Viewpoint Volume 4 Issue 3 Autumnal Equinox 2018 by VerdenGroup

your partners inpractice

WELCOME VIEWPOINTISTHEVERDENGROUP'SQUARTERLY MAGAZINEPROVIDINGOURPERSPECTIVES ONTHEBUSINESSOFHEALTHCARE ABOUTVIEWPOINT

ABOUTTHEVERDENGROUP

ViewPoint is a digital publication that looks at the business of healthcare from the perspective of The Verden Group's consulting professionals and other colleagues working in the field.

The Verden Group is an innovative consulting firm focused on educating and empowering medical practices to navigate through the increasingly complex business of healthcare.

Subscribe to ViewPoint to stay on top of all our news and views on the business of health care.

We deliver expert consulting services and advice and with individuals and groups of any size, from start-ups to super groups. From credentialing to contract negotiations and management, marketing to social management, PCMH transitions and strategic retreats ? we are your Partner In Practice. To learn more about our services, visit www.theverdengroup.com

Read past issues of the magazine and additional content at: verdenviewpoint.com

INTHISISSUE TELEMEDICINE

Gettingtotheheart of thematter

08 12

SOLVINGPRACTICEPROBLEMSUSING A3METHODOLOGY

Furtheringour Dynamic Work Design series, we examine how the A3 method can be applied to root cause analysis.

How do you effectively review merchant service agreements?We show you what to look for.

understandingvirtual careand remotemonitoringcodes

top7payers' pol icy changes for August 2018

The latest Payer policy changesfrom our expertsat The Policy Authority.

Will CMS fund payment of the new CPT codesfor virtual care?We look at what'snext.

WHATYOUNEEDTOKNOW about merchant services

IMPLICATIONSOF(NOT) BILLINGFORTELEMEDICINE

HowtomanageEMPLOYEE MENTALHEALTH Don't dodge the issue. We show you how to support your staff when mental health issuesarise.

Telehealth bringssavingsand enhanced patient outcomesbut be wary of fraud and abuse.

INTHISISSUE HR'srol einempl oyeewel l ness

needtoknow: credit cardprocessing

cl inical researchINyour practice

Interested in participating in clinical research? It'smore practical and profitable than you think.

CMS?Eval uation &Management Code changes: impact onPediatrics

The Trump Administration continuesto wage war on the ACA. Here'sthe latest.

Paul Vanchiere breaksdown how the proposed changesto E & M codesmay impact pediatrics.

MAkINGyour practice websitework for you

thel ikely impacts of texasvS. US

Behavioral HealthResources for TheModernAge Project Teach offersresourcesand helpsNY providers learn how to deliver better mental health care to kids.

Thel atest MEDICALHOME news&updates Read highlightsfrom the 2018 NCQA Congress& the Annual Conference of the FCAAP.

Your website should be a virtual extension of your physical practice... isit?If not, read on to get it there.

THISISSUE'SCONTRIBUTORS STAFF Editor-in-Chief Susanne Madden

PAULVANCHIERE, MBA Paul founded and runs Pediatric Management Institute and provides pediatric practice management expertise to our clients. With over 15 years of healthcare management and finance experience, Paul brings a wealth of knowledge to every project.

Managing Editor Nicole Caldwell

COLLEENLAURIA Cover Design Scott Hodgson Layout & Design Heidi Hallett Web Master Joe Madden

Produced by The Verden Group, ViewPoint is available by free subscription and distributed seasonally. Print copies are available by request. Please contact us for pricing.

contact The Verden Group 48 Burd Street Suite 104 Nyack, NY 10960 877-884-7770 inquiry@theverdengroup.com www.VerdenViewPoint.com

Colleen Lauria is President of Ginger HR Consulting, a proud Board member of NAMI NYC, the largest chapter of the National Alliance on Mental Illness (www.naminycmetro.org), and a writer. She is based in NYC. Find out more about Ginger HR at www.gingerhr.com.

Jamesestes James Estes is the President of Payment Pros, an agency specializing in a personal, custom approach to merchant services that benefits your practice and your patients.

JULIEWOOD,MSc, CCE A highly motivated consulting and research professional, Julie?s experience ranges from contract negotiations, health systems integration and new business development, to medical practice set up and operations management.

TIFFANYLAURIA, LPN Tiffany Lauria is Verden's team Project Coordinator, Researcher, Practice Consultant and ?just get-it-done?go-to person. With a background in nursing and Clinical Research Coordination and Management, Tiffany is well versed in the mechanics of clinical practices and effective work practices across healthcare.

Ariel l eMil iambro, Esq. &JohnMorrone, Esq. Arielle Miliambro, Esq. & John Morrone, Esq. of Frier & Levitt, Attorneys at Law deliver a legal perspective with a focus on transactional and regulatory law.

LETTERFROMthepubl isher

The autumnal equinox - a time for saying goodbye to the summer and preparing for the long winter ahead . . . Personally I find autumn to be one of the most productive times of the year. It may be driven by a last chance to achieve the rest of the year 's goal before we cycle into another, or perhaps it is that the cooler wind brings a renewed focus that spurs us on. Whatever the reason, it is one of my favorite seasons. This issue, we undertook to pull together some highly topical issues like the continued dissembling of the ACA and new virtual codes proposed for Medicare payment along with looking at some risks inherent in telemedicine programs. We also further our dynamic work design initiative by examining process improvement through the use of the A3 methodology, which examines root causes in order to resolve practice challenges and improve processes comprehensively. We turned an eye to the workplace: Colleen Lauria tells us what we need to know about managing mental health on the job, and Tiffany takes us through the process of adding clinical research into private practice (it's not as daunting as you might think). Julie discusses an innovative program in NY - ProjectTEACH - that provides assistance and support of physicians in managing mental health and behavioral issues; and we included a couple of operational articles on how to improve your online brand by making your website work for you, along with a piece by James Estes of PaymentPros regarding what to look for in merchant services. Paul Vanchiere takes us deep into the potential ramifications of how changes to the value of evaluation and management codes (currently proposed by Medicare) would affect Pediatrics, and what to do about it. And Amanda Ciadella, on the Patient Centered Solutions side of our house, shares some insights gleaned at NCQA's Congress and FCAAP's annual conference. She not only attended and reported from the NCQA Congress, she was this year 's honoree for the NCQA CCE Quality Award! We are so proud of her achievements, and all the great work she does on behalf of our clients. . . We hope you enjoy this issue, and I look forward to seeing some of you at the health care conferences later this season!

Susannemadden 7

01 PROCESSIMPROVEMENT: SOLVINGPRACTICEPROBLEMSusing A3METHODOLOGY Susanne Madden, MBA, CCE Founder & CEO, The Verden Group

PRACTICEMANAGEMENT As a follow up to my ?Introduction to Dynamic Work Design? article in the Spring 2018 issue , let?s discuss how you can go about appropriately assessing a problem and getting to the root cause of it before you begin to try to improve it.

on an individual problem rather than trying to lump a bunch of issues together. Focusing on one issue will make it easier to hone in on a root cause for remediation. Solving a larger problem by breaking it down into its smaller parts is an effective way to solve problems permanently.

There are many process improvement tools available and choosing the ?right?one can be a difficult task, particularly when an issue, and its root cause, is poorly defined. We?ve seen countless hours fruitlessly spent by teams attempting to improve the wrong thing. Therefore, it is important to gain a more complete understanding of what is causing inefficiencies in your process before launching into any improvement initiative.

Doyour research You will want to understand enough background information in order to comprehend the extent and importance of the problem. At a minimum, learn about the following: -

One of my favorite approaches to root cause analysis, and subsequent improvement of it, is the ?A3?methodology. Now A3 may be an 11 X 17 paper size in Europe, but in Lean terminology it is much more than that. Typically we use A3 as a way to visualize that which is not readily apparent, and as a means to develop an improvement process to remedy it.

What?ssogreat about theA3?

Once you?ve got a handle on the nature and extent of the issue, and what is causing the issue to be a problem at this particular moment (is it a new problem? Or an old problem that has been acute for particular new reasons?) then you can define your problem statement.

It walks you through a process designed to reduce bias and allow for insight through observation and suspended judgment. Succinctly put, it steps you through the following process in order to truly get to the heart of any issue: -

How was the problem identified? Why is the problem important now (and not before now)? What is the impact of the problem today and what will it be tomorrow? Which stakeholders (staff, departments, etc.) are involved? Is it important to the organization?s goals, mission, and strategy to solve this problem?

TheProbl emStatement

Help to identify the problem or need Allow for definition of the current ?condition?or process Guide assessment of the root cause of that condition Target the condition and allows measures to be deployed to reach it Encourage implementation of a plan to fix it

A well constructed problem statement might read like this: -

I cannot underscore enough the importance of spending the time needed to properly define the problem. Your ?problem statement?determines your area of focus and sets the course of your actions. Here?s how to make sure that you get this right:

Make sure your problem statement is about an actual observable condition, and not about a perceived cause or solution, or what you think it might be.

Patients?insurance information is not getting input to the patient billing record every time a new patient is registered (The issue is defined) The problem has become more frequent in the last 6 months or so. (The time line is identified) The omissions seem to happen randomly. Some data is complete, other times the data is missing altogether. (The context is provided) This has resulted in billers having to call patients, claims being delayed going out for payment by the insurers, and is adding at least 30 to 40 minutes in follow up work with each biller per week. (The impact is quantified)

Now, you may be tempted at this point to jump to conclusions about what is causing the problem. But not so fast?

Always focus on the problem, not what you think the solution ought to be. The simplest way to do this is to focus

Current Condition

the way to the root of the issue. We aren?t asking ?why?5 times about the same question though; each 'why' question is dependent upon the answer to the previous question.

