The Demands of Value-Based Reimbursement Model to Be Met With Medical Billing Specialists

With many of the healthcare reforms set to take effect shortly or having already been in force, providers may have entered a different phase of operational model, which is called value-based model. The unique feature of value-based model is that providers will get reimbursed for delivering superior medical care at a progressively lesser cost. As the public plans such as Medicare, Medicaid, and most of the commercial plans are likely to adopt value-based reimbursement models, it may be inevitable for providers to shift over or find a balance between fee-for-service model and value-based model in order to sustain profitable clinical practices.

To being with, you have Medicare's value-based payment modifier that will be launched for physicians in groups of 100 or more in 2015. The unique thing about this modified value-based payment model is that it works on the principle of ‘carrot and stick’ theory, meaning physicians may either be eligible for either positive or negative payment adjustment depending on their level of compliance with care quality and reporting. To prepare for the eventual 2015 model, it may even be necessary to demonstrate capability for PQRS reporting, beginning as early as 2013. Furthermore, the performance post 2015 will be significant as most of the value-based returns will start yielding from 2017 based on the PQRS reporting post 2015.

While Medicare and Medicaid reimbursements have already begun experimenting with ACO model as a superior form of reimbursing physicians for their services to public healthcare plan beneficiaries, commercial payers, sooner or later, too will be obliged to adopt modified versions of reimbursements. Therefore, providers will have to plan, be prepared and resourceful enough to realize their reimbursements from both public as well as commercial insurance payers.

As far as planning goes, it should all start with:

Thorough evaluation of payer market to find out what value-based payment opportunities await down the line. It may also be important to know the dynamics of payers’ reimbursement methodologies.

Assessment of your current documenting, coding, and billing practices against the requisite standards, dictated by the changing payment models.

Planning progress to the expected level through a phased manner.

Once you have the plan in place to progress to value-based payment model, providers may actually start implementation with:

Value addition to care delivery: It means minimizing the possibility of recurrence of medical conditions. When providers are able to minimize the recurrence, it would contribute to substantially savings in reimbursements that might happily shared by payers with responsible providers.

Better care coordination: Coordinated care, involving physicians and support staff will likely facilitate better clinical outcomes, which are often deemed fit for specials incentives along with regular reimbursements by payers.

Extending patient reach and engagement: When providers begin exploring opportunities to increase their and involvement, it is definitely going to improve care quality, which is the fulcrum for deciding the value-based reimbursements.

Forming new clinical alliances: The value that clinical alliances bring to clinical quality is really unquestionable and the providers’ success as value-based providers will largely depend on how best they network their clinical services with competent specialists.

As providers find themselves engrossed with value-based clinical activities, it may require a dedicated medical billing to look after the process of documenting, coding, and billing claims for value-based reimbursements.

Medicalbillersandcoders.com – with a nation affiliation with resources (medical billing specialists) that can own and execute medical billing functions on behalf of providers stuck in the process of migrating from fee-for-service model and value-based model – offers to mediate the deployment of competent, experienced and versatile medical billing specialists that could effectively look after the operational side of value-based reimbursement model while providers concentrate on the clinical aspect.

Orthopedic Billing Specialist to Take Care of CPT Code Changes Made to Orthopedic Surgery Billing in 2013

This year’s CPT Manual has spelt out extensive coding changes and revisions to orthopedic surgical codes.  In all, there are 500 code changes to the Category I codes, including 251 revisions, 151 new codes and 100 deletions. Moreover, there has been significant overhauling of nerve conduction studies, some revisions to the radiology section, and E/M changes. The extent of these coding changes and revisions, having already taken effect from January 1, 2013, has begun to impact orthopedic reimbursements in a big way. As a result, orthopedic practices may have inherited an ominous task of migrating to   a higher order in orthopedic surgical coding. Given the CPT Manual’s full list of revisions, deletions, and additions to have been effected for 2013, orthopedic practices would require to be conversant with the guidelines for the following coding sections:

Spine CPT Errata, whereinchange has been added to the spine bone grafts (20930–20938), instrumentation (22840–22844, 22848, 22845–22847), and intervertebral device (22851) CPT codes.

Bone marrow aspirate, wherein explanation has been added to bone graft codes (20930–20938) related to bone marrow aspiration. Henceforth, Category III code 0232T should be used when bone marrow aspiration is performed for platelet-rich stem cell.

Cervical Spinal Arthrodesis, which is now required to be coded as per the new guidelines issued to CPT codes 22554, 22585, 63075, and 63076

Cast application, which now includesguideline changes made to “Application and Strapping” section addressing the application of the first cast, its removal, coding by the individual who performs the initial service, and restorative management.

Hip arthroscopy, under whichCPT code 29916 (Arthroscopic labral repair of a torn labrum) is now considered inherent to CPT codes 29915, 29862, and 29863.

