March 2013 MBJ Issue

Medical Business Journal March 2013

MBJ

THE MONTHLY NEWSLETTER FOR THE INFORMED HEALTH CARE PROFESSIONAL ISSUE 2 VOL. 4

Inside this Issue: ……………….……………….……………….……..…………. 2 Sequestration: 2% Cuts for Medicare Physicians …………………………...……………. 8 HIPAA Mega Rule …….………………………………………………….………………. 9 Widespread Ignorance about the Sunshine Act ...………..………………………………. 12 Affordable Care Act: Changing the Design of Insurance Coverage ………………...…..….15 Know Your Contracts ……………………………………..…………………………..….16 EHR: The Good, the Bad, and the Ugly ………………………………….…………..….17 MMI Updates ………………………………………..……………………………..….18 CMS News Updates

The Medical Business Journal is brought to you by the Medical Management Institute The Medical Business Journal is a monthly source of up-to-date information on all issues affecting the healthcare industry. Its content ranges from medical coding and billing to healthcare reform legislature and beyond. The MBJ is not affiliated in any way with the Department of Health and Contributors Human Services, Medicare, or the Centers for Medicare and Medicaid Services. This publication Kathy Dyson lorem ipsum dolor ismet designed set to provide accurate and authoritative information with regard to the subject matter Jennifer Donovan Janet Salyer quam nunc parumcovered. It is sold with the understanding that the publisher is not engaged in rendering legal, Susie M Schlernitzauer accounting or other professional services, and is not a substitute for individualized expert Layout & Design assistance. The CPT codes, descriptors, and modifiers are copyrighted by the American Medical Carleigh Benscoter Association. For more information, please call MMI at 866-892-2765.

Editor in Chief Carleigh Benscoter

CMS News Updates CMS.gov 2/22/2013:

Five New Provisions of the Affordable Care Act The U.S. Department of Health and Human Services (HHS) today issued a final rule that implements five key consumer protections from the Affordable Care Act, and makes the health insurance market work better for individuals, families, and small businesses.

“Because of the Affordable Care Act, being denied affordable health coverage due to medical conditions will be a thing of the past for every American,” said HHS Secretary Kathleen Sebelius. “Being sick will no longer keep you, your family, or your employees from being able to get affordable health coverage.”

Under these reforms, all individuals and employers have the right to purchase health insurance coverage regardless of health status. In addition, insurers are prevented from charging discriminatory rates to individuals and small employers based on factors such as health status or gender, and young adults have additional affordable coverage options under catastrophic plans.

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2/20/2013:

Health Care Law Allows Consumers to Find and Compare OptionsStarting in 2014 Department of Health and Human Services (HHS) Secretary Kathleen Sebelius today announced a final rule that will make purchasing health coverage easier for consumers. The policies outlined today will give consumers a consistent way to compare and enroll in

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CMS News Updates

health coverage in the individual and small group markets, while giving states and insurers more flexibility and freedom to implement the Affordable Care Act. “The Affordable Care Act helps people get the health insurance they need,” said Secretary Sebelius. “People all across the country will soon find it easier to compare and enroll in health plans with better coverage, greater quality and new benefits.”

Today’s rule outlines health insurance issuer standards for a core package of benefits, called essential health benefits, that health insurance issuers must cover both inside and outside the Health Insurance Marketplace. Through its standards for essential health benefits, the final rule released today also expands coverage of mental health and substance use disorder services, including behavioral health treatment, for millions of Americans.

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2/15/2013:

Updates to 2014 Medicare Health and Drug Plans Proposed Beneficiaries will get greater protections, value, and care in the Medicare services they receive through proposed policies released today by the Centers for Medicare & Medicaid Services (CMS). Today’s 2014 Advance Notice and draft Call Letter takes important steps to improve payment accuracy for Medicare Advantage (Part C) and in Medicare prescription drug (Part D) plans for 2014, without shifting costs to beneficiaries. Since the Affordable Care Act was passed in 2010, Medicare Advantage premiums have fallen by 10 percent and enrollment is expected to increase by an estimated 28 percent through this year. In addition, costs of the defined standard Part D plan will be lower in 2014 than they are in 2013. The standard Part D deductible will be $310, down from

$325 in 2013, and cost-sharing amounts will also be lower.

CMS also announced today a proposed rule implementing the Affordable Care Act’s medical loss ratio (MLR) requirements for Medicare Advantage and prescription drug (Part C and Part D) plans that promote greater accountability and transparency.

The proposed rule limits how much plans can spend on marketing, overhead, and profit. Similar MLR requirements are already benefiting consumers in the private health insurance market.