We need to define the current condition, and this requires you to go take a look at the problem. Go observe it in action and see w h at is act u ally h appen in g. Map it out ? even if that map is only the briefest sketch on the back of an envelope. Doing so will give you an in-depth and detailed understanding of the current process as it is actually performed, not how it should be done, or how someone says it is done.

Here?s an example: Our receptionist, Daisy Mae, did not record the patient?s insurance information at check in, again. She really doesn?t understand how important it is to get that information before the patient is seen by the doctor.

Having someone describe how the process generally works or how it is supposed to work is not all that useful; it is the actual application of the process that reveals what deviations occur from the optimal process application that typically shows where the problems lie. The usefulness of direct observation creates your objectivity and renders it devoid of emotion or assumption.

Question 1: Why didn?t you (Daisy Mae) collect that information? Answer: I didn?t have enough time. Question 2: Why did you not have enough time? Answer: The nurse was calling the patient to the back before I was finished gathering the information. Question 3: Why was the nurse calling the patient so quickly? Answer: He wasn?t, but I was juggling three phone calls and registering another patient so it was taking some time. Question 4: Why were you juggling so much at the same time Answer: It was Monday, we are always really busy on Mondays and I am the only one working the front desk. Question 5: Why are you the only one working the front desk on a busy Monday? Answer: ?!

While you may think that directly observing a process is enough to understand, take the time to draw it out, for three reasons: 1. 2.

It will force you to organize the process steps into how it is actually being done, Any diagram quickly and effectively communicates the core issues to others. We are visual beings, and can much more readily absorb information when presented graphically, By diagramming the system, problem-solving efforts are focused on the system rather than the people.

From this process, we switch from the assumption that Daisy Mae does not realize the importance of the task to a much more comprehensive understanding that the issue is really that the front desk is under-staffed, at least on Mondays.

All of this effort results in a much more objective approach and removes tendencies to blame individuals for systemic or process failures.

Jumping to solutions before going through that process may have resulted in spending time and effort in training Daisy Mae to better understand the importance of how missing billing information can impact operations all the way down the line to the bottom line, when what was really need was to determine better coverage for busy patient times during the week. At the most, jumping to solutions would have resulted in mildly alleviating a symptom, but would not have solved the problem.

Root CauseAnalysis One of my favorite methods for defining any root cause is known as the ?5 Whys.? This method can be irritating because it is probing and repetitive, but it uncovers the root of any issue by peeling back, layer by layer, the ?why? of the issue. By asking ?Why?? five times, we can get all

Target Condition The ?target condition' is the ideal state that you are looking to achieve. Determining solutions to specific problems is one thing; designing a better process and outcome is entirely another. We want to not only alleviate the current problem but also use the good work we?ve done to determine if there is a better way to work the process in the future.

Thisiswhat anA3templ atel ooks l ikeandhereiswhereyoucandownl oadanA3templ ate https://citoolkit.com/templates/a3-template/

For example, we could hire more staff to help Daisy Mae at the front desk on Mondays. This helps solve the problem because Daisy Mae now has someone to answer the phones while she collects insurance data during the check in process. But is that really the best way to collect that data in the first place? When we develop a Target Condition, we are seeking to find a better, more efficient and more effective way to carry out a process. The ideal process should be free from inefficiencies. Applying this to our insurance registration example, we can develop a target condition that might look like this: -

Insurance data should be collected and entered into the system by the scheduling team when the patient first schedules their appointment.

Rather than wasting time, energy, and resources in training Daisy Mae (the only front desk resource) to do what she does not have time to do, or adding resources to help reduce the issue by using more people to address the volume of the problem, it is possible to determine that the process should not sit with the front desk resources in the first place, but is better handled earlier in the patient intake process to the benefit of all.

02 understandingvirtual care andremotemonitoringcodes Julie Wood, MSc, CCE Co-Founder, PCS

The American Medical Association (AMA) released its 2019 Current Procedural Terminology (CPT) code set and included sever al n ew codes. The AMA is urging the CMS to adopt the new codes and designate the related services for payment under federal health programs in 2019. The new codes are effective as of Jan. 1, 2019. Currently, there are ?telehealth?codes paid under Medicare: the term ?telehealth services? refers to a specific set of services practitioners normally furnish in-person, but for which CM S w ill m ake paym en t ? when they are instead furnished using interactive, real-time telecommunication technology.? The Social Security Act governs which telehealth services are and are not covered under Medicare.

VIRTUAL/ remotemonitoringcodes Generally, there are five statutory conditions r equ ir ed f or M edicar e cover age of telehealth services: 1. 2. 3.

The beneficiary is in a qualifying rural area; The beneficiary is located at one of eight qualifying originating sites; Services are provided by one of 10 distant site practitioners eligible to furnish and receive Medicare payment for telehealth services; The beneficiary and distant site practitioner communicate via an interactive audio and video telecommunications system permitting real-time communication between them; and The Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCs) code for the service itself is named on the list of covered Medicare telehealth services.

So long as the distant site practitioner complies with each of the above requirements, the telehealth service furnished via a telecommunication system will substitute for an in-person encounter? and it should meet the r equ ir em en t s f or M edicar e cover age so long as other standard coverage provisions are met.

Expansionof Tel ehealthCoverage The new codes allow for an expansion of Medicare?s current telehealth coverage, if adopted. HCPCS code GVCI1: Br ief Com m u n icat ion Tech n ology-Based Ser vice -

If adopted, providers could bill for a ?brief non-face-to-face check-in with a patient via communication technology, to assess whether the patient?s condition necessitates an office visit.?

HCPCS code GRAS1: Rem ot e Evalu at ion of Pr e-Recor ded Pat ien t In f or m at ion -

If adopted, providers could bill for a review of ?recorded video and/or images captured by a patient in order to evaluate the patient?s condition? to determine whether an office visit is necessary.

The traditional telehealth reimbursement codes are severely limited in terms of qualifying providers, site and location. CMS? proposal to cover asynchronous telemedicine and non-face-to-face services is a major step forward for the validity of store-and-forward medical care on the national level. These codes will not require the use of interactive AV technology, as CMS today only pays for asynchronous telehealth in limited demonstration technology. Asynchronous telemedicine is efficient and patient-centered, and aligns to how many service providers deliver services today. New codes for in t er n et con su lt in g between professionals could be extremely useful in the care coordination of complex patient cases. ?Interprofessional Internet Consultation,? not listed under telehealth services CPT Codes- 994X6 or 994X0, have been added to current codes 99446, 99447, 99448, and 94449. The new codes are specifically for non-verbal communication technology. -

If adopted, providers could bill for ?assessment and management services conducted through telephone, internet or electronic health record consultations furnished when a patient?s treating physician or other qualified healthcare professional requests the opinion and/or treatment advice of a consulting physician? with specific specialty expertise to assist with the diagnosis and/or management of the patient?s problem without the need for the patient?s face-to-face contact with the consulting physician.?

Codesfor NewRemotePatient Monitoring(RPM)

2. Addit ion al r eim bu r sem en t f or RPM set u p an d pat ien t edu cat ion .

Three new codes for RPM allow doctors to connect with patients at home and gather data for care management and coordination. These are not included in telehealth services as proposed, but in an entirely new and separately reimbursable service under Medicare.

CPT 99091 does not allow for additional reimbursement to providers for time spent setting up any RPM equipment or educating their patients on its use. The new proposed codes would offer additional reimbursement for on-boarding a new patient, setting up the RPM equipment, and educating patients on equipment.

The three new RPM codes were retitled ?Chronic Care Remote Patient Physiologic Monitoring?, aimed to better reflect how RPM services can be delivered to patients. The specific codes are CPT 990X0, CTP 990X1, and CPT 994X9.

3. New m edical st af f eligible f or r eim bu r sem en t . CPT 99091 expressly states RPM-delivering providers must be ?physicians and qualified health care professionals? leaving out key medical and clinical staff such as RNs, medical assistants, etc. This requirement means the physician or qualified health care professional had to perform the full 30 minutes per 30-day period to be eligible for reimbursement. Many providers could not justify spending that amount of time and resources for the $58.68 per month reimbursement rate from CMS. The new code allows RPM services to be performed by clinical staff, clearing a key hurdle for providers across the country. r to

Currently, Medicare for RPM had been allowed using CPT 99091. The new codes have a few key changes for reimbursement: 1. Less t r eat m en t t im e n eeded t o qu alif y f or r eim bu r sem en t . CPT code 99091 required at least 30 minutes per 30-day period to be eligible for reimbursement. The new code only requires 20 minutes per calendar month, making it easier to track and requiring 33% less time for eligibility.

NewCodes Th ese n ew codes ar e in t en ded as a f ollow -u p an d expan sion t o CM S?cu r r en t cover age of RPM code 99091: 1. CPT 990X0 Rem ot e m on it or in g of ph ysiologic par am et er (s) (e.g. w eigh t , blood pr essu r e, pu lse oxim et r y, r espir at or y f low r at e), in it ial; set -u p an d pat ien t edu cat ion of u se of equ ipm en t ; 2. CPT 990X1 Rem ot e m on it or in g of ph ysiologic par am et er (s) (e.g. w eigh t , blood, pu lse oxim et r y, r espir at or y f low r at e), in it ial; device(s) su pply w it h daily r ecor din g(s) or pr ogr am m ed aler t (s) t r an sm ission , each 30 days; an d 3. CPT 994X9 Rem ot e ph ysiologic m on it or in g t r eat m en t m an agem en t ser vices, 20 m in u t es or m or e of clin ical st af f / ph ysician / ot h er qu alif ied h ealt h car e pr of ession al t im e in a calen dar m on t h r equ ir in g in t er act ive com m u n icat ion w it h t h e pat ien t / car egiver du r in g t h e m on t h .

