Empowering patients to ensure their physician does not miss-out on opportunities to be a better provider

It is observed that on a normal day in the office, the average physician misses an ample of opportunities to engage with their patients. The reason behind this being their busy schedules. Research indicates that this happens because physicians do not have the proper patient-centered communication skills and awareness.

On a typical visit, patients provide their physicians with a number of verbal and non-verbal cues, indicating their thoughts and feelings. This is done to pose a question or just to show concern. The value of the cue is directly dependent on the physician understanding it.

Let’s break down a typical day in the office to better analyze the opportunities involved. On an average, a physician receives 3-4 Patient complaints, 2-3 requests and there are around 4-5 patient expectations.   Add them together and we have 9-12 opportunities, per visit. This is a substantial amount. Hence, it is of utmost importance that attention needs to be paid to those cues.

The cues may be apparent; like a patient complaining of depression, but more often, those cues are not clearly stated and the doctor needs to observe the patient’s body language, facial expressions, etc. to get the hint. Regardless of how a patient expresses them, these cues are opportunities to engage the patient.

Let us take an example to understand this better. Following is a brief conversation about the patient’s knee, and there are 4 cues that the patient expressed verbally.

Doctor: So, how is your exercise regimen since your last visit?

Patient: I’ve haven’t been feeling so great ever since I slipped on the ice and my knee hasn’t been as cooperative. I’ve been missing the exercise.

Doctor: How about the diet? Are you still sticking to it?

Patient: Yes, but…

Doctor: Well, now that the weather is warmer, you could get back to the jogging that we talked about before.

Patient: How about doing an MRI of the knee to check if I have torn something. A similar thing happened to my friend and she got an MRI. Turns out, she had torn her cartilage.

Doctor: If your knee continues to bother you after a month, come and see me.

The 4 cues actually represent 5 opportunities for the doctor. Those opportunities could be utilized to:

1.   Demonstrate that the doctor was paying attention and listening to the patient.

2.   Show comprehension of the patient’s expectations

3.   Relate and empathize with the patient.

4.   Explain why MRI isn’t a necessary procedure at this point of time.

5.   To integrate a diagnosis and a treatment plan in a way that the patient can buy into it.

The reason for a potential “fall-out” due to the response of the doctor to those cues would be:

·         Feeling of mistrust

·         Feeling that the concerns were dismissed easily

·         Feeling that the whole visit was a waste of time

·         Problem not resolved

Long-term potential outcomes might include:

·         Patient acting against the doctor which could cause the problem to worsen.

·         Dissatisfaction

·         Patient doesn’t share potentially relevant health information in future visits.

·         Patient decides to visit the ER instead of seeing the physician

Let’s estimate that the average patient visit generates around 10 such cues, which is a conservative number. If the physician identifies and addresses 50% of those cues, it would leave 5 missed opportunities per visit. This analysis would add up to a 110 missed opportunities on a typical business day. Which makes 440 missed opportunities a week and a staggering 22,880 opportunities a year for just one physician.

Think about the impact the physicians in your provider network could make if they were made aware about some basic communication skills which would enable them to be mindful of, acknowledge and properly respond to these cues in a way that the patient would appreciate.   Investing in improving these skills would no doubt have a significant impact.

Asking Insurers to Deviate from Medical Necessity Clinical Guidelines

Insurance carriers routinely cite evidence-based clinical guidelines when denying treatment authorization. However, a number of insurance industry resources confirm that insurance medical decision makers must consider the patient’s unique medical condition and should deviate from the clinical guidelines when appropriate.

Requesting deviation from the guidelines will typically require an appeal focusing on the patient’s unique medical needs and why application of the guideline is not appropriate. Some of the specific factors to address in such an appeal include the following:

  • Patient’s previous treatments and discussion of failed treatment attempts and unwanted side effects
  • Patient’s secondary diagnoses which potentially complicate treatment
  • Any anatomical anomalies or age-related factors (pre-natal or geriatric challenges)
  • Ongoing diagnostic assessment for unexplained symptoms/atypical disease/disorder presentation

Further, the guideline itself can be called into question if it does not appear to adhere to current industry quality care standards and incorporate the latest treatment options. Some of the specific questions useful for assessing the quality of the guideline include the following:

  • How frequently the guideline is updated to incorporate recent medical developments
  • Patient demographic used to develop standards, ie, did the guideline development include studies involving a diverse patient population inclusive of prenatal patients, geriatrics and minorities to ensure appropriate application across a diverse population.