“The Affordable Care Act helps us strengthen Medicare Advantage and Part D,” said Jonathan Blum, CMS acting principal deputy administrator and director of the CMS’ Center for Medicare. “We are working to ensure that people with Medicare have affordable access to health and drug plans, while making certain that plans are providing value to Medicare and taxpayers.”

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2/15/2013 :

27 Recipients of New Strong Start for Mothers and Newborns Awards Department of Health and Human Services (HHS) Secretary Kathleen Sebelius today announced 27 recipients of new Strong Start for Mothers and Newborns awards, made possible by the Affordable Care Act. Up to $41.4 million can be used by states, caregivers and others to find new ways to prevent significant, long-term health problems for high-risk pregnant women and newborns enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).

“Thanks to the Affordable Care Act, we are helping communities across the country improve prenatal care for expectant mothers so that they can have a healthy delivery and a healthy baby,”

said HHS Secretary Kathleen Sebelius. “The Strong Start initiative will help find ways to reduce the rate of preterm births, which is a public health problem with significant long-term consequences for families and children.”

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2/4/2013:

CMS Announces New Initiative to Improve EndStage Renal Disease Care The Centers for Medicare & Medicaid Services (CMS) today announced a new initiative designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD). Through the Comprehensive ESRD Care initiative, CMS will partner with health care providers and suppliers to test the effectiveness of a new payment and service delivery model in providing these beneficiaries with patient-centered, highquality care.

“This initiative puts Medicare beneficiaries living with End-Stage Renal Disease at the center of their care,” said CMS Acting Administrator Marilyn Tavenner. “Through enhanced care coordination, these beneficiaries will have a more patient-centered care experience, which will ultimately, improve health outcomes.”

Those with ESRD have significant health care needs.

These beneficiaries constituted 1.3% of the Medicare population and accounted for an estimated 7.5% of Medicare spending, totaling over $20 billion in 2010.

These high costs are often the result of underlying disease complications and multiple co-morbidities, such as coronary artery disease and hypertension, which often lead to high rates of hospital admission and readmissions, as well as a mortality rate that is much higher than the general Medicare population.

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Resource: www.cms.gov

CMS News Updates

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DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

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Official CMS Information for Medicare Fee-For-Service Providers

Medicaid Program Integrity: Preventing Provider Medical Identity Theft

Common Provider Medical Identity Theft Schemes

Main Provider Risk Factors

ICN 908265 May 2012

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CMS News Updates: HHS Medicaid Program Integrity

Medicaid Program Integrity: Preventing Provider Medical Identity Theft

Mitigating Risk

Actively managing enrollment information with payers

Monitoring billing and compliance processes

Engaging patients in conversation about the risks of medical identity theft

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CMS News Updates: HHS Medicaid Program Integrity

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Medicaid Program Integrity: Preventing Provider Medical Identity Theft

Remediation for Victims

Report It Your Local Law Enforcement Your State Medicaid Agency

Federal Trade Commission (FTC) Identity Theft Hotline

U.S. Department of Health & Human Services (HHS),

Resources provider

compliance,

visit

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CMS News Updates: HHS Medicaid Program Integrity

Medicaid Program Integrity: Preventing Provider Medical Identity Theft

must

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Official CMS Information for Medicare Fee-For-Service Providers

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CMS News Updates: HHS Medicaid Program Integrity

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Sequestration 2% Cut for Medicare Physicians|Kathy Dyson February 28, 2013 Physicians have struggled to submit Medicare G-codes for electronic prescribing to avoid the 1.5% penalty from Medicare, worked on meaningful use to prevent future cuts, and embraced PQRS to stop value based penalties. In spite of all of that work, it appears that as of April 1, 2013, all physicians will be taking a 2% cut from CMS. Congress has not passed any legislation to resolve the automatic cuts to federal programs. Most programs will see this cut starting 3/1/2013.

Some special provisions in the way the sequestration legislation is written will postpone this cut for Medicare until 4/1/2013.

Physicians are not alone in having their funds reduced. All federal programs, including our hospitals and research centers, will see the same decrease in payments. The numbers being reported as the ‘reduced amount’ appear to range from $85 billion to an anticipated $100 billion over the next decade to Medicare. That amounts to estimates of $11 billion to possibly $16 billion a year. The impact to smaller practices that are already struggling under the stress of reduced payments and increased malpractice expenses could be the final push needed to close up shop.

Dr. Robert H. Marmer, a solo ophthalmologist in the Atlanta area for over 35 years shared his perspective on the change. He points out that, “It is almost impossible to grow a practice with this economic uncertainty. A solo practitioner cannot risk taking on new staff or doing marketing to increase patient loads. In fact, we are having to cut back on staff. Our hands are being tied on giving the time to our patients that they deserve. We have to see more and patients to try and stay where we were last year or the year before that.” He continues, “...this is one more cut to the small practice owner. There is only so much left to take before we can’t stay in business. We have more guidelines and requirements added than

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Sequestration

Dr. Robert H. Marmer, Solo Ophthalmologist

ever before in medicine and get less and less for the work.”

