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I hope you’ve had a great start to your 2023.
Our cover this issue is about HIPAA and the changes for 2023. It’s an excellent article from Compliancy Group that provides a wealth of information, examples, and guidance on many aspects regarding HIPAA and the Privacy Rule.
Natalie Tornese from Managed Outsource Strategies has written an excellent article about the risk factors, diagnosis, and treatment for cervical dysplasia. She has provided important information for billers and coders, as well as patients—which is all of us. It’s a great read and I’m sure you will have many takeaways. As someone who has a loved one affected by cervical dysplasia, I know that awareness is so important for all ages.
Other feature articles in this issue include a look into the new dermatology codes for 2023, recent False Claim Act cases shedding light upon compliance scrutiny, coding changes that will impact radiology practices in 2023, 12 tips to grow your medical practice, the importance of selecting the right EMR and PMS software, overcoming code denials in healthcare, and an investigation into hospitals hiding prices from patients.
Steve Verno is back with a new segment that we’re calling, “Verno’s Voice.” In his article this issue, he has written about his experience with medical debt collectors throughout his life. It’s interesting to see how and why
there are rules around this contentious but necessary issue.
One last thing: We’re not thrilled about it, and please know that we’ve left it as long as we could, but we must raise our prices for a 12-month subscription from $79.95 to $89.95. This is due to increased operating costs across the board that is affecting most businesses and households. I know this may come at an unfortunate time for many of you, so I would like to tell you about our LIFETIME GUARANTEE program in case you don’t already know about it or have forgotten. This guarantee means that, as long as you stay an active subscriber with BC Advantage, your yearly rate will remain the same as it was when you started your subscription with us. Key point to remember: Your subscription needs to remain active. If you let it lapse for any length of time, you will be charged the subscription rate at the time you sign up. We encourage you to take advantage of this incredible lifetime guarantee!
Learn more at www.billing-coding.com/lifetime.cfm
Until next time, Storm
editor Amber Joffrion, M.A. editorial@billing-coding.com
ceo - publisher Storm Kulhan storm@billing-coding.com
coo Nichole Anderson, CPC nichole@billing-coding.com
subscriptions manager Ashley Knight ashley@billing-coding.com
advertising sales@billing-coding.com
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Antonio Arias, MBA, CHBME, with NCG Medical.
As an experienced EMR and insurance billing provider for dermatology practices, Antonio, and the medical billing experts at NCG Medical, can help your practice navigate the billing process to minimize denials and increase revenue. With a knowledgeable partner by your side, you can focus more on treating patients to help your dermatology practice grow, rather than worrying about insurance billing. www.ncgmedical.com
Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, COCAS, CORCM, OHCC, ICDCT-CM/PCS. As CEO and Board Chair of the American Institute of Healthcare Compliance (AIHC), Joanne brings over 35 years of clinical and executive healthcare experience in areas of compliance, coding, documentation improvement, auditing, privacy, security, consulting, and administration. www.aihc-assn.org
Daniel Lebovic, ESQ, Corporate Counsel and Technical Content Manager, Compliancy Group. Mr. Lebovic has 15+ years of regulatory compliance and contract management experience. His background makes him uniquely able to translate HIPAA regulations into content that those without legal knowledge can easily understand. https:// compliancy-group.com
Trevor McElhaney, JD, Consulting Advisory, is the Associate Director of Consulting at the firm’s Knoxville, Tennessee office. His focus areas include feasibility studies for potential ventures, practice startups, strategic planning for growth-stage practices, transactional advisory, and succession planning. His extensive knowledge and experience across primary care and specialty practices allow him to structure each engagement to the individual needs and goals of each client. https://www.doctorsmanagement.com
Eric McGuire, SVP of Coding, AGS Health. At AGS Health, we help you streamline your revenue cycle so you’re free to invest in your organization and its goals. www.agshealth.com
Rachel V. Rose, JD, MBA, is an Attorney at Law, in Houston, TX. Rachel advises clients on healthcare, cybersecurity, securities law, and qui tam matters. She also teaches bioethics at Baylor College of
Medicine. She has been consecutively named by Houstonia Magazine as a Top Lawyer (Healthcare) and to the National Women Trial Lawyer’s Top 25. She can be reached at rvrose@rvrose.com. www. rvrose.com
Erin Stephens, CPC, CIRCC, Sr. Client Manager, Education for Healthcare Administrative Partners. HAP is a revenue cycle management company for medical facilities, with over two decades of experience serving physician practices in a variety of settings and medical specialties. www.hapusa.com
Randi Tapio, MBA, CMRS, CPCS, CHM, CHBP, founded MedCycle Solutions, creating revenue cycle solutions for healthcare practices that will improve efficiencies, maximize reimbursements, and help clients get paid faster. Randi is an experienced healthcare revenue cycle professional with more than 20 years of experience in various healthcare roles, including revenue cycle, administration, and consulting. As an experienced revenue consultant, she has a long history of cultivating strong working relationships with providers, ancillary staff, and healthcare executives. Randi concentrates her efforts in working with independent and hospital-based physician groups to improve revenue by increasing productivity and office efficiency, as well as billing and coding compliance. www.medcyclesolutions.com/
Natalie Tornese, CPC, is a Senior Group Manager responsible for Practice and Revenue Cycle Management at MOS. She brings 25 years of healthcare management experience to the company. Natalie has worked in varied leadership roles with practices and specialties. Her primary focus is revenue cycle management with an emphasis on Medical Billing, Coding, and Insurance Verification Management. She has written numerous articles on all aspects of Practice Management and presently manages a large team focused on Medical Billing, Medical Coding, Verification, and Authorization services for MOS. Contact us at 1-800-670-2809 or visit us at www.outsourcestrategies.com.
Steve Verno, CMBSI, CHCSI, CEMCS, CMSCS, CPM, CHM, is a Professor of Medical Coding and Billing Instruction at Florida Metropolitan University. We are always interested in hearing from any industry experts who would like to
On November 1, 2022, the Centers for Medicare and Medicaid Services (CMS) released their final rule for the CY 2023 Medicare Physician Fee Schedule (PFS). CMS had previously released their proposed version on July 7, 2022. After receiving submitted feedback from the public during the comment period, CMS published the final version that, unless otherwise stated, will have policies going into effect January 1, 2023. Much of what was proposed in July remains in this final version.
Download: https://www.billing-coding.com/pdf/FINAL-2023-MEDICARE-PHYSICIAN-FEE-SCHEDULE.pdf
In 2023, our work to replace paper with digital tools will shift to eliminating paper you send to us. This change:
- Eliminates postal delays, lost mail, and processing time for UnitedHealthcare to receive and scan the documents into our system - May make it easier for healthcare professionals to meet reconsideration and appeal timely filing deadlines by eliminating mail times
As a result, beginning Feb. 1, 2023, you’ll be required to submit claim reconsiderations and post-service appeals electronically. This change affects most* network health care professionals (primary and ancillary) and facilities that provide services to commercial and UnitedHealthcare® Medicare Advantage plan members. This does not affect pre-service clinical appeals.
UnitedHealthcare Provider Portal: Reconsiderations and Appeals interactive guide - https://chameleoncloud.io/review/6828-637e3e1787120/prod
Source: uhcprovider
The latest Fair Health data shows that telehealth usage fell by around 4 percent nationally in October 2022, making up 5.2 percent of all medical claim lines.
Amid the ongoing COVID-19 pandemic, the Fair Health Monthly Telehealth Regional tracker reported that telehealth use fell nationally and in every U.S. census region last October, except usage in the Northeast.
The FAIR Health Monthly Telehealth Regional tracker is a complimentary service that analyzes the changes associated with telehealth usage monthly by tracking various factors such as claim lines, procedure codes, and diagnostic categories. The population represented is privately insured and includes Medicare Advantage but excludes Medicare Fee-for-Service and Medicaid beneficiaries.
Throughout the COVID-19 pandemic, telehealth use increased sharply, largely due to the barriers restricting in-person care.
In January 2022, for example, when cases resulting from the Omicron variant spiked, there was a significant increase in telehealth use in every U.S. census region. Nationally, there was a 10.2 percent increase in telehealth utilization, which resulted in telehealth visits representing 5.4 percent of all medical claim lines.
However, in October 2022, telehealth use fell after three months of relative stability. Its share of medical claim lines also decreased compared to the month prior. Nationally, telehealth use dropped 3.7 percent, from 5.4 percent of medical claim lines in September to 5.2 percent in October.
At the regional level, there was also a decline in telehealth use. In the South, Midwest, and West, telehealth use rates declined by 6.8 percent, 4.9 percent, and 4.1 percent, respectively. In the Northeast, however, telehealth utilization saw a 1.7 percent increase.
Regarding diagnoses, there were various changes to note in October 2022. At the national level and in most regions, COVID-19 diagnoses fell, like the month prior.
Source: mhealthintelligence
Healthcare providers submitting claims for services, supplies, and accessories ordered under the Medicare Intravenous Immune Globulin (IVIG) Demonstration can expect to see an approximate 2.1 percent payment increase over last year. The calendar year 2023 rate for HCPCS Level II code Q2052 is $392.56, compared with $384.59 in 2022.
Source: AAPC
Coded firearm data is playing a larger role for hospitals and health systems as many are placing an emphasis on firearm education and social determinants of health capture.
Unfortunately, a retrospective medical record review recently published in JAMA Network Open is showing a gap in this data.
The study found that 28% of intentional firearm injuries resulting in emergency department admissions were inaccurately coded as accidents. An expert panel recently characterized this coding problem as a glaring gap in the U.S. firearms data infrastructure, the study said.
They reviewed 1,227 medical records for patients who presented to the emergency department with a firearm injury of any severity between October 1, 2015, and December 31, 2019. Researchers determined that 837 (68.2%) reviewed cases were intentional assaults, but of these assaults, 234 (28%) were coded as unintentional injuries in hospital discharge data.
Source: healthleadersmedia
Medicare Advantage plan rates will increase by 2.09% next year, largely in line with analyst expectations but likely lower than payers had hoped.
The 2024 Medicare Advantage and Part D Advance Notice released recently also includes some technical changes to the risk adjustment model, such as using ICD-10 codes instead of ICD-9, making it more up to date and more predictable, said CMS Deputy Administrator and Director of the Center for Medicare Meena Seshamani in a recent call with reporters.
The rule comes on the heels of regulation opposed by payers that would begin retroactive plan audits in an attempt to claw back overpayments. Payer lobby AHIP said that the proposal, the Risk Adjustment Data Validation, or RADV rule, was “fatally flawed.”
Stocks of payers tied to the MA market, like Humana, UnitedHealthcare and Elevance, all trended down closely after.
Source: healthcaredive
Price rise is due to increasing costs that we are all familiar with. We held out as long as we could, but we’ve had to raise the price for a 12-month subscription to $89.95.
