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Nov / Dec 2016 | Issue 11.6

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The Impact of Not Knowing: Why Physician Practices Continue to Struggle

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At the time of writing this, Hurricane Matthew is on its way through the Caribbean. Our Governor has issued a state of emergency and coastal citizens are on the move, evacuating the SC low country. Our hearts and prayers go out for all of those who have already been affected by this (Haiti and Cuba) and for those who are in its path. Something else that has hit close to home is the death of Jacob Hall,

editor Amber Joffrion, M.A. ceo - publisher Storm Kulhan

the Townville Elementary student who was shot by a teenager last week. Townville, SC is about 30 minutes away from us and we have several friends of friends who were directly affected by this tragedy. I know I have mentioned before that I have twin daughters, but I may not have mentioned that they are elementary school aged, so this has been a particularly hard situation for all of us here. We are all praying for Jacob’s family to find the strength to move forward and find some kind of peace within this awful tragedy. Now onto happier topics…This issue is once again jam-packed with a wide variety of topics for you to enjoy. We continue with the second part of a couple of articles that we started with last issue. Maxine Collins and Shirley Kretz from CoreMD Partners continue with their Spotlight on DME; David Jakielo with his series on Challenges Facing Every Medical Billing

coo Nichole Anderson, CPC subscriptions manager Ashley Knight advertising manager Melissa Gilchrist

Company Today; and Patrick Phillips provides us with his second installment of How to Plug the Leaks in Your Cash Flow. I hope you’ve been able to get some great information out of all of these articles. It truly is our pleasure to bring them to you. Our cover this issue has been written by Sean Weiss with contributions from Frank Cohen. We are excited to have Sean writing for us again as he has been keeping busy traveling the country in his role at DoctorsManagement. In his article this issue, Sean discusses reasons why physician practices are still suffering. I’m sure you’ll appreciate his insight. We also have articles discussing the CMS Emergency Preparedness Rule, updated Flu Shot information, and Patient-Centered Medical Home. This is an interesting issue! I hope that you are all staying safe and please have a wonderful, peaceful holiday season.

CONTACT US Billing-Coding, Inc. P.O. Box 80669 Simpsonville, SC 29680 Phone: 864 228 7310 Fax: 888 573 7210 approving CEU associations

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The Impact of Not Knowing: Why Physician Practices Continue to Struggle


NOV / DEC 2016 - 11.6




10. CMS Emergency Preparedness Rule Released – Do You Have a Plan?

26. The Impact of Not Knowing: Why Physician Practices Continue to Struggle


14. Spotlight on DME (Durable Medical Equipment) – Part 2 20. Flu Shot Information: 2016 - 2017 Flu Season

32. How to Plug the Leaks in Your Cash Flow: Part II 36. How to Reap the Economic Payoff from EHR Technology

23. Penalties Doubled in August 2016: False Claims Act and OSHA

40. Patient-Centered Medical Home

24. Revenue Cycle 101: Online Carrier Access

42. Does Your Doctor Keep Your Protected Health Information (PHI) Safe and Secure? 44. Challenges Facing Every Medical Billing Company Today and What to Do About Them: PART II


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www. ww w.bill illing i g-co -codin d g.ccom

46. Office Talk: Control is Important But So Is Judgment 48. 5 Minutes with… Amber Winkler, MHA, PMCH, CCE 49. Reviews: - HBMA Post Event - NAMAS Auditor’s Toolkit Flashdrive


Frank Cohen

Patrick Phillips

Sean M. Weiss

Director of Analytics and Business Intelligence, DoctorsManagement

is Chairman of the Medical Revenue Managers Association of America, the nation’s largest network of certified medical billing experts. He hosts a weekly webcast on business and success for physicians, entrepreneurs, and small business owners.

is a Partner with DoctorsManagement and serves as Vice President of Compliance. Sean is a nationally recognized speaker and consultant with more than 20 years of service in healthcare working with and for some of the Nation’s largest and most respected health systems.

Maxine Collins MBA, CPA, CMC, CMIS, CMOM, Director of Compliance, Audit and Education at CoreMDPartners, LLC.

Dave Jakielo

Rachel V. Rose

CHBME, is an International Speaker, Consultant, Executive Coach, and Author, and is president of Seminars & Consulting.

JD, MBA, is a Houston-based attorney advising on federal and state compliance and areas of liability associated with a variety of healthcare and securities law legal and regulatory issues.

Shirley Kretz COO, CMOM, Vice-President of Operations at CoreMDPartners, LLC.

Steve Matteucci is the CEO of Physician’s Revenue Management, Inc. in Essex, Vermont.

Marge McQuade CMSCS, CMCS, CHCI, CPOM is a certified practice office manager, a certified multi-specialty coding specialist, and a certified healthcare coding instructor who has over 35 years of experience in the medical field.



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MBA, CMRS, CMC, is the president of Business Office Consultants, LLC, which provides Revenue Cycle Management, Credentialing, & Consulting services to a number of healthcare providers in a variety of specialties.


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Amber Winkler MHA, PCMH, CCE, is the CEO and founder of Clarify based in Charleston, SC. She and her teams have successfully achieved NCQA Quality Recognitions, and worked in the population health, research, process improvement, EHR optimization and software space since 2006.

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Kimberly Shutters Founder and CEO of HIPAA Alli, established in 2013, to assist Covered Entities (CE), Business Associates (BA), medical device manufacturers and health application developers/vendors administer their HIPAA/HITECH Privacy & Security Compliance activities.

Mary Pat Whaley is a Physician Advocate and Consultant who blogs at Manage My Practice. Her LinkedIn group of the same name, Manage My Practice, is for those interested in healthcare management.

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HIPAA / Security

CMS Emergency Preparedness Rule Released – Do You Have a Plan? An emergency may be defined as, “a serious, unexpected, and often dangerous situation requiring immediate action.”1 In the world of healthcare operations, outside of a clinical scenario such as a heart attack or a trauma, an emergency can be a natural disaster, a breach or a ransomware attack, which potentially impacts the confidentiality, integrity, or availability of the protected health information (“PHI”).


ncluded in 45 CFR §164.308 are the requirements for a disaster recovery plan, emergency operations plan and data backup plan. These policies and procedures are required in order to be compliant with the Health Information Portability and Accountability Act (“HIPAA”)2 and the Health Information Technology for Economic and Clinical Health Act (‘‘HITECH Act’’).3 For all persons creating, receiving, maintaining, or transmitting PHI, these policies and procedures are compulsory.


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In light of these standards, in September 2016, the Centers for Medicare and Medicaid (“CMS”) released final rules for emergency preparedness requirements across the continuum of care. “As people with medical needs are cared for in increasingly diverse settings, disaster preparedness is not only a responsibility of hospitals, but of many other providers and suppliers of healthcare services. Whether it’s trauma care or long-term nursing care or a home health service, patients’ needs for health care don’t stop when disasters strike; in fact their needs often increase


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in the immediate aftermath of a disaster,” said Dr. Nicole Lurie, HHS assistant secretary for preparedness and response.4 Below is a description of what is expected of individuals involved in the health care industry. In sum, these CMS rules are important and should not be overlooked. Analysis The CMS Final Rule is scheduled to be published in the Federal Register on September 16, 2016 and the requirements need to be implemented by November 15, 2017.5 These new rules came about after CMS reviewed the preparedness plans of various providers and suppliers and found that none were comprehensive enough. While ransomware is not referenced in these Final Rules, the U.S. Department of Health and Human Services (“HHS”) issued guidance, which should be included in these plans.6 The key components that should not be overlooked are: 1.




Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment. Communication plan: Develop and maintain a communication plan that complies with both Federal and State law. Patient care must be well-coordinated within the facility, across health care providers, and with State and local public health departments and emergency systems. Training and testing program: Develop and maintain training and testing programs, includ-

ing initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.7 In sum, no person should be without comprehensive policies and procedures to address both the protection of PHI, as well as the continuity of clinical care during an emergency— regardless of whether the cause is natural or man-made. Conclusion Whether it is a natural disaster or cybersecurity emergency, all parties involved in the process should have a plan. This includes business associates and subcontractors, as well as employees who work remotely. Take the time to update policies and procedures and train—not only may it save a person from being fined, more importantly, it may save a patient’s life.

Rachel V. Rose, JD, MBA, is a Houston-based attorney advising on federal and state compliance and areas of liability associated with a variety of healthcare and securities law legal and regulatory issues.

1. See, (last visited Sept. 10, 2016). 2. Pub. L. 104-191 (Aug. 21, 1996). 3. Pub. L. 111–5 (Feb. 17, 2009). 4. See, (last visited Sept. 10, 2016). 5. See, (last visited Sept. 10, 2016). 6. U.S. Department of Health and Human Services, Ransomware Fact Sheet, available at 7. See, (last visited Sept. 10, 2016).


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Medical Coding

Last issue (Issue 11.5-September/October 2016), we began this article on DME; this is the second and final installment.

Spotlight on DME (Durable Medical Equipment) Part 2 Proper documentation and coding for DME has been in the spotlight for quite some time. Whether you are a supplier or a physician’s office that orders and supplies DME in-house, the pressure of further scrutiny and audits will likely continue to increase as the government focuses on the achievement of goals to accomplish conservation of the Medicare Trust Funds for future beneficiaries.

I •


am including the Table (Table C) referenced in the first part to show the Cross-Walk. You will notice that HCPCS code L0631 cross-walked to L0648 and L0631. Therefore, the code that was being billed, L0631, became the code for the back brace orthotic that required “fitting to a specific patient by an individual with expertise.” Code L0648 became the new code for a back brace

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OTS that requires “minimal self-adjustment.” In the ZPIC audit referred to part I, one deficiency cited by ZPIC auditors was the incorrect use of the L0631 code. The documentation submitted by the practice did not contain the required wording to indicate that the brace was “fitted and adjusted” to the patient as they continued to incorrectly use the code that they had been billing for these braces prior to 01/01/2014, which were intended to represent pre-

Table C. Prefabricated Orthotic Codes Split into Two Codes- Effecfabricated Off-the-Shelf back braces that required only “minimal self-adjustment by the patient.”

tive January 1, 2014 Fee from Existing Code

Crosswalk to New Off-theShelf and Revised Custom Fitted Orthotic Codes


L0455 and L0454


L0457 and L0456


L0467 and L0466

Now, mind you, if you look up the allowable for both L0631 and L0648 (in my locale, at least), they are the same! Therefore, using an incorrect code did not cost the federal government financially. However, the practice referred to in this article filed a Redetermination and was not successful in getting this point of confusion across, and as a result, Health Integrity determined the appeal unfavorable.