Note: CPT codes that contain an ?X?(e.g., 994X9) are placeholder codes that are intended, through the first three digits, to give readers an idea of the proposed placement in the code set of the potential code changes. These codes will not be used for claims reporting and will be removed and not retained when the final CPT Datafiles are distributed. To report the services for ?X?codes, be sure to refer to the actual codes as they appear in the CPT Datafiles publication.

03 IMPLICATIONSOF(NOT) BILLINGFORTELEMEDICINE John Morrone, Esq. & Arielle Miliambro, Esq. Frier & Levitt, Attorneysat Law

Telemedicine can be a means of providing high quality care in a way that increases access for patients and reach for providers while lowering cost for all parties involved. Although this seems like a winning proposition, telehealth is still in its infancy. Both regulators and payors acknowledge the potential cost savings and enhanced patient outcomes that may result from the expansion of telehealth; but they also acknowledge? and are attempting to control? an area that is ripe for fraud and abuse. As business models continue to develop in creative ways, providers must be wary of any arrangement that appears too good to be true.

TELEMEDICINE

Many models evolving in the telemedicine space are funded through marketing efforts on behalf of ancillary providers. While there are compliant marketing models to support and expand telemedicine offerings, the most common models emerging in the past several years are not. In these models, ancillary providers such as pharmacies and durable medical equipment companies are engaging marketers to shepherd patients to telemedicine providers, with the goal of receiving a prescription for medication or DME order as a result. The biggest source of concern in this format? The marketers are typically paying the telehealth companies for each patient they deliver, and the company in turn compensates the provider for his or her service in conducting the encounter. In short, the ancillary provider is reimbursing the physician.

impairing the legitimacy of any resulting ancillary order. In the model described above, these orders are being submitted to the ancillary providers, who subsequently bill insurers for the ancillary products. Insurers, with greater frequency, have turned to analyzing and comparing health insurance claims data with pharmacy benefits claims data. When an insurer identifies a claim for an ancillary service, but finds there is no corresponding claim for a physician visit to generate the applicable prescription, the payor will seek recoupment of the paid claim. In the context of Medicare beneficiaries, the risk is particularly high. We have seen many instances in which reimbursement for pharmaceutical or DME products is not only recouped, but the physician is investigated. In addition to board discipline, physicians are subject to audit and termination by payors as a result of failing to bill for telemedicine encounters. In certain circumstances, we have also seen physicians? ordering privileges and/or provider status terminated by

Setting aside the significant regulatory violations such a model can produce, the source of payment for a telehealth encounter can invalidate the bona fide relationship between the physician and patient, thereby

TELEMEDICINE

Participating in a cash-only arrangement does not remove the hurdles.

Medicare, citing to the noncompliance in the physician?s failure to bill for services to Medicare beneficiaries. Participating in a cash-only arrangement does not remove the hurdles established by state boards or insurers. For physicians aiming to expand their scope of services by participating in a telemedicine arrangement, an understanding of the impact the arrangement may have on the physician?s primary practice is critical. Many telemedicine companies do not accept Medicare beneficiaries, or only accept these patients on a cash basis, in an effort to circumvent applicable billing guidelines and limitations. However, physicians treating Medicare patients are required to bill for services provided to Medicare beneficiaries if services have been rendered, irrespective of whether such physicians have accepted Medicare assignment. Failure to do so can result in revocation of the practitioner ?s Medicare provider status. Despite accepting cash-only for the virtual encounter, the implications of an improper telemedicine encounter illustrate the failure of carve outs of federal reimbursement to protect against regulatory scrutiny. Telemedicine encounters must be conducted in conformity with applicable state law and payor requirements, in accordance with the applicable standard of care, and billed to the patient?s insurer. Telehealth encounters that are reimbursed by any party other than the patient and/or the patient?s insurer will result in an invalid physician-patient relationship, an illegitimate ancillary claim, and discipline for both the physician and the ancillary provider.

Frier Levitt is a national boutique healthcare law firm located in Pine Brook, New Jersey. Its 30 attorneys bring collective experience and backgrounds in pharmacy, hospital administration, professional licensing, Attorney General actions, clinical practice, and medical billing. They provide comprehensive legal services to healthcare providers, including physician groups, laboratories, surgery and imaging centers, Compounding and Specialty Pharmacies, Outsourcing Facilities, chemical manufacturers, repackagers, wholesalers, group purchasing organizations, buying groups, and other healthcare related businesses. Frier Levitt is uniquely positioned to serve as a creative and thoughtful guide to healthcare providers, offering a broad and deep understanding of federal and state healthcare laws and regulations and the industry as a whole. For additional information, visit: www.FrierLevitt.com.

04 WHATYOUNEEDTOKNOW about merchant services James Estes President, Payment Pros The term ?merchant services? might make you shrug, shriek or roll your eyes. Regardless of how you perceive it, merchant services? or credit card processing? has become a necessary staple for most medical practices today. Yet there is still a great deal of confusion as to exactly what fees your processor is currently charging you. There are certain fees that will increase your overall cost of credit card acceptance, and a set of questions you should include when reviewing a new merchant services provider. It?s wise to review merchant statements monthly, or at least quarterly. You should also know what your rates are today versus what they were when you signed the contract. Processors can increase rates up to twice a year, typically in April or October (or both), as long as they give you 30 to 60 days?notice. The notice will be on your statement and say something to the effect of ?Continuing your merchant account with us or use of your merchant account after thirty (30) days will signify your acceptance of the above terms.? This is a good time to consider switching providers. You may be able to opt-out of your contract during this period due to the modification of the original agreement terms.

Rates are not the be-all-end-all to your overall costs. Merchant accounts have myriad charges listed. Some can?t be avoided, and others are superfluous. If you see these fees, contact your agent or processor to ask how to get them removed or switch to another company. Here are some examples of avoidable fees. -

PCI non-compliance fee. This takes a little work on your end to get compliant, but don?t delay. It?s a costly monthly fee that can easily be removed if you take the proper steps.

Monthly PCI compliance. We still haven?t figured out why processors will charge a monthly PCI Compliance fee. Most processors will charge an annual fee, which is typically unavoidable. But the annual fee should encompass all PCI-related charges for the year as long as you maintain compliance.

Breach or data security fee. Most MedMal and BOP insurance policies give base coverage for a data breach, but we advise to review a cyber liability policy to better protect the practice. Don?t rely on a merchant services breach policy to protect the practice.

Daily versus monthly billing, settlement or clearing fee, network access fee. These are just junk fees.

American Express SHOULD be the same rate as the other card brands. AMEX?s new pricing structure (OptBlue) allows for the processor to set the AMEX Rate rather than the card brand. If yours is higher than your VISA/MC/Discover rate, then the processor is making more money on your AMEX transactions.

Visa or MasterCard interchange adjustment fee. Interchange fees are legitimate and set by the card brands; but if you see an ?adjustment fee,? that?s just a sneaky way to get more money.

Paper statement fee. Sometimes this will be listed as a customer service fee. You?ll typically have one or the other, but you shouldn?t see both.

Equipment fee. You hopefully aren?t leasing equipment, which is extremely costly and unnecessary. New equipment isn?t that expensive and should be a one-time cost.

merchant services There are many more fees in existence, and we are

seeing new and creatively worded ones crop up every

Rat e gu ar an t ees. Don?t fall for teaser rates that rise after a short window of time.

month.

Pr icin g gu ar an t ees. This includes the authorization fees per transaction, and any

Every processor or bank in the nation must comply by

other monthly fees outside of the rate they are

the rules set forth by the payment card industry.

offering.

Remember this when it?s time to make a change to your

merchant services provider! Data-security and

Set -u p or applicat ion f ees. There should be zero.

compliance requirements will be fairly uniform. The

factors that distinguish one processor from another will

M on t h ly m in im u m s. Again, these should not exist.

be its employees, the company?s transparency level, the

services it offers, and its access to technology.

Ven dor r epu t at ion . Do they have a reputable vendor to help you with PCI compliance? Can you do it online?

Finding a vendor who understands the needs and -

operations of a healthcare practice will offer a better

HIPAA pr ot ect ion . Do they know or at least understand what information is HIPAA

experience with that company than those who do not

Protected?

have this expertise. This includes the salespeople, -

customer service representatives, managers and

Cu st om er ser vice con t act . Most salespeople in merchant services either only work in sales (not

technical support teams.

service), or they will be gone within 18 months, Here are a few points to get answered, preferably in

and you will be left to rely on service

writing, when you are exploring merchant services

representatives whom you have never met or

companies:

heard of previously for help. -

Ref er en ces. Do they have any healthcare

Con t r act len gt h . A normal contract lasts for

references to provide that can vouch for their

three years, which is OK if they don?t have any

service?

ETFs. Be sure to ask if the contract will

automatically renew; and if so, what kind of

The ultimate goal of choosing a credit card processor is

notice you need to provide to opt-out of that

to be satisfied that they understand and meet your

renewal.

needs and do so at the right price. Think of the

Ear ly t er m in at ion f ee or pen alt y. Red flag! You

relationship as more of a partnership than a way to get

shouldn?t have to pay the processor to leave

the cheapest rate.

them. -

No, your rates and fees shouldn?t be exorbitant; but

Fu n din g t im e. It should be either next-day or

good, reliable service has value.

the following day, never longer. -

On lin e r epor t in g capabilit ies an d cost .