We will honor our commitment through our Lifetime Guarantee program and uphold those prices for qualified subscribers. We appreciate your loyalty to us!
To learn more about this program, visit: billing-coding.com/lifetime.cfm
Mild cervical dysplasia usually resolves on its own but should be monitored as it can progress to moderate or severe dysplasia, which, if not treated, could become cancerous.
Gynecologic diseases involve the female reproductive system and include benign and malignant tumors, pregnancy-related diseases, infection, and endocrine diseases. Cervical dysplasia or cervical intraepithelial neoplasia (CIN) is a common gynecological problem in which abnormal or precancerous cells develop in and around the cervix. The main cause of cervical dysplasia is the human papillomavirus virus (HPV) which spreads through sexual contact. According to the Centers for Disease Control and Prevention (CDC), HPV
causes more than 9 out of 10 cervical cancers.
Here are key statistics on cervical dysplasia and cervical cancer in the United States:
• Each year, about 250,000 to 1 million women get diagnosed with cervical dysplasia.
• Though the condition can affect women of any age, cervical dysplasia usually occurs in those between ages 25 and 35.
• The Centers for Disease Control and Prevention (CDC) estimates that 91 percent of all cervical cancers are caused by HPV, and that at least 80 percent of women will have had HPV by age 50.
• The American Cancer Society notes that HPV is a group of more than 150 related viruses, and 14 of them are known to cause cervical cancer.
Cervical dysplasia is not cancer. A diagnosis of cervical dysplasia indicates that there are abnormal cells on the surface of the cervix. Cervical Intraepithelial Neoplasia (CIN) can range from mild to severe, depending on the appearance of the abnormal cells.
The three categories of CIN are:
• CIN 1 - Mild or low-grade dysplasia - Only a few of the cells are abnormal.
• CIN 2 - Moderate dysplasia - More of the cells appear abnormal.
• CIN 3 - Severe or high-grade dysplasia – This type needs immediate treatment.
Mild dysplasia usually resolves on its own but should be monitored as it can progress to moderate or severe dysplasia. If not treated, severe abnormalities could become cancerous.
The following factors increase the risk of developing cervical dysplasia:
• Becoming sexually active before age 18
• Having multiple sexual partners (though the condition can spread from just one partner)
• Smoking and using products that contain tobacco
• Being over age 55
• Having a weakened immune system
• Not using condoms (condoms help prevent HPV, but don’t fully protect you)
• Giving birth before age 16
• Not getting the HPV vaccine
• Three or more full-term pregnancies
• Family history of cervical cancer
Having HPV does not necessarily mean the person has cervical dysplasia. Experts believe that some high-risk strains of HPV and the duration of the infection may be the reason why some people develop cervical dysplasia after becoming infected with HPV, while others do not.
It can take 10 to 20 years, or even longer, for HPV-infected cervical cells to become cancerous. As HPV infection and cervical dysplasia don’t usually have symptoms, regular screening is important to monitor for cervical dysplasia and detect cervical cancer early. If abnormalities are detected in the cervical cells, further testing may be recommended.
If dysplasia has advanced to cervical cancer, it may cause symptoms such as abnormal menstrual bleeding, bleeding after menopause, increased vaginal discharge, back and pelvic pain, and pain during intercourse.
All women who are or have been sexually active or are age 18 or older should have regular gynecological checkups. This is important to detect any abnormal changes to the cervix as early as possible. When diagnosed, detected early, and managed effectively, cervical cancer is considered one of the most successfully treatable types of cancer. The following tests are used to diagnose cervical dysplasia and determine the severity of the condition:
• Pap test: A Pap test or Pap smear is a microscopic examination of sample of cells from the opening of the cervix that looks for abnormal changes that may be cancerous or may lead to cancer. The Pap test will also show if an infection or inflammation is present. If an ambiguous or minor abnormality is observed, the Pap test is usually repeated to ensure accuracy. If the test reveals a significant abnormality or cervical dysplasia, a colposcopy may be done to further examine the vagina and the cervix.
• Human papillomavirus (HPV) test: An HPV test can be done at the same time as the pap test or separately. An HPV DNA test can identify the presence and type of HPV strains which cause cervical cancer.
• Colposcopy: Colposcopy is an examination of the cervix, vagina, and vulva using a microscope. After the examination, 3% to 5% acetic acid solution is applied to the cervix to detect abnormal cells so that biopsies can be taken. Biopsy is a critical part of colposcopy since treatment will depend on the severity of the abnormality (CIN 1, 2, or 3) in the biopsy sample.
• Endocervical curettage (ECC): In this procedure, an endocervical curette is used to scrape the lining of the cervical canal and take a sample of cells to check for abnormalities.
• LEEP (loop electrosurgical excision procedure): LEEP tests for and treats abnormal cell growth on the surface tissue of the cervix.
Severe cases of cervical dysplasia (CIN 1 or CIN 2) require treatment. There two general types of treatment for cervical dysplasia: 1) destruction (ablation) of the abnormal cells, and 2) removal (resection) of the abnormal area. The type of treatment option the physician chooses will depend on the severity of the cervical abnormality.
The procedures to treat cervical dysplasia may include:
• Loop electrosurgical excision procedure (LEEP): This tissue-removal procedure uses electrocautery to burn off the abnormal cells.
• Cone biopsy: In cold knife cone biopsy, the abnormal area of tissue is removed with a laser, scalpel, or both.
• Laser surgery: Laser surgery treats precancerous conditions by destroying abnormal tissue or small tumors on or near the surface of the skin.
• Cryosurgery: In cryosurgical ablation, extreme cold (liquid nitrogen or carbon dioxide) is used to freeze and destroy abnormal cells or tissue.
• Hysterectomy: If cervical dysplasia persists or does not improve after other procedures, the uterus and cervix are surgically removed. However, as a hysterectomy may not be curative, long-term monitoring
will be required as the patient is at continued risk for vaginal and vulvar cancer. According to MedicineNet, cervical dysplasia may recur in the vagina in about 1-2% of patients who have had a hysterectomy.
Cervical dysplasia rarely develops into cancer. But if it is not treated, there is a chance that the abnormal changes may become cervical cancer.
R87 is the ICD-10 code to report abnormal findings in specimens from female genital organs and includes abnormal findings in secretions and smears from cervix uteri, vagina, and vulva.
Specific codes include:
• R87.6 - Abnormal cytological findings in specimens from female genital organs
• R87.61 - Abnormal cytological findings in specimens from cervix uteri
• R87.610 - Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)
• R87.611 - Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of cervix (ASC-H)
• R87.612 - Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)
• R87.613 - High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)
• R87.614 - Cytologic evidence of malignancy on smear of cervix
• R87.615 - Unsatisfactory cytologic smear of cervix
• R87.616 - Satisfactory cervical smear but lacking transformation zone
• R87.618 - Other abnormal cytological findings on specimens from cervix uteri
• R87.619 - Unspecified abnormal cytological findings in specimens from cervix uteri
• R87.62 - Abnormal cytological findings in specimens from vagina
• R87.620 - Atypical squamous cells of undetermined significance on cytologic smear of vagina (ASC-US)
• R87.621 - Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of vagina (ASC-H)
• R87.622 - Low grade squamous intraepithelial lesion on cytologic smear of vagina (LGSIL)
• R87.623 - High grade squamous intraepithelial lesion on cytologic smear of vagina (HGSIL)
• R87.624 - Cytologic evidence of malignancy on smear of vagina
• R87.625 - Unsatisfactory cytologic smear of vagina
• R87.628 - Other abnormal cytological findings on specimens from vagina
• R87.629 - Unspecified abnormal cytological findings in specimens from vagina
• R87.69 - Abnormal cytological findings in specimens from other female genital organs
• R87.7 - Abnormal histological findings in specimens from female genital organs
• R87.8 - Other abnormal findings in specimens from female genital organs
• R87.81 - High risk human papillomavirus (HPV) DNA test positive from female genital organs
• R87.810 - Cervical high risk human papillomavirus (HPV) DNA test positive
• R87.811 - Vaginal high risk human papillomavirus (HPV) DNA test positive
• R87.82 - Low risk human papillomavirus (HPV) DNA test positive from female genital organs
• R87.820 - Cervical low risk human papillomavirus (HPV) DNA test positive
• R87.821 - Vaginal low risk human papillomavirus (HPV) DNA test positive
• R87.89 - Other abnormal findings in specimens from female genital organs
• R87.9 - Unspecified abnormal finding in specimens from female genital organs
The ICD-10 code for dysplasia of cervix uteri is N87:
• N87.0 - Mild cervical dysplasia
• N87.1 - Moderate cervical dysplasia
• N87.2 - Severe cervical dysplasia
• N87.9 - Dysplasia of cervix uteri, unspecified
Common CPT codes associated with cervical dysplasia include the following.
Colposcopy
Colposcopy CPT codes include: 57452, 57454, 57455, 57456, 57460, and 57461.
Cervical Biopsy
• 57500 - Biopsy(s) of cervix
• 57505 - Endocervical curettage
• 57500 - Cervical biopsy, single or multiple, or local excision of lesion, with or without fulguration
• 57520 - Conization of cervix, with or without fulguration, dilation and curettage, repair; cold knife or laser
• 57522 - Conization of cervix (Loop electrode excision procedure)
• 57500 - Cervical biopsy, single or multiple, or local excision of lesion, with or
Description:
This webinar discusses HBAI services, focusing on coding and billing. Medical necessity is explored, including Optum/ APA examples. The speaker points out changes from the 2019 HBAI services CPT codes to the current codes. Documentation requirements to support proper billing and coding for HBAI services are shared, including time tips to remember.
• 57520 - Conization of cervix, with or without fulguration, dilation and curettage, repair; cold knife or laser
• 57522 - Loop electrode excision procedure
Endometrial Biopsy
• 58100 - Endometrial biopsy with or without ECC, dilation, any method
• 58110 - Endometrial biopsy in conjunction with colposcopy
Human Papillomavirus Test
• 87624 - Human papillomavirus, high-risk types
• 87625 - Human papillomavirus, types 16 and 18 only
• 56501 - Destruction of lesion(s) vulva, simple
• 56515 - Destruction of lesion(s) vulva, extensive
• 57061 - Destruction of lesion(s) vaginal, simple
• 57065 - Destruction of lesion(s) vaginal, extensive
Hysterectomy
Total abdominal hysterectomy CPT codes include: 58150, 58152, 58180, 58200, 58210, and 58240.
Vaginal hysterectomy CPT codes include: 58260,58261, 58263, 58267, 58275, 58280, 58285, 58290, 58291, 58292, and 58294.
High-quality patient management requires meticulous documentation in the medical record. The results of consultations, examinations, and treatments must be recorded. This will also allow coders to assign the appropriate diagnosis/CPT code on claims for appropriate reimbursement.
Globally, cervical cancer is the fourth most common cancer in women with an estimated 604,000 new cases in 2020. It is important to find abnormal cells through routine screenings and other measures so that they can be monitored or removed to help reduce the risk of cervical cancer.
