Like a colossus surveying its landscape from MountOlympus, Epic was once seated on the high altar of EHR greatness.  But as they say, even the mighty fall, and so even though Epic is still a considerable force to reckon with, other innovative products have had their fair share of limelight in the EHR arena.  Of these the five nimblest; Cerner, McKesson, athenahealth, Allscripts, and Greenway Medical Technologies have gone ahead and formed an alliance of sorts, the CommonWell, at the Healthcare Information and Management Systems Society Conference in March of this year.

The Purpose of the CommonWell Alliance:

Facilitating interoperability has been cited as the primary objective of this initiative, but later statements of Epic CEO, Judy Faulkner, seemed to indicate that she and the Verona, Wisconsin based Epic do not buy the argument, and that the alliance could have arisen due to competitive reasons.  “It appears on the surface to be used as a competitive weapon and that’s just wrong, it’s wrong for the country.”

How Important is Interoperability ??

There are now hundreds of EHR products in the market and there is a very real need to find a way for all of them to talk to one another, if the federal dream of health exchanges is to become a reality.  While standards such as HL7 are of some help, these alone will not suffice in the exchange of information between today’s EHRs whose databases hold a multitude of information across many fields.

Also, if a provider is transitioning between EHRs for whatever reasons, the cost of the transition under currently available technology may include a one time fee in upwards of $15,000 in addition to a whole lot of continuing costs, till all the data has been completely transferred into the new system.

This is not an appealing situation to be in, especially for small practices, who already must be reeling financially from the first time bad purchase.  Also, there is a very real possibility of a provider being locked out of his data in his old EHR, if the EHR vendor goes bust or there is an ongoing skirmish with the vendor.  This could affect the ACO credentials of the provider.

To avoid all of the above, better interoperability is certainly a good idea and the CommonWell Alliance, albeit a private initiative, seems to be a step in the right direction.  This is particularly so, since no federal programs are in sight to tackle the issue of interoperability big time.

The Epic Side of the Story:

There is no doubt that Epic has had a stranglehold over the top-end EHR market for some time now.  From a very smallish startup company in 1979 Epic’s earnings today exceeds well over $1 billion, chiefly due to its mid-level and large hospitals clientele, in which it has a market share of more than 40%.  Epic’s highly centralized control of its product installation and support along with its non-inclination to sprout support vendors has invariably given it an unmistakable monopolistic overtone.

But its tightly integrated EHR and ambulatory care product EpiCare Ambulatory, has been incessantly drawing in more and more high-end customer base, such that it has remained the undisputed market leader.

But its negligence of the smaller practices has led to the proliferation of a host of other EHR products, which have started to slowly erode its monopolistic status in the EHR market.

And Epic believes that the CommonWell Alliance is indeed one such effort to surreptitiously undermine its customer base, since a direct confrontation with its product is not going to get the other EHR vendors anywhere, at least in the high-end segment.  Many of its ardent supporters in fact believe that interoperability would not be that big an issue now if everyone had gone “Epic” so as to speak, because the product is already as interoperable among its various components as any EHR could be.

WHAT YOU SHOULD BE DOING AS A SMALL PRACTICE

As a small practice looking to buy that first EHR or trying to correct the mistakes of the first purchase by switching, it would be prudent to remain unmoved by the current Epic-Non-Epic drama being played out.  Both segments of the market have very good reasons to exist, and as an EHR customer what you should be mainly concerned about is the suitability of the product to your practice.

But then sifting through all the arguments and counterarguments to make an informed EHR decision might be too much to ask of a busy provider, already reeling under umpteenth deadlines.  So, the ideal thing to do would be to hand over the mantle of EHR purchase, installation, and support to your medical billing vendor or your EHR support company and let them sift through all the noise, while you continue to provide your fullest attention to your patients.

The $44,000 stimulus per provider via Medicare and $64,000 via Medicaid is just the tip of the iceberg when it comes to the manifold benefits of using a comprehensively equipped EHR like PracticeFusion, Kareo or eClinicalWorks.  A properly implemented and supported EHR system can cover the complete costs of implementation when optimally utilized, either alone or in tandem with an EHR support vendor.

