TRIAD Volume 25, Issue 3

triad SUMMER 2014 VOLUME 25 ISSUE 3

THE AWARD WINNING JOURNAL OF THE MICHIGAN OSTEOPATHIC ASSOCIATION

practice management in this issue: • self-employed vs. employed • health information technology • payment for physicians • patient-centered medical home • regulatory affairs

TA B L E O F C O N T E N T S FEATURES 8

Practice Management

10

Employment vs. Independent Contractor Status

11

Health Information Technology and Electronic Health Records

12

Payment for Physicians

14

Patient-Centered Medical Home

16

Regulatory Affairs

18

Recovery Audit Contractor (RAC) Audit

DEPARTMENTS 5

President’s Page

22

Dean’s Column

23

Advertiser Index

EDITOR’S NOTES In this Summer 2014 issue of TRIAD, we introduce you to the Michigan Osteopathic Association’s Practice Solutions Program. The MOA’s Practice Solutions Program (PSP) is a cost-effective solution to your business and operational challenges. The PSP uses the collective strength of the MOA to bring solutions to you from experienced providers with cost-effecting pricing.

The PSP partners focus on the following areas: n Legal n Revenue and quality n Information technology n Meaningful use and electronic health records selection n Insurance

lawrence prokop, d.O.

These solutions will help you complete the puzzle of the health care transformation. We encourage you to learn more about the PSP by reviewing the different offerings of our partners. We’re certain you will find a solution that best fits your needs at a price you can afford. lawrence prokop, d.O. and adam hunt, d.o., MHS are Editors-In-Chief of triad and members of the MOA Board of Trustees. adam hunt, d.O., MHS

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p r es i d en t ’ s p a g e

I

t’s been said many times: health care, as we know it, is changing. With this change comes great challenge. Some of these challenges are going to be easy to solve; some are going to be extremely difficult. Ultimately, it’s going to take work, management and time to break through this reinvention of health care.

Your practices will need to reinvent its operations to create efficiencies and study its revenue cycle to maximize cash flow. This includes reviewing contracts, technology, workflows, staffing and much more. In late 2013, Medical Economics showcased a list of 10 challenges and opportunities facing physicians in 2014.

myral R. robbins, D.O., FAAFP, FACOFP

After interviews and surveys throughout 2013, the list of challenges and opportunities include: 1. Payment for medical services – ACA and changing payment trends; 2. Government mandates; 3. Payer headaches, and the fine print – Navigating a convoluted payment maze; 4. Time – Finding time for patients despite escalating administrative noise; 5. Technology costs – Sticker shock: the cost of technology; 6. Staffing and training – Higher staff turnover means new practice costs; 7. Putting control back in the hands of physicians – Stress, lack of autonomy negatively impacting attitudes about medicine’s future;

8. Changing patient populations – 2014 is the year of the new patient due to Medicaid expansion;

9. Primary care’s changing role – PCMHs as the future of primary care tied to population-based health care; and, 10. Work-life balance – Reconnecting with life outside of the office.

Indeed, there are a lot of changes and opportunities ahead.

As I mentioned in my inaugural speech, I will work to expand and innovate membership services in response to the unique needs of our members’ changing practice demographics.

In fact, we’ve already done so with the Michigan Osteopathic Association’s Practice Solutions Program (PSP). Inside this edition of TRIAD, I encourage you to learn more about the services of the PSP. We have identified strategic, experienced partners who bring solutions with cost-effective pricing. Currently, our PSP partners focus on the following areas: legal, revenue and quality, information technology, meaningful use and electronic health records selection, and insurance. These solutions will help you navigate through your practice management challenges today. myral R. robbins, D.O., faafp, facofp is the president of the Michigan Osteopathic Association and may be reached at myralrobbinsdo@aol.com.

TRIAD, Summer 2014 5

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TRIAD, Summer 2014 7

practice [ management ] makes perfect!

By Veronica Gracia-Wing

There is no denying that practice management is an art, oftentimes an incredibly frustrating, confusing and overwhelming art. Luckily, there is support for physicians, managers and staff wading through the deep waters of practice management in the form of the Michigan Osteopathic Association’s Practice Solutions Program.

