Another year to start again or go forward or to renew/reflect!  Or we here at Omega are busy with the 5010 format changes!   Reflecting….starting again…don’t have time.  This new format has us all on the run.   Submit the claims, it comes back….this provider wants it one way and the other wants it another….!!   And this once again gets sold as a better way of submitting claims.   All of us in the medical billing business are having to jump over the various hurdles, but we do this and we do this well!

It is not changing of the format that is the trouble, it is whether your staff is keeping abreast enough to make the changes necessary for all of this to happen.  The industry says this is how we need to submit the claims and so we do.   How much money are you the provider going to lose, because you do not have a staff that is up to the challenge of tweaking your formats for the various carriers.

Can hardly wait for the ICD-10 challenges!  How about you guys?  Are you getting your claims out?   By the time you read this, we should have it pretty much smoothed out and running smoothly!   How is your office doing?

More than half of claims submitted in 5010 testing batches are rejecting for 2 reasons…

Make sure your billing provider and service facility addresses are street (physical) addresses.

These addresses MUST have the zip+4 zip code and CANNOT be a P.O. Box; hence, the physical address.

The primary identifier for your practices and your physicians MUST be the NPI# NOT a tax id# or SS#.

Good Luck and from all of us at Omega Billing Service

Yes, the end of version 4010 is December 31, 2011 and the commencement of version 5010 begins!  Are you ready?  Have you checked and tested with your clearing houses and/or payers?  With all the hustle and bustle of December upon us this is just another process that must be done in order for you to maintain a constant cash flow.  So, contact your clearing houses NOW and be sure you are not left behind!

Did you know you could increase your bottom line by $62,500.00 a year?

It’s true and you can do it by stepping up efforts in your office by collecting patient copays.  It’s that simple, so why are you not doing this?  On average, a physician can see approximately 10 patients per day.  Say each patient has a minimum copay of $25 (which is on the low side), these fees are collected up front rather than after the fact, think of the time, and money spent sending out statements, phone calls, etc., trying to collect.  Time passed results in increased cost and decreased revenue.

This is also true for patients with balances after insurance.  Collect coinsurance up-front as well.  After all, you cannot leave the grocery store without paying for your groceries.  At the very least make payment arrangements before the patient leaves the office and stick to it. 

There are many psychological barriers in asking for money.  Seventy percent of Americans live paycheck to paycheck.  Most patients believe they either do not owe and/or cannot pay.  You have to change the patient’s beliefs.  You have to develop a strategy for decision – making about accounts based on sound business reality – not emotion.

Improve your front-end training.  Set goals.  Put the money in your pocket!

There really are benefits for you, the physician, in Version 5010.  It all seems like just another way to make the lives of the electronic medical world chaotic.  I mean face it, 4010 came around some 10 years ago and we are pretty comfortable with it, right?  However, there are some improvements…

System wide improvements within CMS simultaneously and implementing standard acknowledgement and rejection transactions across all jurisdictions.  Improving claims receipt, increasing consistency of claims editing and error handling and returning claims needing correction earlier rather than later.  Assigning claim numbers closer to the time of receipt is also an improvement.  These are just a few of the benefits to be improved upon in the electronic world related to your claims, remittances, eligibility and claims status requests and responses.

A few tips you may or may not know about yet…

• A billing provider must be a provider of health care services not a billing service or clearinghouse.
• Billing providers are entities that perform services and are reimbursed by health plans.
• Make sure you are using the correct NPI for the organization.
• The tax ID must be sent for the Billing Provider on the claim.
• For health plans that assign a unique identifier per member, the individual must be listed as the subscriber.
• The patient is not listed on the transaction.

For health plans that assign a number to the entire family, follow these rules:

• The policyholder is always listed as the subscriber.
• If the policyholder is the patient, the patient is not listed on the transaction.
• If the dependent is the patient, they are listed as the patient in the transaction.

For professional claim transactions, 5010 requires total anesthesia minutes be reported.  In 4010, payers could require the anesthesia time be reported as the total number of minutes OR as units.  Units are no longer accepted for reporting anesthesia time.  Any requirements by a payer to submit anesthesia start and stop times in the 5010 transaction will be non compliant with the TR3.