L0469 and L0468


L0641 and L0626


L0642 and L0627


L0643 and L0630


L0648 and L0631


L0649 and L0633


L0650 and L0637

There were other items, however, that impacted the Redetermination decision. After you have a chance to look at the table below, I will point out very important details that you must have in your documentation to successfully withstand an audit.


L0651 and L0639


L1812 and L1810


L1833 and L1832


L1848 and L1847


L3809 and L3807


L3916 and L3915


L3918 and L3917


L3924 and L3923


L3930 and L3929


L4361 and L4360


L4387 and L4386


L4397 and L4396

The back braces billed after January 1, 2014, however, were taken from inventory on hand at the practice and the labels still had the L0631 code on them. This fact contributed to the incorrect assignment of code L0631 after that date for a code that now required fitting and adjustment to the patient.

See table C right What is required to document in the Medical Record for these items in order to prevent denial due to Medical Necessity? Failure to follow LCD guidelines can indicate the reason for denial and recoupment. The tips below may help to ensure that you prevent an unfavorable audit result for your practice/clinic. 1. Read and understand all specific LCD requirements. When they mention certain required items, they mean it. The LCD for each MAC Carrier can be found on their respective websites and on the CMS website. Here is an example of what it looks like when accessed on the CGS DME Carrier’s website at: lcd-details.aspx?LCDId=33790&ContrID=140. Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO (L33790) LCD #L33790 has an original effective date for services on or after 10/01/2015 and a revision effective date for services performed on or after 07/01/2016.

2. Follow the coverage guidelines for establishing medical necessity and make sure that the same wording is used in the documentation and required forms when appropriate for each specific patient. Sharing this information with your providers can help them understand what needs to be included in the medical record for sufficient documentation. Each LCD begins with the statement concerning General Coverage Guidance that provides the basis for proper payment by the Medicare Administrative Contractor (MAC) for your region. It states: For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of malformed body member, and

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3) meet all other applicable Medicare statutory and regulatory requirements. For items addressed in this local coverage determination, the criteria for “reasonable and necessary,” is based on the Social Security Act § 1862(a) (1) (A) provisions, are defined by the following coverage indications, limitations, and/or medical necessity. 3. Follow the specific guidelines in the documentation for the item(s) covered in the LCD such as the following for spinal orthoses: For spinal orthoses definitions of Off-The-Shelf (OTS), custom fitted and custom fabricated, see the related policy Article Coding Guidelines section. A spinal orthosis (L0450-L0651) is covered when it is ordered for one of the following indications: 1. To reduce pain by restricting mobility of the trunk; or 2. To facilitate healing following an injury to the spine or related soft tissues; or 3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or 4. To otherwise support weak spinal muscles and/or a deformed spine.

L0631 - Lumbar-sacral Orthosis, Sagittal Control, with Rigid Anterior and Posterior Panels Posterior Extends From Sacrococcygeal Junction to T-9 Vertebra, Produces Intracavitary Pressure to Reduce Load on the Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, or Otherwise Customized To Fit a Specific Patient by an Individual with Expertise. L0648 - Lumbar-sacral Orthosis, Sagittal Control with Rigid Anterior and Posterior Panels, Posterior Extends from Sacrococcygeal Junction to T-9 Vertebra, Produces Intracavitary Pressure to Reduce Load on the Intervertebral Discs, Includes Straps, Closures, May Include Packing, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf. (Note: this brace requires “minimal self-adjustment.”) 5. Know and share with your physicians and clinicians the specific medical record and form requirements such as the following taken from this LCD for Spinal Orthoses:

If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.

Documentation Requirements: Section 1833 (e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider.” It is expected that the beneficiary’s medical records will reflect the need for the care provides...

Note: Again, they are very serious when they make the above statement, and in an audit situation, will repeat these statements back to you over and over. Some physicians do not realize that when they sign the Medicare contract (or any private carrier contract), they are attesting that they know the pertinent coverage guidelines for services being billed and will follow them. They may not understand the complexities that the billing specialists and/or the coders have to understand and take into consideration (i.e., NCCI edits, the quarterly changes that are made by insurance carriers, specific insurance contract coverage guidelines and accepted codes) in order to obtain accurate reimbursement.

Prescription (Order) Requirements: General - All items billed to Medicare require a prescription. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items dispensed and/or billed that do not meet these prescription requirements and those below must be submitted with an EY modifier added to each affected HCPCS code. (Note: When the LCD states “signed and dated by the treating physician,” they are very serious about this clause. If it is not both signed and dated, it will not be given credit as a medically necessary order upon audit.)

I refer to these coverage requirements as the “magic words” to include in the clinical documentation for the ordering of items and/ or testing in the physician’s narrative.

Dispensing Order(s): Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file.

4. Read and be very familiar with the CPT©, HCPCS, and ICD-10-CM codes that you are billing on the federal claim form. For the codes mentioned in the crosswalk as the most frequently used codes for back braces, let’s look at the specific code descriptions:


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It must contain: • Description of the item • Beneficiary’s name • Prescribing Physician’s name

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• •

Date of the order and the start date (if the start date is different from the date of the order) Physician signature (if a written order) or supplier signature (if verbal order)

For the date of the order described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders). The dispensing order must be available upon request. For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. Detailed Written Orders (DWO): A detailed written order is required before billing. Someone other than the ordering physician may produce the DWO. However, the order physician must review the content and sign and date the document. It must contain: • Beneficiary’s name • Physician’s name • Date of the order and the start date, if start date is different from the date of the order • Detailed description of the item(s) (see below for specific requirements for selected item(s))

Physician signature and date

For items provided on a periodic basis, including drugs, the written order must include: • Item(s) to be dispensed • Dosage or concentration, if applicable • Route of administration • Frequency of use • Duration of infusion, if applicable • Quantity to be dispensed • Number of refills, if applicable Frequency of use information on orders must contain detailed instructions for use and specific amounts to be dispensed. Reimbursement shall be based on the specific utilization amount only. Orders that only state “PRN” or “as needed” utilization estimates for replacement frequency, use, or consumption are not acceptable. The detailed description in the written order may be either a narrative description or a brand name/model number. Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in the Program Integrity Manual (PMI)

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The DWO must be available upon request. A prescription is not considered as part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record. (PIM 5.2.3).

designee on behalf of the beneficiary). The signature and date the beneficiary or designee accepted delivery must be legible.

Medical Record Information: General (PIM 5.7-5.9) The Coverage Indications, Limitations and/or Medical Necessity section of this LCD contains numerous reasonable and necessary (R&N) requirements. The Non-Medical Necessity Coverage and Payment Rules section of the related Policy Article contains numerous non-reasonable and necessary, benefit category and statutory requirements that must be met in order for payment to be justified. Suppliers are reminded that:

6. Have written policies and procedures in place in order to ensure that all processes are followed to ensure that each of these requirements are met and continuously monitored for appropriate documentation, requirements of the LCD, and for properly signed and dated documents.

Supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. Templates and forms, including CMS Certificates of Medical Necessity (CMN), are subject to corroboration with information in the medical record.

Information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs. The medical record is not limited to physician’s office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive). Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary. Proof of Delivery (PIM 4.26, 5.8): Proof of delivery (POD) is a supplier standard and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s), that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary. Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary (i.e. acting as a


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The LCD continues by giving very specific instructions and requirements for each method of delivery.

Staff training and re-training on the procedures can potentially save your physicians thousands of dollars if these records are audited. In the issue of the January 2014 changes in the Spinal Orthoses codes, Medicare explains in the LCD that there is no physical difference between the two braces. The only difference is what is performed upon delivery. Therefore, because the small group practice mentioned earlier continued to use L0631 as a prefabricated OTS back brace which required minimal self-adjustment for the patient and, due to the fact that the code description had changed (not the brace, just the description), they had to repair hundreds of thousands of dollars! 7. Finally, upon request of records from a ZPIC contractor, it is extremely important that you contact an expert to direct you in the appropriate steps to take before sending out the records. You need to be aware of any supporting documentation that you can submit that could help your case. If in doubt, it is wise to ask for some assistance because it you receive an unfavorable decision, the process of appeal can be costly and lengthy. Also remember to check private carrier coverage requirements, some of which are less stringent than Medicare—while others follow Medicare guidelines.

Maxine Collins, MBA, CPA, CMC, CMOM, CMIS Director of Compliance, Audit and Education And Shirley Kretz, COO, CMOM, of CoreMD Partners, LLC. Our Mission is to be the number one resource for Medical Providers by helping them add quality services to the practice that help improve the bottom line and help them achieve success.

Seeing the world in code? That’s a clear sign you should join us. Reimbursement Connect is an exclusive online community where healthcare reimbursement professionals come together to solve today’s toughest medical billing and coding challenges.

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Medical Coding

Flu Shot Information: 2016 - 2017 Flu Season The recommendations for people with egg allergies have been updated for this season:

T • • • •

he CDC updates flu shot recommendations for the 2016-2017 flu season. A few things are new this season:

Only injectable flu shots are recommended for use this season. Flu vaccines have been updated to better match circulating viruses. There will be some new vaccines on the market this season. Live attenuated influenza vaccine (LAIV)—the nasal spray vaccine—is not recommended for use during the 2016-2017 season because of concerns about its effectiveness. CPT 90674 is a new code for 2017, and some code descriptions are revised for 2017 to indicate dosage as opposed to age. The recommendations for vaccination of people with egg allergies have changed.


• People who have experienced only hives after exposure to egg can get any licensed flu vaccine that is otherwise appropriate for their age and health. • People who have symptoms other than hives after exposure to eggs, such as angioedema, respiratory distress, lightheadedness, or recurrent emesis, or who have needed epinephrine or another emergency medical intervention, also can get any licensed flu vaccine that is otherwise appropriate for their age and health, but the vaccine should be given in a medical setting and be supervised by a health care provider who is able to recognize and manage severe allergic conditions. (Settings include hospitals, clinics, health departments, and physician offices.) People with egg allergies no longer have to wait 30 minutes after receiving their vaccine.