Adherence to routine cervical cancer screening guidelines is critical. Cervical cytology, primary HPV test, co-test, and Pap test are all effective screening options for detecting cervical precancerous lesions and cancer. The American College of Obstetricians
and Gynecologists (ACOG), American Society of Colposcopy and Cervical Pathology (ASCCP), and Society of Gynecologic Oncology (SGO) recommend cervical cancer screening initiation at age 21 years.
ACOG recommends three options for cervical cancer screening in individuals aged 30-65 years: primary HrHPV testing every 5 years, cervical cytology alone every 3 years, or co-testing with a combination of cytology and HrHPV testing every 5 years.
However, despite the availability of these effective options, inadequate screening for cervical cancer continues to be a significant problem in the United States. A recent study that analyzed data on more than 20,000 women who were eligible for screening in the United States found that the rates of timely cervical cancer screening fell overall between 2005 and 2019. The study identified multiple barriers to screening, including women not being aware that screening is needed and not following up with their healthcare providers after abnormal findings from cervical screening. The researchers noted that the COVID-19 pandemic has likely worsened the situation. The study highlighted the importance of effective and efficient tools and systems to help clinicians stay up to date on screening guidelines and the need for more research on “the barriers that prevent clinicians from administering cervical cancer screening” (www.cancer.gov).
The only way to prevent cervical dysplasia is to avoid getting HPV. Getting vaccinated is the best way to prevent HPV and cervical dysplasia. Although it cannot treat pre-existing HPV or cervical dysplasia, the vaccine may prevent infections from returning in some cases. People who already have an HPV infection can reduce their risk of it progressing into cervical cancer by getting regular Pap smears to diagnose cervical dysplasia. Practicing abstinence or safer sex and not smoking or using tobacco products are other ways to prevent HPV infections.
Natalie Tornese, CPC, is a Senior Group Manager responsible for Practice and Revenue Cycle Management at MOS. She brings 25 years of healthcare management experience to the company. Natalie has worked in varied leadership roles with practices and specialties. Her primary focus is revenue cycle management with an emphasis on Medical Billing, Coding, and Insurance Verification Management. She has written numerous articles on all aspects of Practice Management and presently manages a large team focused on Medical Billing, Medical Coding, Verification, and Authorization services for MOS. For more information on how MOS can help your practice, contact us at 1-800670-2809 or visit us at www.outsourcestrategies.com.
Your dermatology practice performs medical and surgical services for your clients; as such, your medical billing strategy needs an understanding of both medical and surgical dermatology CPT codes.
For the new year, we’ve compiled this handy list of essential dermatology CPT® codes and relevant medical billing tips to help you and your practice succeed! Be sure to bookmark this page for easy reference and keep reading to learn more!
The foundation for an optimized healthcare revenue cycle is set in utilizing accurate and appropriate dermatology CPT® codes. When you have the correct codes that are
appropriate for the services rendered and the SOAP notes or other medical documentation to back it up, your claims are more likely to be accepted upon the first submission.
Whether it’s due to accidentally typing in the wrong number, not noting the CPT® code that best suits services rendered, or some other reason, reworking rejected claims takes time and money.
Ideally, your practice should have a 95% clean claims rate – meaning that 95% of your claims are successfully
processed on the first submission. In reality, most practices have a clean claims rate between 75% and 85%, which means that 15-25% of claims have to be reworked.
If each claim costs $25 to rework and you have an average 100 claims that need to be reworked each month, that adds up to a hefty $2,500 a month and $30,000 per year! One essential step you can take to avoid these costs is to ensure that each claim uses the correct dermatology CPT® codes.
These dermatology CPT® codes are essential for your practice:
When a skin biopsy is performed by a dermatologist, skin samples are removed from the surface of the skin to be further examined.
Skin biopsy codes include:
• 11102 - Tangential biopsy of skin; single lesion
• 11103 - Tangential biopsy of skin; each separate or additional lesion
• 11104 - Punch biopsy of skin; single lesion
• 11105 - Punch biopsy of skin; each separate/additional lesion
• 11106 - Incisional biopsy of skin; single lesion
• 11107 - Incisional biopsy of skin; each separate/additional lesion
• 40490 - Biopsy of lip
• 69100 - Biopsy of external ear
Lesions can be benign, premalignant, or malignant, and may be removed by any method, including electrosurgery, cryosurgery, laser, or chemical treatment.
If multiple lesions are removed, multiple dermatology CPT® codes may be used:
• 17000 - Destruction of premalignant lesions (e.g., actinic
keratoses); first lesion
• 17003 - Destruction of premalignant lesions (e.g., actinic keratoses); 2-14 lesions
• 17110 - Destruction of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions
Excisions of Lesions Dermatology CPT® Codes
Excising a lesion involves the surgical removal of lesions and the surrounding tissue.
Codes include:
• 11403 - Excision, benign lesion including margins; trunk, arms, or legs
• 11603 - Excision, malignant lesion including margins; trunk, arms, or legs
Mohs Micrographic Surgery Dermatology CPT® Codes
Mohs micrographic surgery involves the removal of skin cancer; this surgery is typically conducted in several stages, including the removal of tumor tissue and pathologic examination.
Codes are separated using location and stage:
• 17311 - Mohs micrographic technique on head, neck, hands, feet; first stage
• 17312 - Mohs micrographic technique on head, neck, hands, feet; each additional stage
• 17313 - Mohs micrographic technique on trunk, arms, and legs; first stage
• 17314 - Mohs micrographic technique on trunk, arms, and legs; each additional stage
Pathology procedures study skin and tissue at the microscopic cellular level.
Assign codes accordingly:
• 88304 - Level III - surgical pathology, gross and microscopic exam
• 88305 - Level IV - surgical pathology, gross and microscopic exam
• 88312 - Special stain including interpretation and report
• 88341 - Immunohistochemistry or immunocytochemistry
Laser therapy utilizes different laser wavelengths to treat a variety of skin conditions and can be used for cosmetic purposes. On the other hand, phototherapy treatments use UV light to treat skin conditions such as eczema and psoriasis.
These dermatology CPT® codes are as follows:
• 96920 and 96921 - Laser treatment for inflammatory skin disease
• 96900 - Actinotherapy (UV light)
• 96910 - Photochemotherapy; tar and ultraviolet B or petrolatum and ultraviolet B
• 96567 - Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions
• J7308 - Aminolevulinic acid HCL for topical administration
When submitting a claim with E/M codes, it’s important to clarify if the patient was new or returning to your practice:
• New patient: An individual who hasn’t received any services from a physician/non-physician practitioner (NPP) or any other physician of the same specialty who belongs to the same practice within the last 3 years.
• Returning patient: An individual who has received services from a physician/NPP or anyone else of the same specialty and who belongs to your practice within the last 3 years.
Furthermore, it’s important to know that you can bill based on time allotted or based on the complexity of your patient.
For time-based E/M medical billing, use these codes:
• 99202 - 15-29 minutes
• 99203 - 30-44 minutes
• 99204 - 45-59 minutes
• 99205 - 60-74 minutes
If billing based on complexity, use these CPT® codes:
• 99212 - Straightforward level of complexity, minimal risk or chance of complications (approximately 10-19 minutes)
• 99213 - Low level of complexity, low risk or chance of complications (approx. 20-29 minutes)
• 99214 - Moderate complexity, moderate risk, or chance of complications
• 99215 - High complexity, plications (40-54
Some medical billing modifiers; these are as
• Modifier 25 - This CPT® codes for patients practice; don’t use conjunction with
• Modifier 59 - The dermatology CPT® cedure was distinct on the same day.
Antonio Arias, MBA, CHBME, Balancing your dermatology notes, billing, and coding, ity care to your patients energy, and streamline by bundling your practice dermatology insurance Medical!
As an experienced EMR and insurance billing provider for dermatology practices, the medical billing experts at NCG Medical can help your practice navigate the billing process to minimize denials and increase revenue. With a knowledgeable partner by your side, you can focus more on treating patients to help your dermatology practice grow, rather than worrying about insurance billing.
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In 2021, the office/other outpatient codes and guidelines went through revisions. For 2023, the rest of the E/M sections underwent a major overhaul. We cover all sections revised with comprehension checks to ensure attendees will be able to:
•Apply the 2023 E/M definitions and guidelines in CPT to the medical record.
•Utilize the revised 2023 Medical Decision Making (MDM) Table in CPT to review E/M services.
•Demonstrate to physicians and other providers proper documentation that supports the level of services reported.
CHCS provides many types of audits for CPT and/or diagnosis.
•Physician/provider education on multiple specialties.
•CPT, ICD-10-CM, E/M, and specialty specific education solutions.
Education can be customized for your practice, department, or group. Services can be performed on-site, or virtually through our eLearning platform.
Betty A. Hovey is a seasoned healthcare professional with over three decades of experience in the field. She has extensive experience conducting audits for medical practices and payors. She specializes in educating various groups including coding professionals, auditors, doctors, APPs, payors, and others on coding, billing and related topics. Betty is a highly sought-after speaker and has co-authored manuals on ICD-10-CM, ICD-10-PCS, E/M, and various CPT specialty areas.
While only a few of the 225 new codes, 93 revised codes, and 75 deleted codes in Current Procedural Terminology (CPT)® for 2023 will impact radiology practices, it’s essential to know what they are and adjust your practice systems accordingly.
Ultrasound
Code 76882 for a limited extremity study was revised to include “focal evaluation” of other nonvascular extremity structures, such as joint space, periarticular tendons, muscles, nerves, or other soft-tissue structures or masses.
A new code (76883) was added to describe “Ultrasound of nerves and accompanying structures throughout their entire anatomic course in one extremity.” 76883 is a com-
prehensive code that includes real-time cine imaging, to be used once per extremity and not in conjunction with 76882.
According to the AAPC’s Radiology Coding Alert, it may be used for:
• Examination of multiple areas for potential nerve compression
• Measuring cross-sectional areas
• Assessment of echogenicity, vascularity, and mobility, which includes dynamic maneuvers (when indicated)
• Assessment for possible associated muscular denerva-
tion, as well as comparison to unaffected muscles or nerves within that extremity (as needed)
Several codes related to tumor localization were modified to emphasize that they include “acquisition” in a single area, along with the rest of the procedural description.
The revised codes and descriptions are as follows:
See Table 1
Note that these descriptions and those below are paraphrased for readability, not verbatim from the CPT descriptions.
Percutaneous Arteriovenous Fistula Creation
The American College of Radiology (ACR) reported that “two new codes will be available for percutaneous or endovascular approaches for creating arteriovenous anastomoses” in addition to the current codes to describe open surgical creation.
The new codes are as follows:
See Table 2
Somatic Nerve Injection
Coding for the injection of anesthetic agents for nerve
Radiopharmaceutical localization of tumor, inflammatory process, or distribution of radiopharmaceutical agents, including vascular flow and blood pool imaging, when performed.
