Showing posts with label healthcare adminisration. Show all posts
Showing posts with label healthcare adminisration. Show all posts

Thursday, January 14, 2021

How membership medicine fits into a post-COVID medical practice

Finally, 2020 has come to end, and though there appears to be a light at the end of the tunnel, there is still plenty of work to be done.


Primary care physicians and specialists, along with their staff, have been on the front lines of everything from shut downs, to managing COVID-19 patients, to ensuring that patients with chronic conditions aren’t neglecting their health. It hasn’t been easy, and it hasn’t been lucrative either. There are important takeaways from 2020 though, and physicians should consider them in 2021 to improve their medical practices and patient relationships.


Telemedicine


If a physician has a strong relationship with their patient, there is much that can be accomplished over the phone. The key is the development of a relationship based on trust. If the physician knows the patient, their typical health challenges and state of mind, many issues can be triaged virtually.

This works in reverse as well. When a patient isn’t well and feeling vulnerable, they aren’t comfortable calling the 1-800 number on the back of their insurance card for an on-call nurse. They want the doctor who knows them, and who they trust.



Alternate Revenue Streams


When office visits and elective procedures virtually dried up, it became apparent that doctors needed a way to generate revenue outside of these reimbursements. An alternate revenue stream can be a lifeline for a practice, helping them withstand a crisis like COVID-19. It can also help buffer the ever-increasing financial pressure smaller practices are facing every day, even outside of shutdowns.


The Doctor/Patient Relationship


Never before has the value of a personal relationship with one’s physician been more important. Seniors, often living far away from their adult children, need the security of knowing they have someone looking out for them. The idea of waiting on line at an urgent care clinic during a worldwide pandemic was unthinkable for some. A comfortable office visit, where they are ushered into a private room quickly and safely can make the difference between being seen and neglecting their health.

There were some medical practices that had these systems in place and had the tools to survive what 2020 threw at them. Physicians that offered concierge medicine, either in full or in part, had the ability to treat patients conveniently on the phone, continue to earn stable revenue, and provide comfort and peace of mind to anxious patients.

“I never expected to have my established concierge practice benefit me as much as it has in the last six months of this pandemic,” said Glenn Soppe, MD, a primary care physician in Encinitas, California. “We had three months of very low patient visits and related billings. We are pretty much back to normal volume now and have been able to have an almost normally functioning, virus-safe office since July 1st.”

Dr. Elizabeth Halibuk, with a practice in Fairfax, VA agrees. “I have never been happier to be a concierge physician than I am right now,”she said.


The current health crisis may slowly diminish in the coming months, but the need for convenient telemedicine and strong, stable medical practices that can put patients first will not end. The crisis has illuminated this need, and membership in concierge programs is growing and will continue to grow. The key in 2021 is finding the membership model that will complement your overall practice and support your patients.


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Monday, August 17, 2020

Medical Coding: Consult notes, hospital admit code disagreement, and video complexity vs time

Q1. Some insurance companies have started not paying us for consults when they request notes and they don’t see the CC statement showing that the requesting provider received a copy of the note.

What if we create a part of the EMR that says ‘a copy of this note is stored in a shared chart with the referring provider therefore a hard copy is not being sent’. And do you know if they are going to keep paying for these in 2021?


A1. Yes, one of the requirements for consults is that ‘the findings are documented in the patient’s medical record and communicated by written report’, and a payer could deny if they can’t see this element. But don’t assume that an automated and generic one liner as you’ve indicated above will necessarily meet the requirement.

There are several things to consider: 1) If this becomes ‘part of the EMR’, then it could easily end up being used on new patient and other visits and quickly become ‘wallpaper’ and somewhat meaningless since it’s on everything, and 2)–This would only work for MDs in the same group or in the same EMR, and 3) It’s generic – and they like specific – ‘by written report to the requesting physician’ - not just ‘stored in the EMR’.

They’d much rather see some specific reference to an action taken – that the note was sent, faxed, tasked, shared etc. with Dr. X – that’s part of what the extra payment associated with these is for. The idea that there is an EMR ‘solution’ to every requirement is part of the reason the notes have become so bloated – lot’s of generic disclaimers and references intended to ‘cover’ a multitude of requirements. But they don’t really.

This one-liner also has the ‘referring’ provider language – which doesn’t always mean a consult as we know. The best advice is to get rid of referring language and actually require your providers to at least ‘fill in the blanks’ on something – ‘This consult report has been made available in the EMR to Dr. X in response to their consult request.’ And we don’t want to see it on new patients!

As to your second question – Are consults still going to be paid? – this is pretty clearly in the hands of the private payers. The AMA’s CPT manual has continued with these codes for over ten years after Medicare and most governmental payers stopped paying them, but it seems that every passing year another major payer either drops them or tries to limit payment for them. I wouldn’t bet on them long-term, the payer trend seems to be steadily away from them.


Q2. Our coders have a disagreement about the use of the hospital admit codes. CMS states that more than one provider may bill Initial Hospital Care as long as they are of a different specialty and the billing diagnosis is different. I was also able to find reference to this same guidance in the AAPC Procedure Desk Reference. However, the CPT Code book continues to state that only the admitting provider may bill for those Initial Hospital codes and all others must bill Subsequent Hospital Care Codes. So which one is right?