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Options this season include: •

• • • •

Standard dose flu shots. Most are given into the muscle (usually with a needle, but one can be given to some people with a jet injector). One is given into the skin. A high-dose shot for older people. A shot made with adjuvant for older people. A shot made with virus grown in cell culture. A shot made using a vaccine production technology (recombinant vaccine) that does not require the use of flu virus.

Medicare and the Flu Shot

The Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are 95% of the Average Wholesale Price (AWP) as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department. When the vaccine is furnished in the hospital outpatient department, payment for the vaccine is based on reasonable cost. Providers should note that: •


All physicians, non-physician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine. The annual Part B deductible and coinsurance amounts do not apply.

processing contractor with effective dates of 8/1/20167/31/2017. A handy flu shot chart with CPT codes and manufacturers can be accessed at

Mary Pat Whaley is a Physician Advocate and Consultant who blogs at Manage My Practice. Her LinkedIn group of the same name, Manage My Practice, is for those interested in healthcare management. Learn more at

Medicare Payment Allowances and Effective Dates for the 2016-2017 Flu Season Effective Dates 8/1/2016 - 7/31/2017 • • • • • • • • • • • • • • • •

CPT 90630 Payment allowance is $20.343. CPT 90653 Payment allowance is $37.383. CPT 90656 Payment allowance is $17.717. CPT 90657 Payment allowance is pending. CPT 90661 Payment allowance is pending. CPT 90662 Payment allowance is $42.722. CPT 90672 Payment allowance is $26.876. CPT 90673 Payment allowance is $40.613. CPT 90674 Payment allowance is $22.936. CPT 90685 Payment allowance is $26.268. CPT 90686 Payment allowance is $19.032. CPT 90687 Payment allowance is $9.403. CPT 90688 Payment allowance is $17.835. HCPCS Q2035 Payment allowance is $16.284. HCPCS Q2037 Payment allowance is $16.284. HCPCS Q2039 Flu Vaccine Adult - Not Otherwise Classified payment allowance is to be determined by the local claims


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Association of Health Care Auditors and Educators Make Defensible Decisions on Your Audits and Learn to Communicate Effectively Your Results! &RGLQJDQG&RPSOLDQFH:RUNVKRSV

“Intensive Chart Auditing Practicums!” Gain knowledge and learn with hands-on experience from nationally recognized auditing professionals, coding and compliance educators. Dig into regulations and rules as you’ve never seen before. The (CHCA) Certified Healthcare Chart Auditor exam or CHCAS will be available to take the last day of the training. This original, one-of-a-kind program, is a collaborative effort developed by the (AHCAE) Association of Health Care Auditors and Educators and is designed to provide critical elements needed for accurate medical record chart auditing and effective compliance. The Intensive Chart Audit training is designed for those seeking true auditing skills and knowledge within the auditing arena. Whether you are new to auditing or are a seasoned auditor, this program will greatly benefit you! Plus, you will receive the comprehensive AHCAE Chart Auditing Tool Kit, Chart Auditing Resource Manual, and CD / USB to start auditing immediately!

'D\DQG&(8V Join our CPT expert speakers (former AMA trainers) for insight on new codes and changes. Plus, each attendee will take away several valuable resources to use immediately! %RQXVGet compliant for what CMS and the OIG have in store for 2017, and see what’s new for HCPCS Level II!  



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Medical Billing

Penalties Doubled in August 2016:

False Claims Act and OSHA


25 years since the last time any adjustments were made. Since 1990, OSHA has been specifically exempt from a law that required federal agencies to raise their fines to keep pace with inflation.

ugust 2016 was an important month, with penalties increasing for violations of the False Claims Act and OSHA.

On August 1st, 2016, there were new penalties for the False Claims Act. The Department of Justice nearly doubled the statutory penalties under the False Claims Act (FCA) under an interim final rule published June 29, 2016. The minimum penalty charge will double from $5,500 to $11,000 per violation. The new rule sets the maximum violation charge at $21,563, up from the previous limit of $10,781. This marks the first time FCA penalties have been adjusted for inflation since 1999. Additionally, OSHA made drastic changes to their penalty structure, effective August 2nd, 2016. It has been

That exemption was eliminated in the 2015 Bipartisan Budget Bill. For serious and other-than-serious violations, the penalty maximums will rise from $7,000 to $12,471 per violation. For failure to abate, penalties rise from $7,000 to $12,471 per day beyond the abatement date. Willful or repeated violations carry a heavy weight: the maximum penalties have risen from $70,000 to $124,709 per violation. Provided by: 1st Healthcare Compliance

Webinar: OSHA Compliance for Medical and Dental Offices CEUs: 1 CEU approved Category: Practice Management Cost: Free to all current BC Advantage subscribers Presented by: Kelly Ogle, BDSH, MIOP, CMPM, CHOPŽ OSHA and HIPAA Specialist for Doctors Management Length: 60 minutes 2EMHFWLYHbOSHA Compliance: OSHA for Medical and Dental 2IILFHVLVbIRUQHZKLUHVDQGIRUDQQXDOHPSOR\HHWUDLQLQJWKLV training is up-to-date with OSHA’s Hazard Communications information, which includes the most recent labelling and safety data sheet requirements. Visit to download this webinar.

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Medical Billing

Revenue Cycle 101: Online Carrier Access online access to this information, at any time day or night, is a wonderful tool! With just an internet connection and appropriate login information, personnel can obtain the information they need to more efficiently complete their job functions—anytime! Online access can dramatically decrease the amount of time you have to spend on each of these tasks. Going through our insurance aging alone can save you countless hours as the online systems are much more efficient than sitting on hold with the carriers forever! And that’s just one small piece of the puzzle that can be obtained and/or done online!


know it’s obvious to most of us—right? We should all be utilizing carriers’ online accesses. But the reality is that there are a large number of small to mid-sized practices that are not utilizing this free resource!

At most carrier sites, you can check benefits, obtain authorizations, do referrals, check claim status, complete adjustment requests—and so much more. So, where do you start? If you have not done so recently, run your insurance aging. Determine which carriers are the top 5-10 to which you bill. Start with those. With many practices now having either multiple sites, and/or telecommuting employees/vendors, having


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It is important to note: check out the user requirements at each carrier. Some carriers assign one username/password for the company to share—and that’s okay for that carrier. Others are much stricter, and require login information for each person—not to be shared by anyone. So make sure you read the online user agreements carefully, to know the processes at each carrier. If you’re not utilizing online access at the carriers yet, what are you waiting for?

Ranadene K. Tapio, MBA, CMRS, CMC, is the president of MedCycle Solutions, which provides Revenue Cycle Management, Credentialing, Outsourced Coding, and Consulting Services to a number of healthcare providers in a variety of specialties. She holds an MBA in Healthcare Administration & Management and multiple professional certifications. To find out more about the services of BOC, please email Randi@ or call 320-290-6448.

Download CMS Updates Ambulance and Medicare Requirements Update Ambulance billing staff should be aware of revisions affecting ambulance billing requirePHQWVb7KH&KDQJH5Hquest (CR) 9761, (revised) manualizes the Calendar Year (CY) 2016 revisions to the ambulance staffing requirements and provides clarifications on the definitions for ground ambulance services for: Advanced Life Support, Level 1 (ALS1), ALS assessment, application for ALS, Level 2 (ALS2), Specialty Care Transport (SCT), Paramedic Intercept (PI), emergency response, and inter-facility transportation. Downloads/MM9761.pdf

Fee-For-Service Data Collection System: CLFS Data Reporting Template MLN Matters Article Revised This guidance is intended to assist the laboratory community in meeting the new requirements under Section 1834A of the Social Security Act (the Act) for the Medicare Part B Clinical Laboratory Fee Schedule (CLFS). The Quick User Guide, which includes guidance for the Fee-For-Service Data Collection System (FFSDCS) CLFS data reporting template, is included as an attachment in this article. Downloads/SE1620.pdf

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The Impact of Not Knowing: Why Physician Practices Continue to Struggle

In our current environment, medical providers are being inundated with demands from both governmental and commercial payers. With the burden of Comparative Billing Reports (CBRs), Additional Documentation Requests (ADRs), Pre-payment Reviews, Post Payment Reviews, audits by ZPICs, MICs, RACs and Commercial Payers, Denials of medical services for generic reasons such as “Not Medically Necessary,” providers oftentimes find themselves scratching their head asking: “Is this really worth it?” Articles published in the Wall Street journal (August 29, 2014), Forbes (September 11, 2014), The Huffington Post (May 30, 2012), Medical Economics (November 21, 2013), and a host of others over the past 10 years reveal that a very scary percentage of physicians say that, for a number of reasons, if they had to do it over again, they wouldn’t. And much of the discontent and unhappiness center around what they perceive as administrative complex and clinically unnecessary rules and regulations.


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Practice Management


his is well supported by the fact that there are issues with the contractors who have been awarded contracts by CMS. To fact check this, you don’t have to go any further than such respected publications such as Forbes and CBS News. Through investigative reporting, they have seen fit to produce articles and broadcasts to highlight the issues. In addition, highly respected consultants have submitted White Papers to the Senate Finance Committee to make their concerns known. Before I get to the articles and White Paper, let me provide evidence to confirm that my opinion is grounded in facts and not fairy tales. 1.