A study of medical necessity decisions made by private health plans discusses the widespread adoption of clinical guidelines for use in medical necessity decision making. According to this study entitled “Medical Necessity in Private Health Plans: Implications for Behavioral Health Care“, several insurer medical directors acknowledged that clinical guidelines are simply a decision making tool and should allow for flexible implementation.

“Interviewees stated that guidelines are not mandates or absolute protocols; rather, they are considered ‘guideposts’ to be informed by, and adapted to, individual circumstances and psychosocial needs of patients. Ongoing audits, performance measurement of in-house care managers and contracted providers, and member and provider satisfaction surveys are used to monitor the appropriate use of treatment guidelines in medical necessity decisions and to build in quality improvements at all levels of decision making,” states the study, available online at  http://download.ncadi.samhsa.gov/ken/pdf/SMA03-3790/SMA03-3790.PDF.

Denial Management Strategy. Key Points to Consider.

Estimates show denied claims represent over 13% of gross revenue for providers nationwide. Some studies suggest that over 90% of those denials were preventable and nearly 70% could be overturned. An additional 6% of gross revenue was lost to underpayments. These numbers are staggering when you combine lost revenue as a result with the high cost associated with resolving these denials.

To face this challenge, providers must have an effective strategy in place to identify denials, manage their resolution and analyze root cause to facilitate prevention of future denials. Some keys to an effective denial management strategy include:

1) Capturing all remittance information necessary for denial management
A primary source of denial information is the payer remittance advice (RA). Many providers focus on payment posting from the RA and neglect to capture all of the information critical for effective denial management. For denial follow-up, it is important to capture and categorize all payer reason and remark codes.

2) Paying attention to payers who provide hard copy remittance reports 
To maximize collections, providers must manage denials for 100% of their payer mix. Payers who cannot provide electronic remittance advice (ERAs) typically represent around 15% of total revenue, and many providers feel that the cost of capturing denial information from a hard copy remittance report is just too high to chase such a low percentage of revenue. A simple cost/benefit analysis will likely reveal that the cost of capturing denial information from a hard copy remittance report is easily outweighed by the denial recovery opportunity, and the opportunity to identify and prevent future denials.

3) Identifying and managing underpayments
If your denial management process does not identify and manage underpayments, you may be losing up to 6% of your annual gross revenue. Managing underpayments is frequently overlooked as part of a denial management strategy. First, you can qualify partial payment denials from remittances by looking for specific reason codes to identify charge-level denials. Second, it is critical to identify payment variances by comparing remittance paid amount to the expected payment amount. This can be challenging if HIS systems, contract management systems and denial management systems don’t work well together, however, this problem is easily and clearly worth resolving given the amount of revenue at stake.

4) Considering how denied accounts are assigned to follow-up staff
Too often, the focus on resolving EVERY denial results in chasing hundreds of low balance denials while sacrificing valuable resources who could be working on resolving collectible denials. Make sure follow-up assignments are reasonable. If a follow-up work queue has 2,000 denied accounts in it, the likelihood of staff always working on the most important account will be pretty low, and the likelihood of timely follow-up on all 2,000 denied claims is even lower. There are always exceptions that require judgment, however, consider filtering follow-up work queues to include a smaller number of high priority accounts. Also, consider setting a threshold (based on cost to collect or other defined criteria) for automating low-balance write-offs on denials, eliminating those accounts from work queues.

5) Automating or streamlining follow-up activity
Efficiency is the key to maximizing recoveries. Follow-up staff should have tools to save them time, allowing them to work and resolve more accounts. Some examples:

• Payer-specific appeal letter templates that can be auto-filled with account-level information like Patient Name, PCN, MRN, DOS, Denial Reason Codes, etc.
• Write-off authorization tools to streamline the request and approval process
• Canned follow-up actions and notes to prevent staff from wasting valuable time typing the same thing over and over again
• Quick access to view and/or print the EOB and the denied claim
• Automated alerts that notify users when a prior follow-up action has not resolved the denial within the designated period of time.

6) Tracking and analyzing the outcome of denial follow-up
Make sure the outcome of each resolved denial is clearly identified. Analyze outcomes and educate staff to evaluate processes that historically have not been successful overturning denials. If sending the same appeal letter to the same payer for the same denial reason on 100 different claims has not overturned any denials, consider creating a new follow-up plan for that denial reason.