78803 Using SPECT in a single area or acquisition in a single day of imaging. Single areas include, e.g., head, neck, chest, or pelvis.
78830 Using SPECT-CT for anatomical review, localization, and determination/detection of pathology in a single area or acquisition in a single day of imaging. Single areas include, e.g., head, neck, chest, or pelvis.
78831 Using SPECT in a minimum of 2 areas, or separate acquisitions in a single day of imaging, or a single area or acquisition over 2 or more days. Two areas include, e.g., pelvis and knees or chest and abdomen. Separate acquisitions include, e.g., lung ventilation and perfusion.
78832 Using SPECT-CT for anatomical review, localization, and determination/detection of pathology in a single area or acquisition in a minimum of 2 areas, or separate acquisitions in a single day of imaging, or a single area or acquisition over 2 or more days. Two areas include, e.g., pelvis and knees or chest and abdomen. Separate acquisitions include, e.g., lung ventilation and perfusion.
Percutaneous arteriovenous fistula creation, upper extremity, including all vascular access, imaging guidance and radiologic supervision and interpretation
36836 Single access of both the peripheral artery and peripheral vein, including fistula maturation procedures (e.g., transluminal balloon angioplasty, coil embolization) when performed.
36837 Separate access sites of both the peripheral artery and peripheral vein, including fistula maturation procedures (e.g., transluminal balloon angioplasty, coil embolization) when performed.
blocking now includes “imaging guidance, when performed.” With this bundling, separate billing of imaging guidance will no longer be permitted.
The codes affected are as follows:
See Table 3
Evaluation and Management
Interventional radiologists will use Evaluation and Management (E/M) codes more than diagnostic radiologists, as they often meet with patients at a separate time before a procedure. Healthcare Administrative Partner’s article, “Evaluation and Management Coding and Billing for Interventional Radiology,” provides a thorough review of the requirements for E/M billing. For 2023, many of the codes and some of the rules have changed. According to the AAPC, the changes render the CMS 1995
or 1997 Documentation Guidelines for E/M services outdated.
The lowest level of consultation codes (99241 for office or outpatients, 99251 for inpatients) has been eliminated. The minimum requirement is now 20 minutes for an office or outpatient consultation (99242) or 35 minutes for an inpatient consultation (99252), in both cases involving straightforward medical decision making.
Note that Medicare does not accept consultation codes, so the regular visit codes would be used instead.
The table below describes office or outpatient visits:
See Table 4
The inpatient visit codes now include observation care services, and the coding is governed by either time or the level of medical decision making (MDM) in the same way as outpatient coding has been done since 2021. The codes for observation have been deleted.
The following table describes the thresholds of either time or the level of MDM required for the inpatient codes:
See Table 5
To qualify as an initial visit, the patient must not have
received any professional services from a physician or other provider with the same subspecialty from the same group practice during the inpatient or observation stay. A nurse practitioner or physician assistant from the same group is considered to be in the same subspecialty as the physician, even though they do not have such a designation. A patient who is transitioned from observation to inpatient is considered to be in a single hospital stay.
Category III codes are temporary codes that allow for data collection for emerging technologies, services, procedures, and service paradigms. They are not routinely covered by
most payers, including Medicare, when they are initially issued, but that can change as they become more accepted and eventually transitioned into a Category I classification with regular reimbursement.
For 2023, two new codes X031T and X032T are available to report bone strength and fracture risk assessment using digital X-ray radiogrammetry-bone-mineral density.
It is important to keep abreast of all the code changes to optimize the success of your radiology practice.
Erin Stephens, CPC, CIRCC, Sr. Client Manager, Education Healthcare Administrative PartnersHAP is a revenue cycle management company for medical facilities with over two decades of experience serving physician practices in a variety of settings and medical specialties. Our story began in 1995 near Philadelphia where our headquarters is still located. Since then, our client-base has grown to encompass many renowned hospital-based practices and academic medical centers across the country.
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Denial rates are rising because of numerous factors, including the increasing complexity of coding guidelines, increased workloads and staff shortage, adoption of AI and automation in payor claim reviews, increasingly sophisticated remittance processes, and more. However, taking a more granular review of your claims may help avoid significant revenue hurdles or other more serious headaches, like audits.
Traditionally, providers were not as concerned with the initial diagnosis, as under a fee-forservice model. What was important was getting the CPT accurate for provider billing and the final DRG for facility billing. With the shift to value-based care and risk-based contracts, accurately documenting all diagnoses is critical as capitated payments are based on an accurate picture of the entire patient’s health; therefore, capturing everything up front is vital to ensuring maximum reimbursement. Clinical Documentation Integrity (CDI) can help alleviate some of that burden but requires an investment in CDIS resources. The best method is to capture it at the time of service.
Without painting too dramatic a picture, the average cost to rework a claim or appeal a denial averages $25 per claim for practices and a whopping $117 per claim for hospitals. Therefore, failing to properly document, code, and submit a clean claim will impact revenue by either lost revenue for the denied claim or the costs to rework the claims. A couple of dozen dollars is a trifle for a large organization, yet a multitude of such can cascade quickly into substantial loss in revenue and an increase in operational costs to rework claims.
This is why it is crucial to understand the details and risks and determine whether or not you might be well served by developing and following proven strategies for processing encounters, avoiding denials whenever possible, and
engaging the services of outsourced claims support should your internal processes be flawed or too much to handle in-house.
However, processing encounters is more than considering best practices and reducing revenue impingements. Factors outside a hospital’s realm of influence can compromise patient health and the financial health of the organization serving the patient.
Coding is a responsibility shared by the coder, provider, and CDI specialist to create a clinical picture of a patient encounter, so it’s essential to document conditions to the fullest extent possible to demonstrate clinical knowledge
of a patient’s health. The coder must assign diagnosis codes to be as specific as possible. Billers only detect errors once payers notify them in the form of a denial. However, billers can manage denials by monitoring denial trends and reporting coding issues back to the HIM department.
Understanding the denial trends, they can identify the most common causes for coding-related denials and educate HIM.
There are other factors to consider, including:
Avoid missing information in the claim – Missing information may result in a denied claim, so be sure to include the date of onset, medical emergency, or accident. In addition, scrutinize every claim for missing fields and required documentation. Inaccuracies in patient information can also lead to denials, so ensure the accuracy of a patient’s name, date of birth, sex, insurance payer, and policy number.
• File in a timely manner – Do not miss the filing window. Some deadlines are as short as 30 days.
• Eliminate duplicate billing – Duplicate filings account for the most significant percentage of denials. Keep a firm handle on your claims inventory to avoid duplicate filing. Ensure everyone sees what actions have already been taken to prevent this issue.
• Ensure the service is covered – This is one of the top reasons for denials. Ensure pre-authorizations are completed as appropriate. Insurance information changes, so verify patient eligibility at each visit. Sometimes, services are not covered or authorized by a particular plan. For example, a member’s coverage may be terminated, or maximum benefits have already been met. Check a patient’s policy status, look for plan exclusions, and check for referral or pre-authorization requirements. Checking eligibility includes checking plan exclusions, out-of-pocket expenses, and payable benefits.
• Include patient financial counseling where appropriate. Incorporating a process to review what the payer will cover, patient out-of-pocket, and even establishing a patient payment plan helps to improve self-pay collections.
Keep a keen eye on coding. For example, the diagnosis code may
cause a denial because it is inconsistent with a procedure. If a denial occurs, check to see if there was a typo to ensure a diagnosis was not accidentally left out. In that case, correct the claim and resubmit it.
Denials also happen when expenses occur after a patient’s coverage is terminated. Prevent this whenever possible by verifying a patient’s benefits before rendering service.
Double-check termination dates to determine if you need to bill the patient directly. Also, check to see if the patient has other coverage that can be used for the time of service.
Has the filing time limit expired? This is another huge reason for denials. All payers have deadlines for filing, and if claims are not submitted within their time frame, you’ll see a denial code. Be aware of each insurer’s deadlines for filing.
For example:
• Physicians may have 90 days to file a claim.
• Hospitals may take up to a year to file a claim.
• An out-of-network provider may get 180 days after service to submit a claim.
Sometimes, a diagnosis is not covered, resulting in claim denial. Prevent such denials by getting this information in advance. This will help you avoid cutting into your practice’s profits.
Incorporate denial prevention strategies into the daily workflow to avoid denials and keep revenue flowing. Unfortunately, it is not uncommon to have claims denied, so know and understand the most common denial reason codes to prevent them.
At AGS Health, we use a combination of AI-enhanced technology, data-driven services, and specialized support to maximize the performance of your revenue cycle. This means you can focus on the most important part of your business: caring for patients.
https://www.agshealth.com/
In November of 1918, the First World War (naively called “The Great War”) ended. (For people who appreciate or read into symmetry, World War I ended at the 11th hour on the 11th day of the 11th month of 1918). The League of Nations, the peacekeeping body and the precursor to today’s United Nations, was founded in January 1920 by President Woodrow Wilson and held its first meeting in November of that year.
important event took place that November— the Presidential election. Republican presidential candidate Warren Harding, sensing Americans were tired of war, and tired of fighting for peace (ironically, although Wilson formed the League of Nations, the U.S. refused to join), campaigned on the slogan, “A return to normalcy.” His incorrect word usage (the word “normalcy” did not exist when he used it) may have been unserious, but the election results meant business: Harding won in a rout. Normalcy seemed to be back on the menu.
From 2020 to 2022, the U.S. government was engaged in a war of its own, fighting
COVID-19 (or trying to, anyways, depending on who you ask). The Department of Health and Human Services (HHS), the federal agency designed to enhance the well-being of Americans, spent much time and resources navigating this public health crisis.
While COVID-19 has not formally ended, many Americans are anxious to put the events of the last two years behind them— to return to normalcy. As we got further into 2022, HHS’s Office for Civil Rights (OCR) became less focused on COVID-19 public health initiatives and more focused on traditional areas of concern. Enforcement of the Privacy Rule’s right of access provision, and ensuring patient PHI is not impermissibly used or disclosed, took center stage in 2022 and are poised to receive additional emphasis in 2023. The details of HIPAA changes
2023 are described below.
HIPAA Changes 2023: Return to Access
OCR completed investigation of 17 patient right of access cases in 2022. Fifteen of these resulted in a Resolution Agreement (Settlement), and two resulted in the imposing of a civil monetary penalty. The first 2022 resolution agreements were announced in March of 2022. The most recent resolution agreement (at time of writing) was announced on December 15, 2022.
OCR launched its Right of Access Initiative in 2019, bravely taking the radical stand that the rules requiring covered entities to act on patient medical requests must be enforced. In 2019, there were two right of access settlements/fines. In 2020, there were 11. In 2021, there were 12. In 2022, there were 17. Forty-two (42) in total.
