NOTE: While the posts on this blog should generally be concerned with healthcare related issues, the current political situation in Washington along with pending healthcare reform render politics and healthcare inextricably bound. When looking at the current logjam relating to healthcare reform, I think that there are a number of inescapable facts. Although I am far from a political expert, it is possible that the inexperienced person may be able to suggest workable and proper solutions specifically because they are not constrained by the minutia of the political process.


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CALIFORNIA CASE – Aetna Life Insurance Company Vs Bay Area Surgical Management –1-12-CV-217943, Superior Court of California, County of Santa Clara

Posted in News on March 13th, 2012

OVERVIEW:

The world has not changed. Medical insurerstry to maintain healthy profits by, in part, by keeping reimbursements to medical providers as low as possible. On the other hand, medical providers try to get a fair shake based on their education, specialization, financial risk and hard work. Part of the insurer’s strategy is to negotiate rates with medical providers at levels that the often say is patently unfair, and therefore when they are not bound by the network contracts they rightfully seek much higher reimbursement. Obviously the insurer’s bristle at the higher fees charged for out of network medical care.

This “tug-of-war” has resulted in a number of lawsuits throughout the United States that underscore the ying and yang as well as raise questions about the propriety of waiving co-pays and deductibles, as well as the propriety of using patients as leverage against the insurer’s.

THE NITTY GRITTY:

Recently, Aetna sued several California surgery centers for an alleged “fraudulent billing scheme” alleging that the surgery centers induced physicians to refer patients for surgery centers (ostensibly out-of-network centers) with promises that they would not have any financial responsibility for their coinsurance and deductibles.

Aetna claims that the charges that were thereafter submitted were artificially inflated driving up the cost of health insurance coverage.

(Presumably the allegation of inflated billingwas supposed to strike a cord of public outrage which may be tempered by a Feb. 1, 2012 report in the Wall Street Journal that Aetna’s earnings rose 73% as the health insurer continued to benefit from light medical costs amid a sluggish pace of patient visits to hospitals and doctors.)

Aetna alleges that providers are liable for engaging in a fraudulent and illegal kickback scheme when they waive the patient’s coinsurance and deductibles, even if the provider bills the patient but ultimately doesn’t collect.

While I have not had the opportunity to read the California complaint, and the information relayed regarding the case has been distilled from various published sources, it is clear that the defendants have a very different view.

Defendant’s attorney, DaronTooch, a partner Hooper Lundy & Bookman, (defendant’s law firm) says that “this is a calculated move by Aetna to steer patients to contracted facilities.” He continues to say that “the complaint is full of misstatements of fact and law.”

It appears that Aetna and other health insurers do not have standardized fees paid to network providers. Every contract is separately negotiated and it seems that the major driving force in negotiating the contracts is the relative strength of the parties to the negotiation.

For example, if one medical organization controls the majority (or all) of the hospitals in a certain locale, and the health insurer wants to gain a foothold in that market, they do not have a strong negotiating position with the hospitals. The same obviously holds true with any independent physicians Association (IPA) that has a strong negotiating position based on its membership roll, and the specialization and geographic reach of their constituency.

To the extent this is true, the prices for which medical care is contracted are not grounded in allowing medical providers to earn a fair profit, but essentially turn into an unprincipled money grab. Doctors feel that in many (if not the vast majority of) cases they are left holding the short end of the stick. It is easy to understand why.  The medical insurers are the Goliath and the doctors are generally the David, except in this case David does not necessarily conquer Goliath.

From the insurer’s perspective, out-of-network surgery centers charging many times more the amount of the contracted rates that in network centers are allowed to charge gives the insurer’s pause.

The questions:

  1. Arehigh out-of-network charges a natural consequence of taking unfair advantage of medical providers when insurers have the clout, and therefore when they lose that clout there is a certain understandable payback.
  2. Are the insurers at least in part responsible for the out-of-network fees, to the extent that their reimbursement relates to the customary charges in a geographic locale.
  3. Is it improper for medical providers to waive co-pays and deductibles, and even if it is improper, should that render the medical provider liable to disgorge the profits earned on the medical procedures for which they waived the co-pays or deductibles.
  4. How far must the medical provider go in trying to collect the co-pays or deductibles before it is considered a waiver. Is one invoice enough, two invoices, collection agency intervention, or must the patient be sued and must a judgment be obtained.