The Department of Justice obtained more than $3.5 billion in settlements and judgments from civil cases involving fraud and false claims against the government in the fiscal year ending Sept. 30, 2015. i a. This is the fourth year in a row that the department has exceeded $3.5 billion in cases under the False Claims Act, and brings total recoveries from January 2009 to the end of the fiscal year to $26.4 billion. As of June 30, 2016 Strike Force Actions have included: ii a. 1,522 Criminal Actions; b. 2,185 Indictments; and c. $1.98 billion in recovery

CMS Program Integrity Group. This type of environment leads investigators, contractors, and CMS to pursue providers in an aggressive manner, sometimes unfairly, based on little evidence or collaboration of any wrongdoing. The paper goes on to state that they have found that these contractors abuse the use of prepayment reviews. As an example, “It is not uncommon for a Zone Program Integrity Contractor (ZPIC) to implement a 100% prepayment review of a provider’s claims with no notification.” Simply making a statement that payers and their “Contracted Bounty Hunters” are on a “Rampage” (Narratives provided by CBS News and Forbes) (*specific links to these stories are provided above) is a statement most would look at and think, “Well, sure they’re aggressive,” but until you see it in the terms of actual pre- and post-payment reviews, the magnitude of the problems remain nuanced. The table below only takes into account MACs, SMRCs and RACs. ZPICs, MICS, Commercial Payers, etc. are not included. In 2015, the OIG was very critical of the Centers for Medicare and Medicaid Services regarding the award of ZPIC Contracts and the lack of oversight for these contractors. According to the OIG Report of the same year:

In the van Halem Group, LLC White Paper, item number 2 discusses that one significant concern is the lack of trust between the provider community and CMS: CMS and its contractors often cultivate an environment of mistrust and suspicion that all providers of certain services are inherently fraudulent. The sentiment is widely shared by anyone that has worked with CMS contractors in the area of program integrity and a similar environment is probable within the

The Centers for Medicare & Medicaid Services requires potential Medicare antifraud contractors to disclose possible conflicts of interest and strategies for mitigating them (This information is published in multiple public reports). But when officials from the Department of Health and Human Services Office of Inspector General reviewed these disclosures, they identified 1,919 business and contractual relationships as possible conflicts and 16 as actual conflicts, according to the report. In their review, OIG investigators looked at information from 18 offerors (companies

Table 2: Prepayment and Postpayment Claim Reviews by Medicare Contractors, 2013-2014 Medicare Administrative Contractors (MAC)

Supplemental Medical Review Contractor

Recovery Auditors

Number of Reviews

Percentage of total reviews (%)

Number of Reviews

Percentage of total reviews (%)

Number of Reviews

Percentage of total reviews (%)

Prepayment claim reviews







Postpayment claim reviews







Total claim reviews







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that put in proposals for contracts) and 85 subcontractors within CMS...Often the ZPIC contractors have had no experience in the areas of fraud and abuse for which they should be accountable. The result is a loss to CMS of fraud and abuse funds and providers, many of which are small – medium sized businesses, are forced to spend thousands of dollars to address unfounded audits and investigations. This was evidenced when CMS lost $80 million of the $120 million paid to contractors in 2011, due to poor data when investigating fraud and abuse…The significant lack of oversight of ZPIC contractors, who were awarded contracts averaging $81.9 million, is evidenced by the extreme and ill-founded actions taken by some ZPICs in unwarranted efforts to show CMS a return on investment. Contractors often employed significant, aggressive, and over-zealous audits, claims reviews and investigations against legitimate, not fraudulent, providers of healthcare services. The broad brush actions cost legitimate providers huge amounts of time, money and energy— inhibiting their ability to provide care to beneficiaries. Some are forced to leave Medicare, if not health care services all together. ZPICs are large and powerful corporations with the backing of the federal government. They apply heavy handed processes in a punitive manner to many legitimate providers over minor document infractions. Further exacerbating the problems are the individuals employed by CMS to oversee these contractors, who are often young and inexperienced and do not have healthcare or fraud investigation experience. For a couple of years now, I have talked about The Treating Physician Rule. The first section of the Medicare statute is the prohibition “Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided.” From this, one could conclude that the beneficiary’s physician should decide what services are medically necessary for the beneficiary, and a substantial line of authority in the Social Security disability benefits area holds that the treating physician’s opinion is entitled to special weight and is binding upon the Secretary when not contradicted by substantial evidence. Some courts have applied the rationale of the “treating physician” rule in Medicare cases, and have rejected the Secretary’s assertion that the treating physician rule should not be applied to Medicare determinations. In Holland v Sullivan, the court concluded: Though the considerations bearing on the weight to be accorded a treating physician’s opinion are not necessarily identical in the disability and Medicare context, we would expect the Secretary to place significant reliance on the informed opinion of a treating physician and either to apply the treating physician rule, with its component of “some extra weight” to be accorded that


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opinion, [even if contradicted by substantial evidence], or to supply a reasoned basis, in conformity with statutory purposes, for declining to do so. In addition, audit findings may be challenged based upon the opinion of the treating physician who is likely the target of the audit. The “Treating Physician Rule” first arose in a context of a disability determination and holds that an Administrative Law Judge should give greater deference to the opinion of the treating physician than to those of non-treating physicians. The opinion of the treating physician is particularly important when challenging the applicability or reasonableness of a LCD. The Van Halem Group’s White Paper to the Senate Finance Committee outlined and focused on the clinical competency of those both clinically and non-clinicians making determinations on “Medical Necessity.” Until June of 2011, CMS Section 3.4.5.C of the Medicare program Integrity Manual (Pub 100-8) guided contractors in performing complex medical reviews. While Medical Review (MR) staff must follow national coverage determinations and local coverage determinations, they are expected to use their expertise to make clinical judgments when making medical review determinations. They must take into consideration the clinical condition of the beneficiary as indicated by the beneficiary’s diagnosis and medical history when making these determinations. Currently, ZPIC and Medicare Administrative Contractors (MACs) are employing clinical staff; however, they have no ability to use that expertise. As a result, CMS is requiring and paying for clinical expertise but not receiving the cost savings benefit of the expertise. Additionally, a provider under review may be subject to significant claim denials and scrutiny because of issues with insufficient documentation that are not associated with fraudulent activity. Many denials are unfounded and irrational due to the prohibition of allowing ZPIC’s clinical staff to use their clinical judgment and expertise. As a result, these denied claims must be appealed, often times up to the Administrative Law Judge (ALJ) level. This process of denying claims and conducting appeals costs the government a significant amount of money only to see a significant number of the decisions overturned. While medical providers are held to very strict standards with regard to documentation and coding of services, the payers aren’t, and this oftentimes leads to unethical business practices. Take for instance the Medicare Appeals Process. After exhausting the first 2-levels of the process (Redetermination and Reconsideration), a practice has the right to file for an Administrative Law Judge Hearing, which according to CMS Section 1869 of the Social Security Act and 42 C.F.R. part 405

subpart I, OMHA ALJs began adjudicating appeals in July 2005, based on section 931 of the MMA, which required the transfer of responsibility for the ALJ hearing level of the Medicare claim and entitlement appeals process from SSA to HHS. New rules at 42 CFR part 405, subpart I and subpart J were also established to implement statutory changes to the Medicare fee-for-service (Part A and Part B) appeals process made by the Benefits Improvement Protection Act (BIPA) in 2000 and the Medicare Modernization Act (MMA) in 2003. Among other things, these new rules addressed appeals of reconsiderations made by QICs, which were created by BIPA for the Part A and Part B programs. These rules also apply to appeals of SSA reconsiderations. The statutory changes made by BIPA include a 90-day adjudication time frame for ALJs to adjudicate appeals of QIC reconsideration beginning on the date that a request for an ALJ hearing is timely filed. In recent years, the Medicare appeals process has experienced an unprecedented and sustained increase in the number of appeals. At OMHA, for example, the number of requests for an ALJ hearing or review increased 1,222 percent, from fiscal year (FY) 2009 through FY 2014. The increasing number of requests has strained OMHA’s available resources and resulted in delays for appellants to obtain hearings and decisions. Right now, it is taking between 2-3 years to have a case assigned to a judge and then up to another 2-3 years to have the case heard. The biggest issue is what happens following a Qualified Independent Contractor (QIC’s) decision to uphold a redetermination, finding Medicare has the right to demand a refund or to begin off-setting monies from future payments. They can do this even though “due process” has not been granted to the appellant, resulting in a finding of “guilty” by a non-binding entity such as a contractor. These financial losses are crippling medical practices and forcing them into uncharted waters of having to provide services for Medicare beneficiaries without being compensated, because someone other than a judge made a decision that their services billed were not “Medically Necessary” or failed to support the level billed, which we all know is highly subjective. Despite significant gains in OMHA ALJ productivity (in FY 2014, each OMHA ALJ issued, on average, a record 1,048 decisions and an additional 456 dismissals), and CMS and OMHA initiatives to address the increasing number of appeals, the number of requests for an ALJ hearing and requests for reviews of QIC and IRE dismissals continue to exceed OMHA’s capacity to adjudicate the requests. As of April 30, 2016, OMHA had over 750,000 pending appeals, while OMHA’s adjudication capacity was 77,000 appeals per year, with an additional adjudication capacity of 15,000 appeals per year expected by the end of Fiscal Year 2016. If this is not a sign of payers on an auditing rampage, then I am not sure what would constitute one. In general, payers are

asking physicians to provide first-world care in the presence of third-world due process. One of the topics I discuss during calls with clients who have been targeted or have received adverse results from an audit or during lectures is that they have a right to “Challenge Credentials of Reviewers.” Specifically, Section of the Medicare Integrity Manual requires that coverage determinations be made only by RNs, LPNs, or physicians, unless the task can be delegated to another licensed health care professional. Reviews of coding determinations, likewise, must be made by certified coders, but should also be made by those who possess the requisite skills in the specialty they are reviewing. Upon receipt of disclosure of the identity and qualifications of the auditors, request for the disclosure of the identity and qualifications of the auditors should be made. Should the matter be escalated to an ALJ hearing, you have the right to request formal discovery of such materials. The van Halem Group’s paper outlined the fact that “There is a lack of experience and training of ZPIC staff.” In one specific case, a member of management at a ZPIC was questioned regarding issues surrounding numerous errors being made by staff. The ZPIC Manager said, “Not only was he aware of the errors being made but attributed them to issues related to workload, exhaustion, or lack or training.” The White Paper goes on to state, “Many ZPIC investigators lack sufficient training in coverage and reimbursement policies for the services under their review.” There was a case sited in the paper where a provider contacted their local Congressman to address concerns over incorrect denials in a ZPIC audit. The Congressman’s office contacted CMS Central Office and submitted 11 examples of claims denied in error. The actual written response from CMS said they agreed that 7 of the 11 claims were in fact denied erroneously. However, the letter went on to state, “That regardless, the provider’s error rate remained high so they will remain under investigation” despite the fact they had just received confirmation in the very same response that the error rate calculated was incorrect because of errors made by the contractor. This not only supports a lack of training, but a lack of appropriate oversight and fairness.” One of the areas our firm focuses on, specifically through Frank Cohen, is challenging the sampling and extrapolation of an audit finding. The statutory or regulatory provision expressly authorizes the use of extrapolation. However, “… sample adjudication represents a judicially approved procedure that can be reconciled with existing Medicare requirements for case-by-case considering…” Case law clearly holds that a presumption of validity attaches to the amount of an overpayment. Thus, the burden of proof with respect to a challenge to the statistical validity of an extrapolated demand rests squarely with the provider. 42 U.S.C. §

