That probably shouldn’t be surprising. Many vendors are seeing an uptick in the number of small practices now embracing and adopting electronic health records (EHRs), and MGMA presents a logical place to gain information, network with other providers, and learn how to address common implementation stumbling blocks. Basically, MGMA has the playbook on how to implement this type of technology, and smaller practices as well as newer ones can benefit from this knowledge.

The meeting itself focused on a variety of current topics and emerging trends that are important to healthcare practices of all shapes and sizes. For example, it offered sessions that described how practices could enhance operations by increasing revenue, containing costs, leveraging health information technology, and improving the quality of patient care.

The conference also offered sessions that helped physicians think about their practices in the context of health reform and ICD-10. These forward-looking presentations examined the strategic implications of reform and discussed how to achieve economic goals going forward into the new era. There were specific sessions related to Accountable Care Organizations (ACOs)—including one about developing the infrastructure to support an ACO, and another addressing how to ensure physician independence.

One exciting development that came out of the conference was the announcement of the merger between MGMA and the American College of Medical Practice Executives (ACMPE). The resulting association will continue to provide a professional home for members while offering certification; services and education; data and benchmarking resources; and advocacy in Washington, D.C. While the structure of the new association is still under development, it will be interesting to see how the association continues to support medical practices into the future.

Today, more than ever, practices are focusing on ensuring they have a strong revenue cycle – this includes making sure denials are minimized and appealed when appropriate. Today, we are answering some of the most commonly asked questions about denied claims and the appeals process:

• If payers have proprietary edits, do providers have to accept it when they are told the denial is based on these edits or is there a place to check to see if the denial is correct?­ Obtaining proprietary information and edits from payers can be difficult at times. The best course of action is to submit your assignment of benefits and indicate that this agreement allows you to act on behalf of the patient. Since this is on your own policy with the payer, you would expect them to explain how that benefit was applied and calculated. If that does not persuade the payer to explain the denial, you may have to get the patient involved so that they can pursue their appeals.
• How do practices appeal denials when the payer says they are paying on usual and customary reimbursement (UCR discount) when the provider is not in network and the EOB does not state that it is not the patient’s responsibility? UCR discounts are a big part of payer disclosure because you need to clarify if the claim was correctly paid and who is responsible for the account balance. The first step is to get disclosure and find out if this is a UCR reduction that has been applied. According to legal statutes, the payer must disclose what UCR reductions are, how the payer calculates these discounts and what type of data it is based on. Additionally, this disclosure will help providers clarify what they can do with balance billing – such as appeal it or bill the patient for the balance.
• Where do you find the National CCI Quarterly Code Change Report? This report is on the CMS website, however it is broken down according to a range of specific codes. By accessing CMS’s Physician Center, you can select and review a range of codes. Unfortunately there is no place on CMS’s website where the entire report can be downloaded.
• How do you eliminate the “Just write it off” mentality of some employees? This can be an important part of ensuring your bottom line does not suffer. One of the best methods is to track write offs and have processes in place for when accounts can be written off – such as having a manager sign off on specific dollar amounts or even having a manager sign off on all write offs. Practices should also review write offs, and if something is collectable they should go back to the team member who authorized it and show them that the practice could have appealed it and earned revenue. This will help illustrate how collecting on this account will help the bottom line and demonstrate how writing off items has a negative impact on the practice.
• What is the best way to allocate work in billing, collections and denials? By duty or by payer? Although it depends on the practice, typically it works best to separate duties based on payer. This allows each person to know the payer fully and focus on the nuances of each payer.

Do you have a revenue cycle question that you would like answered? Leave us a comment and we will answer it in an upcoming post.

During the hour long event, I noticed that all four of the panelists mentioned that they had leveraged elements of their clearinghouse to support growth without the need to hire additional staff. One person even mentioned that her practice now includes 28 physicians after merging with another group—but she works with the same six billers she worked with prior to the merger.

Throughout this event, I kept noticing some common best practice tips from each of the panelists. And I believe that every practice can implement these strategies in their organization too. Some of the best tips include:

• Using eligibility verification, whether real-time or batch. While real-time eligibility provides maximum flexibility for verification as patients present, most of the panelists say they prefer the time savings of using batch eligibility. In their experience, staff find it more time-efficient to scrape the scheduler and run eligibility once, rather than check eligibility in real-time for each patient.
• Taking advantage of compliance edits. One panelist noted that she works for an oncology practice where diagnosis codes are especially critical for billing chemotherapy drugs and other high-dollar cancer treatments. Her practice consistently uses a compliance edit feature from their clearinghouse to help ensure that any potential problems are identified on the front end, which prevents costly denials.
• Comparing data. In addition to using compliance edits to prevent denials, the practices explained that they often analyze the reason why a claim was rejected by their clearinghouse. This helps the organizations prevent the issue from recurring.
• Using Electronic Remittance Advice (ERA). Every one of the panelists uses ERA to help reduce the manual workload associated with remittance – one panelist even stated that the tool has allowed their organization to grow while reducing billing staff. Another person noted that direct ERA has halved the time it takes her staff to work remittance.
• Benefiting from auto posting. Panelists all report a reduction in errors through automatic payment posting. Saving and tracking the data automatically, rather than manually, provides additional time-saving benefits for the organizations.
• Communicating effectively. All of the panelists have a clearinghouse that provides intuitive and customizable graphs, charts, and other visual data representations which make it easier to communicate trends with providers and other stakeholders.

In the end, all agree that a few simple, best practice tricks help their practices track, trend, and manage revenue cycle data more effectively.

Devoted to helping every practice successfully move to 5010 and ICD-10, ICD-10 Hub allows you to download webinars, read blogs and catch up on the latest news the industry has to offer. Some of the content currently available includes:

• 5010 Timeline – This one-page overview details what steps you and your technology vendors should be taking, plus when to successfully transition to 5010.
• ICD-9 to ICD-10 Mapping – This reference sheet lays out how ICD-9 codes translate to ICD-10 codes.
• 5010 Payer Announcement Updates – This “living” document relays the steps each individual payer has taken and is planning to take in the near future to ensure their preparedness for 5010. This information will be updated frequently with the latest information you need to know.
• Recorded Webinars – Multiple webinars, which each focus on a different aspect of the transitions, are available for free download from the site.

ICD-10 Hub will be constantly updated with new information, blog posts and news about the pending transitions, so that you are fully attuned to what is going on in the medical industry. In addition, a community forum will be launched later this month, which will provide ICD-10 Hub visitors a platform for asking and answering each other’s questions about the current changes in the industry.

To keep up on the latest news on the site, follow ICD-10 Hub’s Twitter account (@ICD10Hub) and join ICD-10 Hub’s LinkedIn group.

Make sure to check out ICD-10 Hub for all the information you need to know about the 5010 and ICD-10 transitions!

Rather than contemplating an EHR purchase or PMS evaluation in the context of “what’s available,” consider how well these technologies will serve as your platform from which to custom-build, taking into account future needs as well as current ones.

It is similar to the time when, as a teenager, I went to buy my first stereo system. I saved up, went to the store, and there they helped me design my own system to suit my listening style. Two speakers or four? Turntable or tape player? Headphones? The stereo store catered to my taste, my music, my needs – and I ended up with a system that was perfect for me.

It’s the same concept with HIT. I often go back to an interesting article posted many months ago on amednews.com that—for all the pros and cons—still remains quite relevant. It addresses the fact that many organizations are considering updating their PMSs just because they can get a “package deal” from an EHR vendor. That’s not necessarily a bad thing. However, you must be certain you won’t be limited by these systems. Think long-term. Don’t shackle future functionality with current system constraints.

One key point to consider: Are you investing in open systems that promote connectivity with a wide range of revenue cycle applications? Among other benefits, the ease of information exchange promoted by open systems fosters both increased efficiency and error reduction (because information doesn’t need to be re-entered into disparate systems).

Be careful. While I definitely advocate analyzing your PMS and other systems in tandem with your EHR, make sure you don’t inadvertently short-change PMS or other functionality by tying your selection solely to an EHR vendor’s offerings. A vendor that limits the software packages you can pair with your PMS, for example, may force you to choose an application unable to support your mission-critical goals such as claims processing or revenue cycle management.

No two healthcare organizations are the same, so the “one-size-fits-all” technology approach simply isn’t feasible. You must have the flexibility to pick and choose among various technologies – perhaps using an EHR system from one vendor and a PMS or lab reporting application from another. In fact, from my experience, I can say without reserve that this is one area where open systems are vital.

I urge you to keep this in mind as you consider which technologies will best position your organization for future prosperity. Be alert to attempts to hinder your selection of complementary software. Consider your EHR options. Consider your other technology options. Choose those you feel will best fit your unique requirements – resulting in “sound” decisions for today and tomorrow.

What has your experience been when considering EHR and PMS options. We would love to hear from you. We invite you to share in the comments section below.

The magnitude of the change is no small matter, either. The roughly 14,000 now-familiar ICD-9-CM codes will be replaced by about 69,000 ICD-10-CM codes; the current 4,000 or so ICD-9-PCS codes will swell to about 72,000 ICD-10-PCS codes. In all settings, physicians will need to provide much more explicit documentation.