T

he Practice Solutions Program, or PSP, offers effective solutions to the business and operational challenges physicians and practices face day in and day out. By calling on the leading experts in the practice management industry, the PSP can leverage the collective strength of the MOA and these providers.

Much like the pieces of a puzzle, the elements of the PSP fit together to complete a health care transformation. Our PSP partners focus on the following areas: legal, revenue and quality, information technology, meaningful use and electronic health records selection and insurance.

In this Summer 2014 issue of TRIAD, we’d like to familiarize you with the pieces of the PSP puzzle, introduce you to some of the outstanding providers with which we partner and share some of their valuable insight into the complicated world of practice management.

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practice solutions program (psp) OVERVIEW Legal

Revenue and Quality

Information Technology

Kerr Russell represents physicians in matters involving all aspects of the operation of their medical practice.

Particular attention is paid to health care law licensing, procedures, rules and regulations and other regulatory aspects of legal matters.

The Rybar Group is a team dedicated to ensuring practices optimize their reimbursements while maintaining efficiency and compliance. Practices can expect Rybar to keep them current with the technical and financial regulations that affect them, allowing them to remain focused on the care side of health care.

Agil IT focuses on serving the infrastructure and support services needs of ambulatory health care and has substantial experience in complex project management including work with HER and practice management platform providers.

Services: • Employment contract review – Understanding the terms and conditions of your employment agreement is crucial.

• Other contract review services – Understanding the variety of other contracts physicians may enter into is also important. Some common contracts include: network participation, office space and equipment leases, real property purchases and development, ownership interest in care facilities and agreements between practice owners.

• Licensing actions – Legal support when a physician’s license to practice is threatened.

• Claim denials and post payment audits – Knowing your rights when you experience challenges with payment claims is essential to maintaining a medical practice’s cash flow.

• Medical staff relations and peer review/credentialing matters – Knowing your rights when your medical privileges are in jeopardy and having legal representation during such an event is essential.

Much like the pieces of a puzzle, the elements of the PSP fit together to complete a health care transformation…

Services: • Evaluation and management review - Accurate documentation supporting medical necessity of patient encounters is key to the economic health and compliance of your practice.

• Charge capture analysis - A poor charge capture process can mean a large loss in revenue for your practice each year.

• Service code/CDM reviews - A healthy service code/CDM is essential to a clinic’s financial and compliance livelihood.

• Fee schedule analysis - The fee schedule for any practice is an important component that affects profitability and revenues.

• ICD-10 services - Understanding and planning for the ICD-10 conversion and transition will ensure implementation success.

• Revenue cycle management Revenue cycle management is recommended to improve the cash flow and financial bottom line of your practice.

• Practice valuation - Provides a report that estimates fair market value of a practice.

• Operational assessment Evaluating practice operations allows you to implement best practices.

• Denials reduction and management - Helps interpret the billing and coding requirements of a variety of payors to reduce denials.

Services: • Hardware selection, acquisition and installation.

• Network design and implementation • Back-up and disaster recovery.

• Remote monitoring.

• Project and general support.

Meaningful Use/EHR Selection Elevation Healthcare provides solutions to the challenges of converging requirements and associated incentives and penalties, as transformations are required not only for physicians, but practice business models and operational design and non-physician clinical and administrative staff.

Services: • Health care IT strategy and implementation.

• Meaningful use and other regulatory initiatives including privacy and security.

• Operational fundamentals.

• Practice transformation including Patient-Centered Medical Home.

• Advanced operations and leadership development including LEAN for health care.

Insurance The MOA Insurance Team specialized in assisting physicians in selecting health benefits for their practice, employees and families.

TRIAD, Summer 2014 9

Q & A with the experts Employment vs. independent contractor status Douglas Ventura executive vice president Agil IT

What’s the background on physician employment status?

The economics of independent practice is driving many formerly independent physicians to combine into larger groups and others to sell their practices to hospitals and health systems. For many new physicians, the reality of their debt loads following medical school and residency also causes them to seek the stability of employment vs. independence or small practice affiliation.

What are some of the benefits and challenges associated with both employed and independent contractor status?