In 2022, OCR emphasized specific aspects of right of access non-compliance, which are recounted below. Providers may expect that these areas of non-compliance will be on OCR’s radar in 2023.
Don’t Look a Gift Horse in the Mouth: Act on Technical Assistance
ACPM Podiatry Group is an Illinois practice. In early April 2019, OCR received an initial complaint from Richard Lindsey (“Complainant”), a former patient who alleged that ACPM refused to provide him with his requested medical records. On April 18, 2019, OCR provided ACPM with written technical assistance regarding the Privacy Rule’s right of access standard (basically, OCR explained what the standard means) and then closed the matter.
OCR then received a second complaint from Mr. Lindsey, alleging that ACPM still needed to provide the medical records after he made numerous requests. ACPM did not respond to multiple data requests from OCR, nor to OCR’s Letter of Opportunity and Notice of Proposed Determination (this is legalese for saying that ACPM blew off OCR’s investigation). Having given ACPM ample time to cooperate with the investigation, OCR issued a Notice of Final Determination and imposed a civil money penalty of $100,000.
In July of 2020, a few months before OCR issued the November 2020 Letter of Opportunity (a Letter of Opportunity is a document alerting a provider that there are preliminary indications of non-compliance; the letter also allows the provider to submit written evidence of mitigating factors or affirmative defenses for OCR’s consideration in making a determination of the amount of a civil monetary penalty).
ACPM finally got off its back, rousing itself to provide Mr. Lindsey with copies of his records. However, Mr. Lindsey informed OCR that the records he received—618 days after he made the initial records request—were incomplete. APCM provided no explanation as to why it could not provide all of the records.
Lesson: OCR provides technical assistance as a way of informally resolving complaints without having to impose more serious measures. When advice is offered, it’s a good idea to follow it.
On March 27, 2020, HHS received a complaint against Danbury Psychiatric Consultants (DPC), alleging that DPC failed to provide access to the complainant’s protected health information (PHI).
HHS’s investigation revealed that, on March 24, 2020, the complainant made an access request for her PHI. DPC failed to respond timely to the complainant’s access request. DPC also withheld complainant’s access on the basis that the complainant had an outstanding balance, and required a signed request or authorization request (a provider may require that a request be in writing, but, if it imposes this requirement, it must notify its patients beforehand of the requirement).
DPC failed to provide access to all the complainant’s PHI until September 14, 2020, after OCR initiated its investigation.
This conduct—holding records hostage for payment—is prohibited under the right of access provision. For its trouble, DPC settled with HHS by agreeing to pay HHS $3,500 and submit to a two-year corrective plan. Under
the CAP, DPC must develop policies and procedures on the HIPAA right of access provision, and must train employees on these policies and procedures.
Lesson: Patient records are not bargaining chips.
Fallbrook Family Health Center, a Nebraska clinic, failed to provide a patient with a complete copy of her designated record set even though she requested it in writing three separate times.
FFHC claimed it failed to provide access due to a former workforce member’s misunderstanding of an individual’s access rights under HIPAA. The nature of the misunderstanding is not publicly known. As a result of OCR’s investigation, FFHC sent complainant a copy of her complete designated record set on June 19, 2020. Fallbrook agreed to take corrective actions and paid $30,000 to settle a potential violation of the right of access standard.
The corrective action plan requires FFHC to “review, and to the extent necessary, revise its policies and procedures related to the right of access to protected health information (PHI),” and to train staff (including new staff, within 30 days of hire) on these policies and procedures. Having effective written policies and procedures, and training employees on these, should prevent further misunderstandings on the meaning of the phrase “provide access” from happening.
On July 20, 2020, HHS received a complaint against MelroseWakefield from an individual (“Complainant”) alleging that she requested the protected health information (PHI) of her mother from MelroseWakefield and had been denied access to the requested records.
HHS’s investigation revealed that, on June 12, 2020, the complainant made a valid access request for her mother’s PHI, having attached documentation—a durable power of attorney—verifying that she was her mother’s personal representative. A durable power of attorney with the
right to make healthcare decisions must be honored. In this case, the complainant was not provided access to the records because of MelroseWakefield’s mistaken belief that the durable power of attorney did not allow the complainant to secure the records.
After the complainant notified OCR of the denial of access, OCR notified MelroseWakefield of the allegations. MelroseWakefield’s collection of minds then (so the record states) reviewed the power of attorney documentation anew, and determined that the complainant should have received access to the records based on her initial request.
The complainant was provided access on October 20, 2020. OCR subsequently settled the matter with MelroseWakefield for $55,000. MelroseWakefield also agreed to the imposition of a one-year corrective action plan.
Under the CAP, the practice must develop policies and procedures that explain to workforce members how to verify the identity and authority of a personal representative for the purposes of a request for access to PHI. These policies and procedures must spell out what documentation, if any, an individual must provide to prove their identity and authority.
On August 31, 2020, OCR received a patient complaint alleging that provider Memorial Hermann Health System failed to provide the patient with her complete medical and billing records. Complainant alleged that she had made five separate requests for these records between June 2019 and January 2020, and that Memorial failed to take timely and compliant action upon the requests.
OCR initiated a formal investigation, in which it determined that Complainant asked for an itemized billing statement on July 3, 2019; that Memorial received the request; and that Memorial did not comply in full until March 26, 2022—564 days after the initial request.
Lesson: Medical records include billing records.
In two 2022 right of access cases, OCR called the provider out for charging patients excessive fees for copies of their records. The right of access prohibits excessive fees.
In its March 2022 Resolution Agreement with provider Jacob & Associates, OCR noted that this provider failed to provide timely access to PHI to a patient who requested that access. OCR also stated that the provider charged an unreasonable fee that was not cost-based, as required by law (incidentally, the provider had also required Complainant to travel to its office to complete its form to exercise her right to access, imposed a flat fee of $25 per medical records request, initially provided an incomplete (one page) paper copy of the records, failed to designate a Privacy Officer, and failed to include required content in its Notice of Privacy Practices).
In September of 2022, OCR entered into a Resolution Agreement with Great Expressions Dental Centers of Georgia, P.C. (GEDC-GA). The Complainant alleged that GEDC-GA failed to provide her with access to her medical records; in response to her November 25, 2019 access request, GEDC-GA had required that the Complainant pay a $170 copying fee before GEDC-GA would provide the Complainant with the requested medical records.
GEDC-GA did not contact the Complainant to send her the requested medical records until February 2, 2021. OCR concluded that GEDC-GA failed to provide timely access, and that GEDC-GA imposed an unreasonable fee not based on the costs of reproduction. OCR settled the matter with GEDC-GA for $80,000.
Note: Providers should know for 2023 (and should train their staff to know) that patients, when requesting their own records for their own use, may only be charged a “reasonable, cost-based fee,” per the right of access provision of the Privacy Rule. Also, providers should know that if a state law allows the provider to charge a higher fee than HIPAA allows and that the state law fee is “per page,” not tied to the actual cost of copying the records, the provider must charge the lower, HIPAA fee.
On June 24, 2022, the Supreme Court of the United States handed down its opinion in Dobbs v. Jackson Women’s Health Organization. The question the Court was asked to decide in Dobbs was, “Are all pre-viability abortions always unconstitutional?” To this question, the Court answered “no.”
To get to “no,” the Court evaluated two of its prior precedents. The first of this was Roe v. Wade, decided in 1973. In Roe, the Court held that a woman has a constitutionally protected liberty interest in terminating a pregnancy up to the point of viability.
19 years later, the Court largely affirmed this ruling, in Planned Parenthood of Southeastern Pennsylvania v. Casey (Casey). In Casey, the Court held that a state could not place an “undue burden” on the right to terminate a pre-viability pregnancy.
To get to “no” in Dobbs, the Court felt bound to decide whether Roe and Casey were still good law. The Court found that they were not, and overruled both decisions.
In its opinion, the Court noted that it was not “outlawing abortion.” Rather, the Court noted that, by removing the status of the right to terminate a pregnancy as constitutionally protected, it was returning the issue to each state. As a result, each state may now pass its own laws on whether, and up to what point in a pregnancy, to permit abortion.
HIPAA limits covered entities’ and business associates’ ability to use or disclose protected health information. In the wake of Dobbs, HHS has issued guidance that addresses how federal law and regulations protect individuals’ protected health information (PHI) relating to abortion and other sexual and reproductive healthcare. HIPAA changes 2023 may include additional guidance.
Just look at the thoroughness of the Post-Dobbs guidance
HHS has already issued in 2022.
HHS guidance issued in the wake of Dobbs describes the Privacy Rule’s use and disclosure restrictions. “The Privacy Rule permissions for disclosing PHI without an individual’s authorization for purposes not related to healthcare, such as disclosures to law enforcement officials, are narrowly tailored to protect the individual’s privacy and support their access to health services.” This guidance provides examples of when covered entities may disclose PHI without written individual authorization.
The Privacy Rule permits but does not require covered entities to disclose PHI about an individual, without the individual’s authorization, when such disclosure is required by another law and the disclosure complies with the requirements of the other law.
“Required by law” means that there is a law that contains a mandate that compels an entity to use or disclose the PHI, and that mandate can be enforced in a court of law. When a disclosure is “required by law,” the covered entity or business associate may only disclose that which the law requires disclosure of. A disclosure of PHI that exceeds what the law demands is not a permissible disclosure.
HHS guidance provides an example of a permissible disclosure: An individual goes to a hospital emergency department while experiencing complications related to a miscarriage during the tenth week of pregnancy. A hospital workforce member suspects the individual of having taken medication to end their pregnancy. The relevant state or other law prohibits abortion after six weeks of pregnancy but does not require the hospital to report individuals to law enforcement.
Since the state law does not require the reporting, the Privacy Rule does not permit such disclosure under the “required by law” provision discussed above. If a provider were to disclose the information, the disclosure would be impermissible, and constitute a breach of unsecured PHI. Where state law does not expressly require such reporting, the Privacy Rule would
not permit a disclosure to law enforcement under the “required by law” permission. Therefore, such a disclosure would be impermissible and constitute a breach of unsecured PHI, requiring notification to HHS and the individual affected.
The Privacy Rule permits but does not require covered entities to disclose PHI about an individual for law enforcement purposes “pursuant to process and as otherwise required by law,” under certain conditions.
A law enforcement request made “pursuant to process” means a request made through such legitimate processes as a court order or court-ordered warrant, or a subpoena or summons. A provider may, if a law requires disclosure, disclose PHI to a law enforcement request made pursuant to process, by disclosing only the requested PHI, and no more.
HHS provides two examples of the “law enforcement purposes” component of the Privacy Rule:
• Example 1: A law enforcement official goes to a reproductive healthcare clinic and requests records of abortions performed at the clinic. Under the HIPAA regulations, if the request is not accompanied by a court order or other mandate enforceable in a court of law, the Privacy Rule would not permit the clinic to disclose PHI in response to the request. Therefore, such a disclosure would be impermissible and constitute a breach of unsecured PHI requiring notification to HHS and the individual affected.
