7 Recommendations to Avoid Audits

On Part II of HIPAA Risks Webinar by Liles and Parker, Atty's at law presented by AMBA, they offered some practical tips to avoid being audited and fined. Not many can afford the steep fines that are assessed by being found guilty of an offense because of carelessness or fraud!





7 recommended  Questions to ask yourself.




1.  Does the claim meet the Medical Necessity requirement for payment? This is the most important question to ask before submitting the claim. If it is not medically necessary to perform the procedure and if it does not meet this criteria, the claim will be denied. 

2.  Did you provide the service?  In order for you to get paid for what you did, you have to be the one to do the service.  The nurse practitioner cannot perform the service and you get the credit for it. If there is an audit, this can be a serious offense.

3.  Coverage Requirement  If you do not know what is covered, look it up in your contract. The service you provide could be medically necessary, but if it is not covered, you will not get paid. That is a waste of your time and resources, neither of which you can afford to squander away on uncovered services. Coverages will invariably differ from carrier to carrier. Make sure you and your staff know what is covered and what isn't. 

4.  Documentation  Know what documentation is required for which carrier. This can be another area in which  insurance carriers will quickly deny claims. Properly document!

5.  Proper coding Was it coded to the highest degree of specificity?  Was it the correct code for the procedure?  Were the modifiers correct? All of these coding issues can cause claim denials...which  can mean a decrease in your income if it continues regularly.

6.  Was it billed properly?   Was it bundled when it should not have been? 

7.  Was the claim legible?  Legibility is key!   Handwriting must be legible or claims will be denied.  If a carrier cannot quickly read the claim, it will be denied. If there is an error on a record, the best way to correct it is to draw a single line through the erroneous word(s) and put the correct word above it. Date and initial your changes. Do not try to make changes on someone else't entry.  That is a red flag for fraud alert!

If there is a pattern of incorrect claims submissions, audits are more likely to happen. This could lead to the loss of your practice, bankruptcy, or other disastrous effects.

Be Audit Free! Submit claims properly by using these recommendations.
Attorneys recommended the tips, after all.

Thanks for reading.

Donna McHugh, CMRS

7 Practical Ways to Avoid a HIPAA Breach

Because I am a certified medical reimbursement specialist, I must do 15 CEU hours every year in order to maintain  my certification with AMBA. Some of the CEU's that I am doing are on the subject of HIPAA Compliance and how serious it is to maintain it. In the webinar by Liles and Parker Law Offices, there were a number of warnings that I had not even thought about. Maybe you haven't, either.  I would like to pass along some insights that I learned.

One warning that was given is to have a compliance plan in place and make sure that you and your staff follow it. Because of the changes and the effects of the economy on states and federal programs, they are looking for an income source to fill in those gaps that were left by cuts in their budgets. Breaches are easier than before and may be considered fraud, so we all must be careful!

 Whistle-blowing is encouraged and is being paid handsomely from huge fines that are being meted out for non-compliance. This headline from today's post from AMBA says:

2012 Record Year for qui tam (whistle-blower) suits. $2.5 billion recovered of $3 billion total in fraud recoveries. 

                                                                  That is a lot of money!!!

As technology advances, there are a lot of ways to make our live easier, but technology does pose problems for security of personal information that must be protected.  It is much easier to commit a breach, sometimes unknowingly. One of the biggest areas of concern with HIPAA is protection of personal medical data.

Here are a few practical tips that I learned from the webinar.

1.  Don't store patient information on laptops. They can be stolen easily and a lot of

     information  compromised. If you do put information on a laptop, password and encrypt the 

     information. Even if the laptop is not stolen and you are very careful, you can still be 

     considered non-compliant and charged with huge fines if the information leak is traced back 

     to your computer.

2.  Do not use flash drives unless they are encrypted. Even then, they are easily lost, 

     slipped in a pocket or briefcase, and the information is gone!

3. Do not allow shredding companies to shred your documents  unless you 

    are present to make sure they are shredded properly and not just tossed into the landfill, 

    thereby unintentionally allowing access to information.  Your office can be fined for the 

    actions of a careless third party . 