Do your research up-front so that you can be confident

Processors should provide this free of charge. -

you?re choosing a vendor who will serve as an integral

Fee debit sch edu le. You want monthly debits

part of your practice?s operations and help increase your

of your fees, not daily, and you shouldn?t be

revenue while keeping costs to a minimum.

surcharged for it.

w w w.Th ePolicyAu t h or it y.com 23

05 HowtomanageEMPLOYEE MENTALHEALTH Colleen Lauria, Ginger HR Consulting

WELLNESSATWORK More than half of all American physicians are experiencing substantial symptoms of burnout, according to the Nat ion al Academ y of M edicin e. Nurses, nurse practitioners, and physician assistants are not far behind. ?Excessive pressures and expectations at work, paired with seemingly unattainable goals for quality and productivity as well as societal loss of t r u st in ph ysician s, has led to a loss of meaning of work and of self,? writes Dr. Vinita Parkashi in an edit or ial in Th e Hill. When you consider the excessive work hours, personal challenges, stress, and inadequate informed consent so prevalent in the industry, it?s easy to see why health care providers are particularly susceptible to mental illness.

?1 in 5 adults will experience a diagnosable mental illness in any given year?- American Psychiatric Association

Managers in the United States are trained not to ask too many personal questions about employees: ?The less you know, the better,? is a common refrain. But this is very challenging to adhere to if you have an employee who is exhibiting signs of (or has disclosed he or she is) suffering from a mental illness. How can clinicians best support their employees and managers when this issue arises?

Talk t o you r m an ager s. Managers know your staff better than you do, and are likely engaging with them more often. Make sure they understand management best practices, your philosophy around dealing with mental illness, and the correct protocol if an employee is to disclose a suspected (or their own) issue. Through regular performance communication and employee meetings, your managers should be able to tell if something seems off.

Make no mistake? if you are a practice leader, you will very likely experience this situation. A full one in every five adults experiences a diagnosable mental illness every year, according to the Am er ican Psych iat r ic Associat ion.

Here are some things they (and you) should be on the lookout for:

Your Rol easaPracticeLeader

Mental illness is the cause of numerous problems in the workplace, from absenteeism and lost productivity to harassment and violence. We must all have heightened sensitivity and be accountable for the wellbeing of our colleagues as these incidences become increasingly common. But a manager ?s role should be more clearly defined than simply being vigilant. Here are some ways to prepare.

Newly onset punctuality or absenteeism problems A rapid decline in performance Emotional outbursts in the office Extreme changes in behavior or demeanor Withdrawal

Don?t be af r aid. If you suspect something is going on with an employee, it is your responsibility (or HR?s if you have a human resources team) to address it. With the ever-growing blurred lines between work and life, there is an increased prevalence of mental illness? and its potential, negative impact on your practice. You can?t you afford to bury your head in the sand. Employees with mental illness want to do a good job as much as anyone; providing them with the right support is part of the responsibility when we hire someone.

Pay at t en t ion . As a practice leader, you should generally be aware of how your staff is doing professionally and personally. Edu cat e you r st af f . Talk to your staff about work/life balance, stress management, and other behavioral health related topics like substance abuse. This can help avoid absenteeism, or worse. If you don?t have an employee assistance program in place, consider getting one.

En su r e f air t r eat m en t . Even managers and employees with the best intentions can treat someone differently without realizing it. We bring biases and fears into the workplace, and it?s nearly impossible to not be concerned. It is critical to ensure fair and equitable treatment of all employees regardless of disability, and mental illness qualifies under the ADA.

There are a lot of great resources available, including Th e Par t n er sh ip f or Wor k place M en t al Healt h and the Nat ion al Allian ce on M en t al Illn ess.

HRMATTERS Sh ow com passion . Almost 40 percent of Americans experience disorders related to mental health or substance abuse in their lifetimes, according to the Un it ed St at e Depar t m en t of Healt h an d Hu m an Ser vices. Odds are, each of us will know someone affected or be affected ourselves during our lifetimes. We can help remove the stigma by supporting our employees and their families through trying times.

Ar e you or som eon e you k n ow exper ien cin g m en t al illn ess? NAMI can help: their mission is to educate, advocate, listen, and lead.

Facing a mental illness is scary for everyone, from the afflicted individual to everyone in his or her community (including employers). With forethought, planning and care, we can make this experience less daunting for everyone involved.

The national helpline phone number is 1-800-950-NAM I (6264) You can find more information by visiting their website at w w w.n am i.or g

Colleen Lauria is a writer based in New York City, president of Ginger HR Consulting, and a proud Board member of NAMI NYC, the largest chapter of the National Alliance on Mental Illness. Find out more about Ginger HR at www.gingerhr.com.

06 conductingcl inical research INPRIVATEpractice Tiffany Lauria, LPN Researcher, Project Coordinator

Not so long ago, the phrase ?clinical research? conjured images of cold, sterile hospital rooms where clipboard-equipped doctors and nurses hovered over tube-laden patients. The medical field has thankfully evolved since then; and progressive, continued growth on the business side of medicine has turned clinical research into a highly accessible, profitable field for the private medical practice. Conducting research in the medical practice, however, is a big undertaking. There are regulatory and safety issues, staffing, space and logistical concerns, an increased workload, and strict timelines with little to no flexibility. There is also the matter of how your patients will view your offer of clinical research participation: Will they see you as progressive, able to offer options for their care? Or will they think they?re being used for damaging experiments or a big payout from the pharmaceutical companies? Creating a comprehensive patient-education program should be one of the first additions to your to-do list!

cl inical research Many practices have enjoyed great success from incorporating clinical research offerings into the practice, as daunting as it may seem to do so. Just as with any new business line, it is vital to do your homework and initiate the project step-by-step to ensure it is launched correctly and with full buy-in from all partners and staff.

Com m on Resear ch Ter m s Spon sor - an organization, company, or individual that initiates, manages and funds the trial.

There are various forms of research that can be conducted in a practice setting. This article will focus on implementing research sponsored by pharmaceutical and medical-device companies, but many of the same considerations apply to conducting behavioral or community impact studies and investigator protocols under NIH or other federally funded grant programs.

Identify Your Motivation

Con t r act Resear ch Or gan izat ion (CRO)sometimes called Clinical Research Organization; provides support to the trial sponsor in the form of management and oversight. May submit regulatory filings, recruit study sites, and monitor trial data collection among many other tasks.

When thinking of research in the medical practice, most often we think of the hundreds of community oncology practices nationwide that have crafted programs to offer the latest in research and treatment options for patients. Yet clinical trials are required in almost every specialty and treatment area to facilitate approval of new treatments and products. Even in primary care, the need for capable investigators in private practice is growing. An internal medicine practice may participate in clinical trials for a blood pressure medication or glucometer, or a pediatric practice may host trials of an investigational infant formula or antibiotic regimen for ear infections. In the business of healthcare, there is nothing wrong with thinking of the financial security of the practice. However, conducting clinical trials is a big investment in time; and without the complete buy-in of all owners and providers, it has the potential to be a failing venture. That is why it?s important to determine whether your providers have a keen interest in the science and research aspect, or solely the financial benefits. Here are some questions that may facilitate a conversation among board members and providers to uncover individual motivation and interest. -

Do you see a clinical need in our practice to offer research options for new treatments? If clinical trials are conducted, would you like to be involved as a principal or co-investigator? Would you be willing to spend time on the additional training needed to participate in conducting research? If there is no interest in being an investigator and the practice moves ahead with a decision to conduct research trials, can we expect full cooperation in identifying patients that may fit the trial?s criteria and in referring these patients to the research team?

Clin ical Resear ch Associat e (CRA)- sometimes called Clinical Trial Monitor; responsible for monitoring the trial activities and data collection at the study sites, among other tasks. Pr in cipal In vest igat or (PI)- the person responsible at the site for administering the study protocol, often a physician or other clinician, or an academic researcher depending on trial type, responsible for ensuring protocol and regulatory adherence, the validity of the site data and reporting adverse events. Co-In vest igat or - works along with the PI to support the conduct of the trial. Clin ical Resear ch Coor din at or (CRC)sometimes called Clinical Trial Coordinator, or Clinical Research Nurse if they hold a nursing license; works with the PI to administer the trial at the site, tasks may include ensuring all protocol procedures and documentation are complete, reconciling investigational product stock, preparing the study budget, and obtaining patient consent. In st it u t ion al Review Boar d (IRB)- reviews and approves all research involving human subjects to ensure that it is conducted in accordance with all federal, institutional, and ethical guidelines to protect the rights and welfare of human subjects.

CLINICALRESEARCH DetermineWhat Your PracticeHas toOffer

in your practice are aligned in their thinking about which clinical trials are a good fit and what the providers are comfortable with.

As an inexperienced research site, it will take time for the research departments at the pharmaceutical companies and contract research organizations (see box Common Research Terms) to become familiar with you and recommend your practice as a study site. With enough outreach, you will be offered participation in a trial, and successful administration of that trial should assure future trials participation.

A cardiac practice would not be a good fit for a trial testing a new gastrointestinal regimen; but the cardiac providers may be opposed to conducting hypertension studies that have a placebo cohort. Laying out a careful framework for your clinical research department will make the launch go smoother, and adjustments can be made as a team further down the line when there is experiential knowledge.

Knowing what your practice has to offer is key to drafting your outreach plan. This process starts with identifying the significant components of your study site. -

Staff andTraining While providers in general are very good at following good clinical practice guidelines, treatment regimens, and documenting everything that is required for billing purposes, providers and staff engaged in conducting research must be excellent at adhering to the study protocol and documentation. There is very little flexibility in research. The investigator would have previously conducted a thorough review of the protocol and study-visit requirements, and contractually agreed that he or she was comfortable conducting the study. Unless a study subject presents with a situation that would make it dangerous to perform study procedures or administer the study treatment, there would be no flexibility for the provider to not follow the protocol unless he or the patient decided to withdraw participation.