While there does not seem to be a lot of good news in the 2% cut, consider for a moment the alternatives that are out there. The proposal from President Obama was to take $400 Billion from health care cuts. The Republican party is asking for even more cuts in the health care budget, to stop the growth of the deficit. The medical director of a mid-size multispecialty physician group pointed out that while he was not happy about the cut, he did believe that the deficit had to be addressed and that it had to start somewhere.

An article published by Medical Economics points out that there will be significant impact to research grants. These same cuts will also impact the Centers for Disease Control and the National Institutes of Health (NIH). The actual impact to jobs is still unknown but estimates say as many as 400,00 jobs in healthcare could be eliminated in 2013 due to this cut. The impact of sequestration is far greater than just healthcare and the final impacts on our nation are still unknown.

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HIPAA “Mega-Rule” Increased Breach Reporting Puts Another Burden On Providers Jennifer Donovan | February 20, 2013 More work!??!! Well, yes, but only if your practice suffers a breach in patient protected health information (PHI). The new HIPAA “mega-­‐rule” insures increased chances that breaches will be reported.

Light bulb: Called the “mega-­‐rule” because it represents the largest set of modiHications to the HIPAA privacy and security rules to-­‐date.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 requires covered entities to report breaches of “unsecure” PHI to affected individuals, HHS, and (for breaches affecting 500 or more patients) the media. The original proposal granted the covered entity some discretion in determining whether the breach caused signiHicant harm, and if it did not the breach notiHication was not necessary. Now, the new “mega-­‐rule” signiHicantly increases regulators’ power to go after HIPAA violators and impose greater penalties.

The HITECH Act increased civil monetary penalties and established four tiers of increasing penalties according to the degree of the HIPAA violation:

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• •

Bottom tier – violations resulting from a provider “not knowing” and without investigation, would have gone unnoticed (no signiHicant harm) Second tier – violations due to “reasonable cause” as opposed to “willful neglect” Third and fourth tiers – violations as result of “willful neglect”

Penalties at the Hirst and second tiers aren’t mandatory but all tiers can equal Hines up to $1.5 million/year.

The Rule was published in the January 25th Federal Register and goes into effect March 26th. It plans the four penalty tiers while increasing the HHS’ OfHice for Civil Rights (OCR) power in some big ways.

To name a few: In cases of willful neglect, the OCR may continue investigations but has the discretion to go directly to the civil monetary process. So while the government

will still consider information resolution and voluntary compliance, they’re moving in the direction of imposing penalties.

OCR can look at additional factors when determining the amount of the penalty to impose -­‐ for example, reputational harm to a patient and past history of an entity’s noncompliance.

OCR has a wider civil jurisdiction over cases involving intentional wrongful disclosure. Normally, this would fall under criminal prosecution. Now, a violator is subject to criminal penalties, but may be subject to civil penalties if criminal is not imposed.

In short, the OCR has a lot of room to impose penalties.

Furthermore, the HITECH Act enables OCR to use the penalties it collects to fund the HIPAA audit process.

Coincidence?

The Rule didn’t state what kind of violation each civil monetary tier holds. For example, when you look at the third tier – its for violations that involve “willful neglect” but are corrected within thirty days. What constitutes a “correction”? Policy change? Termination of business relationship? As you can see, there are still questions to be asked…and answered.

Reduce your risk with these tips:

• • • • • • • •

Make sure you are complying with HIPAA’s privacy and security rules Pay attention to the protection of PHI on laptops and other mobile devices Don’t try to avoid scrutiny by ignoring reporting obligations Have a process for handling security breaches Use encryption and other tactics to avoid breaches Be careful about altering your analysis of harm after breach Be careful about what you say in public because it can come back to harm you Ensure your staff are trained in HIPAA

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Resources: HHS.gov/ocr, HHS.gov/ocr/hipaa, Decision Health HIPAA “Mega-Rule”

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Do You Have the Answers to Patients’ Most Popular Questions About Health Reform?

Jennifer Donovan | February 6, 2013 Cat got your tongue? Is it just me, or does it seem like patients expect everyone in the practice to know every little thing about each nuance of the health care industry? Sometimes I feel if a patient hears the words “healthcare”, “health reform” or “Obamacare” on the radio or any given talk show, it somehow gets flagged in their brain to ask about it at their appointment on Tuesday. As everyone who actually works within the community knows, it is virtually impossible to know everything about everything; there’s just too much out there. However, we can leverage ourselves while providing useful information to our curious patients, if we can anticipate the questions and offer short (but informative) answers.