Did you know there are two acceptable forms to authenticate the health care provider’s signature?

Yes, Medicare/CMS accepts, and recommends a signature log or attestation statement alongside a requested submission of medical records should the charges be audited.  This can save the office as well as the auditing entity valuable time and money.  And we are all about saving time and making money, right?

Physician offices may want to create a signature log to help identify the health care provider associated with either initials or signatures that are not legible.  Face it; most physician signatures are not legible.  Having a sheet similar to a ’key’ to a map or a ‘glossary’ of definitions can be used/submitted to an auditing entity alongside medical records for authentication/verification of physician/health care provider signatures.  This can be done as simple as creating a signed and dated document.

An Attestation Statement is also an acceptable form of authenticity where the medical record is lacking or is illegible.  An example of an attestation statement can be found at http://www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1&ID=14440

Over the last few years, the laws in Texas have changed for freestanding emergency rooms.  Now more and more physicians are opening up these kind of businesses, which is great for all the people who do not want to wait in a regular hospital emergency room!  These free standing ER’s are definitely serving our communities, but allowing us to see a physician without an appointment or the usual waiting period of 2-3 hours!  Good for all of us! 

But with this wonderfulness, also our community needs to know that they are a true emergency center, with board certified emergency room physicians and the cost of going to these centers is not cheap.  They are set up to meet all the same criteria of a hospital emergency room, so they are geared to meet all crisis. 

Billing for these entities is also unique and Omega has met these challenges.  We now have done this kind of billing for the last couple of years and have learned the in’s and outs of this speciality.  We are hear to serve our existing clients as well as our new ones.   Should you be looking for someone who can help you and who has a great track record, I hope that you would consider us as a great resource.

Call us for more details: (213) 358-4900

For Immediate Release: Wednesday, November 03, 2010
Contact: CMS Office of Public Affairs
202-690-6145

MEDICARE IMPROVES ACCESS TO PREVENTIVE SERVICES FOR 2011
NEW PHYSICIAN PAYMENT POLICIES EMPHASIZE ROLE OF PRIMARY CARE

The Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment period that will implement key provisions in the Affordable Care Act of 2010 that expand preventive services for Medicare beneficiaries, improve payments for primary care services, and promote access to health care services in rural areas. The new policies will apply to payments under the Medicare Physician Fee Schedule (MPFS) for services furnished on or after January 1, 2011.

“The rule we are issuing today is a major step toward improving the health status of Medicare beneficiaries by providing coverage for an annual wellness visit that will allow a physician and patient to develop a closer partnership to improve the patient’s long term health,” said CMS administrator Donald Berwick, M.D. “The rule will also eliminate out-of-pocket costs for most preventive services beginning January 1, 2011, reducing barriers to access for many beneficiaries.”

The final rule with comment period implements provisions in the Affordable Care Act that expand beneficiary access to preventive services and, for the first time, provide coverage under the traditional fee-for-service program for an annual wellness visit beginning January 1, 2011. This visit augments the benefits of the Initial Preventive Physical Examination (IPPE or “Welcome to Medicare Visit”) with an annual visit that allows the physician and patient to develop a personalized prevention plan that considers not only the age-appropriate preventive services generally available to Medicare beneficiaries, but additional services that may be appropriate because of the patient’s individual health status.

The rule also implements an Affordable Care Act provision that improves access to primary care services by providing a 10 percent incentive payment for primary care services furnished by primary care practitioners. The primary care incentive payment is available for family physicians, general internists, geriatricians, pediatricians, nurse practitioners, clinical nurse specialists, and physician assistants for whom primary care services represent 60 percent or more of their MPFS allowed charges in a prior period. In this rule, CMS finalizes adjustments to proposed policies in response to public comment so that more primary care physicians and nonphysician practitioners can qualify for the incentive payments, including adjustments for practitioner practice patterns in rural and professionally underserved areas, as well as providing special consideration for practitioners newly enrolling in Medicare.