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1395-ddd holds that a Medicare contractor may not use extrapolation to determine overpayment amounts absent a determination that there is a “sustained high level of payment error or documented educational intervention has failed to correct the payment error.” Such determinations may be made by a variety of methods including a PROBE sample or data analysis and are not subject to administrative or judicial review. In Gentiva Health Care Corp. v. Sebelius, 857 F.2d 1 (D.D.C. 2012), the court held that the responsibility for determining the existence of sustained high level of payment error or the failure of educational intervention may be delegated to contractors. Thus, the threshold for determining whether an extrapolated demand may be made rests with the contractor and is largely immune from review. The propriety of demand based upon a statistically valid random sampling is well-settled and the premise is not subject to challenge. According to Frank Cohen, this does not, however, preclude contractors from the responsibility to generally accepted statistical standards and guidelines. Section 4.2 of Chapter 8 of the CMS Program Integrity Manual iii states the following: “If a particular probability sample design is properly executed, i.e., defining the universe, the frame, the sampling units, using proper randomization, accurately measuring the variables of interest, and using the correct formulas for estimation, then assertions that the sample and its resulting estimates are ‘not statistically valid’ cannot legitimately be made.” Cohen asserts that first of all: That is simply a ridiculous statement; of course there are additional reasons that one could opine that a sample is ‘not statistically valid.’ But within that paragraph, the PIM does outline six specific conditions that must exist in order for a sample to be considered acceptable. It is simply not enough for a sample to be just random. It is well established within the statistical community that a random sample of a heterogeneous universe rarely produces an appropriate sample for extrapolation. In order for the sample to be considered as part of an extrapolation event, the sample must be representative of the universe to which the sample results will be inferred. This is not just statistically correct; it also concurs with good sense. It is simply illogical to attempt to take the results of a sample that does not statistically represent the universe and then try to extrapolate back to that universe for the purpose of estimating the impact of those erroneous results.

Yet, this is what happens more often than not and as a result, extrapolations are overturned at the ALJ level at a very high rate. And when that happens, the contractor will often appeal this to the MAC, who ends up sending it back down to the ALJ for reconsideration. Quite often, contractors will quote Chaves iv to support that the only requirement is that the sample is random, yet that is not what the judge said: Absent an explicit provision in the statute that requires individualized claims adjudications for overpayment assessments against providers, the private interest at stake is easily outweighed by the government interest in minimizing administrative burdens; in light of the fairly low risk of error, so long as the extrapolation is made from a representative sample and is statistically significant, the government interest predominates. (Emphasis added.) My job is that of a physician advocate. My assignment is to protect my clients from what I (and they) see as unwarranted attacks on their work and profession. I have been doing this for a long time (21 years to be exact) and in the overwhelming number of cases, my physician clients are honest, hard-working, competent, and caring professionals. Most came into medicine with a single goal: to be paid reasonably for providing quality care to their patients. At times, it feels like payers have the opposite goal: to not pay them reasonably for providing quality care to their subscribers. Most providers with whom I work live in the stress that sometime in the future, some payer is going to demand that the provider repay them for some service that was provided maybe three or four years earlier. That’s plain insanity. I don’t have expectations that things will change in the near future. In fact, along with many other well respected experts in this industry, I expect it to continue to get worse for healthcare providers.

Sean M. Weiss, CMCO, CMPA, CPC-P, CPC, Partner/ Vice President of Compliance, DoctorsManagement With Contributions by: Frank Cohen, Director of Analytics and Business Intelligence. Since 1956, DoctorsManagement, a medical and health care consulting firm, has helped physicians in all specialties with health care, dental, and medical practice management services in virtually every state across America. With our health care and medical consulting firm’s help, you become free to concentrate on your life’s work and your life outside of work, as well.

i Source: OIG / GAO 2016 ii Source: Strike Force press release 2016 for number 2 iii Medicare Program Integrity Manual, Chapter 8, section 4.2 – Probability Sampling (Rev. 377,05-27-11) iv Chaves County Home Health Service, Inc. v. Sullivan, 931 F.2d 914 (DC Cir. 1991), cert. denied 502 US 1091, 112 S.Ct. 1160(1992).


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Practice Management

How to Plug the Leaks in Your Cash Flow Part ll

In Part One, we explored the Critical Cash Gaps that can be triggered before and after a claim is filed, typical mistakes made when your practice has cash-flow problems, and the many problems that plague medical billing, whether done in-house or outsourced.

N •


ow, let’s examine some common causes of claims rejection: • Billing for a procedure not covered. As mentioned in the last chapter, this is an internal problem at the medical office that can be avoided by a staff member verifying coverage with a phone call before the patient arrives for an appointment. Inaccurate coding. This can be due to lack of knowledge on the part of the staff or poor communication from the doctor to ensure that the right code is used. Not keeping up with code changes is another likely cause of rejected claims. Under-coding. For many doctors, the fear of over-coding or unbundling results in employees being so cautious that the claim is actually miscoded. Human error. Typos, transposition of numbers, and other mistakes in entry can cause a rejection. Slow payments—30, 60, 90, 120 days, or longer. The delays can be caused on the side of the

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practice or the side of the insurers responsible for payment. Overwhelmed staff, slow submissions. The quicker you can get accurate claims submitted, the faster you’ll receive payment. You should know KRZORQJLWWDNHVIRUDFODLPWREHˉOHG Sluggish submissions by an outsourced medical biller. If you use a medical biller, it’s important to know how quickly the claims are being handled. If you’re not asking for reports, you may not know when a given claim was submitted. The clock doesn’t start for the insurer until the claim is received. Ineffective rejected-claims management. An inexperienced employee may not know how to resolve a particular problem with a claim. If it involves one or more calls to the insurer to resolve a legitimate claim, the value of that claim drops in proportion to the amount of time (money) it takes to get it paid. Abandoned claims. At some point, some claims can’t be resolved by the person assigned to the job. It isn’t at all uncommon for employees to

 finally give up and stuff these in a file in the bottom drawer. This is laughingly called the Porsche Drawer in some practices, because so much money is tied up in the claims. Why Uncollected Claims Should Be on Your Radar Unresolved claims have a direct and LPPHGLDWHLPSDFWRQFDVKˊRZ(YHU\ claim left to age without any attention is destined to be a write-off unless strong, effective action is taken. This is lost money that has cost you more than you may realize: • First, you provided the service. • Second, you paid to have the claim filed. • Third, you repeatedly paid to sort out the problem that prevented payment. • Finally, you’ve had to cover expenses with money from sources other than the payments you were expecting from these claims. You may have even paid to borrow money. Uncollected claims may reflect poorly on the employees. If you scrutinize rejected claims, you may find that the source of the problem wasn’t actually an uncooperative insurance company or lack of help at Medicare (although those are easy default targets that are rarely challenged).

uncollectible are skewing your actual financial picture. When a sizable chunk of your money is either uncollected or XQFROOHFWLEOHDQ\FDVKËŠRZSURMHFWLRQV you make that include accounts receivDEOHDUHËŠDZHG You may find yourself in a cash crunch without warning, simply because the abandoned claims became “phantom cashâ€? without your knowledge. Unpaid bills that aren’t reflected in the books are also distorting your actual financial position. This can happen because the staff gets behind. It can also occur when employees simply don’t understand the importance of accurate accounts payable lists. You FDQČ WSURMHFWFDVKËŠRZLI\RXGRQČ W know what’s been paid and what’s outstanding. (PSOR\HHVPD\QRWWKLQNLWPDWWHUV that much. If the attitude you project is that uncollected claims are annoying, but unavoidable, the employees will assume the same posture. Instead, assume an attitude of relentless pursuit of what is owed to the practice. Show the employees how payments affect them, their income, and even any extras you can give them, not just your ability to pay for a new luxury car. Consider bonuses or perks based on improvements.

If employees know that they, or their office-mates, were sloppy in the first place, they may want to bury the problem. Strict reporting systems can make it harder to cover up internal procedural errors that are costing you money.

Medical software. The introduction of medical software was an enormous leap for doctors previously forced to ˉOORXWIRUPVE\KDQG7KHUHDUHD number of popular medical software packages, but software has built-in limitations.

Any unpaid claims that are essentially

Medical billing software is not cheap,



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but the initial price is not the only concern. Upgrades are costly and can run up to several thousands of dollars, depending on the FRPSDQ\DQGWKHQXPEHURIGRFWRUVLQ\RXUSUDFWLFH(YHQVRLWȠV the option many medical practices choose. Changes in CPT and ICD Codes and the Health Insurance Portability and Accountability Act may be in effect before an upgrade is offered by your software company‌ and even longer if you delay in buying and installing your upgrade. This opens the door for rejected claims due to miscoding and problems due to non-compliance with HIPAA regulations. If you outsource your medical billing, you may not know what software is being used. You also may not know if they’re upgrading in a timely way‌ or at all. Outsourcing is an economical choice, but only if your billing service is up to date so you’re always compliant.

ware.� For our purposes, “software� means a billing program that resides on a computer in a doctor’s office or at a medical billing service. True electronic billing is completing and submitting claims online, not just preparing the claim by computer using software installed on the hard drive before uploading it in batches to a clearinghouse. That means that your current medical biller—either in-house or outsourced—has to submit the claims to a clearinghouse electronically. This creates a two-step process: generate the claims; submit the claims in batches. 1.