Here are nine questions patients ask most regarding health reform:

Q: I don’t have insurance. Will I have to get it, and what happens if I don’t?

A: Most Americans will have to have insurance by

2014 or pay a penalty. For individuals, penalties start at $95, or up to 1% of income (whichever is greater).

They can rise to $695, or 2.5% of income, by 2016.

For families, the limit is $2,085 or 2.5% of the household income (again, whichever is greater).

Some people can be exempted through an individual

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Health Reform

mandate due to financial hardship or religious beliefs.

Q: I want health insurance, but can’t afford it.

What are my options?

A: Dependent upon your income, you may be eligible

for Medicaid, which will expand beginning 2014.

Low-income adults, including those without children, will be eligible, as long as their income does not exceed 133% of the federal poverty level.

Q: What if I make too much a month for Medicaid but still can’t afford coverage?

A: You might still be eligible for government subsidies (on a sliding scale) to help you pay for private insurance sold through state-based insurance marketplaces, called exchanges, which should begin operation in 2014

Q: How will the legislation affect the kind of insurance I can buy? Will it make it easier for me to get coverage, even if I have health problems?

A: For those with medical conditions, the law will

deficit by $143 billion over the same 10 years, per the Congressional Budget Office.

For those with high income, you will face higher taxes. Starting this year, individuals with earnings over $200,000 and married couples earning more than $250,000 will pay a Medicare payroll tax of 2.35% (up from 1.45%). Additionally, high-income taxpayers face a 3.8% ta on dividends and interest.

The law will also limit the amount of money one can put in a flexible spending account to pay medical expenses to $2,500

make it easier for you to get coverage; insurers will be barred from rejecting applicants based on health status.

In the interim, the law creates a temporary “highrisk” pool for people with medical problems who have been denied coverage by insurers and have been uninsured for at least six months.

Q: How does the legislation affect young adults?

A: If you’re younger than 26 years old, you’ll be able

to stay on your parent’s insurance coverage as long as you are not offered health coverage at work.

Additionally, people in their 20’s will be given the option to purchase “catastrophic” insurance that will have lower premiums.

Q: I own a small business. Do I have to buy insurance for my workers?

A: This depends on the size of your business.

Companies with less than 50 workers won’t face penalties if they don’t offer insurance. Companies can get tax credits to help buy insurance if they have less than 25 employees. Companies with more than 50 employees that don’t offer insurance will have to pay fees of up to $2,000 per full-time employee.

Q: How does this affect those over 65?

A: The law makes Medicare preventative services, such as screenings for colon, prostate and breast cancer, free to beneficiaries.

Q: How much is this going to cost? Will my taxes increase?

A: The total package is estimated to carry a price tag

of over $900 billion over 10 years. With higher taxes and fees and billions in Medicare payments cuts to providers, the package will narrow the federal budget

Fun Fact

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It ’s true door 2010, t ! In he gove rnment impose d a 10% tax to individu als – a ka “tannin g tax”.

Q: I already have insurance. What will happen to my premiums?

A: It’s hard to predict that at this time. Those who

are sick may experience lower premiums because insurers won’t be permitted to charge sick people more. Healthier people might pay more; older people could still be charged more than younger people, but no more than three times as much.

The biggest question is what happens to rising medical costs, which ultimately drive up premiums… we shall see.

Hope this helps answer some of those questions you and your patients may have been scratching your heads about.

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Resources: money.CNN.com, healthreform.gov, Kaiser Permanente

Health Reform

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The Sunshine Act Regulation Surprising Results Show Widespread Ignorance About the Regulation Jennifer Donovan | February 14, 2013 A recent survey of more than 1,000 physicians by the information technology company MMIS shows that much of the medical profession is unfamiliar with the ACA's sunshine provisions even though they have been in the news for several years. More than half said that they did not know that the law requires drug and device makers to report how much they are giving physicians in money, goods, and services, according to a recent MMIS press release.

That news is shocking to say the least, because 63% of those surveyed told MMIS that they are "deeply concerned" that these payments will be available in a public, searchable database. Twenty-one percent said that they will sever a relationship with a company that submits inaccurate information to CMS. To that point, the American Medical Association and other medical societies have worried that erroneous information about how much physicians receive from drug and device makers could hurt their reputations and careers.

Anticipating that problem, the ACA gives physicians and industry 45 days to review the data for mistakes and submit any corrections before CMS posts it online. Under the final regulations, if a physician and a manufacturer disagree about what changed hands, CMS will publish the manufacturer's data but flag it as disputed. The data can be revised on the CMS Web site, but only at 12-month intervals.