In addition, the final rule with comment period implements another Affordable Care Act provision to improve access to surgical services by providing a 10 percent incentive payment to general surgeons performing major surgery in areas designated by the Secretary as Health Professional Shortage Areas (HPSAs). The rule also implements other Affordable Care Act provisions including a provision that allows physician assistants to order post-hospital extended care services in skilled nursing facilities, and another provision to pay the same Medicare rates to certified nurse-midwives as physicians.

The final rule with comment period announces a reduction to payment rates for physicians’ services in 2011 under the sustainable growth rate (SGR ) formula. MPFS rates are currently scheduled to be reduced under the SGR system on December 1, 2010, and then again on January 1, 2011 under current law. The total reduction in MPFS rates between November and January under the SGR system will be 24.9 percent. While Congress has provided temporary relief from these reductions every year since 2003, a long-term solution is critical.

“Broad physician participation in Medicare is essential to ensuring that beneficiaries continue to have access to care, and physician engagement is critical to our efforts to strengthen the quality of care,” said Berwick. “Medicare needs to be a strong, dependable partner with physicians – and that means the SGR must be fixed. The Administration supports permanently reforming the Medicare payment formula.”

The final rule with comment period continues recent efforts by CMS to improve the accuracy of MPFS payment rates by implementing Affordable Care Act mandates to identify and revise payment for misvalued services. It also addresses concerns about potential physician self-referral by requiring physicians who provide computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) scans in their own offices to notify patients that they may receive the same services from other suppliers in the area.

The final rule will appear in the Nov. 29, 2010 Federal Register. Except as otherwise specified, the policies and payment rates adopted in the final rule with comment period will be effective for services furnished on or after Jan. 1, 2011. CMS will accept comments on certain aspects of the final rule with comment period until Jan. 2, 2011.

For Immediate Release: Wednesday, November 03, 2010
Contact: CMS Office of Public Affairs
202-690-6145

MEDICARE IMPROVES ACCESS TO PREVENTIVE SERVICES FOR 2011
NEW PHYSICIAN PAYMENT POLICIES EMPHASIZE ROLE OF PRIMARY CARE

The Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment period that will implement key provisions in the Affordable Care Act of 2010 that expand preventive services for Medicare beneficiaries, improve payments for primary care services, and promote access to health care services in rural areas. The new policies will apply to payments under the Medicare Physician Fee Schedule (MPFS) for services furnished on or after January 1, 2011.

“The rule we are issuing today is a major step toward improving the health status of Medicare beneficiaries by providing coverage for an annual wellness visit that will allow a physician and patient to develop a closer partnership to improve the patient’s long term health,” said CMS administrator Donald Berwick, M.D. “The rule will also eliminate out-of-pocket costs for most preventive services beginning January 1, 2011, reducing barriers to access for many beneficiaries.”

The final rule with comment period implements provisions in the Affordable Care Act that expand beneficiary access to preventive services and, for the first time, provide coverage under the traditional fee-for-service program for an annual wellness visit beginning January 1, 2011. This visit augments the benefits of the Initial Preventive Physical Examination (IPPE or “Welcome to Medicare Visit”) with an annual visit that allows the physician and patient to develop a personalized prevention plan that considers not only the age-appropriate preventive services generally available to Medicare beneficiaries, but additional services that may be appropriate because of the patient’s individual health status.

The rule also implements an Affordable Care Act provision that improves access to primary care services by providing a 10 percent incentive payment for primary care services furnished by primary care practitioners. The primary care incentive payment is available for family physicians, general internists, geriatricians, pediatricians, nurse practitioners, clinical nurse specialists, and physician assistants for whom primary care services represent 60 percent or more of their MPFS allowed charges in a prior period. In this rule, CMS finalizes adjustments to proposed policies in response to public comment so that more primary care physicians and nonphysician practitioners can qualify for the incentive payments, including adjustments for practitioner practice patterns in rural and professionally underserved areas, as well as providing special consideration for practitioners newly enrolling in Medicare.