7) Identifying root cause and focusing on prevention
Increasing denial recovery rate is good. Decreasing initial denial rate is better! The key to prevention is in identifying the root cause. When providers understand root cause, they can make business decisions to facilitate prevention. Studies suggest that almost 80% of denials are Patient Access errors, but if the cause is unknown, staff may not be solving the right problem. It is worth the effort to evaluate and assign root cause to denials whichinclude identifying trends and taking steps to prevent future denials.

8) Setting and tracking financial and operational performance goals 
Dashboard-style reporting tools are very helpful to communicate performance metrics throughout the organization and to manage performance. Important denial performance metrics includes : initial denial rate, recoveries on denials and underpayments, rate of appeals overturned, monthly denial trends by payer and error type, denial outcomes by payer and error type.

These tips are some of the keys to a comprehensive and effective denials management strategy.

by Todd Thomas, Director of Provider Product Management (Emdeon)

How Does a Practice Deal with All These High Deductible Plans?

One of the biggest trends we’re seeing in healthcare today is a shift towards high deductible plans. This shift first started as more and more employers stopped offering insurance or cut the type of health insurance they offered. This started the trend towards individuals purchasing high deductible insurance plans.

While the shift to high-deductible insurance plans started well before the Affordable Care Act (ACA), the government mandated health insurance and associated health insurance exchanges (HIX) have thrown gas on the already flaming fire. What most patients didn’t realize when they signed up for insurance on the government’s HIX is that a large majority of the plans were high deductible insurance plans. This has led to a huge influx in high deductible plans entering medical offices.

hat does this increase in high deductible plans mean?
This change is one of the most significant changes in healthcare reimbursement we’ve seen.High- deductible plans mean a major shift in who will be paying the bill. Instead of collecting most of your money from insurance companies, your clinic will need to becomeexpert at collecting money from patients as well. Yes, that’s right. You’re still going to have to collect from the insurance companies like before, but you’re going to have to build additional expertise around collecting payments from patients too.

While it’s true that clinics have been collecting payments from patients forever, that doesn’t mean that clinics have been doing a good job of actually collecting the money. In fact, I find practice after practice who hasn’t stayed on top of their patient collections. In the end, they often send their patient collections to a collections agency which frustrates the patients and tarnishes their name or they just write off the patient pay portion completely.

Suggestions to Improve Patient Collections
The first step to improving patient collections is to really understand the details of your patient’s insurance plan. This starts with doing an insurance eligibility check and verifying your patient’s plan details. We wrote about ways to streamline your insurance eligibility checks previously. Doing it right takes time, but with the right workflow automation solutions you can make sure that those working in your practice have the right insurance information. Once they have the right payment information, you’re much more likely to collect the payment from the patient while they’re standing in front of you at the office.

While collecting the patient payment from the patient while their in your office is ideal, there are dozens of reasons why this won’t happen. Some don’t have the money on them. Some walk out before you can collect. How then do you engage the patient in the payment process once they’ve left your office? In the past, the best solution was to send out bill after bill through mail service or possibly call the patient directly. This is an extremely time-consuming and costly process that can take 60 to 90 days to obtain results. Plus, it costs several hours of manpower and postage.

In the electronic world we live in, the first thing you can do to improve your patient collection process is to implement an online patient payment portal. This online payment process increases patient collections dramatically. The next generation patient is so unfamiliar with writing checks and sending snail mail, that those payments often get delayed. However, by offering the online patient payment option, you remove this barrier to payment.

The other way to improve patient collections is to use an automated messaging and collection process. This approach uses a collection of text, secure text, email, secure email and even smart -phone notifications and automated calls in order to ensure the patient knows about their bill and has the opportunity to pay the bill. Plus, these customized decision rules provide a much more seamless and consistent approach to patient collections.

This movement to the empowered patient with a high deductible insurance plan is not likely to go away. Employers are happily getting out of the health insurance business and many want patients to have more responsibility over the healthcare they receive. Being sure that you have a well- thought out-patientcollection workflow is going to be critical to the ongoing success of any medical practice.