There is a somewhat similar in your case that is currently pending, as well as a lawsuit against certain pharmaceutical companies for providing coupons toward the co-pays on branded drugs. However, the details of those cases are best left for another day.

In summary, what do you think?

This blog is intended as an information source for the clients and friends. The content should not be construed as legal advice, and readers should not act upon information in this publication without professional counsel. This material may be considered advertising under certain rules of professional conduct. Copyright © 2012. All rights reserved.

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Breach of Records Story

Posted in News on April 12th, 2010

Story breached by a radiologist who broke into a computer archive system over a period of several weeks after he was terminated in February.

The hospital announced the security breach Monday on its website.

The doctor worked for a radiology group contracted by Griffin Hospital. His job ended Feb. 3, although it’s not clear if he was fired.

His archive password was revoked when he lost his job, but he continued to access the system using passwords of other employees without their knowledge between Feb. 4 and March 5, the hospital said.

The hospital’s Digital Picture Archiving and Communication System (PACS) has medical images, patients’ names, exam dates, exam descriptions, gender, age, medical record numbers and dates of birth. It does not have either Social Security numbers or patient financial information.

The radiologist looked over a directory listing of 957 patients and downloaded medical images, such as X-rays http://www.courant.com/topic/health/medical-procedures-tests/x-rays-HEPAS000036.topic, for 339 of them. In late February, some patients called Griffin Hospital to say they had been contacted by the doctor, who was offering his professional services at a different hospital in the area. The inquires prompted a hospital investigation.

“This breach … appears to have been a deliberate intrusion … to view patient radiology reports,” said hospital President Patrick Charmel.

Griffin Hospital notified Attorney General Richard Blumenthal http://www.courant.com/topic/politics/richard-blumenthal-hpp4069.topic’s office, the U.S. Secretary of the Department of Health and Human Services and all patients whose information had been accessed in the breach.

“Unauthorized accessing of patient information is a violation of the federal [health information privacy] law that my office is empowered to enforce,”Blumenthal said. “I will seek strong and significant sanctions, if warranted by the facts. Griffin Hospital rightly informed my office of this alleged data breach and is cooperating with our investigation.”

Patients who have questions are asked to call the hospital’s vice president for legal affairs, Edward J. Berns, at 203-732-7506

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Letters tip off patients

Posted in News on April 12th, 2010

Boulder Community Hospital officials are investigating anonymous letters sent to patients of a Lafayette clinic along with medical records that the sender claims were pulled from the trash.

A Longmont woman told the Times-Call she received the anonymous letter Monday with a page from her son’s medical records that included private medical information and her Social Security number.

Mary Iannotti, a spokeswoman for Boulder Community Hospital, said Monday afternoon that the Family Medical Associates clinic in Lafayette, which is affiliated with BCH, fielded four calls from patients who reported receiving the anonymous letters.

“This is the first time that we have heard about this concern,” she said. “We will investigate this further and contact any patients that have received this letter.”

Iannotti said she can’t yet answer questions about potential violations, liabilities or potential penalties. And she does not yet know if the hospital will ask police to help investigate the anonymous letters.

The Longmont woman, who asked to remain anonymous, said the letter included photos of the trash can and Lafayette clinic building where the letter writer claimed to have pulled the record from the trash.

She said she called her physician’s office and was told her call wasn’t the first.

“They said they would be getting to the bottom of it,” she said, adding shewas told the documents were supposed to be in a locked trash can.

The woman said the record had handwritten notes on it as though it had been used as scrap paper and that the information included notes about other patients, including a DUI notation and that a family had suffered from swine flu.

The letter urges the recipient to report the incident as a potential federal violation of laws that require medical records to be kept private.

A post office box listed as the return address belongs to the Boulder Community Hospital Foundation.

Iannotti said the foundation is not involved.

Barb Guest of the Longmont United Hospital medical records department said that paper copies of all medical records are collected after use in the hospital, bagged up in the medical records department and shipped to a third-party document shredder for disposal.

She said continuing care physicians and Longmont United Hospital patients may have copies of medical records, and responsibility for their care and proper disposal transfers with the documents

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Your Medical Records May Be a Prized Possession – To Other People

Posted in News on April 8th, 2010

When we think about the security that doctors’ offices must maintain for PHI, and the burdens that HIPPA/HITECH place on medical practices, we generally think of safeguards for accidental dissemination, the loss of the laptop, the malicious acts of a disgruntled employee, or a person looking at medical records because of idle curiosity or prurient interests.