A2. Good question, it would seem that the AMA and CMA are saying opposite things – but they are both right in their own way. It's just that AMA /CPT doesn't take into account CMS's payment policy of using the 99221-99223 codes to cover the inpatient consults that they don’t pay for. So AMA’s guidance is a coding rule that applies to those ‘initial hospital care’ codes in their intended use as ‘admit’ codes. What CMS is showing you is essentially a payment policy that as above really accounts for different specialists using the ‘admit’ codes to represent their initial inpatient consults. Sometimes it hard to sort out coding rules versus more billing or payment-oriented guidance.



Q3. Can you clarify the guidelines for coding 99213 vs 99214 on complexity vs time? After the COVID waiver to expand video visit coverage I was advised that billing for video visits was based strictly on time. I have certainly had some Level 4 visits based on complexity of decision making but that last less than 25 minutes needed for Level 4 based on time.

A3. So whether it's a Telehealth visit with audio/video or a face-to-face office visit, at least for the duration of the PHE either vector allows you to code by total time or by the level of medical decision-making (MDM) alone.

As you may know this is also how the codes 99202 - 99215 will work starting in 2021 - time or MDM. That time being the MD time (attending time) and that time including some pre and post encounter elements not previously included (such as the time it takes you to type your note).

Back in March/April CMS had announced these upcoming 2021 rules would be in effect during the PHE. At this point, as 2021 draws near, we really don't see them going back to the 'old' way, although this is possible.

So in your scenario above, those visits that had (documented) moderate decision-making could have been billed as 99214's based entirely on that without regard to time. The EM office visits code have never been set up to have time as the key determinant of a code level. They had only allowed using coding by time as an option when certain circumstances led to the time becoming the predominant character of the visit, trumping as it were the level of MDM.

It is the online codes 99421 – 99423 and the audio only telephone codes 99441 - 99443 that must be coded based on the time involved. Maybe that's what you were thinking of.


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Thursday, August 22, 2019

Assess whether acquisition makes sense for your medical practice

"We said yes because the hospital offered us a 'sweet deal.'"


This was said by a senior surgeon and long-time client who called to report that operational integration had taken a nosedive just a few short months after his practice was acquired. Patients were waiting for hours. The manager they'd brought along had just been fired. Staff struggled to use the hospital's billing system, which was not designed for practices. And established patients were outraged at the new "facility fee" charges.

The physicians had been so enamored of the financial aspects of the hospital's 'sweet deal' they didn't stop to consider the operational and cultural changes that came along with it. The result was a disaster that took more than a year to unravel.

If your private practice is solo or a small group, you've probably grown to appreciate the ability to more or less do what you want, how you want, and when you want. If you jump into acquisition for purely financial, or other wrong reasons, you may be in for a shock. Here are some questions for managers and physicians to ask before taking the leap.

1. Why are you making this move?


This is an essential question. "We want someone else to handle the business detail" is not a good answer. Frankly, if you are seeking acquisition because the physicians don't like the business side of the practice, they are in for a big surprise. The new masters of your practice's universe—whether a hospital or private equity group—are unlikely to let them off the hook. Have physicians neglected coding and documentation guidelines? Do they overlook report review and monthly meetings? All could spell trouble with a new owner.

2. Are you really ready to follow new rules?


Once acquired, you will be expected to act and comply with rules, protocols, and regulations. These include showing up on time, starting office hours as scheduled, and submitting charges promptly. And you'll need to follow all rules, even if they don't entirely make sense or are potentially detrimental, from the practice's perspective.

Our firm reviewed two orthopaedic practices where the acquiring hospital moved the X-ray unit out of practice suite and onto another floor. The orthopaedic patients had to “take a number,” because other specialists in the building referred patients to the X-ray unit too. Patients would disappear downstairs and sometimes not return until an hour later. Imagine what that did to the schedule! But the hospital now owned the machine and the revenue, so administrators made the rules.

3. Are you prepared to give up the business tasks you enjoy?


Some physicians appreciate being involved in certain business aspects; for instance, employee selection. But under a new regime, hiring tasks are the responsibility of human resources. Their assessments may differ from yours.

Think carefully about certain aspects of the practice's business affairs that you and the physicians truly enjoy. Maybe it's technology selection or clinical protocol development. Although you may have some input on these in a larger organization, it's unlikely you'll be a decision-maker.

4. Will you be able to tolerate organizational layers and little ability to impact decision-making?


You'll need to accept both in a large organization.

Consider the practice that had to abandon a customized orthopaedic software system for Epic. After years of using a technology platform that met their needs and had features they desired, Epic wasn’t as effective and slowed them down. But they had no choice in the matter.

In another case, the physicians' experienced practice manager was let go and the hospital filled the position with someone who was marginally competent and had no decision-making authority. This manager couldn't even address minor issues such as calling an exterminator. She had to call her manager, who had to call a director for approval. Meanwhile, there were bugs in the exam room. True story.

And, one frustrated doctor recalled being required to produce the same number of RVUs, but was given fewer exam rooms and less-skilled staff to do it.

5. Is this a culture you want to work in?


Make sure you consider the business and clinical philosophy, strategic vision, leadership, and governance issues of any acquirer you consider. The leading reason practices break apart and physicians pull out of hospital employment to return to private practice is lack of cultural fit. This hasn't changed in our firm's 30+ years of working with physicians. If you don't like the way the organization does business now, you'll like it even less when you are amongst its ranks. No amount of a 'sweet deal' can overcome the nagging feeling of being part of place that doesn't align with your personal philosophies or support your professional goals.

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