT having prepared.
Where are the holes in your practice? Documented clinical protocols? HIPAA privacy training for your staff? Coding and billing errors by your physician, coders or billing team?
Put on your calendar to tackle these one at a time. Compliance is more than another set of pesky rules – it can be a matter of life and death!

What’s the Difference Between an Audit and a Review?

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So you’ve selected which type of internal audit/review you’re going to conduct for your practice.  Now you need to determine if you’re going to do an audit or a review.  What is the difference you may ask?

Audit

An audit is conducted after claims have been submitted to a payor.  The advantages are that a claim has gone through the entire process, and the analysis can include how the payor adjudicated the claim.  It allows for a complete picture of the results of the service delivered by the provider.  This will let you know which services a payor:

·        bundles or unbundles

·        up or down codes

·        pays, and how much

·        denies, and for what reason

A primary disadvantage to performing a claims audit is that if problems are discovered, they have already been submitted to the payor so you may need to:

·        submit voids or adjustments to correct billing errors

·        self-report compliance errors

Review

A review is performed before any claims are submitted to the payor.  It allows for the discussion and research of any issues that arise, and the capture of any additional supporting documentation that may not have been included in the initial submission.  Of course, care must be taken to ensure documentation is not improperly supplemented.  Provider notes may not be altered, studies that were not reviewed by the provider at the time of service are not admissible, etc.

Performing a review enables you to make any coding or billing corrections prior to submitting claims, avoiding the need to submit claim corrections.

A review also offers the practice an opportunity to discuss any issues identified to determine the course of action to take.  This is particularly important when documentation deficiencies deem a service unbillable, or when a compliance issue is identified.

A disadvantage of performing a review instead of an audit is that you don’t have a full picture of the impact of the service provided on the practice.  Without seeing how the payor adjudicates the claim, valuable insights into the bottomline net results are missed.

 

Which type of process makes the most sense for your practice?  Weigh the pros and cons of each, and give us a call

If you’ve got any questions or need help selecting a chart review method.  Contact us at sue@habaneroinc.com. 

Be Your Own Medical Record

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It started as a professional curiosity, but now it has become a habit, and I recommend it to everyone.  Maintain your own medical record.

I’ve found this helps me better understand what is going on with my own health, and it also makes it easier to communicate amongst the various healthcare practitioners you may see over the years.

Medical filesFor example, I recently went for a DEXA scan for bone density. It’s something that is recommended, especially for women, and especially for women with bone issues. My GYN had ordered the test, and when I went to have it done, I asked the technician for a copy of the scan and she printed it out right then and there.  Same thing when I had some 3D dental xrays taken a few months ago.  It made it easy for me to get second opinions, and eliminate a potentially unnecessary over exposure to another xray.

I suggest maintaining copies of all your blood results too.  This can help you when you are doing your own research into health related topics, be it research into traditional or alternative medical topics.

You may also want to consider doing this for any children, friends or relatives for whom you have, or may have, responsibility for.  For example, if an elderly relative were suddenly in need of medical care, would you be able to provide a list of their medications to emergency responders?

The bottom line, in today’s healthcare arena, we all need to be proactive in taking care of our health and the health of our loved ones.  As in many other areas of life, information is power!

– As published in GEM Magazine. Author: Susan Montana

Please direct your health care reimbursement questions or topics you would like to know more about to Sue@HabaneroInc.com.

ICD-10 Implementation Challenges & Taking Action

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Documentation? Training? Vendor readiness?  Coding?  Billing?  Where do I start?

There are many ICD-10 implementation challenges a medical practice faces.

• How will I properly document my medical records to support the coding and billing of the new ICD-10 coding system?

• Will my billing system be able to process ICD-9 for dates of service prior to October 1, 2014 that may need to be rebilled or followed up?

• Payor systems are supposed to be ready for ICD-10.  How will I know that the payor processed my claims correctly?

• How will my staff manage the extra work load that is inevitable during the transition period?

• How much is this going to cost me???

 

According to CMS, Providers should plan to test their ICD-10 systems early, to help ensure compliance. Beginning steps in the testing phase include:

• Internal testing of ICD-10 systems

• Coordination with payers to assess readiness

• Project plan launch by data management and IT teams

 

For providers who have not yet started to transition to ICD-10, below are actions steps to take now:

• Develop an implementation plan and communicate the new system changes to your organization, your business plan, and ensure that leadership and staff understand the extent of the effort the ICD-10 transition requires.

• Secure a budget that accounts for software upgrades/software license costs, hardware procurement, staff training costs, work flow changes during and after implementation, and contingency planning.

• Talk with your payers, billing and IT staff, and vendors to confirm their readiness status.

• Coordinate your ICD-10 transition plans among your partners and evaluate contracts with payers and vendors for policy revisions, testing timelines, and costs related to the ICD-10 transition.

• Create and maintain a timeline that identifies tasks to be completed and crucial milestones/relationships, task owners, resources needed, and estimated start and end dates.

 

Habanero, Inc. is available to assist in preparing you and your staff for ICD-10 Implementation.  Our Implementation Roadmap seminar  will guide you in developing your own customized plan for your business or practice.   If you don’t have the time or resources, our consultants can help.  Call 631.244.5661 or see our full in-house training schedule for more information.

55,000 New Diagnosis Codes with ICD-10

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ICD-9 contained 14,000 codes.  ICD-10 contains 69,000 codes!  Which code do I use?

The introduction of ICD-10 has been in the works for many years and there is a lot of information available.  In fact, the rest of the world has been using ICD-10 for years, and the United States is just now catching up.

Unlike the CPT procedure coding data set, which is controlled by the American Medical Association (AMA) and subject to copyright laws and licensing fees, the ICD-10-CM, ICD-10-PCS code sets and the ICD-10-CM official guidelines are available free of charge. (click here for official guidelines)

It’s a complicated code set, and using it is not intuitive.  It requires an understanding of anatomy and physiology, along with a clear understanding of the complex official guidelines.

The American Health Information Management Association (AHIMA) recommends training should begin no more than six months before the compliance deadline. Training varies for different organizations, but it is projected to take 16 hours for coders.  Training for medical practitioners is all about their documentation.  Providers who currently have comprehensive documentation habits will have an easier time of it than provides with poor documentation tendencies.

Habanero, Inc. has assisted large and small providers in preparing for ICD-10.  We offer a variety of overall and specialty-specific ICD-10 training to help you and your staff navigate this complex, yet vital corner of the healthcare arena.

ICD-10 Transition: Y2K will look like a child’s game

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ICD-10 will impact every area of your medical practice or billing company!

There have been so many changes put upon medical practices in recent years, from EMR, new HIPAA and HITECH privacy and security requirements, advances in medical care, payor audits, just to name a few.  You may not have appreciated just how big the transition to ICD-10 is.

Everyone covered by HIPAA must transition to ICD-10.  Your participation is not optional!

You may be thinking that codes change every year, so why is the transition to ICD-10 such a big deal?  ICD-10 codes are different from ICD-9 codes and have a completely different structure. Currently, ICD-9 codes are mostly numeric and have 3 to 5 digits. ICD-10 codes are alphanumeric and contain 3 to 7 characters. ICD-10 is more robust and descriptive and there is not a one-to-one crosswalk from ICD-9.

ICD-9 is 30 years old, it has outdated and obsolete terms, and is inconsistent with current medical practices.  It’s time for a change, and the sooner you begin, the more time you’ll have to get it right.

Habanero, Inc. has been consulting to the healthcare industry since 1996 and is poised to help your medical practice or billing company prepare for, and transition to, ICD-10.  We offer affordable training classes and consulting services.