2. Some small medical billers may find the high price of upgrades out of reach. If you currently outsource to a billing service using software, be sure to ask whether they’re current with all system and coding updates. Otherwise, you’re risking rejection of claims and HIPAA compliance issues. Software can have unexpected technical issues. If a young assistant is typing information into the software and there’s a glitch, tech support is typically available quickly if you’ve bought from a reputable software company. The question is not whether tech support is available, it’s how long it will take to resolve any problems. And does your data entry person have more than keyboard skills so she can implement what the support technician tells her to do? By the time the problem is fixed, there may be DEDFNORJRIFODLPVWRˉOHZKLFKLQWXUQGHOD\VSD\PHQW7KDWČ V KRZDWHFKQLFDOSUREOHPFDQWXUQLQWRDFDVKËŠRZSUREOHP Server-Based Software vs. Cloud-Based Billing Systems Let’s clarify what “electronic billingâ€? means in relation to the government mandate. Many doctors assume that working with software is, by definition, “electronic billing.â€? There are many people—both in medical offices and medical billing services—who’ve generated their claims with software, then printed them out and put them in the mail. More recently, software users would generate the claims using software and then upload batches to a clearinghouse or payer. Technically speaking, software does drive cloud-based systems, so there remains some confusion about the use of the term “soft-


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The software/submit process has three main points, depending on the features available on the software used, that often sabotage timely payments. Checking for accuracy manually. Some strides have been made to give the individual entering the data some assurDQFHWKDWWKHFODLPVGRQČ WKDYHJODULQJËŠDZVLQWKHGRFXment that would trigger a rejection. However, the burden of inputting correct numbers ultimately rests with the human operator. Certain coding errors, for example, may not be caught prior to submission of a claim. Batches are checked by the payer for problems. As mentioned earlier, the sooner you can notice the smallest discrepancy of information, the sooner you can get paid. Any delay causes the batch to be kicked back. In submitting, that means the person may have to start collecting from the day the error was present, tracking down and fixing errors in a batch of claims. This is lost time for the biller and likely more expense for the medical practice.

In contrast, a cloud-based solution eliminates these and other problems for you automatically. In Part Three, we will discuss how to evaluate a cloud-based, electronic claims filing system versus an outsourced solution.

Patrick Phillips is the Chairman of the Medical Revenue Management Association of America, the nation’s largest network RIFHUWLILHGPHGLFDOUHYHQXHPDQDJHUV+HLV)RXQGHUDQG&(2RI American Business Systems ( and is the author of Cash Crunch to Cash Flow and his most recent book, The New Thriving Medical Practice, available on and in major bookstores nationwide. He can be reached at info@absystems. com.

AHIMA CDI Academy: Inpatient and Outpatient Best Practices January 25–27, 2017 | San Juan, Puerto Rico Accurate clinical documentation not only tells the patient’s story, it is at the core of quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending. Some of the topics covered include: • Review key coding guidelines of principal/primary and secondary diagnoses • Examine opportunities for CDI in the outpatient setting • Realize the impact of coded data on secondary data uses such as meaningful use incentives, quality measures, and public health reporting Whether you are new to CDI or an experienced CDI professional, the Academy offers unique content you can apply to your situation.

Register by December 12, 2016, and save $100 with early bird pricing! 1694.16

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Practice Management

How to Reap the Economic Payoff from EHR Technology

History teaches us that new inventions do not automatically and immediately generate greater productivity. Slapping an internal combustion engine on a horse buggy didn’t make travel more efficient. The new engine needed a new vehicle, one that could exploit all the advantages this technology had to offer. Even then—to really make travel more efficient—better roads had to be built, traffic rules had to be developed, signs and signals had to be installed, and mechanics had to open garages. The engine alone couldn’t improve travel; it needed an infrastructure to make it work better.


his is true of all new technology, even information technology. Just because an innovation is digital doesn’t mean it will immediately increase productivity. Studies have been done about this, but here’s a personal anecdote: I graduated from law school and passed my bar exam in 1989, right around the time law firms were transitioning from typewriters to word processors. In those early days, these computers were used as nothing more than glorified typewriters. They were helpful, since


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legal secretaries never had to use white-out, or worse, retype an entire page, to save a document. So, the word processor saved the office some time. But it also cost time: time to boot up, time to upgrade, time to deal with all the bugs in the system. Plus, the secretary had to take an additional step: after typing, she had to send the document to the printer. Law firms would never get a productivity bump from this new machine as long as they used it in the same old way.

When did the computer increase law office productivity? Not until lawyers changed their office procedures and workflow to take advantage of the new technology. In my practice, unencumbered by habit or history, I took my forms apart and added merge markers in them so that I could build customized documents for each client. I created macros that took me through the steps of entering client data and putting together an entire suite of legal documents much faster than even the most experienced legal secretary could do. And this helped me make my practice more responsive to my clients. I could meet with a client on a Monday and be signing his documents a week later.

which has actually slowed him down and decreased the number of patients

he can see. “I’m working harder and getting a little less,” he said—the very

There’s always a lag between the introduction of new technology and the increase in productivity it promises. New infrastructures and updated procedures have to be developed to fully use all the wonderful features of the new technology. This is even true of electronic health records technology. The New York Times recently ran an article entitled, “Why the Economic Payoff From Technology Is So Elusive.” Although the article deals with technology in general, the author uses the increased use of EHRs in doctor’s offices across the country as the prime example of how this great, new technology hasn’t delivered on its promised productivity gains. One doctor featured in the article has been “grappling with the software and new reporting requirements”

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opposite of increased productivity.

We will be increasing the subscription rate in 2017, due to all the additional resources and CEUs we are providing our members. BUT YOU CAN KEEP YOUR RATE LOCKED FOR LIFE!

As long as you keep your subscription current your rate will never increase! THAT’S OUR GUARANTEE TO YOU! Need to check your renewal date or renew? Login at www.billing-coding. com/renewals or call 864 228 7310. Storm Kulhan CEO Billing-Coding, Inc


The point of the article is to explore why this is happening. First, the author cites some productivity pessimists. They believe that growth has simply died and that it’s unrealistic to expect new technology to produce the kind of productivity increases that were seen from past inventions and innovations. Next, the author cites the productivity optimists. They believe that new technology always brings about more productivity, we just have to wait for it to show up. But the author settles for a middle position that asserts that new technology needs help to increase productivity. He writes, “The electronic records, health experts say, represent only a first step toward curbing costs and improving care. ‘People confuse information automation with creating the kind of work environment where productivity and creativity can flourish,’ said Dr. David J. Brailer, who was the national health technology coordinator in the George W. Bush administration. ‘And so little has gone into changing work so far.’” In other words, doctors are buying EHRs and using them as a digital replacement for a paper system, exactly like lawyers used word processors in the early 1990’s. Where they once pulled a paper chart off the shelf, doctors now call up a digital one on their computer or laptop and simply use it as a glorified paper chart. Whatever productivity gains they achieve by not having to file, find, and retrieve the paper files are lost in learning the new system and measuring for meaningful use. The key for doctors seeking productivity gains from their new EHR is to build the proper infrastructure around their new technology. Having an electronic patient chart is great, but only if the chart can connect seamlessly with the scheduling office on the front end and with the billing service on the back end. In my business, we offer our clients a fully integrated system that connects every step of their workflow together more efficiently.

Flu Shot Information: 2016 - 2017 Flu Season

Revenue Cycle 101: Online Carrier Access

Patient-Centered Medical Home

Nov / Dec 2016 | Issue 11.6

The Physician Practice Educational Solution



of Your Practice – Great How toThe PlugFace the Leaks in Your Cash Flow: Part II Customer Service

The Impact of Not Knowing: Why Physician Practices Continue to Struggle

Proud to be a member of:

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This includes practice management software that sends data to the EHR, an EHR that generates claims and sends them to the biller, a billing software that’s connected to a clearinghouse, and a clearinghouse that verifies patient insurance back to the front office. All this integration makes the EHR more than just a fancy chart. Now, when the doctor meets her patient, she can open his chart, which has been populated by the front office, can see his insurance verification, can proceed with the encounter, can immediately generate an insurance claim when she’s done, and can have that claim submitted to her patient’s insurance company later that

day. Our goal is to create a work environment where productivity and creativity can flourish. I recently talked with a doctor who was using an EHR in her practice. It was a stand-alone product and she used it like a paper chart. In fact, she had two MAs working for her and part of their responsibility was to print reports and other documentation and add it to the patient’s file. Since nothing was integrated, a lot of work was duplicated: insurance verification had to be checked, re-checked, and communicated to the doctor; patient demographics had to be entered more than once; extra steps had to be taken to create claims and get them to the biller. The whole office was working hard but the doctor was only able to meet with 10 patients a day. She wanted to see 16 patients each day, but that seemed impossible.

departments, her people could work just as hard meeting 16 patients a day as they were currently working while meeting only ten. By meeting more patients, reducing costs, and billing more efficiently, her income would increase by about 80%. And that’s the very definition of increased productivity: the same people doing the same work for more money. Doctors shouldn’t despair that technology doesn’t increase productivity anymore. Nor should they wait around for productivity gains to magically appear because they use some new piece of software. Instead, they need to find the right system and create the right kind of workflow to get the most out of this new technology. EHRs can make doctors more productive, but only if they use it wisely.

Steve Matteucci is the CEO of Physician’s Revenue Management, Inc. in Essex, Vermont.

I showed her how, by integrating her technology with her various

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Medical Coding

Patient-Centered Medical Home Before I started graduate school, I was a billing associate at a private pediatric office. We knew we were trying to become a Patient-Centered Medical Home (PCMH), but very few of us really understood what that meant. I was confused, so having felt the same way that some of you may currently feel, I thought I would take a second and briefly explain PCMH. (phone, email, patient portal, timely patient visits) What is PCMH Recognition? Above, I briefly discussed the PCMH concept and guiding principles. There is also PCMH Recognition (or certification or accreditation) available. There are a few governing bodies that offer PCMH Recognition. The National Center for Quality Assurance (NCQA) is by far the largest and most widely known.


hat is the PCMH Concept? A Patient-Centered Medical Home is a form of primary care delivery for adults, pediatrics, and adolescent patients. So what does that mean?

It means that as a patient’s primary provider, the physician will put together a team that facilitates the treatment of each patient. This involves the patient in their own care: helping them understand the treatment plan, having them actively participate in care delivery decisions, and being more engaged in their own health. The PCMH concept also advocates coordinating care, measuring performances, using technology, and working as a team. Patient-Provider communication is another touchstone of the PCMH concept. Communication allows patients the ability to inform their doctor’s office of problems with medication or other treatment without an onsite visit.