Medicare Shared Savings Program gets tweaked by CMS

In an effort to shift healthcare from a fee-for-service payment model toward a care quality-based model, CMS continues to offer support and incentives to physicians that form or join an accountable care organization. With that in mind, CMS has released a proposed rule that aims to improve care coordination within ACOs as part of the agency’s Shared Savings Program. The industry can submit comments about the proposal through February 6, 2015.More than 330 accountable care organizations (ACOs) are members of the Shared Savings Program, and there are 4.9 million beneficiaries in the participating organizations. Fifty-eight organizations that participated in the first year of the Shared Savings Program reported earning a combined $315 million in shared savings payments.

The 110-page proposed rule aims to clarify the following aspects, among others, of accountable care.

  • Requirements for ACO participant agreements, the application and application review process. This provision was added because past Shared Savings applications contained incorrect information which caused them to experience processing delays. CMS recommends ACOs view itsACO Participant Agreement Guidance to confirm their application will be accepted.
  • The identification and reporting of ACO participants. This step specifies that an ACO must include a list of all its ACO participants during the application process and submit an updated list annually.
  • Eligibility requirements based on the ACO’s number of beneficiaries, structure and governing body. A section of the ACO agreement clarifies participating ACOs must “include primary care ACO professionals that are sufficient for the number of Medicare fee-for-service beneficiaries” and that the amount of beneficiaries must be 5,000 at a minimum.
  • The two-sided performance-based risk tracks for ACOs. Track 1 is a shared savings only option, while track 2 applies to ACOs that take on performance-based risk. Upon reviewing these two choices, CMS has proposed the creation of a third track in which providers would accept even more performance-based risk. Track 3 ACOs would have greater incentive to improve their care quality because doing so could maximize their cut of any shared savings.
  • ACO public reporting and transparency. This can be accomplished by each ACO maintaining a website that lists the organization’s name, identifies ACO participants and discloses data on their shared savings and losses owed to CMS.

The new proposed ruling is a clear indication of how important health IT is to the success of an ACO. As detailed in the document, the rule would require an ACO to outline in its application what technologies would be used to promote more coordinated care for their beneficiaries. Examples of things that could be listed in an application include the use of EHRs to track patient’s data, telehealth services to remotely monitor patients and the electronic exchange of patients’ health information.

CMS is working to document the success of ACOs and share insights and accomplishments with the healthcare industry to spur the creation of more accountable care groups. The proposed rule offers a template for participating ACOs to make to make certain information — such as the identification of ACO participants, governing body members and the amount of any shared savings or shared losses incurred — available to the public on a website that meets CMS requirements.

The need for an outcome-based payment model and a reduction in healthcare costs are the leading forces behind the creation of ACOs. Some of the first ACOs faced significant challenges during the early adoption stages due to a lack of supporting technologies and health information exchange platforms. Due to the public disclosure of ACO success stories, along with a helpful push from meaningful use criteria, physician-led groups and hospitals have a growing interest in signing up for ACOs.

Article by: Reda Chouffani

Future of Healthcare is Telehealth. Know Your Training Resources.

Adopting new technologies can be a difficult, often times daunting task. Fortunately, if you’re entertaining the idea of practicing telehealth there’s some great telehealth training companies out there to get you started. Here’s list of top five trainingsitesforteleheath

1. Telehealth.org

The Telemental Health Institute was one of the first organizations to offer evidence-based online training for behavioral health providers seeking to deliver online services that are legal, ethical and clinically sound. It provides 100% online training for both graduate students and post-graduate seeking continuing education units for psychiatrists, psychologists, social workers, counselors, nurses and coaches (CEUs and CMEs). You can also benefit from:

  • A secure forum with access to 2,000 professionals from over 36 countries worldwide.
  • Mobile compatible coursework packaged in various Levels, leading to the TMHI Certificate.
  • Monthly, topic-specific webinars via telephone, computer, and app-smart devices     Podcasts, kindle books and CD formats for onlineconference topics.
  • A low-cost “Inner Circle” option that allows you to start with dipping a toe-in-the-water.
  • Tools and successful strategies to develop your online presence, products and services.
  • Yearly online conferences with experts from across government and health care explaining key licensing and reimbursement strategies.
  • Mini-training videos at no additional cost.

One of the best things about this program is that you can get fully-certified in as little as one week. So if time is a matter of concern, this might be your best bet.

2. Allceus.com

Allceus has been providing e-therapy certification training since 2006. They offer a simple system towards getting certified regardless of work setting, approach, and educational or professional training. Allceus’s e-therapy course abides by general education requirements for certification in online therapy. You can also expect to complete the e-therapy coursework within 20 credit hours, broken down into:

  • 4 hours of best practices.
  • 4 hours of clinical principles/treatment modalities.
  • 2 hours of legal and state jurisdictions.
  • 10 hours of electives within the course schedule.