All of this was the focus of a recent panel discussion, where industry experts discussed the transition to ICD-10 and 5010. On the panel was: Rhonda Buckholtz, Director of Business and Member Development at the American Academy of Professional Coders (AAPC);  Michele Madison, a partner in the Atlanta healthcare law office of Morris, Manning & Martin; and Ken Bradley, Vice President of Strategic Planning at Navicure.  All three agree time is growing short.  The Centers for Medicare & Medicaid Services (CMS) essentially feels it already has delayed implementation by finalizing the current 2013 deadline. (The agency initially proposed a 2011 deadline.) The implementation date, therefore, is not likely to budge.

The panelists all liken the ICD-10 transition to the HIPAA and NPI transitions of not so long ago.  It will be costly, will similarly affect reimbursement, and will probably require concurrent processes for a while. (In the case of NPI, it was provider numbers; this time, it will be ICD-9 and ICD-10 codes.)

After listening to the discussion, it’s clear to me that the transition to the 5010 transaction standard and the transition to the ICD-10 code set walk hand-in-hand with each other. While practices can rely on their vendors to take care of many 5010 requirements, they must make sure their vendors are doing so. And practices must not treat the ICD-10 transition as “just another system upgrade.” Make no mistake: it will require a fundamental change in business and business processes.

Testing of those new processes will be critical. For instance, you should know whether your practice management (PM) and electronic health record (EHR) systems can correctly exchange information in the new formats—before your reimbursement is at risk.

So, what can you do now to prepare? Here are some tips from the panel:

1)     Assign staff to assess and address both 5010 and ICD-10 needs. In a small practice, this might be the office and IT managers. Larger practices (or hospitals) will need to involve more staff.

2)     Ask your electronic health record (EHR), practice management, and clearinghouse vendors about their preparation plans. Questions should include: What are my hardware/software needs? Are upgrades included in my contract? What is your testing schedule—both for 5010 and for ICD-10?

3)     Create a training schedule. While specific training should wait until closer to implementation, discuss the basics now. Run a report of your most-used ICD-9 diagnosis codes, then use the General Equivalency Mapping (GEM) files published by CMS (and also on the AAPC website) to map them to their possible ICD-10 counterparts. Compare the differences, see what documentation will be required, and use that information to begin crafting your training plans.

You’ve likely heard it before, but there truly is not a moment to waste. Once you take a serious look at all of the areas in your practice where ICD-10 codes will make an impact, you will see there is much work to be done, and little time in which to do it. It is vital to your organization’s future financial stability to make sure you have a full transition plan in place soon.

Does your practice have an ICD-10 plan in place?  Let us know in the comments section below.

The long-anticipated proposed rule defining meaningful use finally was released by the Centers for Medicare and Medicaid Services (CMS) on Dec. 30. On the same day, we also received the interim final rule setting initial EHR technology standards, implementation specifications and certification criteria from the Office of the National Coordinator for Health Information Technology (ONC).

You can view both rules in the Jan. 13, 2010, Federal Register at http://www.access.gpo.gov/su_docs/fedreg/a100113c.html.

As it turns out, CMS will define meaningful use objectives in three distinct stages. Providers who meet the criteria in each of the three stages may be eligible for thousands of dollars in incentive bonuses through the American Recovery and Reinvestment Act (ARRA). In the initial proposal, however, CMS has only defined the requirements for Stage 1, which focuses on:

“…electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes…implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information.”

Stage 1 includes many of the recommendations that the HIT Policy Committee made last summer, although with modifications. Among them: use computerized provider order entry (CPOE); implement drug-drug, drug-allergy and drug-formulary checks; maintain up-to-date problem lists; use electronic prescribing; incorporate clinical lab-test results into EHR as structured data; and check insurance eligibility electronically from public and private payers.

Stage 2 criteria, to be proposed by the end of 2011, is expected to expand on Stage 1 criteria to more fully emphasize structured data exchange. Stage 3 will focus on “…decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health.”

Look closely at this proposal. As you read, it becomes clear that interoperability is a major tenant of meaningful use. In fact, I would argue that saying this proposal defines meaningful use of “the EHR” falls short of the whole truth. Be careful not to limit your thinking to “medical record” technology alone. The reality is that the current definition requires interoperability across the entire HIT spectrum. CPOE, e-prescribing, clinical and outcomes data, insurance eligibility. You cannot achieve even these elements – which represent just the tip of the iceberg – unless interoperability is a criterion for every aspect of your HIT.

“‘Meaningful use’ is a term defined by CMS and describes the use of HIT that furthers the goals of information exchange among health care professionals.” That statement, found in the background section of the proposed rule, points to the undeniable standard toward which we are headed. It requires us to move data not only within our own organizations, but among myriad entities and applications.

Does your HIT – across the board – possess the interoperability necessary to meet future requirements? That’s the question we all must examine. Feel free to share your thoughts below.