The skinny on the Sunshine Act regulations that affect you Payments to doctors from drug medical device companies will go public this fall. You may be thinking: “What’s the big deal? I’m not doing anything wrong…am I?”, or likely you’re thinking, “What does that mean exactly?” Whether you have or haven’t wondered how much the Sunshine Act will affect you and your practice, your curiosities should subside after reading this.

First, let’s start with a little background info: Section 6002 of the Affordable Care Act, the Sunshine Act has been a part of federal law since March 23, 2010. It took three years for CMS to formulate a final 285-page rule, effective 60 days from publication in the Federal Register, currently set for publication February 8, 2013.

So, what does this mean today: This final rule will 12

The Sunshine Act Regulation

require applicable manufacturers of drugs, devices, biologicals, or medical supplies covered by Medicare, Medicaid, or the Children's Health Insurance Program (CHIP) to report annually to the HHS secretary certain payments or transfers of value provided to physicians or teaching hospitals ("covered recipients") Now, you may be wondering what this will accomplish: “Disclosure brings about accountability, and accountability will strengthen the credibility of medical research, the marketing of ideas and, ultimately, the practice of medicine,” Sen. Chuck Grassley (R-Iowa), who co-authored the legislation, said in a statement. “The lack of transparency regarding Senator Chuck Grassley payments made by the pharmaceutical and medical device community to physicians has created a culture that this law should begin to change substantially.”

This “culture” has to do with the way pharmaceutical and device manufacturers went about their business.

The over-all effect of the Sunshine Act on physician practices is simple. Under Stark Law a physician may not refer patients for designated health services (DHSs) including prescription drugs and devices, where the physician or a close family member has an ownership, or financial relationship. Under the AntiKickback Statute, a physician may not prescribe drugs or devices if the physician has been paid in cash or in kind, if one purpose of the payment was to influence referrals.

The Sunshine Act will make it much more difficult to conceal such payments by an industry which has had a storied history of such payments. As officials with the Centers for Medicare & Medicaid Services (CMS) put it, “the Affordable Care Act (ACA) calls for disclosing ‘transfers of value’ by drug and device makers to spotlight possible conflicts of interest that may compromise education, research, and clinical decision making, all to the detriment of patient care.” Final regulations released February 1 spell out exactly what these companies must do.

Here’s a flyby of what CMS has laid out for a timetable in this exercise in transparency: 1. August 1, drug and device makers should begin compiling information on transfers of value to physicians during the last 5 months of 2013.

They must forward this data to CMS by March 31, 2014. The agency, in turn, will release the data in a searchable format on a public website

by September 30, 2014.

2. Manufacturers and group purchasing organizations will be responsible to report the data including physician ownership and investment interests to CMS by March 31, 2014. Though the “covered recipient” (see #3) they are not required to report. CMS suggests physicians may need to maintain their own records of what they receive or do not receive in case drug and device makers get it wrong. The agency estimates that it will take a medical practice employee about 5 hours a year to do the sunshine bookkeeping for a single physician, who will later need approx. 1 hour, on average, to review it.

serving as faculty or as a speaker for a medical education program, grants, any other nature of the payment, or other transfer of value.

5. One break for physicians is that payments to speakers at accredited continuing medical education (CME) events need not be reported, even if a drug or device company funds the CME activity. The payment is off the radar as long as the manufacturer does not select the speaker or pay him or her directly (that role belongs to the CME provider). As eloquently put by organized medicine, “...the world of CME is already well policed to root out conflicts of interest and that the regulations would scare off physicians and industry from accredited CME activities.” Well said.

3. Payments to a “covered recipient” means: • a physician, other than a physician who is an employee of an applicable manufacturer, or; • a teaching hospital Speaker at an accredited CME event

Covered Recipient: Teaching Hospital

4. Payment includes: consulting fees, compensation for services other than consulting, honoraria, gifts, entertainment, food, travel (including the specified destinations), education, research, charitable contribution, royalty or license, current or prospective ownership or investment interest, direct compensation for

6. There is a de minimis provision of $10 per gift, or annual aggregate of $100, which does not need to be reported (e.g. pens, coffee mugs, etc.).

Although, the ACA requires drug and device makers to report any transfer of value to a physician that is worth $10 or more (e.g. speaker's fee or honoraria, a research grant, or an in-kind item or service such as food, travel, lodging, and entertainment), transfers less than $10 — like a Starbucks — are not necessarily reportable unless they add up to more than $100 over the course of 1 year. Excluded altogether are product samples, educational materials meant for patients, and short-term loans of medical devices. Again, another reason to keep your own records and/or set standard policies with your reps in regards to what you do or don’t accept.

7. Discounts and rebates need not be reported.

8. Product samples are excluded from reporting.

The Sunshine Act Regulation

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9. Penalties for failure to report are $1,000 to $10,000 per payment, which is not reported with an annual limit of $150,000, unless the payment is “knowingly” omitted, in which case the penalty shall be at least $10,000 with an annual limit of $1,000,000.