The benefits of independence are a much greater influence in (or outright control of) decision-making over personnel, policy and strategy. Independent physicians have greater flexibility in the operational and financial dimensions, and even often the clinical dimensions, of their practice. The challenge is that they must also provide the leadership and management infrastructure – something they received little if any training for in medical school. This places a very high premium on hiring the right practice management staff. This challenge has become increasingly difficult with the waves of mandated or financially encouraged regulatory changes imposed on practices and expected to continue for the foreseeable future.

Alternatively, employed physicians are part of organizations with staff to address these changes.

What would you like physicians to know about employment status matters?

There are affordable services available to help physicians costeffectively retain their independence and continue to practice medicine in a manner amenable to them.

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Daniel Schulte, J.D. attorney Kerr Russell

What are some of the benefits and challenges associated with both employed and independent contractor status?

The typical benefit to being an independent contractor is the flexibility to work for more than one practice or to split your time between working for more than one practice and/ or other activities (e.g. teaching, research, etc.). The typical challenge is that independent contractor relationships usually do not come with the benefits that employment relationships do and there is an extra tax burden involved.

What types of counsel does Kerr Russell provide in employment matters?

One example would be the agreement’s covenant not to compete and anti-solicitation provisions. In an employment agreement you would reasonably expect these provisions to be inflexible since the employer has a legitimate interest in protecting the business of the practice. In the independent contractor context this is less so, especially when the contractor is not devoting all his or her professional time to the practice. In either case, the difference between these restrictions being enforceable and enforced needs to be carefully explained and understood.

What would you like physicians to know about employment status matters?

Be willing to spend a reasonable amount up front to have your contract reviewed and explained to you. It is always less expensive to know exactly what you are getting into and negotiate unfair/unreasonable terms than it is to just sign and then have to unwind or dispute the relationship later.

Health Information Technology and Electronic Health Records Wesley Gipe founder Agil IT

What’s the background on health IT? This is one of the most frustrating areas for independent and small practices. The requirements for implementing new technology have increased and will continue to do so. Practices need a long-term strategy to manage their expenses and they need service from reliable providers who understand the unique needs of the ambulatory environment.

What’s the current state of health IT and electronic health records?

Health care information technology is more than just EHR. On the application side, EHRs capture the most attention because of the meaningful use program and related incentives and sanctions, but there are many other important applications like patient portals and practice management solutions. The meaningful use program is in a state of uncertainty with the recent announcement of CMS’s intent to delay stage two. In addition to the applications, there are several important interface technologies that practices need to deploy, including laboratory, payment processing systems and information exchange systems. Finally, the application and interface environment is ultimately dependent on having a robust and reliable network and overall infrastructure with strong back up and disaster recovery solutions, all supported by remote monitoring and experienced service.

What do you wish physicians knew about EHR?

There are many excellent solutions – the key to selecting the right solution is a thorough, objective process.

What might physicians not know about health IT/EHR that they should?

Physicians and practices need to know that IT can get better. Far too many practices accept poor service and lack of vision as the norm when it does not have to be and should not be. Their IT services provider should be a business partner and not a vendor.

How has health IT services evolved or improved over the years?

Applications have become increasingly complex which in turn has increased the demand on users and infrastructure. Unfortunately, many practices get their IT services from general providers who do not have experience with this complex environment or understand the unique needs of ambulatory practices.

TRIAD, Summer 2014 11

Payment for physicians: Billing and coding Laura Lovett consultant The Rybar Group

Lynn Marie Pepper consultant The Rybar Group

Claudia Birkenshaw Garabelli director, revenue cycle the Rybar Group

12 TRIAD, Summer 2014

What’s background and current state of billing and coding?

Significant improvements within the entire revenue cycle can occur with improved billing and coding processes.