In addition, the final rule with comment period implements another Affordable Care Act provision to improve access to surgical services by providing a 10 percent incentive payment to general surgeons performing major surgery in areas designated by the Secretary as Health Professional Shortage Areas (HPSAs). The rule also implements other Affordable Care Act provisions including a provision that allows physician assistants to order post-hospital extended care services in skilled nursing facilities, and another provision to pay the same Medicare rates to certified nurse-midwives as physicians.

The final rule with comment period announces a reduction to payment rates for physicians’ services in 2011 under the sustainable growth rate (SGR ) formula. MPFS rates are currently scheduled to be reduced under the SGR system on December 1, 2010, and then again on January 1, 2011 under current law. The total reduction in MPFS rates between November and January under the SGR system will be 24.9 percent. While Congress has provided temporary relief from these reductions every year since 2003, a long-term solution is critical.

“Broad physician participation in Medicare is essential to ensuring that beneficiaries continue to have access to care, and physician engagement is critical to our efforts to strengthen the quality of care,” said Berwick. “Medicare needs to be a strong, dependable partner with physicians – and that means the SGR must be fixed. The Administration supports permanently reforming the Medicare payment formula.”

The final rule with comment period continues recent efforts by CMS to improve the accuracy of MPFS payment rates by implementing Affordable Care Act mandates to identify and revise payment for misvalued services. It also addresses concerns about potential physician self-referral by requiring physicians who provide computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) scans in their own offices to notify patients that they may receive the same services from other suppliers in the area.

The final rule will appear in the Nov. 29, 2010 Federal Register. Except as otherwise specified, the policies and payment rates adopted in the final rule with comment period will be effective for services furnished on or after Jan. 1, 2011. CMS will accept comments on certain aspects of the final rule with comment period until Jan. 2, 2011.

For more information, see: www.federalregister.gov/inspection.aspx#special

See also Fact Sheets on the final rule posted at:
www.cms.gov/apps/media/fact_sheets.asp

In August of 2009, one day after the statutory deadline set by Congress in the American Recovery and Reinvestment Act (ARRA), HHS released its interim final regulations on patient notification of breaches of unsecured Protected Health Information (PHI). These regulations were required under a part of the ARRA known as HITECH – the Health Information Technology for Economic and Clinical Health Act. HITECH included a number of amendments and additions to the HIPAA privacy and security rules. As with all of HIPAA Administrative Simplification, these provisions apply throughout the health care system, and not just in dealings with Medicare or other government programs.

The interim final regulations that pertain to the breach notification provisions in HITECH mandate covered entities (CE) such as health care providers, insurers and clearinghouses, and their business associates (contractors and vendors that access and use PHI for a covered entity) to notify patients in writing following the discovery of a breach of unsecured PHI. As of this writing, the health care industry is still operating under the interim final regulations.

In mid-August of 2010, HIPAA watchdogs noticed a strange occurrence – the final rule on patient breach notification which had been wending its way through the regulatory approval landscape, was mysteriously pulled from the process. HHS had removed the rule from consideration at the Office of Management and Budget, with no advance word or explanation as to why. Insiders speculated on the cause of the interruption, and the following week the New York Times published an article openly declaring that the regulations were being re-written by the administration to tighten up perceived holes in the breach notification requirements.

At issue is the “harm threshold” analysis inserted in the rules by HHS – a welcome, realistic provision according to many health care CEs, and an improper loosening of the rules to some privacy advocates and members of Congress, who crafted the patient notification requirements in early 2009. What HHS will do with the breach regulations, and how it will affect billing companies’ implementation of them, is still up in the air.

The current regulations define a breach as “the unauthorized acquisition, access, use, or disclosure of protected health information (PHI) which compromises the security or privacy of such information.”

Congress included these three narrow exceptions to the basic definition of breach:

1. where the recipient of the information would not reasonably have been able to retain the information;
2. certain unintentional acquisition, access, or use of information by employees or persons acting under the authority of a covered entity or business associate;
3. certain inadvertent disclosures among persons similarly authorized to access protected health information at a business associate or covered entity.