Sunshine Act: Money transfers that must be reported • Consulting fees; • Compensation for non-consulting services, such as serving as faculty or speaker in a non-educational capacity or continuing education program regardless of whether it is certified or accredited; • Honoraria; • Gifts; In additional efforts to prevent any temptations of pass-offs, drug and device makers also must reveal whether a physician or his or her family members have an ownership stake in the company beyond publicly traded stock.

In general, and in closing, it may look like the fine print promises to make the lives of many physicians a little more complicated, right? Well, maybe at first. If you’re worried that the government will now have even more information on you that before wouldn’t have worried you, as long as you are not engaging in criminal activity, it shouldn’t worry you now either.

“I think it’s unrealistic to believe that OIG staff will do nothing but query this database and build cases,” a CMS representative states, “I would expect the government to focus first on the drug companies and maybe on doctors receiving large sums.”

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• Entertainment; • Food and beverages; • Travel and lodging; • Education; • Research; • Charitable contributions; • Royalties, copyrights or patent licenses; • Current or prospective ownership or investment interest; • Grans; and • Monies for space rental or facility fees

Resources: mmis-inc.com , CMS.gov, OIG.gov, MGMA.com 14

The Sunshine Act Regulation

Affordable Care Act Changing the Design of Insurance Coverage | Janet Salyer | Feb 24, 2013

Effective January 1, 2014, the Patient Protection and Affordable Care Act (PPACA or just ACA) requires all Americans to have health insurance, either through their work or by purchasing an individual/ family policy. The plan designs for insurance policies must be updated for January 1, 2014, to include Essential Health Benefits (EHB’s), meet actuarial values (AV’s), and limit out of pocket cost sharing for individuals and families. These guidelines apply to policies for individuals and families, small groups and all government plans including Medicare, Medicaid, and Tri-care, CHIP and veterans’ healthcare.

On February 20, 2013, The Department of Health and Human Services (HHS) released the final rule for Essential Health Benefits (EHB’s) which must be covered by every plan effective January 1, 2014.

HHS states the purpose of the essential health benefits (EHB’s) as the following: 1. Help consumers compare & purchase health insurance 2. Promote consistency in plans 3. Protect consumers 4. Limit out of pocket expenses Essential Health Benefits (EHS) have been referred to as Minimum Essential Benefits (MEB).

ACA also states that EHB’s must include items and services in the following 10 categories: 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care EHB’s must be equal to benefits offered by a “typical employer plan.” HHS requires each state to establish a “benchmark” plan based on 2012 plan designs but updated to include all the EHB’s. Insurers may be innovative and offer a variety of plans, but the benchmark must be met. The selected benchmark plans for each state are already finalized for benefit year 2014. The summaries of benefits chosen by each state for the benchmarked plans are available at http://cciio.cms.gov/resources/data/ehb.html.

In addition to EHB’s, starting January 1, 2014, non-grandfathered health plans must meet Actuarial Values (Av’s), or metal levels: Bronze plans: 60%; Silver plans: 70%; Gold plans: 80%; and Platinum plans: 90%. A fifth plan design, Catastrophic-only plans, will be available to young adults and for people for whom coverage would otherwise be unaffordable. These standardized plans will make it easier for consumers to compare their options and find the right plan.

These plans designs must be available in the private market and the exchanges.

A final protection for consumers, starting in 2014, is an annual limit on out-of-pocket cost sharing for individuals and families. This guideline is expected to follow the high deductible plan guidelines for out of pocket maximums. While not yet set for 2014, the comparable limit this year is $6,250 for self-only coverage. The purpose for this rule is to ensure that individuals and families with health insurance don’t need to file bankruptcy.

Market analysts believe that adding these three criteria to health insurance policies will sharply increase the cost of health insurance. The ten categories of EHB’s go beyond the average major medical policies purchased by consumers today.

It is believed that the hardest hit by these increases will be the young, healthy consumers.

As ACA final rules are being released frequently, it’s more important now than ever to “Stay Informed on Reform.”

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Affordable Care Act

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Know Your Contracts Review Your Contracts to Keep Your Practice’s Health Intact| Jennifer Donovan | February 18, 2013 There are a myriad of reasons to

know what your contracts state. I can’t tell you how many times I have to refer to a physician’s contract before I can move forward with an analysis report.

For purposes of this article, I want to hone in on one speciHic reason: to correctly bill patients who haven’t met deductibles. Check your contracts with insurance companies to know what you have to bill patients with high-­‐deductible health plans (HDHP), who haven’t met their deductibles yet.

