The switch to ICD-10: Are you ready?

Transcription

1

2 healthcare insider Spring 12 The switch to ICD-10: Are you ready? The switch from ICD-9 to ICD-10 for diagnosis and inpatient procedure coding becomes a requirement on October 1, That gives private practice physicians over a year to prepare. But brace yourself: ICD-10 contains 51,000 more codes than ICD-9 did. Better analysis ICD-10 contains more than 68,000 codes altogether and accommodates a host of new diagnoses and procedures. This greater coding detail enables better analysis of disease patterns and a wider variety of potential treatment outcomes that can improve care. In addition, ICD-10 will help you streamline claims submissions, which means initial claims will be easier for payors to understand. The ability to report laterality might actually decrease denied claims. The challenge is to train clinicians to document the highest level of specificity to code accurately, and for your staff to accurately process all ICD-10-based claims. Transition team Your top priority: Create an ICD-10 transition team even if it s only one or two people. Appoint a lead person who has credibility among all the functions likely to be involved in the effort, such as clinical, administrative, IT and billing. Then assemble a team of practice members who can prepare, use and transmit ICD-10 coded data. When the team has defined its objectives, it should develop appropriate metrics for measuring progress. One of the first tasks should be to conduct a gap analysis that answers the questions Where is the practice now? and Where do we want it to be on October 1, 2013? The difference between those answers will define what must be accomplished. The analysis will require several subtasks, such as identifying the systems, software applications and vendors affected by ICD-10 and detailing how they re affected. In addition, the team should look at ICD-10 s impact on the practice s work processes and flows. Third parties Another key task for the team is to acquire information from pertinent third parties about their roles in the ICD-10 switch. Don t acquire the necessary software and hardware until you ve contacted everyone involved. Major players include: Software vendors. Will they be upgrading applications to accommodate ICD-10? To facilitate the transition, will they support ICD-9 and ICD-10 simultaneously for a while? Are the software upgrades likely to require hardware or network upgrades, such as more powerful computers or file conversions? How much lead time will there be for testing the upgrades before the 2013 compliance date? Clearinghouses and billing services. What are their plans and schedules for conducting ICD-10 testing with payors? By what date will they be able to accommodate ICD-10? How soon will they be able to receive test transactions from providers and what will the process be? Payors. A few payors usually represent the bulk of a practice s revenues. Ask them about their ICD-10 conversion plans and what their implementation timelines look like. Testing and training Consider conducting a short training session immediately to introduce practice staff to the ICD-10 deadline and its implications. Then gather the relevant information and prepare a step-by-step implementation plan tied to a timeline and backed up with sufficient resources of money and personnel. Don t delay. Putting off these tasks will only make the transition more difficult and expensive. When your software is eventually upgraded or replaced, new hardware is installed, and work processes are reshaped, test the system to ensure it can generate ICD-10 codes, claims, and data accurately and reliably. Once you re confident in its ability to generate ICD-10 codes as regularly as ICD-9 codes, work with your reimbursement partners to begin external testing. Its purpose should be to determine the ability of clearinghouses, billing services and payors to receive ICD-10 coded test claims from the practice. All partners should be willing to confirm receipt of compliant claims and report any deficiencies in the transaction. When conducting the testing, provide extensive, job-specific training of physicians and staff particularly those whose positions entail extensive use of coding data. Make sure you include a general training program for reminding all staff of the importance and practical details of ICD-10 coding. Ready or not All physician practices must develop a forwardlooking strategy to meeting the ICD-10 deadline. If you re not ready to make the change by October 1, 2013, you won t be able to file acceptable claims and may not receive timely reimbursement for services. As a final safeguard against transition troubles, consider setting aside cash reserves or expanding your bank line of credit. Don t forget about Version 5010 standards! As of January 1, 2012, all electronic claims filed by physician practices must use the Version 5010 standards for electronic transactions. Version 4010 claims are no longer accepted. All practices should be in compliance now.