Most observers agree that these exceptions will assist a covered entity or business associate in reducing the number of notifications it must send to patients resulting from ordinary, inadvertent access or disclosures. [Note: There is some confusion over the interpretation of the first exception, which will hopefully be answered in an FAQ or other official communication.]

The interim final rule continues its explanation of the CE or BA’s responsibility if patient information is improperly accessed or disclosed. It provides that a harm threshold analysis must be performed by the CE or BA upon unauthorized access, use or disclosure to determine whether the action “poses a significant risk of financial, reputational, or other harm to the individual” and, therefore, compromised the security or privacy of the information. This analysis is expected to be the key issue at stake in the new final rule.

Such an analysis must encompass a risk assessment which considers the following factors:

1. Who impermissibly used or to whom was the information impermissibly disclosed (was it to another CE)?
2. Can and did the CE take immediate steps to mitigate the impermissible use or disclosure (e.g., receipt of satisfactory assurances that information will not be further used or disclosed)?
3. Was information returned prior to being accessed (e.g., a stolen laptop recovered where forensics show nothing was accessed)?
4. Was the information partially de-identified (e.g. only name and hospital or transport)? Was the information sensitive in nature (sexually transmitted diseases, behavioral health, info that could impact employment)? Did it contain anything that would increase the risk of identity theft (e.g. SSNs, date of birth, etc.)?
5. Was the information de-identified (limited data sets) by removing all 16 direct identifiers, plus date of birth and ZIP code? If so, then it may be an exception to the breach definition (CE or BA will need to perform risk assessment if info contains any of the identifiers).

The burden of demonstrating that an impermissible use or disclosure was not a breach (because it did not pose a significant risk of harm to the individual) lies with the CE or BA; such analysis must be documented if notification to the patient(s) is not made.

The HITECH Act says that all covered entities and business associates must notify patients in writing without unreasonable delay after the discovery of a breach and in no case later than 60 days once the breach is known.

The notice must contain, as far as is possible, the following information:

1. A description of what happened, including when the breach occurred and when it was discovered;
2. A description of the type(s) of unsecured PHI that was breached;
3. The steps individuals should take to protect themselves against potential harm from the breach;
4. A description of what the covered entity involved is doing to investigate the breach, mitigate losses and prevent future breaches, and;
5. Contact procedures for any questions and to learn additional information, including a toll-free number, email address, web site or postal address.

Patient notifications should be written at an appropriate reading level, using clear language and syntax, and not include any extraneous material that may cloud the message. The notice must be in written form, using first-class mail to the last known address for the individual. Email may be used where the patient has agreed in advance to use email for communication and notifications.

<??> <??> If 10 or more patients are involved that cannot be contacted by mail, the covered entity must post a public notice for at least 90 days in a conspicuous place on its website or through the media. If 500 or more patients are involved, then the major print and broadcast media in the area must be informed, as well as the Secretary of Health and Human Services.

Removal of the harm threshold analysis from the regulations will certainly open up billing companies and their clients to more administrative and financial burden by requiring letters to go to patients whose information goes astray, even where there is no risk of potential harm to the patient as a result. Supporters of the current provision say that more notifications to patients will not cause better privacy and security protections, but will cost the system more and cause unneeded anxiety and concern.

The Office of Civil Rights at the Department of Health and Human Services, charged with enforcing HIPAA privacy and security regulations under the original HIPAA and the new HITECH regulations, was reportedly urged by the White House to reconsider the breach notification rules due to the controversy over the “harm threshold.”

An OCR spokesman was quoted in the Times article as saying, “We decided to pull it back. We had second thoughts. We hope to issue a final regulation this fall.”

In the meantime, it is important for all HBMA member companies to review and strengthen not only their own privacy and security policies and procedures, but also those of their vendors and business associates, and to make sure that employees are well-trained to communicate mistakes or other errors in handling PHI to the privacy officer immediately. Whether the “harm threshold” analysis will survive or not, billing companies face new challenges every day to catch mistakes, minimize their reoccurrence and respond correctly under the law.