What is the patient population in your practice? Identify patient age ranges, gender mix, ethnicities and any other determinants that you are tracking in your practice or the community, such as illiteracy rates or prevalent languages. Will you be drawing trial participants from your practice only or the community? Identify frequently seen diagnoses and conditions, medical devices commonly used in the office or by patients in the home, and anything else that you feel your site can offer significant access to: infants needing to use formula, sleep-deprived teenagers, grandparents being caretakers, etc. Highlight unique aspects of your population. If including non-patient community members, you must gather information on the local population, as well. Detail the make-up of your research team: How many investigators and co-investigators will be involved in conducting actual study visits? How many other non-investigator providers will be referring patients to be trial participants? How many study coordinators or research nurses are available at the site?

Are all of your providers prepared for this shift in clinical care? Similarly, documentation in research is everything. Even something as small as a missing temperature recording can become a big issue for a trial. The providers and staff must have more than just a desire to participate in research? they must be truly conscientious and focused on the proper administration of the trial.

You will need to market your practice as a study site very capable of conducting clinical research studies, and one with enough of the targeted population to recruit from. Your clinical practice grew from a combination of word-of-mouth, marketing, promotion and good logistics (location, etc.), so keep in mind that marketing your new clinical research line of business is not an overt play for money, it?s a necessity, as it is in your regular practice.

At a minimum, all investigators and staff must complete human subject protections and good clinical practice training, which is offered through various organizations (and sometimes at no cost). However, an inexperienced research team may benefit from further training. A good place to start is on the websites for The Association of Clinical Research Professionals (ACRP) and The Society of Clinical Research Associates (SOCRA).

The other reason you will want to break down your capabilities is to ensure that all of the key decision-makers

Whenever possible, having someone with experience on your research team can be of great benefit. Be sure this is

Education

someone familiar with running protocols, conducting informed consents and assents, and dealing with the Clinical Research Associates (CRAs; see box Common Research Terms) who will review your study records with a fine-toothed comb. This experienced team member does not have to be an investigator or provider. Consider hiring an experienced clinical research coordinator or clinical research nurse to anchor the department while your experience grows.

Patient handouts and information on your practice website should simply and clearly review information such as ?What is Clinical Research?,? ?Why Are we Conducting Research?? and ?Is Participation Required?? Updates in your patient newsletter and signage at your front desk or patient board should reinforce the basics, but also list study opportunities in a way that does not promote the idea that the patient will absolutely benefit from study participation. Time. Even before offering participation in a specific trial to a patient, spend a few minutes with each of your patients at their next visit to let them know about your research program and that they may be offered participation in a trial at some point. One of the biggest components of having your patients participate in a clinical study is the amount of time that will be spent with that patient in study activities and education. Set aside some time before offering a trial to increase the familiarity of your patients with research on a whole for a more welcoming response.

Patient Education A carefully constructed patient education program can help your patients tune into the value of clinical research participation and the possible benefits to their health and the health of others. In a way, you will need to re-orient patients to your practice. They will be used to coming in, spending a few minutes with the provider, and then leaving with a treatment plan and follow-up appointment. In a practice that conducts research, that same patient may now be offered a choice to treat with an investigational product, or even a placebo, asked to read some information they may find confusing, sign consent forms, be given multiple follow-up appointments, and even receive payment!

IsResearchtheRight Fit? There are many other aspects to conducting research in your practice that will need to be considered before you make the commitment. For many practices the opportunity to offer alternative care, contribute to advancement, and supplement the practice?s bottom line with another line of business make this endeavor well worth it. Project start-up will require the most effort, but soon enough your independent medical practice can have a fine-tuned clinical research department.

Think ahead about what your patients will need to welcome this adjustment in their medical practice.

Training Have you educated your staff? From the receptionist to the physician, is the message the same? Have you given them the training needed to effectively convey this positive message to the patients? 30

Federal / PrivateGrants andInvestigator InitiatedResearch When conducting pharmaceutical or medical device sponsored research, the protocol provided to the practice has already met with regulatory approval. The investigator conducts a thorough review of the protocol and supporting documents and agrees to adhere to the protocol and study visit procedures and treatments. There are many opportunities for providers/investigators to conduct research on their own initiated protocols or to create a study in an area of interest that meets the needs of an advertised funding opportunity. This type of opportunity may require additional skills, such as grant, technical/scientific and protocol writing, data analysis and possible familiarity with the federal process depending on the grant source. There are millions of dollars of grants available through federal, state and private funding. Here are a just a few resources to start your search: Feder al The most comprehensive site for viewing opportunities from most of the federal programs, including the National Institutes of Health is: -

www.Grants.gov

There are also sites specific to particular needs: -

www.ruralhealthinfo.org/funding

St at e Many states and state departments of health may have funding opportunities right in your community. These may come from state or private resources. Examples: -

www.health.ny.gov/funding

https://kansashealth.org/grants

Pr ivat e an d M edical Societ y Numerous foundations and big businesses offer grant funding, and a search of your specialty?s medical association should turn up a number of opportunities: -

www.wkkf.org/grants

www.ama-assn.org/about/community-health-programs

www.aap.org/

07 TheImpact of CMS?Eval uation&Management CodechangesonPediatrics Paul Vanchiere, MBA Consultant & Founder of PMI

The Centers for Medicare & Medicaid Services (CMS) recently proposed that the Work Relative Value Unit (wRVU) for 99201-99205 and 99213-99215 be the same in 2019. Representatives from CMS claim the goal behind this effort is to reduce the documentation burden of providers. Yet applying the same value for each of these CPT codes undermines the foundation of the RVU system. This change also has the potential to create a negative impact on the financial bottom line for organizations that rely on RVU-based indicators to measure productivity and provide incentive bonuses for physicians. One of several other potential consequences of this change is reduced access to subspecialty pediatric care for children? and additional burdens on general pediatric practices. Given the stakes for financial bottom lines and patient care, providers should take steps to weigh in with CMS on the impact this proposed change will have, and to prepare for the adoption

and

implementation

change.

the proposed

CMSCODECHANGES TheCurrent RVUFramework

should be exercised when abruptly changing the individual values of a collection of CPT codes. Such values are normally evaluated by a group referred to as the ?RVC Update Committee,? or ?RUC,? which extensively studies each code before assigning or adjusting its relative value components. While CMS reserves the right to determine the final RVU values assigned to CPT codes, consideration should be given to the precedent that assigning a collection of CPT codes the same values would set; and the extent to which this would open the door to additional scrutiny of this vital instrument that sets pricing for much of the US healthcare system.

The Health Care Financing Administration, predecessor of the Centers for Medicare and Medicaid Services (CMS), established the Resource Based Relative Value System (RBRVS) in 1992. This system assigns a relative value unit, or RVU, to services rendered by a physician for a patient. There are three components of RVUs: 1.

Wor k : This number is supposed to represent a provider ?s compensation related to the estimated time spent with the patient, plus the education and skills necessary to complete a given procedure; Pr act ice expen ses: This number represents a practice?s estimated cost to provide a service, including rent, clinical salaries, and utilities; and M alpr act ice: The estimated cost for medical liability insurance on a ?per-procedure? basis.

ProposedRVUchanges The specific language of CMS?s proposed RVU changes includes the following: ?To improve payment accuracy and simplify documentation, we propose new, single-blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services.?

In theory, this is a point system allowing providers to be paid a proportional amount whether they are doing an aortic valve replacement or a level-3, established Evaluation & Management (E&M) visit. By assigning different values to reflect the physician?s expertise, level of decision making, technical acumen needed to provide the service, and cost to provide the service, RVUs help to normalize payments for different services and procedures in health care while also considering the varying levels of effort, expertise, and risk associated with different types of medical care.

Practically speaking, CMS proposes to pay the same rates for 99202-99205 ($135) and 99212-99215 ($93), instead of the differential payment rates currently in use.

Comparing the RVU analysis for a level-3 established patient E&M visit with that of an aortic valve replacement using the 2018 national Medicare fee schedule illustrates the point:

Figure 2

Financial Impact Figure 1 While the 99201, 99202, 99203, 99211, 99212, and 99213 CPT codes will see an increased payment rate, providers billing a high percentage of 99204, 99205, 99214, and 99215 should expect a revenue decrease. On a line-by-line basis, 99213 will see an increase of more than 25 percent. Meanwhile, 99214 and 99215 will see a decrease of 14.7 percent and 37.2 percent, respectively. Since the Medicare Fee Schedule is the gold standard by which to set state

Under this established, RVU system, the estimated physician?s training, cost and skill required to perform an aortic valve replacement is 31 times greater than that needed to treat a child requiring an expanded assessment with low to moderate severity. While the RVU system is not without its faults, caution

CMSCODECHANGES Medicaid payment rates, these changes in E&M code rates will trickle down to practices almost immediately. Practices with few to zero Medicaid patients will feel the pinch as every insurance company bases its contractual, allowed amount on a percent of Medicare. Regardless of the number of Medicaid patients in a Pediatric practice, CMS?proposed change has the potential to adversely affect the financial stability of Pediatric practices.