Providers, though, are struggling to balance patient care and implementation/appropriate use of technology, such as EMRs, automated leveling tools, and paperless encounter forms. Providers are still waiting to start preparing for ICD10. There is increased scrutiny for appropriate coding by payors and the government, leading to more pre- and postpayment audits. More patients are waiting to seek treatment until they have multiple issues or their condition has become completely out of control due to higher deductible amounts, driving levels of service higher due to medical necessity but skewing bell curves and making administrators and providers nervous due to risk of the potential for over coding. There is a hybrid use of paper and EHRs throughout practices; their use forces process/technology changes which may or may not improve the overall

process. These processes need to be reviewed, the quality of the data and interfaces/data flow analyzed and ensure that the intended result is reached. Sometimes facilities are purchasing practices, which may keep physician systems in place, but may have unintended consequences. Overall, a lot of improvement could be made on both the understanding of how to properly code, the revenue cycle flow/process within the practice and payment review. Payors are also tightening deadlines and providers sign contracts without verifying if deadlines are reasonable. The result is poor AR performance.

What are some of the latest trends in payments?

Higher deductibles are impacting patients and providers in multiple ways. Patients are deferring treatment due to fear of out-of-pocket expenses or they are defaulting on their bills leaving the providers and facilities uncompensated for services rendered. Not only are payments now connected to quality and the overall continuity of patient care but there are also incentives for primary care services.

How have these services evolved or improved over the years?

Health care is in a constant state of change and we are continuously working to keep up with the changes. The introduction of more automation has compounded problems it was actually intended to eliminate, in addition to creating new problems. The ACA is continuing to change the requirements but many are not clearly defined or even scheduled for implementation yet.

What are some of the challenges or frustrations you hear about often and how do you address those?

Providers feel overwhelmed by non-patient care requirements that continually change. They got into medicine to take care of patients, not be experts in documentation, coding, billing and finance. This is where we stress the importance of a good support staff. Providers shouldn’t be expected to do everything; they should take care of their patients and document what they do. Having people in place to handle coding, billing and the running of the

business side of their practice is vital in this day of heavy and constantly changing regulation. Additionally, there are a large number of individuals in practice management leadership that are not as involved in understanding the latest payment trends, and as a result, monies are lost that should be obtained.

What do you wish you could tell physicians as they explore the world of payments?

There is a difference between coding and billing. Coding is determined by the documentation of the services provided.

Codes are used to populate bills but accurate coding based on documentation does not always equate correct billing based on specific payors guidelines. Also, getting paid for a service does not mean that it was coded and billed appropriately. Most bills are paid without any documentation ever being reviewed by the payors. The payors are trusting the providers to represent their services accurately and according to applicable guidelines. It is the provider’s responsibility to ensure they are submitting correct bills base on what is supported by their documentation. Additionally, we recommend incorporating a robust point of service campaign since 85 percent of employers and insurance plans have high deductibles. Finally, implement a proactive denial and rejection management program, complete rootcause analysis and confirm that the CPT codes billed are sustainable.

What might physicians not know about billing and coding that they should?

Be aware of changes related to your voucher/EDI payments, incorporated this year as a result of the CAQH CORE mandates. To be specific, make sure you notify the bank at which you receive your EFT payments to send you the tracer number on the EFT so you are able to re-associate the EFT to the ERA payment voucher.

TRIAD, Summer 2014 13

Patient-Centered Medical Home (PCMH)

Dr. David Share senior vice president of value partnerships at Blue Cross Blue Shield of Michigan

What’s some background on Blue Cross Blue Shield of Michigan’s PCMH? BCBSM’s award-winning Patient-Centered Medical Home model is comprised of 12 initiatives made up of 140 capabilities that are based on the Joint Principles of the PatientCentered Medical Home developed by the major national medical societies in 2007. Our PCMH program launched in 2008, and our PCMH Designation program, the largest in the country, followed in 2009. Each of the 12 initiatives is comprised of capabilities that encompass what it means to be patient-centered. Due to the size of our program and our successful approach that emphasizes collaboration and customization, BCBSM is considered to be at the forefront of the patient-centered medical home approach nationally.

What are some of the latest trends in PCMH implementation or research?

BCBSM has had several articles about our PCMH program published in peer-reviewed journals, with several more expected to be published in the next year or so. Of particular interest is an article published last July in Health Services Research. In that article, lead author and BCBSM epidemiologist Dr. Michael Paustian suggested that full implementation of the BCBSM PCMH model is associated with a savings of $26.37 per patient per month for adult medical costs. These significant potential savings for the health care system, associated with implementing our PCMH model, is a very exciting finding indeed.

How have these services evolved or improved over the years?