• Example 2: A law enforcement official presents a reproductive healthcare clinic with a court order requiring the clinic to produce PHI about an individual who has obtained an abortion. Because a court order is enforceable in a court of law, the Privacy Rule would permit but not require the clinic to disclose the requested PHI. The clinic may disclose only the PHI expressly authorized by the court order.
Expect HIPAA updates in 2023 to consist of additional guidance on when providers and PHI they hold may and may not be used in the service of state abortion investi-
gations.
HIPAA Changes 2023: Return to Appropriate Use of Technology
Healthcare providers frequently use online tracking technologies—scripts or codes on a website or mobile app used to gather information about users as the users interact with the site or app. These technologies frequently have access to PHI. HHS recently issued a guidance bulletin to raise awareness of the inappropriate use of online tracking technologies.
The bulletin discusses how the HIPAA rules apply to different types of online tracking technology, including tracking on user-authenticated webpages, unauthenticated webpages, and within mobile apps.
User-authenticated webpages, such as patient or health plan beneficiary portals, require a user to first log in with their credentials. A provider’s user-authenticated webpage generally has access to PHI. To protect user privacy, HIPAAcovered entities must configure user-authenticated webpages that include tracking technologies to allow those technologies to only use and disclose PHI as permitted by the Privacy Rule. HIPAA-covered entities must ensure that any ePHI collected by such technologies is protected and secured in compliance with the Security Rule.
In addition, when an online tracking technology performs business associate functions for a HIPAA regulated entity, the regulated entity must ensure that any disclosures made to the technology vendor are permitted by the Privacy Rule.
A provider may maintain an unauthenticated webpage. An unauthenticated webpage does not require patient login as a precondition to access. Webpages with general information, such as provider’s location or services, may be unauthenticated. Online tracking technologies on an unauthenticated webpage generally do not have access to PHI. If an individual must enter credentials or registration
information on the login page to access the portal, the information collected by the tracking technology is considered to be PHI, protected by HIPAA.
Tracking technologies on a provider’s unauthenticated webpage that allow individuals to search for doctors or schedule appointments without entering credentials may also have access to PHI. If these technologies collect individuals’ email addresses and/or IP addresses when the individual makes the search, the provider is, in effect, disclosing PHI to the online tracking technology vendor. The result? HIPAA applies, again.
Online Tracking Technology within Mobile Apps: Who’s the Collector?
Providers may offer mobile apps to individuals. These apps allow individuals to help manage their health information or to pay bills electronically. The apps collect information typed by the user or uploaded into the app. The apps may also collect information provided by the app user’s device, such as fingerprints, network location, or device ID—a movable feast of PHI. When such PHI is collected, the provider must ensure that whatever PHI the app uses or discloses is in accordance with HIPAA.
A different result presents when the user voluntarily downloads or enters data into a mobile device that was not developed or offered by or on behalf of the provider. Here, HIPAA does not apply. The provider is not creating, transmitting, maintaining, or receiving PHI. The provider is not out of a legal thicket, however. Other regulations, such as the FTC’s Health Breach Notification rule, may apply. This rule regulates impermissible disclosures made by mobile health apps.
Providers in 2023 should be mindful of avoiding PHI pitfalls when using online tracking technologies. Providers must ensure that all disclosures of PHI to an online tracking technology are permitted by the Privacy Rule, and, unless an exception applies, must also ensure that only
the minimum necessary PHI to achieve the intended disclosure purpose is disclosed.
Also, providers should address the use of tracking technologies in their risk analyses and risk remediation processes. Providers should also implement appropriate administrative, physical, and technical safeguards, (such as encryption, access controls, authentication controls, and audit controls), when they access ePHI stored in the tracking technology vendor’s infrastructure. These controls ensure that ePHI is protected from unauthorized access.
Don’t be surprised if 2023 HIPAA changes include issuance of further guidance on online tracking technologies, along with greater enforcement to ensure that providers who use online tracking technologies, use them only as allowed by HIPAA.
HHS has one additional weapon in its 2023 stockpile to strengthen Privacy Rule protections: its Notice of Proposed Rulemaking to modify the HIPAA privacy rule. If HHS pulls the trigger and makes the proposed rule final, HIPAA 2023 Privacy Rule Changes may be significant—for enhancing patients’ rights to access their health information, and for adding obligations on providers to ensure that they provide this access. Patient and privacy advocates have been pushing for this enhanced protection—this normalcy—for a decade, given the last major changes to the HIPAA Privacy Rule were made in 2013.
Daniel Lebovic, ESQ, Corporate Counsel and Technical Content Manager, Compliancy Group. Mr. Lebovic has 15+ years of regulatory compliance and contract management experience. His background makes him uniquely able to translate HIPAA regulations into content that those without legal knowledge can easily understand.
Group gives healthcare professionals confidence in their compliance plan, increasing client loyalty, and profitability of their business while reducing risk. Find out more about Compliancy Group and HIPAA compliance. Get compliant today! https://compliancy-group.com
As touted by the U.S. Department of Justice (DOJ) and Members of Congress alike, including Senator Chuck Grassley (R-IA), the False Claims Act, 31 U.S.C. §§ 3729, et seq. (FCA) is the federal government’s primary tool to root out fraud and put money back into the federal fisc. The statistics are not out yet for fiscal year ending Sept. 30, 2022; however, for FY 2021, the DOJ obtained more than $5.6 billion in settlements and judgments from civil cases (excluding Medicaid). As then Acting Assistant Attorney General Boynton indicated in a Feb. 1, 2021 press release, “The False Claims Act is one of the most important tools available to the department both to deter and to hold accountable those who seek to misuse public funds.”
Deterrence is a critical aspect of the law. The most effective way to rightfully evade liability is for a person to cultivate a culture of compliance. The first step for healthcare industry participants is to implement comprehensive fraud, waste, and abuse training, hire outside auditors to conduct statistically significant coding/billing audits, and create comprehensive policies and procedures that address the Stark Law, the Anti-Kickback Statute (AKS), and the FCA. A good place to start, whether as a newcomer to compliance or as a seasoned participant, is to consider recent FCA cases/
settlements and HHS-OIG enforcement actions. These two resources provide a roadmap for areas to emphasize to potentially avoid liability or mitigate liability, per the United States Department of Justice Manual, if a government investigation ensues.
Recent Highlights
While there are cases pending in front of the United States Supreme Court, some of which have not been granted certiorari—a request that the Supreme Court review the record
of a lower court for review and opinion.
Most cases are resolved without the need to access higher courts. Here are three recent actions to consider:
• January 4, 2023 – $745,000 False Claims Act settlement with medical device distributor Jet Medical, Inc. and related companies, to resolve civil and criminal allegations. While the complaint alleged that for a period of five (5) years, misbranded medical devices were introduced into interstate commerce, which have the potential to harm patients because there was no FDA approval and no acceptable investigational study conducted regarding the safety and efficacy of the device, there are other components that providers other than medical device companies and distributors should consider. First, don’t solely rely on a sales representative’s word. Conduct independent research to ascertain whether or not investigational studies were performed and the indications. Second, consider the impact on patient safety. Lastly, put these items into internal policies and procedures.
• December 29, 2022 – DOJ filed a complaint alleging that one of the United States’ largest pharmaceutical distributors violated the Controlled Substances Act (CSA) and contributed to the opioid epidemic and related deaths. The emphasis of the complaint is that like other companies, Amerisource Bergen placed profits from opioids over patient safety. According to the DOJ press release, “Pharmaceutical distributors that sell controlled substances, including AmerisourceBergen, have a longstanding legal obligation to monitor the orders that they receive from pharmacies and other customers and must inform the DEA each and every time they receive a suspicious order.” From a compliance standpoint, physicians and other providers, as well as facilities should ensure that their record keeping is accurate, that adequate training is required, and that there are policies and procedures in place for dispensing, disposal, cybersecurity,
claims/prescription submissions, accounting, and reporting.
• December 15, 2022 - $3 million settlement to resolve allegations that a privately held company and its subsidiary violated the AKS, which led to the submission of false claims. In essence, the DOJ alleged that Ocenture “participated in a genetic testing fraud scheme with other marketers and clinical laboratories. As part of the alleged scheme, Ocenture solicited genetic testing samples from Medicare beneficiaries directly and through other marketers.” In turn, physicians were paid to falsely attest to medical necessity for genetic testing. In some ways, the defendants were fortunate—other laws could have also been utilized, which are specific to labs, in addition to the AKS and FCA. The best prophylactic measures include training, ensuring that AKS safe harbors are met, and appreciating that the exclusion from participating in government programs is a possibility.
The FCA will continue to be a driving force in recovering funds for taxpayers, as well as holding those accountable who commit (or allegedly) fraud. Appreciating the laws and safe harbors is the first step. Training, adequate policies and procedures, and reporting are other mitigation factors. Finally, compliance teams and defense counsel should consider mitigating factors available in the Justice Manual. In sum, in the words of Henry Wadsworth Longfellow, “It takes less time to do things right than to explain why you did it wrong.”
Rachel V. Rose, JD, MBA, is an Attorney at Law, in Houston, TX. Rachel advises clients on healthcare, cybersecurity, securities law, and qui tam matters. She also teaches bioethics at Baylor College of Medicine. She has been consecutively named by Houstonia Magazine as a Top Lawyer (Healthcare) and to the National Women Trial Lawyer’s Top 25. She can be reached at rvrose@rvrose.com. www.rvrose.com
As a healthcare organization, choosing the right electronic medical record (EMR) and practice management system (PMS) software is critical for the success and efficiency of your operations. The right software can streamline patient care, improve data accuracy and security, and reduce administrative burdens, among other benefits. On the other hand, choosing the wrong software can lead to wasted time and resources, decreased productivity, and even patient safety issues.
With so many EMR and PMS software options available, it can be overwhelming to determine which solution is best for your organization.
To help you make the right decision, here are some key factors to consider when evaluating EMR and PMS software:
• Cloud-based vs. on-premises systems: One of the first decisions you’ll need to make is whether to go with a cloud-based or on-premises system. Cloud-based systems are hosted on remote servers and accessed via the internet, while on-premises systems are installed and run locally on your organization’s servers. Cloudbased systems offer the advantage of being easier to set up and maintain and can be more cost-effective in
the long run. However, on-premises systems may provide more control, customization options, and potentially better security for sensitive data.
• Integration with other healthcare systems: It’s important to consider how well the EMR and PMS software will integrate with your organization’s other systems, such as labs and pharmacies. A system that seamlessly exchanges information with these other systems can save time and reduce the risk of errors.
• Customization options: No two healthcare organizations are exactly alike, so choosing software that can be customized to fit your specific needs is important. Look for software that offers various customization options, such as adding custom fields or creating templates for everyday tasks.