In fact, medical records, and particularly insurance information are a valuable commodity that many fraudsters and criminals actively seek. The sad reality is that medical identity theft is a growing problem, and the migration to electronic medical records is increasing the incidence of medical identity theft.

By way of introduction, medical identity theft occurs when a criminal uses a victim’s identity and insurance information without the victim’s consent to obtain medical treatment or to fraudulently make medical claims. Typically, either a dishonest person seeks medical treatment, or a real or sham medical office makes claims for medical treatment that was never provided. According to Javelin Strategy & Research, there were more than 275,000 cases of medical identity theft in the United States last year, which was twice the number reported in 2008. The average fraud cost $12,100 which was more than twice the average of typical identity theft.

From the insurance perspective, the effects can be catastrophic. In its simplest form, the consequence for the individual is a negative health history that is replicated on many different databases and reports available to insurers. Trying to clean that up seems to be as difficult as getting something erased from the Internet. What happens to the person who bought life insurance and claimed to be in good health but then died within two years of the policy initiation? Invariably, the insurance carrier will launch an investigation to make sure that all the information provided on the application was correct. When they check the person’s health history, they could find a medical condition that does not comport with the answers provided on the insurance application. From the insurer’s perspective, they will be able to deny coverage. From the beneficiary’s perspective, they may not know the actual medical history of the deceased. Even if they know the truth, how can they ever clean up that mess?

Someone I know very well recently had an unusual situation. His wife opened an invoice for his prostate surgery and knew nothing of it. For a number of weeks, she did not know how to broach this with her husband and tried to tiptoe around the issue, finally asking her husband if he had any health issues or if he had had any ambulatory surgery. When the husband looked at his wife with a blank stare, she finally asked him if he had any prostate issues. Needless to say they both had a chuckle and the claim is now under investigation.

Stories like this do not always end as well.

Jennifer Leuer, General Manager of Protectmyid.com, an identity protection service provided by Experian, commented,”It’s (medical identity theft) becoming the credit card with a $1 million limit.”

The take away from this issue is that the HIPPA/HITECH requirements are not only for the passive loss of information, but for thieves who troll for the opportunity to either sell patients’ insurance information or to improperly obtain medical care or patient billing.

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The Lens through Which to View Healthcare Reform — Part 2

Posted in News on April 5th, 2010

The Indirect Costs

In the previous segment, I shared certain thoughts regarding the direct costs of healthcare reform. Although the direct costs are subject to many divergent interpretations, I believe that the scarier part is the indirect costs.

Aside from taking away the freedom of choice of younger, healthier Americans and forcing them to purchase insurance and subsidize the higher cost of healthcare for older Americans, in most cases, it will be employers that are forced to purchase the insurance. Oftentimes, individuals feel that employer provided insurance is a freebie. I am reminded of Milton Friedman and his 1975 book, “There Ain’t No Such Thing As a Free Lunch,” and think that it is most applicable to employer-sponsored health insurance.

When insurers purchase insurance for their employees, typically they either purchase a group plan or self-insure. In most cases, the higher the cost of the healthcare is for the employees, the higher the cost is to the employer. From an employer’s perspective, the amount spent on a person’s salary is not how the cost of the employee is calculated. The employer takes the salary, benefits, and associated expenses and calculates the total cost. If healthcare costs more, the employee costs more, and in order for the company to be profitable, the employee must generate more profit. Even if the employee does, in fact, generate more profit, the employer will invariably try to run the company efficiently with fewer employees. Obviously, this will tend to affect unemployment, which is already way too high for comfort. Another analysis employers will use in the face of higher per employee costs is the use of technology to cut down labor. Once again, this may negatively impact on keeping Americans employed. If the employer cannot operate efficiently with fewer employees and technology will not optimize his/her operations, the prospect of off shoring labor becomes much more compelling. Let’s face it — the higher the cost of an employee, the more appealing China, India, the Philippines and a host of other countries become to mitigate labor costs.

The next indirect cost is increased taxes. Many economists feel that the more Americans are taxed the less the economy flourishes. President Reagan worked on that theory; he lowered taxes and the economy took off on afterburners.