Remember, with the start of the year came insurance resets; patients likely haven’t met their deductibles which means the doc may not see a cent from the insurance company because the practice is submitting the Hirst claim. Additionally, with the surge in HDHPs and health spending accounts (HSA) (13.5million in 2012 from 11.4 million in 2011) due to Health Care Reform, this is something you will see more and more.

Many contracts require the allowable amount to be billed because that’s how the insurance

company tracks how much of the deductible has been met, but if you can only collect the allowable from the payer, you have to know what that is.

The trick comes in when multiple tiers come in to play. As you may Hind, contracted rates have become easier to obtain from some companies than others, but that is the root of how you will be able to Higure out what the patient owes before they leave your practice. (Did you know when a patient leaves your practice, the chances of paying their bill drops an astonishing 70%?

Plus, you incur postage cost!)

Getting the rates ahead of time trumps trying to obtain the information at the time of service.

Remember, more often than not patients want to get in, get out, get back to work/school/playing hookey…once they see the doc, they’re out. Even if you’re super computer savvy and the payer has a website, logging in and Hinding the info you need is much more troublesome and counter-­‐ productive than if you had the rates loaded into your practice management system.

Knowing your rates also gives you the leverage to determine whether you are being reimbursed correctly.

Now you may be thinking, “BUT some contracts require that we wait for the EOB before billing the patient”…and/or, “the EOB tells me what to collect”. Simply put, the game is changing and ask yourself, “Will the health of your practice improve or not if we put ourselves in a position to refund money as opposed to chasing it?” You may even want to think about a very prominent organization that utilized the “pay and chase” model… not a thorn in your side. IF you do Hind you have collected the deductible that the patient had paid part or all of, commit to returning overpayments promptly.

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Resources: Practice Management Resources Group, CMS, MGMA.com

Tips for Smoother Billing • Inform patients of practice policies for payment. Have the conversation before providing services. Then, get the info regarding how much of the deductible the patient has met and have the discussion with them when they arrive so they aren’t surprised.

• Consider dropping contracts with payers that won’t provide rate info. If you can’t get the contract rates, write a letter to the company and copy the state insurance commissioner stating that by not providing the rates, the payer is violating the contract. If this doesn’t get them to produce the rates, considering dropping the contract might be the next best option for plans that don’t have a large number of your patients.

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Know Your Contracts

Electronic Health Records The Good, the Bad, and the Ugly | Suzanne M Schlernitzauer | February 28, 2013 The buzz in the industry these days seems to be on EHRs. Some practices that have electronic systems love them, others that have them don’t. A recent report published in Medline Plus stated that even with the $44,000 incentive bonus from the U.S. government, only one in six doctors had adopted EHRs to the level required for the payment.

There have been numerous articles written on this subject of late, from several different perspectives – many sides of that same proverbial coin. The whole premise of “electronic” management of patients’ clinical information seemed very promising – and it can be. But it needs to be done carefully and correctly, starting with purchasing the correct system for your office.

There are many benefits to the use of EHRs – this is the Good The EHR is a great tool to help practitioners provide higher quality of care for their patients.

And this is possible, providing the system is set up and used properly. The shortcuts you take on the front end stand to become a headache for you later, but we’ll get into that in the Bad part.

EHRs also make for ease of record retention, insuring appropriate E/M level compliance, reducing the risk of misfiling or losing documents (oh, did I mention that you need a good back-up system and a recovery plan?). Many of the EHR systems also allow for multiple, concurrent users.

Further, they aid in HIPAA compliance, as long as secure passwords are used and care is taken to log off of workstations when they are not in use. EHRs also have the potential to save money on staffing, storage space and document destruction costs.

Some of the things that the EHR will not help – the Bad

prior visits that are not pertinent to the current encounter.

Unless proper training is carried out up front and the system implementation is done properly, you stand to have issues later on when using the system. Predefined templates, while they ease the data entry part of the process, may have a tendency to make practitioners lazy. You run the risk of checking an incorrect box, using an incorrect template, or falsely taking credit for a higher level visit than was actually carried out.

While not inappropriate or necessarily “ugly” many technologically challenged or extremely busy practitioners have initiated the use of scribes – someone tasked with completing the EHR and documenting the outcome of the examination in the physicians’ stead. The practitioner is still responsible for reviewing the clinical documentation and signing off that it is correct. Failure to do so voids the documentation – like the examination or visit was not done at all.

There is the auto-populate function - answers to the patient profile, Review of Systems or exam criteria all default to “Negative” or “Normal”. The practitioner is then tasked with changing and explaining anything found to be “Positive” or irregular.

There is great potential for disparity in the documentation that can cause a quality of care issue – or when audited, would cause your clinical documentation to be called into question, thus creating an ancillary liability issue.