4. Cellphone usage in the office should be limited. Nowadays, with the use of cameras on 

    cellphones, information can be quickly compromised and data sent over the web in a matter 

    of seconds. Be careful who has access to your records. Make sure the person is trustworthy. 

    You cannot be too careful with information.

5, Have a plan in place for social networking. ie. Facebook, LinkedIn,etc. Although they are 

    wonderful  communication and advertising tools, here is some advice concerning them.

                           a.  Never friend patients on Facebook. That is a breach of their privacy and

                                patient-doctor confidentiality.

                            b. Don't let patients "like" you on Facebook.

                            c. Never talk about your patients on the social network sites.

 6. Copy machines have hard drives in them and they store the information which is 

     scanned. Make sure to turn off those settings so that it does not save your information when 

      you scan them on the copier.

7.  Completely erase old phones and destroy. Do not recycle. There are ways to restore 

     data on phones...and if the phone is traced back to you, your messages, although deleted, 

     may be used in a breach case. The best way is to totally destroy the phone so that there is 

     no way that the information can be restored or retrieved. 

There is so much more that could be shared on this subject, however this is only the tip of the iceberg. We as healthcare workers have to be so diligent to protect information. The more you educate yourself, the better  your chances are of staying away from non-compliance problems.

Protect yourself from a fine or lawsuit. Be informed. Know the laws and comply.

Thanks for reading.

Donna McHugh, CMRS

The ICD-10 Timer is Ticking

The deadline of October 2014 is getting closer and now is the time to prepare. Some changes will take place this October. Are you ready?

 The ICD-10 changes will affect more than just the inpatient and outpatient coders. Its effects will be far reaching. Now is the time to prepare. We should not be waiting until the last minute. 

In order for this to happen, billing forms were updated, EDI formats were updated to 5010.  Vendors, hospitals, clearinghouses, physicians offices and other healthcare providers have to make changes in their systems and update equipment, software, and educate their employees.  It is an overwhelming task if the provider waits until the last minute.

The changes will be like learning a totally different language and culture in a short time. It will take a transition time. CMS has established guidelines to help us prepare to learn the new language. There has to be a learning curve. If the education and implementation are delayed, it will affect the cash flow ultimately. 

According to a survey by CMS called, "Version 5010 and ICD-10 Readiness Assessment" 

Those participating in the survey were:

•  404 health care providers, (including hospital and pharmacy chain administrators and health care practice managers)
• 101 payers, (including directors or higher at health insurance companies, managed care organizations, and pharmacy benefits managers)
• 90 vendors, (including managers at health IT system developers, billing services and clearinghouses)

The results:

Providers

• 83% percent of providers indicated they were aware of the upgrade to Version 5010.  
• 81% percent of providers indicated they were preparing for the upgrade.
• 93% Providers  in  large practices aware of Version 5010
• 96% large practice settings  were taking steps to prepare for the Version 5010 upgrade.
• 80% smaller practices were aware of the changes.
•  75%  of small practices were preparing for upgrades.

• 85% of large hospitals were aware of the 5010 upgrade while
• 80% of small hospitals were aware.
• 84% large hospitals and small hospitals are preparing for the transition.

When it came to the changes with ICD-10 transition, 

• 87%  ICD-10 codes of providers were aware of the changes.
• 78% were aware of specific deadline for compliance . 

 Deadlines

• 75% were aware of the specific deadline for the upgrade.
• 64% said they think their organization will be compliant by the deadline. 

  

To further complicate matters, while the providers are scrambling to educate and train their employees and staff, the payers and vendors are also doing a lot of educating and preparing for 5010, !CD-10, new CMS-1500 forms, etc. to accommodate changes. 

Payers (including directors or higher at health insurance companies, managed care organizations, and pharmacy benefits managers)

• 79%  of payers said they were aware of the upgrade to Version 5010 
• 81%  are aware of the deadline for the upgrade.
• 87%  were aware of the upcoming transition to ICD-10 codes.
• 83%  were aware of  the deadline for compliance.   
• 87%  were preparing for  Version 5010. 
• 80%  said they thought their organization would be compliant by the deadline.
• 88%  said their organization was taking steps to prepare for the ICD-10 transition and   they believed they would be compliant by the deadline. 