In order to be PCMH Recognized, you must submit an application and meet specific requirements. NCQA’s requirements cover the following categories: • • • • • •

Patient-Centered Access Team-Based Care Population Health Management Care Management and Support Care Coordination and Care Transitions Performance Measurement and Quality Improvement

Chances are you already meeting a number of the requirements and provide high quality care—PCMH simply allows you to capitalize on it, and receive higher reimbursement for it. Want to pursue PCMH Recognition? Get in touch. Also, check out our recent blog post about why PCMH is a smart financial and strategic move for your practice.

Your office will also handle the referral process as well as create a treatment plan to carry out.

Sources: NCQA, PCPCC

PCMH aims to: • Increase the patient’s participation in and knowledge of their care • Increase care coordination between providers (primary, specialty, facilities) • Increase patient communication with their doctor’s office

Amber Winkler, MHA, PCMH, CCE, is the CEO and founder of Clarify based in Charleston, SC. She and her teams have successfully achieved NCQA Quality Recognitions, and worked in the population health, research, process improvement, EHR optimization and software space since 2006.


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Quality-based measurements are no longer optional. MACRA, MIPS, APMs

The new payment models are on the way and PMI has your staff training covered.

Get answers to important questions such as: how will my data and metrics impact the new payment models and how will the government use my data?

Attend a live class that will explain important physician reporting and reimbursement information releImproving the business of medicine through education vant to these new programs.

Visit for more information or call 800-259-5562 for distance learning options. BC Advantage Magazine


HIPAA / Security

Does your doctor keep your

Protected Health Information (PHI) Safe & Secure? Today, I visited my local dentist office for a new patient consultation and to interview them before choosing them as my Covered Entity (CE). After examining the waiting room and completing the necessary paperwork, I was called into the treatment room. •


uring my appointment, I met several different staff members, including their office manager responsible for HIPAA, and finally, the provider. The rest of the visit went as most dental exams do—no need to say more! After asking the office manager different questions about their Notice of Patient Practices (NPP), I decided the practice did not understand—or were choosing not to practice—HIPAA Privacy & Security responsibilities. I’d like to tell you that I only had to do this one time before I found a CE I trusted with my care and HIPAA Privacy & Security information, but sadly no, that was not the case. I interviewed four different practices and only one of them would I trust and recommend with my information and care. I share this information with you to help you learn what to look for when you visit your next provider of care. The first question to ask yourself upon choosing a CE is: Did your CE provide you with their NPP? CE’s are required to provide their patients with a NPP in plain language that provides: •

A description of how the practice uses or discloses (shares) your PHI.


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The CE’s legal duties with respect to the information, including a statement that the CE is required by law to maintain the privacy and security of PHI. How you will be promptly alerted if a breach occurs that may have compromised the privacy or security of your information. Assurance that the CE will not use or share your information other than as described in the NPP unless you instruct them in writing that they are allowed. If you consent, you may change your mind at any time, in writing. The individual’s rights with respect to the information and how the individual may exercise these rights, including how the individual may complain to the CE. A list of contacts for additional information about the CE’s privacy policies.

A CE must follow the duties and privacy practices described in the NPP and give you a copy of it. A CE must make its notice available to anyone who asks for it. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. A CE must prominently post and make available its notice on any website it maintains that provides information about its customer services or benefits. The NPP must also include an effective date. For more information see 45 CFR 164.520(b) for the all NPP requirements: Also see: Frequently Asked Questions about the Privacy Rule

Kimberly Shutters, Founder and CEO of HIPAA Alli, established in 2013, assists Covered Entities (CE), Business Associates (BA), medical device manufacturers, and health application developers/vendors in administering their HIPAA/HITECH Privacy & Security Compliance activities.

Make life a little easier with Optum360 online digital coding tools. Always up to date with the proper code sets and updates, our online digital coding tools help you spend less time searching for that elusive code, researching compliance rules and codes, or digging for referential information.

Learn more at Product information | One-on-one demos | 30-day trials | Auto demos Or call 1-800-464-3649, option 1.

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43 4 3

Practice Management

Challenges Facing Every Medical Billing Company Today and What to Do About Them Part II

In my last article, I discussed some of the issues facing medical billing companies today, including declining revenues, increased expenses, and the new role of EMR vendors in the medical billing arena—plus the employment of physicians by hospitals once again.


he above four areas that I examined are basically all outside challenges that you face day in and day out, but you really can’t control. However, you must develop strategies to try to minimize their impact.

I will now discuss some challenges that may be found internally in your organization that will have an impact on your continued success or your eventual demise. ISSUE: Upgrade your technology to include an additional arsenal of available tools that will enhance your revenue cycle collection capabilities. It’s imperative that you embrace what has been available the past few years from HBMA recommended vendors. STRATEGY: Three of the most popular offerings that will guarantee an increase in collections as well as a reduction in operation expenses are:


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1. 2.


Patient portal that allows guarantors to view their statements and pay their bills directly on line. Electronic presentment or more commonly known as “emailing patient statements.” This feature not only speeds up the time from statement creation to receipt by the guarantor, it also reduces the overall statement cost either for you or your client. Credit card on file feature where you will be automatically able to charge a responsible person’s credit card for any remaining copays or deductibles without first generating a statement and waiting for the normal payment turnaround time.

Remember, the above three tools are not only a huge convenience for your client’s patients, it’s mandatory for patients under the age of 30 because most of them have never written a check in their lifetime as everything they do is online. With this age group, if you don’t offer an online solution, your client may never get paid.

ISSUE: The Standard End of Month Reporting packages that most companies have been presenting to their clients for years, containing the practice data, is not enough. Your clients need information. With all the issues facing practices today, your client needs to embrace a Proactive approach to their practice and abandon the Reactive mode of the past. STRATEGY: Many of the practice management software systems we utilize today lack a robust reporting capability that can turn data into information so you should also have access to one of the new “Business Intelligence” (BI) applications. (I am not naming them here as I don’t want it to seem that I’m endorsing any one product.) Our clients need a plethora of information to help keep their practices vibrant. A few examples of informational reports are: •

Evaluation and Management bell curves that can easily compare their ongoing performance to the CMS and their specific specialty norms. Graphic presentations of data, such as shifts in payer mix, modality, referring physicians’ data, etc. Zip code and birthdate analysis of their patient populations.

The possibilities of what data can be tracked and reported on are much more numerous in BI software than what is found in the normal Practice Management canned software programs. ISSUE: Developing a competent second in command as well as a strong support-

ing management team. At least once a day I’m sure you realize that you can’t do it all yourself. Here we are in 2016 and there still isn’t any formal school that you can attend to learn the intricacies of how to be a successful medical biller. STRATEGY: The only way to surround yourself with an excellent supporting cast is to grow your own. You may be able to find some candidates with “experience,” but very rarely are they experienced in how you want to deliver service to your specific clients. It is important to carve out learning time every day and week. One way to achieve this goal is to make a list of every task you do on a regular basis and then decide which team member you will train to be able to handle this item ongoing. The advantage of this approach is twofold; you’ll start to develop team members that will become more valuable to your business and it will free up your time to accomplish other, more important tasks. This is a great time to be in the Medical Billing Business—as long as you don’t grow complacent. I wish you continued success.

Dave Jakielo is a Medical Billing Consultant, International Speaker, Executive Coach, and Author, and is president of Seminars & Consulting. Dave is past president of Healthcare Billing and Management Association and the National Speakers Association Pittsburgh Chapter. Sign up for his FREE weekly Success Tips at or Text Davespeaks to 22828. Dave can be reached via email Dave@Davespeaks. com; phone 412-921-0976.

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Office Talk

Control Is Important But So Is Judgment Many managers think that what they need most is a greater control over their office and staff. If you are one of those managers, you might be right, as long as you don’t make the mistake of initiating an elaborate system to determine if your employees are doing what you want, only to suddenly discover that they are accomplishing less overall and that even your own productivity has declined and that the system you created has produced the opposite of what you intended. ing of insurance payments found an ingenious way of counting to show that she had little problem with backlogged claim postings. She simply counted as “backlogs” only those claims she had payments for and not those with denials she had not handled yet. It later showed that she had thousands of dollars not recovered sitting in a draw un-worked. Many managers feel reassured that their authority is still intact when they continue to receive reports but they may be getting information that they used to need but they don’t need anymore. Many overlook the effort that is wasted in getting those reports together, effort better used elsewhere. I know managers who have had their employees track what they do on a daily basis and that is fine for a short time, but on a continual basis, it actually is time that is cutting into the employee’s productivity.


o many managers, “control” means requiring approvals before allowing certain activities to take place or must know, with varying degrees of detail, what employees are producing, compared with what they are supposed to be producing. So what can go wrong if you insist on controlling your staff? You may assume that you have accomplished your job as a manager when you initiate controls, though you think you need more controls if you want to see results; the fact is you may actually have overlooked sensible corrective actions. So what can go wrong when you put controls in place? You may not get accurate information if your employees are uneasy about what you will do with it. Even honest people won’t bring any rope if they think you may hang them. One example is an employee responsible for track-


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Many managers use the “do it my way” or the “we’ve always done it this way” type of control and that can sometimes prove very ineffective. Many times, the person doing the job may actually have a better, more efficient way of doing the job. One example is a manager who was leaving and in training her replacement, she showed her all the reports she printed and cross referenced and there were mounds of paper trails in a fully automated office. When she left and her replacement started doing the job, she found that most of the reports were duplicate information that could easily be found in the billing software without having to print out everything. Her time was freed up to give her time to do more important tasks. Though you must have control over the office you manage, too much of it can be unhealthy, thwarting the initiative of your employees, breeding their resistance, taking more of their time (and yours) than you can justify, and costing more than it can save. What can you do to exercise controls effectively?