• Support for population health management and
analytics: In today’s healthcare landscape, it’s increasingly important to track and analyze population health data. Look for EMR and PMS software that offers robust analytics and population health management capabilities to help you identify trends and improve patient outcomes.
• Ease of use: Finally, remember to consider how easy the software is to use for clinicians and other staff. Time spent struggling with a confusing or cumbersome system can add up quickly, leading to decreased productivity and morale.
When evaluating EMR and PMS software, it’s important to involve stakeholders from your organization in decision-making. This will ensure that the needs and concerns of all relevant parties are considered. Additionally, be sure to conduct demos or trials of the software to see how it performs in a real-world setting and gather feedback from current software users to understand how well it works in practice.
Selecting the right EMR and PMS software is crucial for the success and efficiency of any healthcare organization. By considering factors such as integration, customization options, population health management capabilities, and ease of use, you can make
an informed decision that will help improve patient care and support the ongoing success of your organization. If your organization needs help selecting, implementing, and optimizing an EMR and PMS software, contact MedCycle Solutions, who will steer you in the right direction.
Randi Tapio, MBA, CMRS, CPCS, CHM, CHBP, founded MedCycle Solutions, creating revenue cycle solutions for healthcare practices that will improve efficiencies, maximize reimbursements, and help clients get paid faster. Randi is an experienced healthcare revenue cycle professional with more than 20 years of experience in various healthcare roles, including revenue cycle, administration, and consulting. As an experienced revenue consultant, she has a long history of cultivating strong working relationships with providers, ancillary staff, and healthcare executives. Randi concentrates her efforts in working with independent and hospital-based physician groups to improve revenue by increasing productivity and office efficiency, as well as billing and coding compliance.
https://medcyclesolutions.com
The Federal Hospital Price Transparency Rule helps Americans know the cost of a hospital item or service before receiving it. Compliance is mandatory. The regulation aims to improve the affordability of hospital care by promoting price competition. However, a low compliance level among hospitals would compromise the operational effectiveness of this regulation. Understanding hospitals’ compliance status to the regulation has important implications for its enforcement effort and effectiveness assessment.
The Hospital Price Transparency Final Rule (“the final rule”) was published in November 2019 and went into effect in January 2021. The Centers for Medicare & Medicaid Services (CMS) is the federal agency responsible for enforcement and has been working with the American Hospital Association (AHA) to comply with challenges related to compliance. The government expects hospitals to be compliant as there has been ample time to prepare for its implementation and to comply with the
requirements.
The House Committee on Energy and Commerce is calling on the government watchdog, the Government Accountability Office (GAO), to investigate how well hospitals are complying with price transparency rules, in addition to evaluating how CMS is monitoring and enforcing hospital compliance.
In the U.S., hospital prices vary widely, but are not visible to
patients or the public. In 2019, the federal government finalized a rule requiring hospitals to disclose the prices they negotiate with insurers. The Hospital Price Transparency Final Rule requires hospitals to make public a machine-readable file containing a list of all the standard charges for all items and services, and to display charges for the hospital’s 300 most shoppable services in a consumer-friendly format.
Under the final rule, hospitals are required to make public the gross charges, the discount cash price, the payer-specific negotiated charges, and the de-identified minimum and maximum negotiated charges for all items and services.
For hospitals found to be noncompliant, the Department of Health and Human Services will issue a written warning notice or request a corrective action plan (CAP) if noncompliance constitutes a material violation of one or more requirements of the final rule. If the non-compliance is still not resolved, hospitals will face a civil monetary penalty (CMP).
In November 2021, CMS finalized the 2022 Medicare Outpatient Hospital Prospective Payment Rule, which increased CMPs for hospital noncompliance from a maximum of $109,500 per year to a sliding scale of up to $2 million per year for larger hospitals. As of January 2022, CMS has issued over 300 warning letters and 98 requests for CAP for hospitals deemed to be non-compliant. In June 2022, CMS issued CMP notices to two hospitals for failure to comply with the final rule.
On January 1, 2021, CMS began proactive audits of hospitals for compliance with the final rule and a review of complaints submitted via the hospital price transparency website. Since January 2021, articles and studies have revealed the lack of compliance, bringing this issue to the attention of Congress. The government is concerned with continued press releases and studies revealing high rates of hospital noncompliance with the final rule. Just a few published press releases are cited below.
The Wall Street Journal’s article, “Hospitals Still Not Fully Complying with Federal Price-Disclosure Rules,” reported in December 2021 that some of the biggest hospitals have failed to comply with the final rule. A study by the Johns Hopkins
Bloomberg School of Public Health found that more than half— 55 percent—of hospitals were non-compliant with the final rule in “Study Estimates That More than Half of U.S. Hospitals Not in Compliance with New Pricing Disclosure Rules in First Five Months.”
Another report issued by the Patient Rights Advocate found that only 14 percent of hospitals were fully compliant with all of the provisions of the final rule as stated in their “Semi-Annual Hospital Price Transparency Compliance Report,” published in February 2022. Additionally:
• Over half of the approximately 40 percent of hospitals that posted negotiated rates were non-compliant with other provisions of the final rule, including failure to post the payer specific negotiated rates.
• Twenty percent of hospitals did not allow consumers to see the discounted cash price, which is in clear violation of the final rule. This follows a series of other reports documenting hospitals’ slow compliance with the requirements of the final rule, and some hospitals’ complete lack of compliance.
Until there is a higher compliance rate, the government will continue auditing and monitoring for hospitals failing to comply.
This article provides a summary of the basic rule and references Public Disclosure Requirements under the rule with helpful links to the Federal Register (see Resources below).
Each hospital location operating under a single hospital license (or approval) that has a different set of standard charges than the other location(s) operating under the same hospital license (or approval) must separately make public the standard charges applicable to that location.
The hospital must ensure that the standard charge information is easily accessible, without barriers, including but not limited to ensuring the information is accessible:
• Free of charge;
• Without having to establish a user account or password; and
• Without having to submit personal identifying information (PII).
The digital file and standard charge information contained in that file must be digitally searchable.
Standard charges must be posted two ways (both are required):
1. Machine Readable File
45 CFR §180.50
A hospital must include a single machine-readable digital file containing the following standard charges for all items and services provided by the hospital: gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges.
• Gross charge means the charge for an individual item or service that is reflected on a hospital’s chargemaster, absent any discounts.
• Discounted cash price means the charge that applies to an individual who pays cash (or cash equivalent) for a hospital item or service.
• Payer-specific negotiated charge means the charge that a hospital has negotiated with a third-party payer for an item or service.
• De-identified maximum negotiated charge means the highest charge that a hospital has negotiated with all third-party payers for an item or service.
45 CFR §180.60
A hospital must display at least 300 “shoppable services” (or as many as the hospital provides if less than 300) that a healthcare consumer can schedule in advance. A hospital must contain plain language descriptions of the services and group them with ancillary services, and provide the discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges.
• Discounted cash price means the charge that applies to an individual who pays cash (or cash equivalent) for a hospital item or service.
• Payer-specific negotiated charge means the charge that a hospital has negotiated with a third-party payer for an item or service.
• De-identified maximum negotiated charge means the highest charge that a hospital has negotiated with all third-party payers for an item or service.
• De-identified minimum negotiated charge means the lowest charge that a hospital has negotiated with all third-party
payers for an item or service.
A hospital is deemed by CMS to meet the requirements hospital maintains an internet-based price estimator meets the following requirements:
• Provides estimates for as many of the 70 CMS-specified shoppable services that are provided by the hospital, as many additional hospital-selected shoppable is necessary for a combined total of at least 300 services.
• Allows healthcare consumers to, at the time they tool, obtain an estimate of the amount they will ed to pay the hospital for the shoppable service.
• Is prominently displayed on the hospital’s website accessible to the public without charge and without to register or establish a user account or password.
For additional details on monitoring and enforcement,
• 45 CFR Subpart C regarding Monitoring & Enforcement;
• 45 CFR subpart D for information on appealing a tary penalty.
Other sources referenced in this article:
• CMS Resource Page citing Regulations, Hospital Price Transparency Sample Formats, FAQ, Quick Reference and more: https://www.cms.gov/hospital-price-transparency/ resources
• 2019 Federal Register: Medicare and Medicaid Programs: 2020 Hospital Outpatient PPS Policy Changes and Rates and Ambulatory Surgical Center Payment System Changes and Payment Rates. Price Transparency Requirements for Hospitals to Make Standard Charges Public: https://www. federalregister.gov/documents/2019/11/27/2019-24931/medi care-and-medicaid-programs-cy-2020-hospital-outpatient-ppspolicy-changes-and-payment-rates-and#h-84
Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CMDP, COCAS, CORCM, OHCC, ICDCT-CM/PCS. As CEO Chair of the American Institute of Healthcare Compliance
Joanne brings over 35 years of clinical and executive care experience in areas of compliance, coding, documentation improvement, auditing, privacy, security, consulting, and tration. www.aihc-assn.org
Do you want to expand your medical practice without collapsing? Here are 12 realistic tips to safely and effectively grow your practice in 2023.
If you are a private practice owner, you may feel it is difficult to attract new patients. By setting a plan and sticking to it, you can set yourself up for success in 2023. Medical practice management requires the collaborative efforts of all team members.
Here are 12 realistic ways you can grow your physician practice this year. With these tips, you can expand your reach, attract new patients, and increase profitability in your medical practice.
The first step for success in 2023 is to determine your
goals. Setting SMART goals will provide your healthcare team with a focus and hold them accountable. SMART goals are Specific, Measurable, Achievable, Relevant, and Timebound.
You can set personal, professional, and financial goals for your practice.
Here’s how to set a SMART goal:
• Specific - State what you want to accomplish (considering who, what, where, and why).
• Measurable - Determine how you’ll measure your goal
(so you know it was met).
• Achievable - Make sure it’s a goal that stretches your abilities but remains achievable.
• Relevant - Set a goal that aligns with your practice’s main objectives.
• Time-bound - Set a specific deadline so you can stay on track.
A SMART goal will give your team a practice management blueprint, provide a detailed timeline, and keep you all on the same page.
For example, you might decide to increase your number of patients by 15% in two months. This goal is specific, measurable, achievable, relevant, and time-specific. In addition, a strong electronic health record (EHR) and medical practice management software can help automate the tracking process to ensure you are staying on track in real-time.
In order to achieve your SMART goals, you need talented and dedicated staff in all areas of your practice (e.g., office staff, revenue cycle management, practice management and business operations, patient care, etc.)
Make sure your staff member team is professional, well-educated, and efficient. Otherwise, your staff will slow your practice down. Your staff should know how to run the office and how to interact with patients. Search for people with exceptional people skills. By establishing a strong team, you’ll have the support you need for success. Then, you can use these creative ways to increase patient satisfaction as a team.
Once you have your team, make sure to create an environment where they feel like a united front.