Practices are on a continual journey to implement PCMH capabilities, and as a result, each year additional practices become more patient-centered by achieving PCMH designation. As more practices implement greater numbers of PCMH capabilities, the better health care becomes for patients across the state of Michigan – especially because, as part of our social mission, our PCMH model supports practices and physician organizations in their efforts to transform the information systems and care management processes they rely on to provide the best possible care to their patients.

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What are some of the challenges or frustrations you hear about often and how do you address those?

Many of the challenges we hear about center around how challenging it can be to truly transform a medical practice into a patient-centered medical home. As new systems and processes are put into place, there may be difficulties, but there are also opportunities for growth. In general, physicians report a high degree of satisfaction with our program.

What’s the one thing you wish you could tell physicians as they explore the world of PCMH? Becoming a patient-centered medical home is neither fast nor easy; however, we have often heard from program participants that the rewards - in terms of being able to care for patients safely and effectively, to transform their practices, and to be fairly compensated for doing that work - ultimately outweigh the struggles.

What might physicians not know about PCMH that they should?

If physicians are interested in participating in our PatientCentered Medical Home model, they are welcome to join us in that endeavor; the PCMH program is open for participation to both specialty and primary care physicians, and they must first join a physician organization that participates in the PGIP program in order to begin implementing PCMH capabilities.

Contract negotiations Daniel Schulte, J.D. attorney Kerr Russel

What might physicians not know about contract negotiations that they should?

Changes to contracts are made as a result of negotiations.

Many physicians believe that when they are presented with contract nothing can be done and they must sign - this is not true. Physicians must understand what they are signing and when the contract contains unreasonable terms they should be called out. Insurers, health plans administrators do respond especially when the requested changes to their contract are coming from multiple physicians. In addition, if there are contract provisions that are unreasonable or difficult/impossible to comply with, given circumstances that are unique to your practice, you must bring them to the attention of the other party. Exceptions are made when necessary.

Direct primary care vs. fee for service Laura Lovett and Claudia Birkenshaw Garabelli the Rybar Group

What might physicians not know about direct primary care and fee for service that they should?

Although we have not seen this a great deal in Michigan (with the exception of cosmetic services which are generally not covered and OB services for the uninsured), physicians need to be cautious. CMS has a “limited fee” mandate, even if you do not participate with them. It’s important to note that a few providers in the country have had problems with the OIG when they implement this process. We expect this unique marketing of physician services to increase, as it already has throughout the country.

TRIAD, Summer 2014 15

Regulatory affairs Peggy A. Leiby account executive Association Benefits Company “Powering the MOA Insurance Team”

What is some background on the ACA and the impact it has on practices?

The Affordable Care Act is the nation’s health reform law enacted in March 2010. It contains numerous provisions that had stated would expand health coverage to 25 million Americans, increase benefits and lower costs for consumers, provide new funding for public health and prevention, bolster our health care and public health workforce and infrastructure, foster innovation and quality in our system and more.

The ACA aims to reform both our private and public health insurance systems, in order to expand coverage to 25 million Americans by 2023. It is also intended to lower costs and increase benefits for consumers, and to incentivize quality and innovation in our health care system. In addition, the ACA includes critical funding for public health and prevention.

What services does Association Benefits Company provide in helping physicians/ practices meet ACA requirements?

We can explain in normal language what ACA means to their practice and how it affects them as far as the compliance issues. Additionally, we can assist them meeting compliance requirements. We also guide our groups through the Open Enrollment process. If they are unhappy with the increase in premium, we can quote alternate plan designs, and if they request, alternate insurance carriers. These are just a few examples of the support we can provide.

What are some of the things on the horizon for practices and ACA? Ensuring their company or practice is in compliance with the ACA laws. If they aren’t, they could pay penalties of $100 per day per employee, retroactive to when it is determined they were out of compliance. In 2014, we can expect expanded Medicaid coverage, individual requirement to have insurance, Health Insurance Exchanges including tax credits and cost sharing subsidies, guaranteed availability of insurance, no annual limits on coverage and essential health benefits. In 2015, physician payments will be tied to the quality of care they provide.

What’s the one thing you wish you could tell physicians as they explore the world of ACA and their practice?