Vendors  (including managers at health IT system developers, billing services and clearinghouses)

• 85% percent  indicated they were aware of the upgrade to Version 5010. 
• 84% are preparing for the Version 5010 upgrade.

• 75% said they are aware of the deadline for the upgrade.
• 83% of vendors also said they are aware of the upcoming transition to ICD-10 codes.
• 78% are taking steps to prepare for the ICD-10 transition. 
• 72% are aware of the the deadline for compliance .
• 75 % said they thought their organization would be compliant by the deadline.

By the numbers indicated from this study, the majority of medical providers, payers and vendors are preparing for the deadline for implementation, however some are not. This survey was completed in Dec. 2011. Time has passed since then, but there still may be those who are overwhelmed and not wanting to go to the expense of upgrading. However, the inevitable is happening and those who are ready will transition smoothly. But, if you lack the knowledge and skill, you will essentially be left in the dark ages.

So, what can you do?

Providers:

• Make sure your billing and coding departments/ or outsourced company are prepared by having the education they need to transition. 
• Make sure that your clearinghouses and IT systems are ready.
• If your  billing software and clearinghouse is not ready, find one who is prepared.
• Remember, if the support staff is ready, there will be loss of income to you on a daily basis because your claims will be aging.

Billers and Coders

• Make sure you have the proper tools and training to be able to make the transition smoothly.
• Make sure that that your provider is ready. You may need to educate front desk staff as well as the provider when to learn what is needed for the transitions. 
• The superbills will have totally different codes. Make sure the provider has the new codes ready by the deadline.
• Learn all you can! If billers do not know the ICD-10 codes, now is the time to learn them so you can read the proper charges to submit for services. 

The more we are all informed and plans for upgrades are implemented, the better it will be for all of us in the medical community. The changes are coming. Get Ready!

Thanks for reading.

Donna McHugh, CMRS

Resource:

www.cms.gov "Version 5010 and ICD-10 Readiness Assessment" 

Affordable Care Act Pros and Cons

According to the Health  Health and Human Services (HHS) Secretary Kathleen Sebelius announced (March 2013) that

 71 million Americans in private health insurance plans received coverage for at least one free preventive health care service, such as a mammogram or flu shot, in 2011 and 2012 because of the Affordable Care Act. 


Additionally, an estimated 34 million Americans in traditional Medicare and Medicare Advantage plans have received at least one preventive service, such as an annual wellness visit at no out of pocket cost because of the health care law.

Taken together, this means about 105 million Americans with private health plans and Medicare beneficiaries have been helped by the Affordable Care Act’s prevention coverage improvements.

According to this report:

The Affordable Care Act is giving Americans better value for their health insurance plans by:

• Eliminating lifetime dollar caps on essential health benefits, and phasing out annual caps. 
• Prohibiting health insurance companies from denying coverage to children based on a pre-existing condition, such as asthma or cancer.
• And in 2014, it will be illegal for health insurance companies to deny coverage to any American or to charge more because of a pre-existing condition.  No longer will 129 million Americans with health conditions have to fear seeing their premiums increased or getting locked out of the insurance market.
• The law will also make it illegal for a health insurer to charge women more simply because they are women. “That means,” Secretary Sebelius said, “being a woman will no longer be a pre-existing condition.”

But is the Affordable Care Act really a good thing for Americans?

Some think not. There are a lot of different areas of healthcare that will not improve.

• There will be a shortage of healthcare professionals. 

 A new study by the National Monitor predicts that the implementation of the PPACA, coupled with the nation’s aging population, could lead to a shortage of 52,000 primary care physicians by 2025.

The study also noted that office visits to primary care physicians will likely increase from 462 million to 565 million by 2025, further straining the system.

The shortage will be made worse by funding cuts for residency programs for newly graduated physicians. Without the hands-on training, quality will suffer. Residency is vital to the success of doctors of all specialties.