Chemodenervation, in which a new guideline change is introduced for CPT code 64614 used in  Chemodenervation of muscle(s); extremity and/or trunk muscle(s)

Intraoperative nerve monitoring is now included in the primary surgical service and is not separately reportable.

New CPT codes applicable to procedures for spine, shoulder arthroplasty, elbow arthroplasty, nerve conduction, extracorporeal shock wave: wound healing, etc.

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While these are some of the notable changes and guidelines to have been effected for orthopedic surgical coding since the beginning of 2013, orthopedic practices may need to follow these action steps to be fully compliant with the changes and revisions:

• Analyze the 2013 CPT Manual in its entirety to understand the guideline changes found throughout it. Specifically focus on the E&M changes and new codes that may have applicability to your practice.
  
  
• Revise charge capture tools, electronic health record (EHR) lists and short lists or favorites, if charge capture is performed within the EHR.
  
  
• Enroll with an accredited orthopedic surgical coding course.

Medicalbillersandcoders.com – which has always stood by the physician community during times of medical billing and coding crisis – has arranged for networking with the right resources (orthopedic coding specialists) to maneuver through this major surgical orthopedic coding changes and revisions. The competence and experience of our select pool of surgical Orthopedic Billing specialists should help you minimize the impact of this coding change and revision while ensuring appreciable increase in orthopedic reimbursements.

Negotiating Your Reimbursement Rates during this Phase of Payer Consolidation & Health Insurer Monopoly Power

Physicians’ choice of health plans and contracts seem to be getting fewer and fewer with each passing moment as U.S. health insurance sector, particularly the private sector, witnesses unprecedented payer consolidation, acquisitions, and mergers amongst private health insurance carriers. Besides contradicting the hope that such consolidation, acquisitions, and mergers would bring down the cost premiums for patients, it has virtually helped a few players to wield monopoly over the entire commercial health insurance landscape. The situation has grown so unchecked 70 percent of 385 metropolitan areas in the U.S. do not have competitive conditions, and as much as 40 percent of these areas have a single health insurer controlling the majority share of the commercial health insurance market. As a result, physicians have virtually lost the bargaining leverage that they would have enforced had there been a perfect competitive market for commercial plans.

Physicians only source of revenue is from reimbursements from services they offer to patients, who may be supported commercial health insurance plans or public programs, such as Medicaid and Medicare. With most of the commercial health insurance market moving toward monopoly, physicians, mostly those practicing in small groups, are finding it difficult to negotiate adequate reimbursements. As a result, those insurers with monopoly powers are dictating the payment rates, which are often below the acceptable scale. Such unilateral administration of payments could leave physicians struggling to meet their financial obligations, obligations, including payroll, and to invest in and sustain desirable quality of medical care to their patients.

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Even the thought of accepting public insurance plans may not prove to be all that profitable – most of the patients may not have the resources to pay for out-of-pocket expenses well above the rates borne public programs, such as Medicare and Medicaid, whose rates are deemed insufficient to cover for a decent quality of medical cost. Thus, small physicians are often left with no choice but to accept rates dictated by dominant commercial insurers.

While the physicians associations have voiced strong protest against health insurer consolidations, in particular, mergers between two health insurers which threaten to create a single insurer with absolute power, it may take a while to disintegrate the trend towards a competitive market that can bring back bargaining power to physicians and patients alike. Till such time, physicians may well have to be content with rates as fixed their commercial payer. Alternatively, they can entrust their Medical Billing processes to an external entity that can use its competence and experience to arrive at as profitable a rate as possible. 

Medicalbillersandcoders.com – which has been a preferred platform for comprehensive medical billing resources – can help physicians impacted with the trend of commercial insurance consolidation. Our nation-wide affiliation with chosen pool of medical billing experts helps us to deploy resources that enhance medical billing efficiency, reduce the possibility of delay, denials, and improve practice revenues. Their expertise and experience could easily be extended for negotiating as best a reimbursement rate as possible even at this juncture of commercial payer monopoly.

How best are medical practices prepared to address HIPAA breaches?

Contrary to the notion that government’s move to digitize healthcare information would enable healthcare providers, doctors, and insurance companies comply more aptly with HIPAA’s guidelines for patients’ privacy and security, there has been an upsurge in HIPAA breaches with providers being reported for breaches of some kind or the other. Electronic Health Record (EHR) systems, which are made mandatory for providers seeking to attain ‘Meaningful Use’ status, have shown propensity to be manipulated either internally or by unscrupulous external elements. Either way, providers have been held accountable and penalized for breach of HIPAA’s mandate for ensuring patients’ information safety and security. With the cost data breaches being unbearable and providers or doctors’ credibility at stake, it is inevitable that HIPAA breaches are responded instantly with remedial measures, such as:

• Replacing or removing the staff that may have committed the violation at a particular EHR access point. If the HIPAA breach is traced to an external attack, EHR access may need to be secured against all possible external threats such as hacks or thefts by manipulating EHR system passwords.
  