That PPACA (Patient Protection and Affordable Care Act) affects all group health plans – no matter your size. Please, read MOA communications about health care reform and DOL Audits increasing in numbers and anything you receive from Association Benefits Company. We are trying to protect and guide, not instill fear.

To learn more about the services or contact the providers in the Practice Solutions Program, visit www.mi-osteopathic.org/psp.

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Symposium for Primary Care Medicine Sponsored by:

Friday & Saturday November 7- 8, 2014 Sheraton Detroit Novi Hotel Novi, Michigan

For Physicians, Physician Assistants and Nurses: 17.0 Category 1-A AOA CME Credits 17.0 AMA PRA Category 1 Credit(s)™

Specialty Credits Issued:

Internal Medicine | Family Medicine

Featuring a Self-Guided ENT Workshop Registration Opens August 15, 2014. Please call (248) 471-8350 or visit http://www.botsford.org/physicians/ TRIAD, Summer 2014 17

Avoid Being Put on the RAC: Be Prepared for a Recovery Audit Contractor Audit

By Kathleen Stillwell, MPA/HSA, RN, CPHRM Patient Safety Risk Manager II, The Doctors Company What is a RAC Audit?

Any medical practice submitting claims to a government program, such as Medicare, may contend with a Recovery Audit Contractor (RAC). RAC audits are not one-time or intermittent reviews; they are a systematic and concurrent operating process for ensuring compliance with Medicare’s clinical payment criteria, documentation, and billing requirements.

The RAC program was signed into law by the Medicare Prescription Drug Improvement and Modernization Act of 2003 and made permanent by the Tax Relief and Health Care Act of 2006.

Its purpose is to identify improper Medicare payments—both overpayments and underpayments. The RACs use proprietary software programs to identify potential payment errors in such areas as duplicate payments, fiscal intermediaries’ mistakes, medical necessity, and coding. RACs also conduct medical record reviews. In fiscal years 2010 and 2011, RACs identified half of all claims they reviewed as having resulted in improper payments.

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The program’s mission is to detect and correct past improper payments so that the Center for Medicare and Medicaid Services (CMS) can implement actions that will prevent future improper payments: • Providers can avoid submitting claims that do not comply with Medicare rules • CMS can lower its error rate • Taxpayers and future Medicare beneficiaries are protected

Who Is Subject to a RAC Audit?

• Hospitals • Physician practice • Nursing homes • Home health agencies • Durable medical equipment suppliers • Any provider or supplier that submits claims to Medicare

Who is the RAC Auditor?

CMS has contracted with RAC auditors for each region in the United States. It is important to know who the RAC auditor is in your region. Never ignore a letter from one of these organizations. The United States is divided into four regions. Each region has a designated recovery audit contractor.

Michigan is in Region B. • Region A RAC Auditors: Performant Recovery, Inc., and subcontractor, PRG-Schultz USA, Inc. • Region B RAC Auditors: CGI Technologies and Solutions, Inc., and subcontractor, PRG-Schultz USA, Inc. • Region C RAC Auditors: Connolly Consulting Associates, Inc., and subcontractor, Viant Payment Systems, Inc. • Region D RAC Auditors: HealthDataInsights, Inc. Las Vegas, Nevada, and sub- contractor, PRG-Schultz USA, Inc.

What Does the RAC Review?

The recovery audit looks back three years from the date the clam was paid.

RACs are required to employ a staff consisting of nurses, therapists, certified coders, and a physician.

The RAC reviews claims on a postpayment basis. There are three types of review: • Automated—no medical record needed • Semi-automated—claims review using data and potential human review of a medical record or other documentation

Areas to include in your assessment and monitor- ing plan include: • Review denied claims categories by RAC audit.

• Keep abreast of notifications on CMS website.

• Review annual Office of Inspector General (OIG) work plan to identify audit areas.

• Monitor RAC progress at regional RAC (their web postings).

• Perform audit of your bill

• Complex—medical record required

What Can You Do to Prepare for a RAC Audit?