Higher drug costs. Pharmaceutical companies will pay an extra $84.8 billion in fees over the next ten years to pay for closing the "donut hole" in Medicare. This could raise drug costs if they pass these fees on to consumers.

Obamacare does not apply to businesses with less than 50 employees. Larger businesses are required to offer health insurance, but receive tax credits to help employees pay premiums. In 2014, the tax credit increases to 50%.

Higher deductibles and fines to poor Americans.  Those who don't purchase insurance, and don't qualify for Medicaid or subsidies, will be assessed a tax of $95 (or 1% of income, whichever is higher) in 2014. It increases to $325 (or 2% of income) in 2015, and $695 (or 2.5% of income) in 2016. 

Employment and benefit losses.  Even now employers are making tough decisions. People who have  been full time workers are being reclassified as part-time workers and as a result are losing benefits. The employers cannot afford to pay insurance premiums for their employees. Some are changing to a higher deductible plans for families. That means more hardships for families as they, too, are making tough choices.

Between 3-5 million people could lose their company-sponsored health care plans. Many businesses will find it more cost-effective to pay the penalty and let their employees purchase their own insurance plans on the exchanges. Other small businesses might find they can get a better plan through the state-run exchanges. 

ObamaCare is going to be about more than making healthcare choices. It is going to affect our everyday lives because of job losses, less hours, and reduced benefits, higher deductibles and co-pays...and the list goes on.

So, while the government says The Affordable Care Act is a good thing, many disagree and are forced to make difficult decisions that will affect many for generations to come.

Thanks for reading,

Donna McHugh, CMRS

Resources:

 http://www.healthcare.gov/law/timeline/full.html

http://aspe.hhs.gov/health/reports/2013/PreventiveServices/ib_prevention.cfm

Healthcare.gov 

(Source: CBO CBO Report on Health Care Reform and the Budget; Wall Street Journal, What Health Insurance Ruling Means, June 28, 2012; NPR, Medicaid Expansion, June 27, 2012)

Obamacare Cons

( Washington Post Factchecker, Tax Breaks vs Tax Hikes, July 6, 2012)

Many Changes in Healthcare Forms

The year of 2013 will be a year of huge changes in the healthcare community! 

Are you ready for them? With the passage of the Affordable Care Act, huge changes have happened in the world of Medicare, Medicaid and Commercial Insurances. This has made it extremely important that the medical billers and coders are particularly aware of the changes that will affect the way that they do their jobs. Now is the time to be learning and implementing as much as possible.

The physicians and other healthcare professionals are already facing huge changes in their offices as they transition to EHR systems. Whether good or bad, these changes have affected the way that healthcare  is being done in our world. It is up to those of us who work in the healthcare professions to stay abreast of what is happening. 

One of the biggest changes is the implementation of ICD-10. United States will be transitioning to the ICD-10 because we are the only country that still uses ICD-9 and it is creating confusion with the global healthcare insurance marketplace.

According to CMS, the implementation date is October 1, 2013. This chart from AAPC shows some of the challenges that coders will be facing. 

Issue	ICD-9-CM	ICD-10-CM
Volume of codes	approximately 13,600	approximately 69,000
Composition of codes	Mostly numeric, with E and V codes alphanumeric. Valid codes of three, four, or five digits.	All codes are alphanumeric, beginning with a letter and with a mix of numbers and letters thereafter. Valid codes may have three, four, five, six or seven digits.
Duplication of code sets	Currently, only ICD-9-CM codes are required. No mapping is necessary.	For a period of two years or more, systems will need to access both ICD-9-CM codes and ICD-10-CM codes as the country transitions from ICD-9-CM to ICD-10-CM. Mapping will be necessary so that equivalent codes can be found for issues of disease tracking, medical necessity edits and outcomes studies.

In order to accommodate these changes and the others made recently in the healthcare system, the CMS-1500 Health Insurance Claim Form is being updated. Not only will coders have to learn a different system, but so will medical billers! 