A recent report stated that Berkshire Hathaway Bonds yielded a lower return than the United States Treasury Bills of similar maturity. Apparently, investors have more faith in Berkshire Hathaway than they have in the United States Treasury. While there have been recent reports that there is a real danger of America losing its AAA rating, investors are apparently starting to vote their dollars recognizing that America has or is falling off its perch. Increased debt will only exacerbate this situation. The fact that Social Security will pay out more this year than it collects will further hurt our economy by requiring the government to borrow more money. As interest rates rise, the deficit will balloon and the cost of operating most businesses will increase as well. The totality of this circumstance does not bode well for Americans. The obvious question is if this was the right time for healthcare reform. More importantly, considering all the costs, should this legislation have been rammed through with a “reconciliation” bill?

The next question to be answered is what effect it will have on the medical community.

While I have been dealing with the total cost of healthcare reform, there will apparently be a dramatic shift in where medical dollars are spent.

As 30 million Americans receive health insurance and many millions of Americans qualify for Medicaid, it is reasonable to assume that primary care physicians will become much busier. It is also reasonable to assume that specialists will become busier to the extent that these doctors continue to accept Medicaid. (Why Doctors and Medical Billing Companies Should be Concerned About the Outcome of Pending HealthCare)

Provided that primary care physicians take care of various ailments at their early stages, emergency room visits that are much costlier and certain hospital stays may decline. It is significant to note that the decline in hospital visits may not adversely affect many hospitals’ bottom-line as while there may be fewer patients, the overwhelming majority of them will have health insurance and, as a result, the hospital’s recovery rates should be higher.

I specifically did not list one of the criticisms of the projected cost of healthcare in Part One because it is most appropriate to discuss it now. I refer to the fact that projected decreases in reimbursement rates for doctors that are part and parcel of the projected costs have been criticized as being overly optimistic. Critics of the projection feel that when push comes to shove the government will either choose not to, or will be forced not to significantly lower doctors’ reimbursement rates. Clearly, the votes are not in on that one.

I believe that with the increased millions of people that will be covered by insurance, with the graying of America and the many millions of people becoming eligible for Medicare, with the looming debt load that America is carrying, and with the inevitable increase in interest rates (and, thereby, the cost of maintaining our astronomical level of debt which will further increase our deficit), the government may have no choice but to seek ways in which to cut the actual cost of the delivery of healthcare. I am fearful that the government will have no choice but to, at best, not increase medical reimbursements to meet increased costs and, at worst, actually lower reimbursement levels to doctors.

If that happens, not only will becoming a doctor seem a less appealing career alternative, it will force doctors to work harder, thus facing the prospect of earning less despite their harder work. Obviously, doctors will be forced to optimize their medical practices, to become more efficient and to cut costs in every way possible. The time doctors spend in the administration of their practices (including patient billing and recovery) will have to be revisited. Staff levels and physical office size will have to be reassessed. It will take heroic efforts by doctors to ensure that patient care is not negatively affected.

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The Lens through Which to View Healthcare Reform – Part 1

Posted in News on March 30th, 2010

It is becoming increasingly clear that the average American cannot really figure out the details of healthcare reform. Obviously, if an individual has a pre-existing condition or suffers from an illness which he/she fears will approach his/her policy’s lifetime limits, healthcare reform may be like winning the lottery. When we look at it from a national perspective, however, we hear divergent views from the Democratic camp (extolling the virtues of their legislation) and the Republican camp (claiming that it is the death knell of America).

How is the average citizen supposed to formulate an opinion? I believe that, currently, it would be very difficult as the legislation is extremely complex and virtually all the commentators choose particular aspects of the law to buttress their particular position.

After giving some thought to the recent legislation, reading various reports, and recognizing the difficulty of synthesizing the totality of this most voluminous legislation, I think I may have stumbled on some real truths regarding understanding the benefits and possible burdens of our future healthcare.

Obviously, the first question to be answered is how will Americans benefit? Even this question is a bit more complex than it seems at first blush. Obviously, increased benefits, and the increased millions of people that will finally have health coverage is part of the benefit.

However, many young healthy Americans have chosen not to purchase health insurance reasoning that the odds are significantly in their favor that they will not need any medical care. Even if they have to visit a doctor for something minor, it would still be much cheaper than insurance premiums. Under the new legislation, though, they will not have this choice but will be forced to purchase insurance, or their employers will be forced to purchase insurance for them.  Apparently, the math is correct. As Anthem Blue Cross of California explained, the outsized increase in their insurance rates was because a significant number of lower-cost younger subscribers had opted not to purchase insurance leaving a pool of insured individuals that were both older and more costly. The question remains whether there is a true benefit to the people whose freedom of choice has been taken away and are now forced to subsidize older and costlier subscribers. I think that it may be dependent on basic differences in Democratic and Republican ideology and the question of the propriety of forcing a redistribution of wealth. I hasten to point out that increased taxes or a more equal redistribution of wealth might be more beneficial than forcing younger people who may not have significant means to subsidize the healthcare of older people.