Potential Issues with Electronic Medical Records

Assess your risk for billing issues by performing a risk analysis of your billing practices. Assign a knowledgeable member of your staff to review your billing processes and to develop a billing compliance plan. Consider hiring a contractor for this task. Identify billing issues, keep track of denied claims, and look for patterns and determine what corrective actions you need to take to avoid improper payments. Common billing errors include:

The Office of Inspector General (OIG) is studying the link between electronic medical record (EMR) systems and coding for billing. There is a concern that some EMR systems may upcode billing through automatically generated detailed patient histories, cloning (when you cut and paste the same examination findings), and templates filled in to reflect a more thorough or complex examination/visit.

Review these issues with your EMR company and determine if your EMR program has the potential to automatically upcode billing based on EMR documentation.

• Inadequately trained staff.

• Lack of time.

• Did not follow recommendations in Federal Register bulletins.

• Did not consult Health and Human Service bulletins.

• Misinterpretation of rules.

• New staff/New billing company.

The person responsible for implementing the billing compliance plan should regularly monitor RAC progress in your region. Each RAC must maintain a website with information on new audit focus areas and the status of a provider’s audits.

Medical billing is complex. Billers and coders must be knowledgeable about many areas pertaining to billing/reimbursement. Be sure your billing staff understands local medical review policies and is knowledgeable of practice jurisdictions. Billing personnel must staff stay current on coding requirements and keep up with industry changes, understand denial and appeal processes, and be able to identify resources for support.

What to Do if You Are Audited Do not ignore a letter from the RAC auditor. It is recommended you have an attorney assist you with your response to a RAC audit. Check with your insurance company to determine if you can get help with the audit. The Doctors Company, for example, provides RAC audit legal assistance for all members as part of its MediGuard® coverage. Before you send records to the auditor, be sure to review them in a “self-review.” Are there common themes? Are you coding with the correct documentation? Make copies of everything you send to the RAC auditor and be sure to keep a copy of all documentation. Send medical records via certified mail.

Fundamentals for Compliance

Staying on top of the RAC audit process is important as there are multiple policies and procedures governing RAC audits. The RAC can request a maximum of 10 medical records from a provider in a 45-day period. The time period that may be reviewed has changed from four years to three years.

Establish compliance and practice standards and conduct internal monitoring and auditing to evaluate compliance. Conduct appropriate training and education for staff and respond to deficiencies identified during internal audits. Establish corrective action plans and enforce disciplinary standards when necessary.

Responses are time-sensitive, and significant penalties may result if they are not handled properly. RACs are paid on a contingency basis for overpayments and underpayments. If you agree with the RAC demand letter you have the choice of paying by check or recoupment from future payments, or you may request an extended payment plan.

TRIAD, Summer 2014 19

certified mail. It is recommended you have legal representation to advise

Avoid Being Put on the RAC (continued) If a recoupment demand is issued, you may pay by check within 30 days with

you in the response to a recoupment demand, to determine if you should appeal, and to ensure you meet the required regulatory requirements of the appeal process.

future payments, or request or apply for an extended payment plan. There

CMS recently announced that it is in

is an appeal process if you do not agree

the procurement process for the next

with the audit findings.

round of Recovery Audit Program

Do not confuse the RAC Discussion

contracts. To accommodate the tran-

Period with the appeals process. If you

sition, CMS will ensure all Recovery

disagree with the RAC determination,

Auditors complete outstanding claim

do not stop with sending the discus-

reviews by the end date of the cur-

sion letter detailing why you disagree

rent contracts. In addition, a pause

with the findings. File an appeal before

in operations will allow CMS to con-

the 120th day after the demand let-

tinue to refine and improve the Medi-

ter. Send correspondence to RAC via

care Recovery Audit Program.

20 TRIAD, Summer 2014

More information on the growing risk of government investigations and audits can be obtained through five short videos featuring tips from

The Latest News Regarding RACs

no appeal, allow recoupment from

Where to Get More Information on Government Audits

Kevin R. Warren, Esq., of Michelman & Robinson LLP's Healthcare Practice at http://ow.ly/rP02n. The videos address how to create an effective compliance program, why it's important to train staff to avoid improper and exaggerated coding, what steps to take if your practice receives a subpoena, and how to properly protect electronically stored information.

TRIAD, Summer 2014 21

d e a n ’ s col u m n Remembering what makes us different can help us move ahead together

by William Strampel, D.O.