The new form will have a number of changes. And the implementation date is the same day as the ICD-10 implementation date. October 1, 2013!  You can find those changes at: http://www.nucc.org/

Here is just a sampling of some of the changes.

• Item number 1-- Deleted "CHAMPUS" and changed (Sponsor's SSN) to (ID# DoD#).
• Item number 8-- Deleted "PATIENT STATUS" and content of field.
• Item Number 14-- Changed title to "DATE IF CURRENT ILLNESS, INJURY OR PREGNANCY (LMP), Removed the arrow and text in the right-hand side of the field. Added "QUAL." and a vertical, dotted line to accommodate a 3-byte qualifier.

The NUCC recommended timeline for transitioning to the 0212 version of the 1500 Claim Form is as follows:

June 1, 2013 – Health plans, clearinghouses, and other information support vendors are ready to handle and accept the revised (02/12) 1500 Claim Form.

June 1 – October 1, 2013 – Providers can use either the current (08/05) or the revised (02/12) 1500 Claim Form. Health plans, clearinghouses, and billing vendors are able to accept and process either version of the form.

October 1, 2013 – The current (08/05) 1500 Claim Form is discontinued; only the revised (02/12) 1500 Claim Form is to be used. All rebilling of claims will be on the revised (02/12) 1500 Claim Form from this date forward, even though earlier submissions may have been on the current (08/05) 1500 Claim Form.

There is still time to learn about these changes. The more informed you are, the easier the transition will take place in your office. 

Here's hoping that all of the changes will go smoothly for you.

Thanks for reading.

Donna McHugh, CMRS

Resources:

http://www.aapc.com/icd-10/faq.aspx#what

http://www.newmedicalforms.com/revised-cms-1500-02-12-claim-form-1/

www.cms.gov

The Daily Buzz, April 16, 2013, Larry Weston, AMBA,

www,nucc.org

Do We Need A Navigator?

What is a Navigator and What do they have to do with healthcare?

In the new legislated changes in healthcare, confusion is reigning! CMS has announced the creation and funding for Navigators.  What are they and how will they help us navigate the rapid changes not only in laws, but in billing and adjustments in physician reimbursement.

The Centers for Medicare & Medicaid Services (CMS) announced the availability of new funding to support Navigators in Federally-facilitated and State Partnership Marketplaces.

"Navigators are individuals and entities that will provide unbiased information to consumers about health insurance, the new Health Insurance Marketplace, qualified health plans, and public programs including Medicaid and the Children’s Health Insurance Program."

How are they going to help?

“Navigator” program will help consumers understand new coverage options as they enroll in new Marketplaces. (The marketplace meaning: mandated insurance coverage for all Americans.)

What's the problem?

According to CMS, Navigators will be a valuable resource funded with $54 million dollars! 

Wait a minute! Where did that money come from?  Weren't physicians reimbursements cut by 2%  beginning last week?...  That 2% cut will have a huge trickle down effect causing the physicians to make difficult decisions.

• There is huge potential for job loss because the physician will not be able to afford to keep all of his staff.
• The physician may not be able to pay for the benefit packages that his staff once enjoyed. They may have to choose insurance plans with higher deductibles and co-payments for their workers. 
• The physicians and their patients are going to be making a lot of  difficult choices in the days ahead. Some of those decisions will affect the quality of life especially for the aged and disabled, the poor and underemployed. 

Hmmm! How are the Navigators going to help clear up this confusion? Will they have solutions with the common good in mind? October is coming.   We will have to wait and see.  

Thanks for reading.

Donna McHugh, CMRS

Resources:

April 03, 2013 and April 09, 2013 Press Releases CMS Announcements

http://www.cms.gov/apps/media/press/release.asp?Counter=4576&intNumPerPage=10&checkDate=&checkKey=&srch

What's The Big Deal About A 2% Cut?

                              What is the big deal about a 2% cut in Medicare spending?

Actually, this is the question on the minds of a lot of people today. Two percent doesn't sound like much, but in an economy of rising unemployment, foreclosures, and rising fuel prices it means a lot! The results can be far reaching and devastating causing the financial situation in this country to worsen for several reasons. Let's take a look at some ways that it will affect your practice or business. 