3 Going Boutique: Concierge practices gain the attention of many physicians As the United States continues to move toward a three-tiered health care system, much attention has been directed at the top tier of concierge medicine a generally more personalized and convenient form of care provided in exchange for an annual fee. Many physicians, increasingly disenchanted with filing claims and wresting reimbursements from public and private payors, are now considering whether to go boutique. How it works In a concierge practice, patients pay an annual retainer or subscription fee of between $1,500 to $5,000 (for an individual) and $3,500 to $8,000 (for a couple), depending on the services received. Those services include: immediate and 24/7 access to physicians via phone, or personal visits, Same- or next-day appointments, and An emphasis on wellness, prevention and health counseling. Beyond that, the practice can offer whatever premium services its patients desire and are willing to pay for: spa-like amenities and décor, house calls and out-of-office care, and telephone or consultations, for example. A caveat: The concierge fee doesn t and can t apply to clinical services for which third-party reimbursement may be sought from Medicare or private payors. The practice can either: 1) continue to perform the third-party billing function for its patients, or 2) forgo that responsibility entirely, leaving it up to patients to deal with their insurers. A substantial investment may be necessary to get started. You ll likely want a redesigned office space, for instance, along with staff retraining for greater customer sensitivity and new EMR capabilities for enhanced follow-up. Because your practice will want to get the word out about its concierge services, you ll also incur some marketing expenses. It can take one or two years to build up the patient volume to turn a significant profit. Say goodbye to stress Once a concierge practice becomes fully operational with satisfactory patient flow, several benefits could begin to emerge. First, if you choose to eliminate third-party coding and billing from your practice entirely, you ll remove the stress and distraction of this difficult function. You also may be able to downsize your existing coding and billing staff, potentially cutting payroll expenses. With a smaller daily patient volume, you may need fewer front desk staff. Plus, moving to the concierge model often lets physicians focus on areas of medicine about which they re truly passionate. Of course, there are risks to the concierge model. Once patients remit their annual fees, you ll be the only manager of how they use your services. Be aware that patients will have virtually unlimited access to you and your physicians at any time. Above all, you ll be solely accountable for the fiscal welfare of the practice. 10 steps to a safe transition If the notion of a concierge practice interests you, do your homework before you make the switch. Here are 10 steps that can help you transition to this new practice model: ask your physicians whether they re willing to adapt to a more interactive relationship with patients. decide whether the new practice format will continue to bill third-party payors or operate as a totally direct-pay operation. research patient demographics and the local market to see if there is sufficient demand with the necessary financial resources to participate. determine which noninsured services and amenities you ll offer. decide whether you ll need additional training for staff and physicians. calculate the monthly or annual fee/retainer that you ll charge patients to cover costs for the new services. Set a timetable for initiation and phase-in of the new format. communicate with patients about the transition via letters, s, or phone calls, or during office visits or in focus groups. ascertain how to handle existing patients who won t convert to the new practice model. Create marketing materials and launch a campaign. If the transition process seems overwhelming, ask your health care advisor for help or look into franchise opportunities. Know what you re getting into Under the right circumstances, morphing into a concierge practice could be a good decision perhaps even the best you ve ever made. Just be sure to know what you re getting into.