Scenarios It is not uncommon for a general pediatric practice to have an E&M distribution like this:

Figure 3 While much can be said about the practice with the distribution displayed above, this is a common pattern seen when PMI is called in to evaluate a practice. Based on CMS?proposed rates, this practice with a heavy emphasis on 99213 could see a potential increase in revenue:

Figure 4 A practice with the same number of visits (21,371) but higher percent of 99214/5 codes should plan to experience a decrease in payments:

Figure 5

CMSCODECHANGES As one can see, the impact of CMS?proposed rate changes will influence practices?bottom lines to varying degrees based on an individual practice?s E&M distribution. The only way to measure the impact your own practice may experience is to run a similar analysis. Practices that historically rely heavily on 99213 are expected to see an increase; while practices coding at higher levels (more 99204, 99205, 99214, and 99215), should brace for decreases in revenue. This illustrated reduction of more than $92,000 cannot be offset by any decrease in overhead cost, as this analysis examines only the individual CPT codes involved and not the entire visit. Such payment reductions can only be offset by a reduction in provider compensation or an increase in hospital subsidies (if available to employed providers).

Impact onMental HealthCare Since the payment for treating a runny nose or dealing with a child with mental health issues will be given the same weight (and the same payment rate), it is clear that the proposed change could adversely affect a provider 's willingness to spend the time necessary to address such concerns. While most, if not all, of PMI's clients would never let a child's mental health needs go unattended, the real focus come down to adequate compensation for taking the necessary time to help the child/family facing mental health issues. Under CMS' proposed change, they are advocating that the provider be paid the same for treating simple concerns versus taking the time necessary to address mental health issues. PMI believes that CMS' declared intention to "reduce the documentation burden of providers" poses additional unintended consequences that need to be fully evaluated before the proposed changes are finalized.

Impl icationsfor Pediatric Sub-special ists Many pediatric subspecialists will see a greater impact on financial performance, following Medicare?s decision to stop paying consultation codes (99241-99245 and 99251-99255) for Medicaid patients due to varying state Medicaid payment policies. Subspecialists are not able to bill the consultation codes for Medicaid patients in many states across the country. As such, they are relegated to using the 99214/99215 codes for such patients (appropriate, based on current CPT guidelines). The squeeze comes when these subspecialists are faced with a 37.2-percent reduction in their ?bread and butter ? codes for consultations (99215) and have a high percentage of Medicaid patients, which is perfectly normal. PMI finds it very difficult to see how large pediatric academic centers with a high percentage of Medicaid patients in states that do not pay for consultation codes will be able to continue to adequately pay such providers for their time and effort to care for children without additional hospital subsidies or a reduction in provider salaries. The unintended consequence of CMS?proposal points to a potential reduction in access to subspecialty care for children in various regions of the United States. For example, if Acme Children?s Hospital in Anywhere, USA, employs many pediatric subspecialists that routinely rely on 99215 to bill for their services, the projected reduction of more than 37 percent related to this code for Medicaid patients is sure to have a negative effect on financials. Aside from seasoned subspecialists being pushed into retirement because of this financial reality, PMI expects acceptance of CMS?proposal will lead to further reductions in access to subspecialty care.

CMSCODECHANGES Additional pressure on subspecialty care can be seen when looking at Resident Match Program results released in December of 2017:

Figure 6 As the data indicates, there are fewer people going into key subspecialty areas of pediatrics than are needed. The reduction in financial stability for subspecialists further decreases the likelihood of future candidates continuing their educations for an additional three years? only to find compensation has decreased while student loan obligations continue to rise. Physicians, hospitals and academic centers only have a few options to address the issue. Each response brings residual effects on other aspects of financial operations: 1.

Hospitals can find ways to increase subsidies for employed, subspecialty providers in order to offset costs allocated to their ?cost centers,? thereby allowing more funds to flow through to the bottom line and to support provider compensation/benefits; Academic centers can shift funds from within their respective practice plans to support the communal good of ensuring appropriate levels of compensation for all providers within the institution; or Physicians, if the salaries cannot be protected in some way, may move away from a given region to join a larger institution in areas that are financially favorable.

While there may be additional ways to address potential impacts to subspecialty pediatricians, the point remains the same: the financial impact from CMS?proposal is certainly going to be painful for subspecialty care and could lead to additional shortages of access to subspecialty care within various regions across the country, thereby increasing demand on general pediatric practices.

Impl icationsfor RVU-IncentiveContracts Hospitals and practices interested in offering production incentives to physicians utilize a wRVU-based formula because it provides an incentive for the work actually being done with no regard for payments received for services rendered. This is particularly popular with organizations that have providers care for disproportionate percentages of Medicaid patients. A typical wRVU bonus incentive may look something like the example to the right (Figure 7). CMS?proposed changes in wRVU won?t nullify the applicability of wRVU-incentive bonuses. That said, the changes will require physicians, practices and organizations to re-evaluate numbers so providers have reasonable chances of earning bonuses. Providers are not likely to earn bonuses if employers simply leave existing contracts alone with the same threshold (number of wRVUs needed to earn a bonus), given the proposed reduction in values for 99204, 99214, 99205 and 99215.

Figure 7 37

FutureContract Threshol dsWil l NeedToBe Re-Cal ibrated

First, providers can weigh in with CMS. The proposed changes are not yet finalized, and provider perspectives may help to prevent the rule?s implementation or persuade CMS to modify the proposed language. You can weigh in with CMS in a variety of ways:

Aside from the obvious problems that arise from comparing a provider ?s RVU productivity for 2019 to any previous year(s), there are several issues practices and providers need to bear in mind if CMS?proposal is accepted as written. 1.

For providers currently receiving a base salary plus bonus payment for billing more than a specified number of wRVUs, care must be taken to address how an employer plans to account for the impact of CMS?proposal. If a provider currently has a high percent of 99214 and 99215s, they should not expect to reach the same number of wRVUs in 2019. As such, the incentive threshold needs to be adjusted in the contract to set a reasonable expectation in terms of provider productivity. PMI recommends that any providers seeking employment from a hospital or practice with such a bonus arrangement consider requesting that the contract state the wRVUs are to be based on the 2018 wRVU values. If a contract is silent on the issue, it is best to clarify the employer ?s intention in advance. For practices and hospitals seeking to offer or renew RVU-based incentives, care should be taken to account for the proposed change in wRVU values. Determining the appropriate bonus rate to be paid for each wRVU above a specific threshold can be challenging under the best of circumstances. If practices are unable to build the proper models to evaluate the financial impact of offering an RVU-based incentive, they run the risk of either jeopardizing a practice?s financials or not being able to compete with production incentives other employers offer. The proposed changes may simply be too much, and consideration of an incentive based on charges or payments generated may be in order. PMI notes, however, that this may conflict with a variety of philosophical approaches and may undermine the idea of ACO?s, MIPS and MACRA.

Contact your state chapter of the American Academy of Pediatrics (AAP) to see what efforts are underway to bring attention to this issue. Taking advantage of this opportunity to speak as a unified voice lends credence to your voice and adds value to being a supporter and member of your state AAP chapter. Contact your federal representative or senator to educate them on the impact CMS?proposal will have on pediatrics, particularly subspecialty care. Depending on the financial stability of subspecialty employers, there could be potential access-to-care issues for their most vulnerable constituents. Contact state medical directors to share your thoughts. These professionals have significant influence over payment policies of the organizations they work for.

Second, you should prepare now for implementation of the proposed changes. This includes reviewing managed-care contracts to determine whether payment rates are based on the current year ?s Medicare rates/values. It is not uncommon for some insurance companies to pay a percentage of the current year ?s Medicare rates while others will specify in the contract the year of Medicare rates they intend to pay. For the practices that have contracts specifying the allowed amounts as X percent of the 2018 fee schedule, you should not see any change for that payer. For practices with contracts with X percent of a given current year ?s Medicare rates, you can expect to see a decrease in revenue if you use 99204, 99205, 99214 and 99215 extensively. While CMS is in a difficult position of trying to satisfy many competing interests, this effort is clearly not the way to address the ?documentation burden? of physicians. If CMS continues down this path as proposed, pediatric practices will face even greater pressure to squeeze out operational efficiency or reduce provider compensation.

For practices looking to consider performance incentive bonuses based on revenue generated, check out PMI's online calculator to help guide you on such efforts by clicking here.

If your practice needs any assistance identifying opportunities to improve your financial performance, take a

Call To Act ion : Considering the potential impact of CMS?s

look at w w w.Pediat r icSu ppor t .com or reach out to us to

proposed RVU changes, PMI recommends that providers take a few important steps.

discuss how we can help.

JOINUSAt THESE CONFERENCES&EVENTS

AAPNATIONALCONFERENCE -

November 2-6, 2018

Orlando, FL

Presenting & Exhibiting, Booth # 349

PEDIATRICPRACTICEMANAGEMENTCONFERENCE -

January 25-26, 2019

Nashville, TN

Presenting and Exhibiting

08 MAkINGyour practice websitework for you Susanne Madden, MBA, CCE Founder & CEO, The Verden Group First published in Physician's Practice.

If I asked you how your website is performing, you might be tempted to tell me about your search engine optimization (SEO) strategy, how many ?hits?you receive weekly, or perhaps you may just shrug and say you don?t really know. You may have invested plenty in SEO and can be easily found online as a result, but what do viewers find when they get to your site? I want to know whether your site truly represents you, your practice, and its culture. Does it convey the personality, clinical philosophies, and quality of care that your practice provides to patients? Ideally, your website should be a virtual extension of your physical practice. At the very least, it should convey general contact information? phone, fax, hours, location? as well as some specific

information about your physician(s), care team, and services. Can visitors easily pick out the most relevant information, such as a phone number prominently displayed at the top of the screen? Do they have to scroll to the bottom of the site, or worse, click into a separate page to find your address?

Squarespace, and other platforms offer responsive templates that convert well to mobile device screen sizes as well as allow for easy viewing and interaction from any device. If you already have a website, when was the last time you viewed it on a mobile device? Ongoing changes to mobile platforms may result in less than perfect scaling, so check frequently to ensure your site looks great across all device sizes.