To do so, start by finding creative ways to get to know everyone. Make sure each member of your team feels valued. That way, your staff will feel comfortable communicating with you about their needs. Try going out for birthdays or establishing other office traditions. Consider entrusting the human resource
function to your practice administrator or another strong team member.
Uniting your team will ensure your medical practice remains a united front.
You want your medical practice to stand out from others in your area. In order to show potential patients that you are a unique healthcare provider, consider your value proposition. Then, advertise this unique value as a part of your brand.
What do you want people to know you for? (For example, quality healthcare, superior office staff, state-of-the-art medical facilities, same-day telehealth appointments, etc.)
Consider what your patients need and look for in a healthcare practice. Once you determine your unique value, stick with it.
Sometimes, patients become frustrated and unruly on the phone. As a result, it’s important to make sure your staff at the front desk can handle these patients.
Consider offering phone training to your staff. This skill will ensure that your team acquires the correct patient information from patients while remaining calm and respectful. As a result, they’ll streamline the process, keep patients calm, and help your practice grow.
Google processes over 40,000 search queries every second. That’s about 3.5 billion searches a day. With search engine optimization (SEO), you can make sure patients find your website online when they search using Google.
Create helpful blog posts, infographics, and videos for your patients. Show them that you have a wealth of knowledge you can offer.
Posting online will help you attract new patients. At the same
time, you’ll show existing patients that your practice is there to help.
7. See Your Practice from the Patient’s POV
Put yourself in a patient’s shoes for a moment. What problems do they experience when they visit your practice?
For example, they might have to wait an hour before they see a doctor or have questions about medical billing.
This frustration could cause you to lose patients. In order to use these creative ways to increase patient satisfaction, you need to prioritize the patients’ needs. Sometimes, that means not taking new patients for a while and focusing on office management.
8. Expand Your Services
Look at your competitors. What services are they offering?
Determine if there are any new services you can add. Consider the demographics in your area, as well. For example, if your practice is located in an area where seniors live, you might want to offer free health screening for seniors.
Provide healthcare services that reflect your patients’ needs to further expand your practice.
9. Send Out Surveys
Determine your strengths and weaknesses as a medical practice by sending out satisfaction surveys. Your patients will tell you what you’re doing right and how you can improve.
10. Stay Updated Technological advancements occur in the medical field all the time. Make sure your practice offers the best by remaining equipped with the most current medical equipment and tools.
Then, advertise your new portable ultrasound machines or X-rays as a part of your brand.
Let your patients know the curve.
11. Use the Right Billing
The right billing software workflow. This can your cash flow, and
A high-quality medical medical practice a know you have a well-managed over less efficient
12. Remain Social
Show patients that social between visits. emails with your latest social media, or use software to send reminders current patients.
You can use these conversation with
That way, they’ll remember your practice is there to help.
Ready to grow your independent practice this year?
With these 12 tips, you can set new goals and accomplish each one! Expand your reach, discover new patients, and increase profitability with these 12 tips!
Want to simplify your practice this year? Contact DoctorsManagement today to get started!
Trevor McElhaney, JD, Consulting Advisory, is the Associate Director of Consulting at the firm’s Knoxville, Tennessee office. His focus areas include feasibility studies for potential ventures, practice startups, strategic planning for growth-stage practices, transactional advisory, and succession planning. His extensive knowledge and experience across primary care and specialty practices allow him to structure each engagement to the individual needs and goals of each client.
https://www.doctorsmanagement.com/
I was born into debt collection. In 1953, both my parents quit high school in their final year. In 1953, if you quit school, you were a social pariah; no one would hire you, because it was deemed that if you quit school, you would also quit your job. My parents did find work at a small mom and pop diner, but it barely paid the rent, so we moved to a run-down apartment next to the railroad tracks. The medical bills for my birth were overdue, and the debt collectors came to our apartment. In the 1950s, there were no debt collection laws, so debt collectors did everything possible to collect what was owed.
We moved five separate times to stay ahead of the collectors. One day, a postal worker showed up; however, it wasn’t the post office; it was a debt collector wearing a postal uniform, so we moved again and left the state. We lived in a broken-down, roach-infested apartment in Maryland, but that was all that my parents could afford. We lived there for two years until the debt collectors returned. My parents made a midnight move, borrowing a friend’s car,
and moved back to the place of my birth in New York. We moved three more times; the debt collectors were back. They came to me while I was in school and threatened all of us with bodily harm, so we moved again. My father found work at a small, local movie theater, while we lived in another rat and roach-infested apartment—though my mom did her best to keep the place as clean as possible. I slept on the couch in the living room and my parents slept on a Murphy bed that came with the apartment. Our strug-
gles didn’t seem to matter.
The debt collectors came back again; only this time, they set fire to the theater and told my dad that if he didn’t pay, our family would be in the burning theater, so we moved three more times. With all of these moves, my grades suffered. On top of that, teachers didn’t want to tutor someone who might move away at a moment’s notice, and for the same reason, kids don’t want to play with them. But things started to look up. My father found work at a retail warehouse, and he found a nice, small house that cost $20 a month. We lived there for five whole years.
Then the debt collectors were back again. My mom took me to see a doctor when my throat became inflamed; she paid the doctor bill by bartering with the doctor—paying him with home-cooked meals. The doctor said I needed my tonsils removed, so I was put into the hospital for surgery. As the bleeding wouldn’t stop, the doctor was required to return for an additional surgery. That medical bill drove my parents further into debt.
When I was born, the hospital bill had everything included, but this new hospital billed for everything separately— down to the toilet paper. The hospital brought in their own debt collection company. This time, the debt collectors came in with a van and emptied the entire house of everything that wasn’t nailed down; they took our clothes, beds, dishes, and even our pet dog. Once again, we made a midnight move to upstate New York. I was now 14 years old, and my parents told me that I needed to go to work to help with the bills, so I found work as a bag boy at a grocery store. And again, the debt collectors came back.
On payday, the debt collector came to the store and took my paycheck to apply to the debt that my parents owed, so when I graduated high school, we moved one more time. I found work as a security guard, and yet again, the debt collector followed us and contacted my employer to garnish my paycheck to put toward my parents’ debt. They continued following me. In 1972, I found myself in the Army, making $200 a month, $100 of which was taken out to
pay the debt collectors. This time didn’t hurt me as much as before, as I at least had “free” food and a “free” place to sleep. In 1974, I finally paid off my parents’ debt, but I kept sending them my monthly allotment. They moved into a nice home, where they stayed for 20 years. In 1988, my father was unfortunately diagnosed with cancer, at which time, he incurred more debt, but thankfully, debt collection and reporting laws had been enacted. One is called the Fair Credit Reporting Act (FCRA) (October 1970); another is the Fair Debt Collection Practices Act (FDCPA) (March 1978).
The things that the debt collectors did in the 1950s, ‘60s, and ‘70s were now illegal, but that didn’t and doesn’t stop the bad debt collectors. At one point, after the debt collection and reporting laws were enacted, I was working as a medical biller in South Florida. I was living with my mother, who had cancer, and she had a ton of medical bills due to her diagnosis and treatment. One morning, two men in grey suits knocked on her door, and without approval, they barged into the mobile home and displayed official-looking badges. I asked to see them.
The badges stated Homeland Security. I demanded to see other identification; the leader said that wasn’t necessary.
I went into the other room and called the director of Homeland Security. He asked to speak with the two men; they left immediately and never returned.
The doctor I started working with told me that my first task was to find a good debt collection company since he was displeased with his debt collection company’s work. I recognized that the company had been stealing from him, so I fired them immediately. They weren’t happy and asserted that the doctor worked for them and not the other way around. After securing all of the documents for my doctor, including computer data, I also sent a certified
letter terminating the debt collection company. I had to involve the bank regarding bank transfers between the account for my provider and the debt collection company. The debt collection company hired a lawyer to sue my doctor and me, but my doctor had a much better lawyer, who sued the debt collection company, which decided to settle out of court, my doctor making back the money he lost.
One day, I was speaking at a medical billing seminar, and at the seminar was a debt collection company. After I finished speaking, we discussed my need for a good and honest debt collection company. They were just what I was looking for, so I created a contract, which my doctor’s lawyer reviewed and approved.
The contract between the doctor and the debt collection company outlined the following:
1. None of the money would go into the debt collection company’s bank account; all money would be deposited into the doctor’s bank account.
2. The debt collection company would produce reports showing deposits and withdrawals once a week.
3. The debt collection company could not be given any accounts for at least 30 calendar days. This was to prevent seeking an account that had pending insurance claims.
4. No accounts would be placed into debt collection that had Medicare or Medicaid.
5. All value accounts had to be worked.
6. There was no penalty if we wanted an account returned to us.
7. There would be test accounts sent to them to validate that they could produce the work.
8. We were to review all statements produced to see what they were sending out.
9. We would insert a “dummy account” to check the phone calls made to the dummy account.
This list was based on my experience with the terminated company. As a few examples, they would demand accounts, including some unpaid accounts that still had insurance claims pending payment, and
when the insurance company paid the claims, the debt collection company took credit for the work and was paid their 40% for nothing. The previous company would also only work accounts that had a high dollar value, and they would ignore any low value accounts. Additionally, the terminated company made phone calls that clearly violated both state law and the Fair Debt Collection Practices Act. I learned this when I got a call for the dummy account and the caller refused to identify who she was and who she represented; she informed me that if I didn’t pay the bill for the dummy account, I would be arrested and sent to jail immediately. When I returned the call to the company owner, he denied that his employee called me, but he didn’t know that the call went to my voicemail; however, even after the owner listened to the voicemail, he still denied the call ever happened. As a result, his company was immediately terminated.
I went through at least five different debt collection companies before I found the company that I met at the billing conference. The company I hired at the conference was called Mnet Financial. With most debt collection companies, they specialize in one form of debt over another, such as credit card debt. Mnet specializes in medical debt. My doctor stayed with Mnet for almost 10 years until he decided to retire from medicine. In all of those 10 years, at no time did we have any issues with Mnet, and they are the only debt collection company I recommend or endorse.
My mom’s debt finally ended when her cancer returned, and she was placed into hospice. While the debt collectors didn’t want to give up, and tried going after me and my siblings, they quickly learned that I knew all about debt collecting. Every now and then, I get a letter telling me I owe a debt from 40 years ago, so I use the FDCPA to fight back, and they give up.
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Healthcare is among the top occupations affected by crises, acts of violence, and safety threats. This cannot be overstated. Employers are responsible for maintaining a safe work environment, but no organization is crisis-proof. Response to threats requires fast decisions and well-planned (and practiced) emergency response protocols.
Every healthcare entity is required to have a well-organized, detailed emergency response plan. It’s so much more than an onboarding protocol or book on a shelf. Crisis leadership training involves practiced activities, escape plans, and procedures to address or retreat from threats. Heidi Wysocki and Ed Pietrowski are experts that will arm you with the knowledge and skills to create and maintain a crisis response plan in your organization.
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