The second question is at what cost? This question can be broken up into direct cost and indirect cost. Even with the projected direct costs there seems to be very different opinions. On the one hand, because President Obama drew a line in the sand that the cost could not exceed $1 trillion over the next decade, the numbers were jiggled and tweaked until the Congressional Budget Office (a nonpartisan agency) issued a projection that the cost in the next decade would be $940 billion. Hooray!

A former congressional budget office official has stated, however, that the way in which the $940 billion projection was achieved was in part by starting taxes and other offsetting revenues sooner than the costlier parts of the legislation take effect. In more simple language, what he is saying is that the government decided to delay the implementation of many parts of healthcare reform so that there would be fewer years of greater expense in the next decade while collecting money for many more years of the coming decade. If he is right, the second decade may be much more expensive than any Democrat wants to talk about.

If that was not enough, an analysis by RAND, an independent think tank, suggests that the reforms will actually increase America’s overall health spending–public plus private–by about two percent by 2020 (so much for savings).

The Cato Institute, a libertarian think tank, points to the Massachusetts health care reform of a few years ago which is similar to Obamacare. It finds that the law has not improved people’s health, and claims that estimates understate the law’s cost by at least one third.

So much for the direct costs. In the next segment, I will continue with the indirect costs.

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Health Care Reform – Does the End Justify the Means?

Posted in News on March 23rd, 2010

Last night the House passed transformative healthcare reform which is expected to be voted on by the Senate and signed by the President sometime this week.

The legislation promises to eliminate issues of pre-existing conditions, and provide insurance to the tens of millions of Americans that currently do not have insurance coverage.

While details of the bill will emerge in the future and will answer questions such as the government’s role, the real cost, who will pay for it, and behind-closed-doors promises that were made, I think that some time is needed to digest the thousands of pages and hundreds of amendments that are part of this voluminous legislation.

At this juncture, there appear to be a number of issues that warrant discussion even if we do not yet know the content of the bill.

While this healthcare legislation is heralded as being the current day equivalent of the enactment of Social Security, Medicare and Medicaid, there are distinct differences. In the case of Social Security, Medicaid and Medicare, the legislation was passed by significant margins of both the Democratic and Republican parties. In the case of current healthcare reform, the last few weeks of negotiation, fighting and alleged arm-twisting was solely within the Democratic Party. In fact, none of the House votes were Republican. Speaker Nancy Pelosi’s claim that this legislation is bipartisan because there are some amendments that were suggested by Republicans seems disingenuous.

Virtually every poll I have seen indicates that the majority of Americans are against the current healthcare legislation.

As I understand it, “reconciliation” must be used to pass this legislation despite the fact that many scholars believe that this was not the intent of reconciliation. They view it as an abuse of a tool that was created to be used for minor fiscal impasses, not for legislation that is reported to take control of one-sixth of our economy.

Pro-life legislators, many of whom were elected because of their views on abortion, allowed legislation to pass with the promise of an executive order. I am sure they are well aware of the fact that executive orders can be rescinded at any time by the President that ordered them as well as any succeeding President. If I recall correctly, President Obama’s first act in office was to rescind President Bush’s ban on foreign aid to the extent that it paid for any abortions. President Obama’s rescinding of that order demonstrates his deep-rooted belief in being pro-choice. Can one really blame the pro-life people who feel that they were sold out by the very legislators on whom they relied?

The majority of the states have not only voiced their displeasure with the legislation, but have promised to sue the federal government seeking a ruling that the legislation is unconstitutional.

I have repeatedly said that I believe that the current healthcare situation in the United States cannot continue as it is. The question is how it should be changed and when it should be changed.

Considering everything in this post, however, the question is if the end (even according to those who believe that the current legislation is the right way to go) justifies the means? Is it proper to pass monumental legislation without the will of the majority of Americans, without the will of the majority of the states, without the will of at least part of both of our parties, and absent a lot of lobbying, individual payoffs to constituencies and an apparent healthy dose of arm-twisting, with not even a clear mandate from the Democratic Party?

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Group Appointments – Group Benefits or Group Headache?