How well or poorly your site performs even these basic tasks can make a considerable difference between prospective patients deciding to book an appointment with your practice or moving on to a competitor. There is no greater waste of SEO dollars than to drive visitors to a poorly performing website.

Tel l Your Story How are your physicians, care team, and staff presented online? Go beyond the standard curriculum vitae. Describe your clinicians?interests and a sense of the type of care that each provides. For example, if you have a physician with a special focus in a particular area, state that. When applicable, link to or include patient testimonials to clinicians.

Once you have the basics down, you?ll want to go a few steps further and ensure the site is a virtual representation of your physical space. Use your website to showcase your staff, services, and patient satisfaction. As an added bonus, the more useful you make your site, the less time staff will have to spend on the phone answering questions about medication dosage, where to find medical record transfer forms, what certain procedures entail, and so on.

Short video vignettes by physicians literally speak louder than words and give a sense of the personalities behind the written profiles. Not only will you provide a more content rich experience for potential patients to make choices about whom to see, you will ensure a better fit between patient and physician personalities, too.

Virtual Representation Begin by branding your practice consistently across your physical and virtual assets. Ensure that your logo is highly visible on your site. Use the same colors and fonts on your site as on physical signage, marketing materials, and business cards.

Don?t hesitate to share the history of the practice. Patients will appreciate knowing about your practice. List key staff members to give prospective patients a sense of familiarity before they even walk through the door.

Patient Testimonial

Allow your virtual representation to mirror the care with which you have designed the physical space patients experience when they arrive at your office. If it has been beautifully designed, make sure that your website has been, too. For example, if you have a modern layout and furniture, make sure your website has the same modern aesthetic and utilizes the same colors and tones as the physical space. Conversely, if your office could use an update, don?t represent it as a state-of-the-art facility online.

Visitors to your site are the same folks who are interested in reading product reviews before they buy on Amazon. Give them a similar experience online and have your existing patients ?sell? your services for you. You can solicit testimonials directly. You can also pull these reviews through from your social media sites, Google, Yelp, Healthgrades, Leapfrog, and more. Don?t be afraid to ask for reviews. If you routinely ask patients upon checkout if they had a good experience, you?ll accomplish two things. First, you will be able to address any discord at the time it occurs and are therefore more likely to prevent a patient taking to the Internet to vent publicly about it. Second, it provides you the opportunity to ask a satisfied patient to post a positive review. When you have hundreds of reviews, a couple of negative ones here and there? and there will always be negative reviews? won?t affect your overall score.

Ut ilit y Make your site as useful as possible. If you can allow patients to book appointments online, not only are you freeing up staff time from booking those manually, you are offering patients much greater convenience. If your electronic health record system vendor offers a patient portal, take advantage of that. The patient portal may allow you to communicate securely with patients, push out care plans, send updates to them, allow patients to access pertinent parts of their health records, and request medication refills.

Be aware that these reviews also help, or hurt, your profile with Payers. For example, United Healthcare displays Healthgrades?reviews in its physician directories as part of a participating physician?s profile. The more positive reviews you accumulate, the better your Payer profiles will be, too.

If you are building a new site, make sure to utilize a website platform that allows for easy mobilization, also known as responsive design. By way of example, Wordpress, 41

09 l ikely impacts of texasVS. Unitedstates Susanne Madden, MBA, CCE Founder & CEO, The Verden Group

Judge Reed O?Connor ?s decision in a Texas federal district court case pertaining to the Affordable Care Act (ACA) may shortly assume center stage in news media reports since oral arguments were ended Sept. 5, 2018. It is possible that O?Connor ?s decision on this legal case filed on Feb.28, 2018, may have been rendered by the time you read this article. Regardless of the verdict, Texas v. United States is likely to be just one of many cases under President Trump targeted at dismantling the ACA.

Brief IntroductiontoLawsuit The suit focuses on whether the law?s requirement that most Americans have health insurance is unconstitutional, but that comes with broader implications due to the Justice Department?s unusual decision earlier this year whereby it disagreed with the plaintiffs that the entire law should be struck down, but it decided that the individual mandate and several other central provisions, including protections for people with pre-existing conditions, would be fair game. Filed by 20 Repu blican st at e at t or n eys gen er al and governors of Maine and Mississippi, Texas v. United States will likely have major adverse ramifications for patients, medical providers, and insurers offering plans on the federal exchange. Defeat of the Republican-sponsored AHCA (resulting in a Trump tirade aimed at Senate Majority Leader McConnell) in 2017 did not halt President Trump?s goal of fully repealing the ACA. Instead, the strategy merely shifted to the non-legislative sphere (e.g., executive orders, DHHS rulings, and lawsuits).

Republ ican Reaction to Texas Case ? Not Al l Are Happy It is not only Democrats that are unhappy with the DOJ?s support of the Texas lawsuit. Even such ACA-opponent members of Congress as Lamar Alexander, Mitch McConnell, and Orrin Hatch were ?caught off guard? that the US Department of Justice (DOJ) under the leadership of Jeff Sessions supported the Texas argument that both the individual mandate and required coverage for preexisting conditions are unconstitutional, according to an ar t icle in Healt h Af f air s. Since coverage for preexisting conditions is widely popular, most congressional Republicans are r elu ct an t t o oppose t h is ACA pr ovision prior to the November congressional elections. They reacted instead to the Texas-filed lawsuit reaching Judge O?Connor ?s court by introducing a preemptive bill on Aug. 23, 2018, to protect coverage for preexisting conditions? albeit with en or m ou s looph oles.

ACAupdate Defendants: WhoAreOpposingthePl aintiffs?

individual mandate ? rendering the individual mandate itself unconstitutional.

Under normal circumstances, the DOJ would defend legislated federal law. But due to Jeff Sessions?refusal (as directed by President Trump) to offer a defense against the plaintiffs? lawsuit, California?s attorney general (AG) Xavier Becerra intervened to provide the defense (along with the AGs of 16 other states plus Washington, DC).

Furthermore, Paxton argued that the elimination of this IRS financial penalty was central to the federal funding of each provision of the ACA, making all provisions of the ACA unconstitutional. Thus, the underlying argument presented by the plaintiffs in the Texas federal district court was for an injunction against the ACA in Texas until its constitutionality could be determined. Of course, the constitutionality of the ACA would need to be addressed in the United States Supreme Court.

The American Hospital Association and numerous other healthcare organizations have filed amicus briefs in support of the defense. Additionally, the American Academy of Family Physicians (AAFP) website notes that? besides the AAFP? the following physician membership organizations filed a joint amicus brief to resist this latest attempt to dism an t le t h e ACA: -

The Congressional Budget Office (CBO) determined in November 2017 that elimination of the individual mandate alone would result in an increase of 4 million uninsured people in the United States in 2019 alone, and 13 m illion in 2027. Since the mandate was a mechanism to ensure health insurance coverage of the entire US population, and not just people requiring immediate medical care.

American Medical Association; American College of Physicians; American Academy of Pediatrics; American Academy of Child and Adolescent Psychiatry

DeterminingSeverabil ity? Why It Matters

What IstheTexasAttorney General Seeking?

Paxton presented the legal issue of severability as one of the central issues in the Texas v. US case, his argument being that the ACA?s individual mandate could not be separated from some other key ACA provisions.

As lead plaintiff, Texas is demanding a preliminary injunction against the entire ACA in Texas until the constitutionality of aforementioned provisions are determined. This may seem like a legally far-fetched strategy; but Judge Reed O?Connor previously ruled against Obama Administration rules prohibiting healthcare providers from discriminating against transgender people, and another requiring states to reimburse federal premium taxes paid by Medicaid managed care plans (per an article in Managed Care m agazin e).

A June 2018 New Yor k Tim es ar t icle suggests two specific ACA provisions could be derailed if the plaintiffs?claim that the individual mandate cannot be separated from other ACA provisions is upheld. These two provisions are termed guaranteed issue and community rating. While the guaranteed issue mandate is that insurance companies need to sell insurance to anyone who wants to buy it (such as someone with a preexisting condition), the community rating mandate is that every consumer who buys similar health insurance will be charged a similar price. The result is that in tandem these ACA provisions protect the capacity of patients with preexisting conditions to obtain health insurance that covers their most pressing health needs.

The following Republican-controlled states are supporting Texas in this lawsuit, according to the w ebsit e of t h e Nat ion al Con f er en ce of St at e Legislat u r es: Alabama, Arkansas, Arizona, Florida, Georgia, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Nebraska, North Dakota, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia and Wisconsin.

JudgeO?Connor?s RecordasaRepubl icanAppointee

Pandora?s Box: Congressional Repeal of the Tax Penalty

Based on Judge O?Connor ?s judicial record, it is not probable that he will completely dismiss the plaintiffs? arguments and rule in favor of the defendant (and especially since the federal government? as named defendant? is supporting the plaintiffs?arguments).

Texas Attorney General Ken Paxton argued that a provision in the tax reform law passed in 2017. eliminating the IRS financial penalty for failure to have health insurance, was tantamount to a repeal of the ACA?s

On the other hand, the sudden elimination of ACA provisions in Texas via an injunction is widely recognized as likely to gen er at e ch aos in t h e Texas h ealt h car e syst em (and for insurers in Texas). Given the mainly favorable public opinion of the ACA?s provision requiring preexisting condition health insurance coverage, it is generally expected that Judge O?Connor (a George W. Bush appointee) will attempt to bump the case to a higher Texas federal court stacked with Republican appointees in order to delay halting preexisting condition coverage in Texas.