4 healthcare insider Spring 12 How to grow your practice with group medical visits Group medical visits are a growing trend in physician practices. Under this appointment model, a physician sees and consults with multiple patients in a single setting at one time. While your initial reaction may be no way, don t sell the idea short. It may be a viable way to grow your practice. Studying the concept There are two types of group visits. The first is the shared medical appointment (SMA) or the cooperative health clinic (CHC), in which eight to 12 patients with the same chronic condition meet with a physician in a conference room for two to three hours. After the practice staff registers the patients, verifies their insurance coverage and takes their vital signs, the session begins with an introduction of the day s topic perhaps exercise, diet or medication. The doctor then addresses each patient individually about his or her specific condition and creates individual treatment plans and provides specific education as appropriate. During the meeting, medical chart entries are made as though it were a series of separate private visits. Patients can ask questions about their own or others cases. Typically, SMAs or CHCs are held monthly or quarterly with the same group of patients. As a result of the shared intimacies, the group develops a cohesion that allows it to function much like a support group. The second form is the drop-in group medical appointment. These meetings last half as long as an SMA or CHC, are attended by whichever patients choose to appear, and tend to address a variety of episodic or acute care conditions. Satisfying everyone Group visits have the potential to satisfy everyone involved. Physician productivity increases, because they see more patients in a day and increase their primary care billings. Plus, doctors are more satisfied with their patient interactions, as group visits can be a nice departure from the usual routine. In addition, several clinical disciplines are involved in the visits, improving coordination of care. All of this leads to fewer specialist referrals, ER visits and repeat hospital visits by group members. From the patient standpoint, they re typically more satisfied with their physicians and trust them more because conversations are more intimate and informal. They re also supported by other group members in coping with their sicknesses and can learn from the experiences and questions of other group members. Patients will also become more knowledgeable about the disease processes affecting them, and their overall health care education will improve. Plus, patients may likely adhere better to their medication regimens and self-care guidelines with the support of others. Although there s no conclusive evidence of better clinical outcomes, they definitely don t worsen. Be aware, however, that privacy issues can arise in a group session. Before joining, patients should be advised that personal health information may be disclosed during a group visit and asked to sign a HIPAA disclaimer acknowledging this fact. Getting into the nitty-gritty It will likely take a few group sessions before the practice becomes comfortable with them. Your staff must learn how to: Explain the purpose and structure of the meetings to patients, gather the same types of information from attendees as they would gather for an individual office visit, and schedule the group visits regularly. Physicians will also need to develop a new presentation style for these meetings. A common question about group medical visits concerns billing. No third-party payors currently distinguish between group and individual visits. Plus, there s no CPT code for group visits, so it s generally best to bill for each patient as though he or she had been seen individually. Most of the time that means using standard evaluation and management (E/M) codes to Some coding consultants have suggested using ( unlisted evaluation and management service ) and ( physician educational services rendered to patients in a group setting ). Make sure you check with the appropriate payors beforehand. The same documentation must be completed for components of the visit, such as vital signs, lab tests, medical history, physical examination and therapy decisions. Exploring the option Group visits don t work for every practice, But don t let that stop you from exploring this intriguing new option in patient care.

5 Practice Notes: Ensure your outsourcing arrangement bears fruit If your practice is falling behind in its billing and collections, consider outsourcing those functions. Be aware, however, outsourcing can work either very well or very poorly. Here s how to ensure your experience is fruitful. 1 Pick only the best When outsourcing billing and collections, look for a firm with certified professionals committed to improving your practice s financial performance. It should be able to handle electronic and paper claim transmissions, insurance verifications and authorizations, plus standardized billing policies, procedures and protocols. The firm must adhere to best practices for billing and collections, and provide timely reporting on performance indicators you request. A provider must also have state-of-the-art IT systems and coding methodologies that optimize revenue opportunities while complying with all laws and guidelines. As competition among billing and collections firms is keen, insist that your pick go beyond basic services, offering training and continuing education for your staff and doctors. Also, ask the firm to contractually commit to identify ancillary income for your practice. 2 Go to the core Even if a potential provider looks good, you should still request a list of references (or even a complete client list) and ask each one about its level of satisfaction with the firm. Also ask your state s medical societies whether the prospective provider is in good standing with them. In addition, determine whether the firm has adopted and documented their own compliance plan that adheres to the Office of Inspector General (OIG) guidelines. Look at the firm s benchmarks, such as claim turnaround times, net collection rate, days in accounts receivable and determine how often and in what detail reports will be provided to you. 3 Seed the contract in your favor When you decide on a billing and collections firm, turn your attention to the specifics of the contract. It should start with a description of the firm s expertise in claims submission for the practice s specialties, followed by a list of services to be provided, performance standards to be met and a payment schedule. The contract should also state that the firm will continually update its payor policies and profile information as well as inform your practice of any such changes. Of course, be sure to have your legal counsel review the contract before you sign it. 4 Insist on a sweet deal Outsourcing your billing and collections function can be a sweet deal but only as long as you find the right provider and sign a sound contract

6 Call the healthcare TEAM at henderson hutcherson & McCullough, Pllc george wilmoth, cpa, pfs adam medlock Freight Depot 1200 Market Street Chattanooga, TN hhmcpas.com