T

his is an especially challenging column to write, because it will appear in print sometime after the American Osteopathic Association’s House of Delegates meeting and the voting that will take place related to graduate medical education. I wish that I could say, “See, I told you exactly what would happen,” or “I knew where we would come out,” but as I have said numerous times, I cannot predict the future. This is especially true now.

There are some things that I am confident in predicting: n

The discussion on the topic of osteopathic graduate medical education’s future will not end at the close of the House of Delegates. Regardless of what is said in the debate and the results of the voting, we will not be finished with this discussion and cannot be finished. This topic is too important.

n

Whatever your feelings are about the possibility of an AOA merger with the ACGME, it’s important to recognize some constants.

n

In many places (Michigan is not one of them), the number of osteopathic graduate medical education slots has not kept pace with the number of graduates.

n

Ninety percent of graduate medical education is the same for D.O.s and M.D.s.

n

The nation and state are facing a dire shortage of primary care physicians.

I maintain that there is another set of constants that is equally important. The osteopathic philosophy, at its heart, is what separates us from allopathic physicians, including our foundational belief in the body’s innate ability to heal itself, the emphasis we place on holistic healing and the importance we place on truly listening to our patients and making them partners in their health care. Even more than our knowledge and use of manipulative medicine, these tenets are keys to our future.

These cornerstones make our profession unique and important, and regardless of what transpires related to graduate medical education, if we can hold onto what is important, I believe we’ll continue to be a thriving profession well into the 21st century and beyond.

William Strampel, D.O., is Dean of the Michigan State University College of Osteopathic Medicine. He can be reached at pat.grauer@hc.msu.edu.

22 TRIAD, Summer 2014

advertiser index MIT, powered by Association Benefits Company............. 7 Botsford Hospital........................................................... 17 TRIAD Staff Lawrence Prokop, D.O. & Adam Hunt, D.O., MHS, Editors-in-Chief William Strampel, D.O., Contributing Editor Kris T. Nicholoff, CEO and Executive Director Lisa M. Neufer, Director of Administration Kevin M. McFatridge, Manager of Communications Cyndi Earles, Director, MOA Service Corporation Shelly M. Madden, Manager of Membership Marc A. Staley, Manager of Finance Wendy Batchelor, Manager of Physician Advocacy Carl Mischka, Advertising Representative reZüberant Design, Layout and Cover Design 2014-15 Board of Trustees Myral R. Robbins, D.O., FAAFP, FACOFP, President Robert G.G. Piccinini, D.O., President-elect Bruce A. Wolf, D.O., Secretary/Treasurer Michael D. Weiss, D.O., Immediate Past President Edward J. Canfield, D.O., Past President Lawrence J. Abramson, D.O., MPH, & Craig Glines., D.O., MSBA, FACOOG, Department of Insurance John W. Sealey, D.O., & Kevin Leikert, Department of Public Affairs Lawrence L. Prokop, D.O. & Adam Hunt, D.O., MHS, Department of Education Jeffrey Postlewaite, D.O. & David Best, D.O., Department of Membership

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The osteopathic profession in Michigan is made up of osteopathic physicians, osteopathic hospitals and an osteopathic medical school. This TRIAD stands together to serve our patients and one another. TRIAD, the official journal of the Michigan Osteopathic Association, serves Michigan’s osteopathic community, including its osteopathic physicians, hospitals, medical school and patients.

The Michigan Osteopathic Association will not accept responsibility for statements made or opinions expressed by any contributor or any article or feature published in TRIAD. The views expressed are those of the writer, and not necessarily official positions of MOA. TRIAD reserves the right to accept or reject advertising. The acceptance of an advertisement from another health institution or practitioner does not indicate an endorsement by MOA. TRIAD (ISSN 1046-4948; USPS 301-150) is published quarterly by the Michigan Osteopathic Association, 2445 Woodlake Circle, Okemos, MI 48864. Periodical postage paid at Okemos, MI 48864 and other post offices.

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For advertising inquiries, please contact Carl Mischka at 888.666.1491 or via email at cmischka@mi-osteopathic.org TRIAD, Summer 2014 23