Posted in News on March 12th, 2010

I recently read an article in the Washington Post entitled “Group Appointments Give Patients Better Access to Physicians,” which I found intriguing. The URL for that article is appended below.

Essentially, the article touts the benefits of doctors simultaneously treating groups of patients. The benefits seem to be shorter wait times, more face time with the doctors (albeit with many other patients), and more patient involvement in their own care. Most intriguing was the apparent willingness of patients to share possibly embarrassing health issues in a group as compared to patients’ reluctance to share embarrassing information with their doctors in a one-on-one setting. The article further sites a 2006 review of nearly 20 studies published in the Journal of the American Board of Family Medicine calling group appointments “a promising approach.”

Both as an attorney and a person involved in medical billing, the first question that came to mind was how does this group setting for the practice of medicine and the sharing of private information, not only with a doctor and his or her medical staff but with other patients, mesh with HIPAA – HITECH? The second question that came to mind was why there was no mention of the potential pitfalls in the article?

Of course, my first reaction was that any medical group embarking on group care would have the patients sign HIPAA waivers which would warn the patients that inherent in their agreement to be treated in a group treatment setting was their agreement to waive certain privacy rights they would otherwise have in a one-on-one doctor consultation.

The idea is that patients who agree to group treatment settings should understand that they are relinquishing certain privacy rights even without any explanation from the doctors or requirements to sign special waivers. There is this part of me, however, that still questions what happens when a patient says something that is truly embarrassing and that information is disseminated. It is not hard to imagine what type of information this might be in an OB/GYN practice, although there are many other areas of medicine where the same could occur.

Assuming the medical practice had crossed all the “t”s and dotted all the “i”s with regard to potential financial liability, they should eventually prevail after a thorough audit either by the government for a HIPAA violation or by a civil lawsuit.

In any event, if a medical group decides to embark on group treatment, I think they should have very clearly drafted documents as well as an orientation session, preferably by video. This way they can amply demonstrate that the patient was fully informed of the inherent loosening of patient privacy, as well as offer the patient the alternative of one-on-one treatment.

The question is if the benefit outweighs the potential risks that doctors and medical practices face. I am not a doctor and I am not in a position to offer an opinion except to say that in doing any analysis of this sort, it is best to recognize that there is a potential for embarrassing information to be disseminated. There is also a potential that the person who feels aggrieved may seek recourse either through government intervention or through a civil lawsuit and even though the doctor may win, the win may be obtained at significant cost.

As an aside, to the extent this is done to maximize practice revenue, it is entirely possible that as this method of treatment gains popularity, third-party payers will adjust their reimbursement schedules accordingly.

http://www.washingtonpost.com/wp-dyn/content/article/2010/03/08/AR2010030802945.html

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THE CONVERSION FROM ICD-9 TO ICD 10 PROMISES TO BE A GAME CHANGER

Posted in News on March 11th, 2010

Virtually all medical practices are involved with medical billing. Currently, the language of medical billing is ICD-9, which is 3 to 5 digits in length with either the letters V or E as the only alpha characters used in ICD-9.

On January 16, 2009 the Department of Health and Human Services (HHS) published a regulation requiring the replacement of the ICD-9 code set with the ICD 10 alternative as of October 2013. The ICD 10 promises greater specificity and the ability to identify disease etiology, anatomic site and severity with the additional characters in ICD 10 allowing for the identification of the body system, root operation, body part and device involved in the procedure.

The question is how this transition will impact on your medical practice. As it currently appears, the transition has the capacity to wreak havoc for the following reasons. The ICD-9 code set has approximately 4,000 line items while ICD 10 has approximately 5 times as many line items. The increased number taken in conjunction with a certain lack of compatibility between the two protocols has difficulty written all over it. Recent reports indicate that the learning curve from ICD-9 to ICD 10 will be significant. Aside from the thousands of new codes that will be introduced, apparently, just 5% of all ICD 10 codes map directly to ICD-9 codes, and conversely, only 26% of ICD-9 codes map to ICD 10 codes.

While the current compliance date for ICD 10 is October 2013 and that date is not etched in granite, this is not the type of transition that happens with the flick of a switch. Billing staff, whether working for in-house or outsourced medical billing companies will need significant training. Failure to be properly trained and prepared may cause serious disruption to a medical practice’s revenue cycle management, or in simple English, the cash flow of medical practices may be (at least temporarily) very seriously disrupted.