The flip side to all of the benefits – this is the Ugly Some practitioners are looking at the EHR as a way to “game” the system and increase or maximize reimbursements inappropriately.

Cloning has become a word that is now often associated with medical records. It has become a major concern for the Department of Health & Human Services and the Department of Justice that will cause a whole new onslaught of audits. Many EHR systems allow you to cut and paste from one patient encounter to another – hence, the cloning of patient records. It may also allow for carry forward of diagnoses from

To sum it all up The EHR should be looked upon as a great tool to improve the care you give. But remember the old GIGO philosophy – garbage in, garbage out. Don’t make your new system obsolete and useless before it has had time to prove itself. Do it right the first time and it may just serve your practice well.

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About the Author: Suzanne M. Schlernitzauer is the President of Integrated Medical Audit Specialists, Inc. (IMAS), a fullservice medical audit and consulting firm in Miami, FL. IMAS serves insurance and reinsurance carriers, TPAs, self-funded employers, hospitals, physician practices and the legal profession.

Schlernitzauer has over 40 years’ experience in the health insurance industry and is presently President of the Florida Medical Auditors Association (FMAA).

Electronic Health Records

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MMI Updates Exciting New Member Perks, CEU Courses, & ICD-10-CM Program We hope you all are having a positive and productive start to 2013, just like we are at the Medical Management Institute! We have brought on some great new instructors, launched a brand new website, introduced an amazing new membership perk, and have created impressive educational CEU courses and certification programs. We have included as much information as possible on each new item below, however please feel free to contact us if you have any further questions.

bundle package if you are renewing your RMC, RMM, and/or RMA. Check it out on our website at http://mmi-classes.com/collections/limited-timeoffers/products/anatomy-terminology-inpreparation-for-the-icd-10-transition.

New Member Perk: Dyson’s Digest So you might be wondering why you have been recently receiving an email twice a week with interesting articles, news on our courses, and general coding updates...this is a new perk to our MMI/ARHCP members! Ms. Kathy Dyson, the new Learning Director for MMI, has been putting these together twice a week through a brand new subscription called “Dyson’s Digest.” The information in these articles are also updated twice a week on our blog at http://mmi-classes.com/blogs/ dysons-digest, so we definitely suggest that you bookmark this link for future reference. And please leave your comments/questions/insights about the articles at the end of each one- we are very interested to hear what you think!

Brand New CEU Courses

The highly anticipated 2013 Spring Quarter Classes are now available at pre-sale price ($200 discount) until March 20, 2013! Topics include: • • • • •

Security Risk Assessment PPACA PQRS is Here to Stay Understand the OIG Compliance Requirements ICD-10-CM Overview & Implementation Planning

These are worth a total of 12 CEUs and will be prerecorded videos with exciting visuals and a powerpoint presentation to follow. Check it out by visiting http://mmi-classes.com/collections/ceuoptions/products/sq.

ICD-10-CM Certification Program

Anatomy & Terminology is a brand new online, interactive course designed for those who are new to the medical coding field, as well as those preparing to transition for ICD-10-CM. This course is worth 12 CEUs and is on a brand new learning system that caters to you the student, offering fun and interactive learning tools such as electronic flash cards, practice quizzes, and supporting PDF documents. You can purchase this on its own, or as a 18

MMI Updates

While we are all very excited about the updates and changes going on at MMI, this would have to be the most exciting of them all! We will soon be launching an online, customizable ICD-10-CM Certification Program! We have updated the program, so please check out the changes on the guide to the right. We will keep you posted on the pricing, projected launch date, and more on our blog and via email.

Contact Us! Any questions/comments/concerns? Please don’t hesitate to contact us: email: info@mmiclasses.com, phone: 866-892-2765

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MMI Updates

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Provider

Clinical Staff

Need to be Licensed

ICD-10 Documentation Requirements

ICD-10 Documentation Requirements

ICD-10 for QHCP

Biller [Pre-Requisite]

Billing for ICD-10

Advanced Anatomy & Physiology

Registered Medical Biller

Coder

Specialty Coding for ICD-10

ICD-10 for Office Staff

Certification Exam

Certification Exam

Basic Coding for ICD-10

Advanced Anatomy & Physiology

ICD-10 Documentation Requirements

ICD-10 Implementation Planning

Specialty Coding for ICD-10

Office Readiness for ICD-10

ICD-10 for Office Managers

Assessment of ICD-10 Prerequisites

ICD-10 Documentation Requirements

ICD-10 Implementation Planning

CERTIFIED

Manager

Your Guide to Becoming ICD-10-CM Certified

THE MONTHLY NEWSLETTER FOR THE INFORMED HEALTH CARE PROFESSIONAL

Medical Business Journal March 2013

MBJ

ISSUE 2 VOL. 4

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