According to an article written by Mark Crane on medscape.com, this 2% cut could lead to job losses in the healthcare industry.

"Earlier this week, American College of Physicians President David Bronson, MD, told Medscape Medical News he 

worries about the deleterious effects of budget cuts for agencies such as the Centers for Disease Control 

and Prevention, the US Food and Drug Administration, and the National Institutes of Health. A report released 

jointly by the American Medical Association, the American Hospital Association, and the American Nurses Association 

found that:

"766,000 healthcare and related jobs could be lost by 2021 just
because of a 2% cut in Medicare payments."

It is a steep and vicious cycle downward both for the physician, healthcare workers, support staff and patients.

"Overall, the cut will mean $11 billion less for doctors, hospitals and other providers in 2013. "One in five Medicare patients already is facing difficulties in finding a doctor to take them. If you cut their pay, this access problem will only get worse."
The threat of payment cuts isn't new for doctors who treat the nation's 47 million Medicare patients." 

• If you cut the physician's pay, they are going to look at alternative ways to make up the difference so that they can stay in business. 
• The doctor may be faced with the decision of staff cuts. Who would be let go? 
• The work load will increase on his already overwhelmed staff. 
•  Up-coding or bill fraudulently for services not rendered are a greater temptation.

 Possible Solutions:

• Outsource medical billing to a reputable medical billing company. Research proves that this is a viable option because you would be saving money on office space, utilities, professional fees, insurance premiums, vacation pay, etc. This option could save thousands of dollars annually.
• Maximize income by minimizing lost revenue through re-submission of unpaid claims, rejected claims, etc. There is huge loss of revenue from simple errors that may be time consuming, but worth the effort in reimbursement.
• Refuse to treat Medicare/Medicaid patients. That is a trend across the nation, but it will not help in the long run. Yes, their payments may be much smaller than the commercial insurers, but it still is a source of income! Small amounts do add up in time.

That brings us to another effect of the Medicare cuts... the elderly patients on fixed incomes who come into your office. Many of them are facing financial strain already because of added responsibilities of raising grandchildren or helping their children who lost jobs and homes because of the downturn in the economy. They are paying more for their medicine to sustain their quality of life and they trust you as their doctor to provide the care that they need. When you turn them away because it does not seem financially feasible to continue their care, you are turning away some little grandchild's future with their grandmother or grandfather. They are forced to make tough decisions that may be ultimately detrimental to their health. 

• If you do not treat them, they may be forced to find a doctor with much less expertise than you have. They lack the patient rapport that you have.
• The patients are less likely to tell a new doctor everything because they do not trust him or her fully. This can be medically devastating!
• They are not as likely to seek healthcare for early prevention of diseases such as cancer, heart disease, and other silent killers. 
• They may not purchase the needed medications because they can't afford them, thus causing  preventable illness or death.

By eliminating the Medicare and Medicaid patients, that leaves you with self-pay customers, commercial insurance beneficiaries and military or worker's compensation patients. Here is the problem. 

• The self-pay are un-insured and may be slow pay so you end up writing their bills off unless you have a very good medical billing specialist and collections agency.

• The commercial insurer beneficiaries still have co-payments and co-insurance payments. If their policy is at 70/30 or 80/20, you still need to collect those percentages.  

So, you can see that the 2% cut does make a big difference overall. There are a lot of tough decisions that physicians must make, but the right ones could lead to better quality of life for your patients, financial health for your practice, and overall peace of mind.

Thanks for reading.

Donna McHugh, CMRS

Resources:

1.  http://money.cnn.com/2013/03/02/smallbusiness/medicare-doctors-spending-cuts/index.html

2.  The Daily Buzz, Larry Weston AMBA,  Article: CMS describes how sequester will be applied to Medicare payments

3. .http://www.huffingtonpost.com/robert-kuttner/us-budget-cuts_b_2850554.html

4.  http://www.medscape.com/viewarticle/780133  CMS Now Says Sequester Medicare Pay Cut to Kick in April 1
by Mark Crane