Medical billing companies must start planning for training and developing internal protocols to ensure that their clients are not left with gaping holes in their collections. Let’s face it, the insurance carriers will not be upset if they have the opportunity to delay or deny significant numbers of claims.

Medical practices must decide if they want to retrain their staff and the drain on their current resources that this training will cost. They must also decide if they are willing to take the risks for incomplete, untimely, or inefficient transition. Similarly, if they timely train their staff, those employees will be in great demand that may lead to very attractive offers from other medical providers and medical billing companies.

For those who wait for the last minute and are not currently thinking about how to navigate this massive change, the results are almost certain, and they are not encouraging. I believe that every billing company and medical practice that currently has in-house billing must listen to the wake-up call and prepare accordingly or suffer the consequences.

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HEATHCARE REFORM – WHO DECIDES?

Posted in News on March 5th, 2010

One of the hallmarks of our great country is that we are a DEMOCRACY. To effect a proper administration of the will of the people and the good of the nation, we have a very detailed electoral process and a rather sophisticated checks and balances system at both the state and federal levels.

The question I pose to you is if, during the time that they are in political office, elected officials receive the mandate from their constituents empowering them to act at their sole discretion irrespective of what the constituency truly wants. Or is the expectation that the elected officials will use their best judgment in making decisions to the extent that they understand what the people who elected them want and the elected officials are, therefore, morally if not legally bound to follow the will of the people.

Depending on your understanding of the democratic process, it follows that you will have a differing view on the purpose of the many polls that sitting elected officials conduct to gauge the attitudes of their the people they represent. In the first case, one might assume that polling is primarily done to prepare for reelection runs and to make sure elected officials stated policies comport with the expectation of the voters. In the second case, one might assume that the reason was to better understand the will of the people and to properly represent them. Even in the latter case, though, reelection planning might still be part of the calculus. I believe that this question goes to the root of our understanding of democracy.

Now for the applicability to healthcare.

It is readily apparent that America cannot (on a forward-going basis) afford its own healthcare. With health-care spending at approximately 17% of GDP (meaning that 17% of every dollar we produce goes to healthcare), and with all estimates of future healthcare costs rising quicker than projected inflation or projected increases in GDP, we know that, ultimately, the cost of healthcare will strangle us.

The real question is not IF we need healthcare reform, but HOW it can be accomplished. In addition, because of other possibly more pressing economic challenges e.g. our current deficit, unprecedented levels of debt, high unemployment etc.,  is this the right time to enact sweeping health-care reform, which brings us to the question of WHEN.

When internecine fights were going on in the House and in the Senate, one could chalk that up to the regular ying and yang of the political process. It started to become uncomfortable when the elusive 60th vote was needed in the Senate. There were those who thought that the rules should be changed, but in the end the vote was bought.

Thereafter, the Massachusetts race, which took everyone by surprise, further complicated the bought-and-paid-for 60th Senate vote. This left a few alternatives — either get the house to approve the Senate version (which proved undoable), try to get a new 60th Senate vote (which similarly proved to be undoable) or use “reconciliation.” This last approach is a method by which only 51 votes are needed to modify legislation as long as it is done, not for the substance of the law, but for minor revisions relating to the dollars and cents of the bill and how it relates to the budget. Reconciliation was never intended to ram major legislation through the Senate without the otherwise requisite 60 votes.

There were reports that members of Congress were upset that senators from less populous states had the same vote as senators from the larger states. Isn’t that the reason why we have a House of Representatives that tracks the population and a Senate that tracks the rights of the states and together the idea is that we will get a true voice of both the people and their respective states? To argue that the Senate is unfair when things go against you seems to be arguing that if you don’t get what you want our system of government is to blame.

What I found particularly troubling were reports that Speaker Nancy Pelosi asked members of the House to vote for healthcare even if it might cost them the midterm elections. In my own humble opinion I think that she was asking them to “take one for the team.” My question is who is the team? Is it the Democratic Party, President Obama, or the people that elected them to Congress? My logical conclusion is that if he/she could lose an election for voting for healthcare, that particular member of Congress was not voting the will of his constituents.

Virtually all of the polls I have seen show that America is deeply divided over pending health-care reform. I believe that I have a simple solution.

Why don’t we go back to the basics—good old democracy?

Why don’t we ask the Democrats to prepare their version of healthcare reform and ask the Republicans to do the same? Thereafter, it can be posted on the Internet and a national referendum should be held so that the will of the people prevails.

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