To start the e-therapy certification process you will need to buy a 90-day interval priced right under a Benjamin Franklin, if coursework isn’t finished under that time frame you will have to buy an additional 90-day period. Certificate can be saved as a PDF or printed upon completion.

3. Afhcan.org

This Alaskan, FDA listed, and maker of medical devices also provides an assortment of telehealth programs. AFHCAN Telehealth Solutions started in 1998 with a mission to making healthcare accessible to rural Alaska. The result of such a mission was tCounsult, a store-and-forward method that utilizes an interim lock-point between the point-of-delivery and point-of-receipt, a form of encryption for successful eTheraphy and training. They offer both group and individual online therapy training courses worldwide. You may choose from three different courses:

  • Understanding Telehealth & the Role of the Coordinator (you).
  • Becoming a Certified Telehealth Coordinator
  • Knowledge and skills needed to manage a telehealth program

Within three 10-week courses you can expect to be proficient in all of these areas.

4. Onlinetherapyinstitute.com

Kate Anthony and DeeAnna Merz Nagel, two accredited psychotherapists inducted their personal goals onto an online setting with hopes to disseminating their experiences and knowledge on health and technology. In light of such a unique mixture, The Online Therapy Institute and Online Coach Institute were created. These two institutes offer an array of training opportunities that help providers become comfortable and familiar with practicing in an online setting. You can expect training in the following areas:

  • Working therapeutically using asynchronous email.
  • Working therapeutically using asynchronous chat
  • Working therapeutically using audio
  • Working therapeutically using video and blended technologies

5. Telehealthresourcecenter.org

If none of the telehealth programs mentioned above appeal to your current telehealth needs or if you believe that you still need a further understanding of how to properly approach telehealth than the Telehealth Resource Center (TCR) is your best bet. This organization is the heart of 14 other TCRs across the nation and is sponsored by our very own U.S. Department of Health and Human Resources office for telehealth advancement. TCR will help you develop and identify:

  • A training strategy that best fits your schedule
  • A telehealth training program that best fits your location and circumstances,
  • All the factors that contribute to successful telehealth integration

Best of all, in addition to helping you find the strategy, program, and factors, this centers’ resources can all be accessed at little to no cost. For more information on telehealth subscribe to our blog in the form provided!

By Giovanny Ayala

Outsourced Claim Creation for Physician Practices

A great deal of expertise goes into running a successful physician practice – from the skilled clinicians who deliver patient care, to the front- and back-office staff who manages the business aspects of the practice. Yet, after focusing on the care delivery aspects of the business, many practices often don’t have enough time to properly focus on their billing tasks. This prevents practices from earning the maximum reimbursement for the services they performed.

In these situations, outsourcing billing tasks – such as claim creation –  is worth consideration. Claim creation services are able to devote their entire attention to the practice’s revenue cycle management (RCM) process, and are focused on keeping up to date with ongoing regulatory changes to reduce claim denials and maximize reimbursement.

Once a practice outsources its claim creation, the process is initiated with one of two options to begin claim creation:

  1. The practice scans superbills and patient demographics to electronically send to the claim creation team. This may also include scanning the billing data and consult information from hospitalists to send to the claim creation team.
  2. The practice ships superbills, patient demographics, and other relevant billing information to the claim creation team.

Once documents are received by the claim creation service, there are typically two ways to generate a claim:

  1. Manual Claim Entry: Before any claim is generated, patient insurance verification is done. Claims are then created from a route slip, superbill and other billing information. Claims are then scrubbed for errors that may cause denials. Once claims are created, they can be either sent back to the practice for submission, or the claim creation service can electronically submit the claims.
  2. Electronically Generated Claims: This process is sometimes known as Autogeneration. These claims are created using the evaluation and management (E&M) coding engine within the practice’s EHR interface. Additionally, these claims can be created by using the electronic superbill within the practice’s EHR system, or can use the charge capture system within the practice management system. Auditing of the newly created claims can still be done before submission by either the practice or the claim creation service.

Outsourcing the claim creation process benefits practices on multiple levels. It enables them to remain focused on care delivery, while also ensuring that they receive maximum reimbursement for the services they deliver.