Keep it simple. Don’t ask for more than your staff can readily give you without losing productivity. Only control what needs controlling. The saying “If it ain’t broke, don’t fix it” may seem extreme, especially for managers who believe in preventive measures, but it does contain much wisdom. Since you can’t control everything, choose the things which make a significant difference in the success of your practice, those areas where there’s danger that, without controls, something might go seriously wrong. Think carefully whether your means of control are helping or hurting. You can create a bottleneck if your approval is needed for every initiative and you are too busy to give each one your attention. Let people in on the purpose. They can cooperate with you more fully if they know what use you’re making of the requested information or why you want a job done a certain way. At the same time, they can let you know how the controls are affecting their work. Let your employees control what they can, instead of having to come to you. Your employees are undoubtedly closer to the details of their position than you are, and are thus in a position to spot problems immediately and do what needs to be done. You are the gainer when they feel that it’s “their” job, not just yours.

Consider whether you are giving signals that do not jive with the controls you set. One manager regularly kept staffers waiting before starting scheduled meetings and was always late for everything, but at the same time insisted on enforcing the policy that they return from lunch not one minute late, because “time is money.” It’s hard to convince people that you mean what you say if you are not personally consistent with your own philosophy. The thoughts on the subject of controls swing in several directions, from the view that controls mean constant observation and elaborate report systems, to the notion that employees need direction and help much more than they need controls, to a more realistic idea that controls should be used, but only when they are needed, and only with those employees for whom they are needed. If your employees know your expectations, you have policy and procedures in place, adding additional controls can only lead to inefficiency and low morale amongst your staff. Control doesn’t mean power.

Marge McQuade CMSCS, CMCS, CHCI, CPOM is a certified practice office manager, a certified multi-specialty coding specialist, and a certified healthcare coding instructor who has over 35 years of experience in the medical field. The Professional Association of Healthcare Coding Specialists (PAHCS) is a communications network and member support system dedicated to enhancing the compliance, documentation, and reimbursement capabilities of healthcare coders.

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5 Minutes with...

Amber Winkler


BC Advantage (BCA): Can you tell us a little bit about yourself and why you started your own healthcare consulting company? Amber Winkler (AW): After graduate school, I worked in healthcare for about 5 years before starting Clarify in 2011. During my work in and after grad school, I was fortunate to get some varied but complementary experience and exposure to the industry. It was 2009 and I was working in the PCMH, population health, and EHR optimization space—this was early compared to many other healthcare organizations and the industry as a whole. Many organizations are just now starting to tackle these projects, or haven’t even started yet and it is 2016. This and my previous work allowed me to have certain experience, expertise, and exposure in a few areas, and laid the foundation for my ability to start a company and begin to help others. Looking back, I guess it was 2010 and into 2011 when I began feeling and thinking that I wanted to take the work I was doing and lessons learned and use that to work with more healthcare organizations, groups, and practices. BCA: What does a typical work day normally entail for you? AW: There really is no normal. That’s one of the things I love about my life, but it’s something that I know would drive other people crazy. Whether I’m in office or on the road, every day (or at least weekly), I spend time on client work, the business, networking, development, how to improve, follow-ups, and brainstorming. I also try to read or listen to a podcast, and get some form of exercise in daily. There are definitely pros and cons to my “schedule.” There are some early mornings or late nights involved, but on the opposite side, today I went to yoga at 9:30 a.m., and occasionally I’ll play a round of golf in the late afternoon. I try to listen to my body, brain, and energy levels and give myself a break when it’s needed. I find this is the best way I can ensure the time I spend working is effective and that I’m able to be creative and think critically. BCA: Being a healthcare consultant, what challenges do you face on a day-to-day basis when helping practices achieve NCQA? AW: Each practice or organization has strengths and weakness-


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es, but they are always different. One of the first challenges is understanding a client’s culture. Asking the right questions and clear communication is also an ongoing emphasis and area that can make or break relationships. What resources, skills, or strengths does a client have that we need to capitalize on? What areas or processes need to be improved, put in place, or strengthened? Expectations and perception are also difficult to quickly understand and manage. As a consultant, I come in as an outsider, and there are always inner-organizational dynamics, relationships, protocols, processes, and history that we quickly need to understand, navigate, or ignore in order to be effective. That’s right, I said ignore. Not always, but at times, the reason we’re impactful is because we push through mental constructs, barriers, or patterns of behavior that are holding the group back from achieving the progress they desire. BCA: In your opinion, is it important for every practice to have a healthcare consultant? AW: I actually don’t think every practice needs a consultant. I also don’t think every organization and a particular consultant will be a good fit. When an organization or leader understands the value of consulting, and invests in it to better their organization, save time, and do things right the first time, it is an ideal consultant-client relationship. What I will say is, many practices don’t think they need a consultant, or believe they can’t afford it without looking into it, and they are the ones who actually need a little help the most.

Often the staff or teams at these organizations are the most extended or overworked, and people end up feeling they aren’t doing anything well. This is terrible for morale and retaining staff. Turnover is costly. Often it is actually less expensive (direct and indirect costs) to subcontract us (Clarify) than to put the additional work on your staff or hire an additional person, and that person likely doesn’t have expertise in certain areas, so they’re trying to learn this from scratch. In the projects we take on, we’ve done that type of work before, so we can save people time, help them avoid or quickly solve problems, and even find ways to save money and make money in our work together. Here’s a quick story. We showed up for our first meeting with a new PCMH and Population Health client. They’re a fantastic, very effective group. They were planning on hiring a registered nurse (RN) and assumed they needed this role immediately. This would be a very expensive addition to their team. In five minutes, we shared with them how to avoid or delay this new hire until they had a specific set of reasons or roles. The average RN salary in the U.S. is $67,930. When you consider salary plus benefits, we probably saved them nearly $100,000 in five minutes. BCA: You’re the CEO of Clarify. How hard/easy would you say it is to develop effective measurements and reporting systems that drive improvement for your clients? AW: This is one of my favorite parts of what we do with clients. I wouldn’t say that it’s easy, but it’s rewarding. What is easy and what is difficult varies by the size and capabilities of the organization. Sometimes, large health systems have almost unlimited capabilities, but it may take longer or be more complicated. And smaller organizations face different challenges. We almost always are able to find a way to utilize existing measurement systems, tools, or technologies for reporting and measurement,

and using what we find to make improvements. Our goal is to make small changes that deliver big results. It is not our aim to make massive, disruptive, or heavy-handed changes. BCA: What has been your biggest achievement so far in your career that means the most to you? AW: This is tough. Along the way there have been both big and small wins for our clients and our company. Speaking at both the first and second annual NCQA PCMH Congress is a proud moment (2015 and 2016). NCQA is the market leader in PCMH Recognition and they are a PCMH “governing body” of sorts. It is an honor to speak on that type of national platform, particularly two years in a row. Another achievement is starting the company in 2011 just after my 28th birthday. Starting a company was a lifetime goal of mine. BCA: If someone would like to obtain a career as a healthcare consultant or become a self-employed healthcare consultant, what kind of advice could you give them? AW: It’s a lot of fun, and always full of challenges and rewards, for me. But it’s not for everyone. Your life and path will be very different if you pursue work at a large consulting firm, a small firm, or if you start your own firm. Every company is also unique. It will also vary based on your level of experience or expertise. If you’re a student or in a position to intern, I’d recommend doing an internship to see how you react to the environment and preferably try a couple of environments. If you know or can connect with people who work in the industry or similar companies to those you seek, ask them questions about what it’s like and see if that feels like a good fit for you. If you have an interview, ask good questions and find out as much about the company culture and job expectations as you can. Do some honest soul-searching about things like travel, your preferred work style, if you like project-based work, if you can handle change. Your research and answers will help inform your decisions. For example, I enjoy business-related travel, but a project helped me realize I do not like to travel four days per week every week. I know people who do this and love it—it’s their “normal.” A friend from graduate school is an employee of a company, but serves as “internal consultant” of sorts, working with different departments and projects all the time—he worked at a large firm before landing his current role. Consulting means a lot of different things; there are many different types of consulting and consulting environments, so being honest with yourself will help you find a good fit. There’s no point in being miserable at work— life is too precious and short, so do something you love.

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PRODUCT Reviews HBMA Conference Review Recently, Melissa Gilchrist from our company attended the 2016 Healthcare Billing and Management Association (HBMA) Healthcare Revenue Cycle conference in Atlanta, GA. BC Advantage has worked with HBMA and their members over many years and we wanted to share some highlights to our readers so that you get a good idea of what to expect from such an event. With 3 full days of educational sessions, attendees were able to listen to leading healthcare presenters on topics such as: • ICD-10 At One Year: How Does Your Practice Measure Up • Medicare Audits and Appeals • Best Practices in Revenue Cycle Management • Navigating the Politics of Healthcare • And much more… We were lucky enough to spend some time sitting in on a few sessions, and really found the “Determinants for Successful Transition from PQRS 2016 to MIPS 2017” by Dan Mingle, M.D., M.S. very informative and well worth attending. The HBMA exhibit hall also saw its largest number of exhibitors, making it an exciting time for attendees to mingle and learn about new technology and resources that are available to them. Exhibitors ranged from consulting firms, software, RCM, and technology just to name a few. 2017 HBMA Healthcare Revenue Cycle conference will be held Sept 14 -16th Phoenix AZ. More details at

Title: NAMAS Auditor’s Toolkit Flashdrive Price: $15.00 Where to get it: The NAMAS Auditor’s Toolkit on jumpdrive is a useful resource for medical auditors. Save yourself time by having everything that you need to audit effectively in one place. With the NAMAS Auditor’s Toolkit Flashdrive, there will be no more searching through your various resources to get the job done as everything you need is there. Each 4GB flash drive comes with a lanyard and a built-in LED flashlight within a designer, resealable blister packaging and contains these useful medical auditing tools: • • • • • • • • •


Cardio Audit Tool 95 & 97 ENT Audit Tool 95 & 97 Eye Audit Tool 95 & 97 General Multi System Audit Tool 95 & 97 GU Male Audit Tool 95 & 97 GU Female Audit Tool 95 & 97 Hem & Lymph & Immuno Audit Tool 95 & 97 Musculoskeletal Audit Tool 95 & 97 Neuro Audit Tool 95 & 97

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• • • • • • • • •

Psych Audit Tool 95 & 97 Respiratory Audit Tool 95 & 97 Skin Audit Tool 95 & 97 MAS Surgery Audit Tool NAMAS Audit Tool 95 & 97 CMS E&M guidelines 1995 Documentation Guidelines 1997 Documentation Guidelines OIG Work Plan



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