Adding Kavanaugh to the Supreme Court not only does not bode well for decisions impacting the constitutionality of the ACA, but also for women?s access in future to reproductive health services. For example, while serving on the US Court of Appeals (District of Columbia), Kavanaugh sided with the plaintiffs against allowing an insurance company?s usual em ploym en t -based con t r acept ive cover age in his dissenting argument framed on the right to religious liberty.

This tactic will also expedite forwarding the case to the Supreme Court to decide the ACA?s constitutionality.

The Trump Administration was unable to repeal the ACA legislatively, but may win their war against the ACA within two years by dismantling it through DHHS rules and lawsuits aimed at a Supreme Court determination of constitutionality. No matter if this creates undue financial hardship and preventable disabilities for millions of Americans.

Concl udingThoughts? Preparingfor 2019

TheConfirmation Impact of Kavanaugh as a Supreme Court Justice Neil Gorsuch and Brett Kavanaugh were hand-picked as Supreme Court nominees by the Federalist Society because they both support the philosophy of weakened federal government authority in favor of states?rights and prioritizing individual religious liberty.

President Trump, his cabinet appointees, and many of the congressional Republicans do not care about the wide-ranging public health impact? but professionals engaged in the provision of healthcare coverage or services should care.

Kavanaugh?s confirmation by Congress as a Supreme Court Justice is therefore expected to solidify a conservative court (including the tendency to decide cases in favor of state self-determination, and individual religious choices in the retail business realm). Since the Republicans control Congress, it is unlikely that Kavanaugh will not be confirmed (unless Democrats win control of Congress in the November elections, and Kavanaugh?s confirmation is delayed until December).

Newsflash, President Trump and Attorney General Sessions: harnessing the legal and judicial systems to gut provisions or overturn the ACA is a bad idea. Returning to the pre-ACA healthcare system status quo will just cost states and the federal government billions of dollars to care for a more unhealthy and disabled population in the long run.

10 Behavioral HealthResources for TheModernAge Julie Wood, MSc, CCE Co-Founder, PCS

Project TEACH is a statewide organization in New York working to provide children and families with skilled, prompt and compassionate care for mental health conditions while strengthening and supporting the ability of New York?s pediatric primary care providers (PCPs) to deliver care to children and families who experience mild-to-moderate mental health concerns.

WhoQual ifies? All pediatric primary care providers (PCPs) who treat children, adolescents and young adults in New York are eligible to receive Project TEACH services at no cost thanks to funding from the New York State Office of Mental Health. Beneficiaries include pediatricians, family physicians, psychiatrists, nurse practitioners, and other prescribers. Additionally, other mental health professionals who provide ongoing treatment to children (such as child and adolescent psychiatrists, general psychiatrists, and psychiatric nurse practitioners) may request a second opinion through consultations.

What Patient ServicesAreAvail abl e? Services include consultations (plus consultations), the ability to ask questions through a Project TEACH Liason Coordinator to find the appropriate resource for the PCP; and tracking down referrals and linkages for appropriate and accessible community mental health for patients and families. Psychiatrists working with Project TEACH can also provide appropriate support when there are long wait times for community referrals.

Project TEACH does not provide crisis services or evaluations for emergencies, but can refer severe or urgent cases to appropriate emergency services and parents are not able to contact Project REACH directly either, they are encouraged to contact their PCP for services.

assist in identifying appropriate specialty referral resources and linkages for patients and families.

What Provider ServicesAreAvail abl e? Project TEACH offers education for providers in a variety of formats, from basic online sessions to live, multi-day intensive trainings. Educational opportunities include training on core topics of ADHD, aggression, anxiety and depression. This training is free to any New York State PCP. See a list of educational opportunities h er e.

Any New York State PCP may call for a consultation with a Project TEACH child and adolescent psychiatrist, regardless of the type of insurance that the patient has. When a face-to-face consultation is provided, families with insurance may be billed.

Core trainings are led by Project Teach?s regional provider teams on-site at practices or nearby locations. Core trainings can be provided through a series of two- or three-hour sessions, or in one longer program depending on a practice?s needs. The group?s regional provider teams cover assessment and management of the important mental health issues that children and adolescents face. The program also offers specialized, in-depth ?live intensive trainings? in each region. These trainings address how to recognize, assess and manage mild to moderate mental health concerns in children and adolescents.

The following scenarios may result from a telephone consultation through Project TEACH. The child and adolescent psychiatrist may: -

Answer questions from the PCP over the telephone. Request to see the patient for a face-to-face evaluation in order to answer the PCP?s questions. Face-to-face evaluations are also available by telepsychiatry for patients who live more than one hour away from the closest Project TEACH site and or do not have access to transportation. Refer the PCP to the liaison coordinator for information about resources in the community. Refer severe or urgent cases to appropriate emergency or other community services.

The organization additionally provides free access to on-demand content through its online learning management system. Sessions focus on a variety of topics related to mental health in children and youth. Courses include everything from screening in primary care to marijuana in kids.

The expectation is that face-to-face consultations will occur within two weeks of the requests. All face-to-face consultations are followed by written reports to the referring prescriber(s) within 48 hours. A written summary is not provided following phone consultations.

HowToGet Started There are two easy ways to get started with Project TEACH. Enroll your practice either by filling out the enrollment form on the website, or by calling the regional Project TEACH team in your area directly. You can find Region al Team in f or m at ion h er e.

Col l aborativeCare A NYS PCP can ask a question about any case involving children and adolescents up to age 21. Questions can relate to a particular patient, diagnosis and treatment for a specific mental health disorder, pertain to medications and treatment strategies, or be more general inquiries about child psychiatry and behavioral health. Project TEACH liaison coordinators can

Project TEACH services are delivered in every region of New York State. See the regional map to locate the Project TEACH team in your county. Click here to learn more about Project TEACH?s Maternal Depression Conference, Oct. 12, in Albany.

11 thel astest MEDICALHOMEnews Amanda Ciadella, MPH, CCE PCMH Specialist/Senior Consultant

We are already well into ?conference season? with NCQA?s Congress behind us and the MGMA and AAP annual conferences ahead later in the fall. We thought we?d share some highlights with you in ViewPoint this issue.

Highl ightsfromNCQA?sCongress NCQA's annual congress was held in sunny San Diego? not a cloud in the sky for four days! The weather outside was just a precursor for what was happening inside: the industry?s best minds getting together to share ideas, teach one another, and ultimately improve the delivery of healthcare. Sessions echoed sentiments of what's occurring in the industry in general; in particular, a shared desire to change the system so it works better for patients and clinicians alike. Some key topics included: -

Behavioral health: The importance of integrating behavioral health into primary care and discussion of the barriers to implementation. New York State PCMH: New York practices wishing to keep their PCMH recognition must follow the requirements for NYS PCMH going forward. MACRA: it isn?t going away anytime soon. Start monitoring and trending your data! MIPS: PCMH/PCSP recognition will give practices full credit in the ?improvement activities? area of MIPS. Payment: Payer trends for supporting (or not) the PCMH model.

The 2017 PCMH Standards and Guidelines have a heavy emphasis on integrating behavioral health into the primary care setting. NCQA has taken the concept a step further with the behavioral health distinction? a gold star for practices that have successfully integrated behavioral health into their practice. Both conferences offered sessions to educate attendees on how to successfully cross that bridge. Sessions covered the following topics: -

Lack of funds for implementing mental health services Overcoming the mental health stigma Appropriate medication management at the primary care level The opioid epidemic?s impact on mental health Social determinants of health and how they can help determine who needs mental health services

Annual Conference of the Fl orida Chapter of the American Academy of Pediatrics (FCAAP) We work very closely with the FCAAP, helping to support its members to make the transition to PCMH (more details for members and non-members can be found h er e) The FCAAP annually hosts ?The Future of Pediatric Practices,? which brings together Florida's pediatric providers for two days of exceptional educational opportunities. There is a track for everyone, from Medical students who had the chance to showcase their research to seasoned pediatricians who could learn from Dr. Colleen Kraft, President of the American Academy of Pediatrics, and with Chip Hart of PCC on how to make their practices more efficient. There?s something so energizing about a pediatric conference: the new energy the residents bring to the field, and the dedication those that have been in the field for decades bring to share. Children roam the hallways, friendly faces are there to help, and no question is off the table. It?s a great learning experience for all. Two common themes at both conferences were one, getting paid for achieving PCMH recognition; and two, the importance of mental health in primary care.

Pediatricians and OB/GYNs in Florida have been successfully receiving higher payment for achieving PCMH status under the M an aged M edicaid Ph ysician In cen t ive Pr ogr am . There are Medicaid incentives in several other states; however, people do not know where to go to begin the search. The Patient Centered Primary Care Collaborative, of which we are members, offers a great resource to determine if there are incentives in your area: you can find it h er e. And while there are many payers that do not pay for PCMH, it is becoming more and more relevant to do so across the country as value-based contracting becomes more prevalent. Adele Allison of DST Health Solutions, LLC, told the crowd at the NCQA Congress that, based on 2015-2016 data for the 2017 Public and Private National Health Plan Survey, 84 percent of the market (or 245.4 million Americans in the health insurance sector) had what were classified as value-based payments made to their providers.

Dear Clients, I wanted to thank all of you who nominated me for the NCQA PCMH CCE Honoree Award? I won! It is my sincere pleasure to work with all of you and I could not have achieved this success without you. The best part of my job has been having the opportunity to get to know each of my clients and what makes your practice unique. Thank you for your cooperation and trust during your projects and support afterwards. I look forward to working with you all again on another project. Amanda

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WE MANAGE YOUR COSTS AND SERVICES, YOU MANAGE YOUR PATIENTS. Find out how you can join here: www.IPMSO.org

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