  
• Parallel recommendation to improve the HIPAA program; an intrinsic part of such improvement program would necessarily mean reframing EHR policy and staff training or reorientation in accordance with changing EHR environment.
  
  
• Apprising your EHR vendors of the need for better customizing the EHR systems so that you may possibly withstand any kind of threats to patients’ health data.
  
  
• Establishing protocols for tasks, timelines and communication among the team to ensure everything on your EHR system runs as smoothly as possible.
  
  
• Accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity and availability of electronic protected health information (EPHI).Irrespective of the compliance requirements, it is important that scope of the assessment is clearly defined, and communicated across the staff entrusted with the responsibility of conducting healthcare data in accordance with ‘Meaningful Use’ criterion under HIPAA.
  
  
• Determining how personal health information (PHI) and electronic personal health information (EPHI) are received, stored, transmitted, accessed or disclosed.
  
  
• Documenting HHS, which will require the analysis in writing, including material gathered and the corrective actions took to remediate problems uncovered by the assessment. The significance of such reports is that they act reference as well as proof during audits or verification by authorities.
  
  
• Conducting periodic risk assessments to mitigate the possibility of a potential data breach.

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While providers or doctors may have some form mechanism to respond any case of healthcare data breach or violation, it may not always possible for everyone to have comprehensive set of measures, working to put their EHR systems compliant with HIPAA audits. Therefore, they may have to seek external help to keep eternal vigil on their data systems.

And, when it is the question of sourcing resources for such an array of data-related tasks, Medicalbillersandcoders.com offers to mediate for the deployment of best resources that have demonstrated expertise and experience in implementing secure and HIPAA compliant healthcare data management systems and processes.

What Do Stage 2 Meaningful Use Guidelines Have in Store for Radiologists?

Stage 2 meaningful use guidelines are finally out, and radiologists may heave a sigh of relief since most of the ambiguity that existed in Stage 1 about their eligibility and the ways to approach the qualification criterion seem to have been made amply clear by CMS and the Office of the National Coordinator (ONC). The American College of Radiology (ACR) needs word praise for its relentless effort in getting most of the necessary changes made to radiology guidelines before the Stage 2 meaningful compliance regime comes into force.  While it is not before 2014 that radiologists should complying with newly laid out guidelines, it may still require some crucial adjustments in processes and technology to be fully ready for compliance and qualification under State 2 of meaningful use criterion.

Even as the Stage 2 requirements offer clarity for how computerized physician order entry (CPOE) will impact radiology, providers would still be required to use CPOE to order more than 30 percent — instead of the 60 percent CMS originally proposed — of radiology procedures during an EHR reporting period in order to qualify for MU incentive payments. Therefore, the necessity of having an efficient and effective computerized physician order entry (CPOE) would still be there.

As regards the problem of complying with the MU requirements on account of rarity of face-to-face contact with patients, radiologists and other providers may get reprieve from noncompliance penalties, but still they would be required to be versatile with specialty codes use in the Provider Enrollment Chain and Ownership System (PECOS). And this proficiency in using the Provider Enrollment Chain and Ownership System (PECOS) would definitely require specialized training or they might have to appoint external coding specialists for the purpose.

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While Stage 2 rules do not require an EHR to store images, providers or radiologist would still be required to ensure that they an active link to the images. Despite the initially proposed linkage of 40% being brought down to 10% finally, it would still be quite a task to keep those 10% active as and when required for clinical study, interpretation, or sought by patients for various documentation needs.

Along with these inherent challenges, providers or radiologists may still have to sort out the issue with employing clinical decision support (CDS) as The Stage 2 rules to do not expand the definition of CPOE to include computerized decision support (CDS). Also, there may be issues with transporting images in the absence of clear cut rules even in Stage 2. While DICOM mode can be relied upon for secure encoding images,   IHE profiles, such as XDS-I and XDR-I would still have to be sent via secure email, which may sometimes be vulnerable to security and privacy threats. Therefore, it could require a dedicated monitoring to see that such files are not exposed to threats.

Amidst managing as critical a practice as radiology, complying with these set of Stage 2 guidelines for meaningful use might either be too demanding or detrimental to the very purpose of diagnostic or imaging excellence.  Medicalbillersandcoders.com – with an objective to ensure diagnostic or imaging excellence unaffected by Stage 2 demands – has offered to mediate the deployment of Radiology Billing specialists that have the requisite competence and experience to implement processes and technology on behalf of radiologists, seeking to comply with the Stage 2 guidelines, and qualify for incentives.