OTHER FACETS OF EHR USAGE:

The following are some of the savings that a clinic will most likely accrue even before laying their hands on that first dollar of stimulus incentives:

A.  Transcription Cost Savings:  The first is the most fundamental savings you will be able to make, most often in conjunction with an EHR support vendor.  This involves your medical transcription requirement.  No matter how top-of-the-line your EHR may be with many “point-and-click” options and voice recognition features, some amount of actual transcription may be required.

Let us suppose you’re a very small practice seeing only 5 patients per day 5 days a week.  You still would have about 100 charts to be transcribed per month.  Even if your EHR allows you to let go off a full-time transcriptionist (costing anywhere between $2500-$3500 per month), there still needs to be a personnel to use the EHR for chart creation and transcribe the missing portions.

Rather than employing a part-timer, costing anywhere around $1000-$1500 per month, who may not be that familiar with your EHR, you can opt for partnership with an EHR support vendor, who may provide free support for your EHR, while providing transcription for as low as $5 per chart and also coalescing all the different components of the reports in the EHR.  This, at the least would save you $6000 every year.

B.  More Optimal Coding Via EHR:  A study was conducted and published in 2005 (way before meaningful use) that studied 14 single physicians or very small practices.  The results were:

“Initial EHR costs averaged $44,000 per full-time-equivalent (FTE) provider, and ongoing costs averaged $8,500 per provider per year.  The average practice paid for its EHR costs in 2.5 years and profited handsomely after that.”

How did they do this? That too without the federal stimulus of today…

1.  Efficiency-Related Gains:  The clinics used the EHRs for routine tasks, such as prescribing, documenting, data retrieval, and internal messaging, and almost all used it to assist in medical billing and revenue cycle management.

2.  Less of under-coding:  Under-coding is responsible for about 10% of loss of revenues for physicians even today.  The EHRs automatically gave the  providers the correct level of evaluation and management, based on the information entered during a patient encounter.  This not only helped a medical coder to determine at which level a visit should be coded, i.e. level 1, 2, 3, 4 or 5, but also helped the coder to seek more supporting documentation.  The clinics on average were able to increase their average coding level by 3.5 percent without running afoul of RAC audits.

C.  Tax Code 179:  The fiscal cliff brought changes to this code such that clinics can now enjoy benefits (to be added as an expense) upto $500,000 pertaining to software purchases.  Thus, if your taxable income before the code application was $300,000 and the cost of your EHR software was $80,000, then your taxable after the application of the code is only a mere $220,000 (this is unless of course the high-quality, low-priced, cloud-based EHRs still won’t do for you).

D.  Other Miscellaneous Reasons:  Medicare’s Physician Quality Reporting Initiative (PQRI) & Medical Home Incentives are a couple of other non-meaningful use initiatives that yield sizeable ROI for your EHR.  The former of course is a Medicare initiative that rewards physicians upto 1% of Medicare Part B charges for a particular year.  The task on the part of the physician is to send special billing codes or certain quality metrics to CMS via certified EHRs.

The latter is an initiative participated by even private biggies like Blue Cross Blue Shield (across more than 40 states) benefitting more than 5 million patients and thus correspondingly their treating physicians.  The idea under the program is for the physician and a select group of support staff to act as a single point of reference for the patient, thus creating a “virtual medical home.”

GOING BEYOND MEANINGFUL USE:

Thus, as can be seen, there is more than meets the eye, i.e. beyond meaningful use, when it comes to EHR usage.  If you’re in the dark about some of the above, it might be a good idea to seek an EHR support vendor or a medical billing vendor now.  Alternatively, if you already have one you may arrange a tête-à-tête with them to discuss how better you can wring your EHR to yield more ROI than presently.

Some Statistics on ICD-1O

Come Oct 1, 2014, ICD-10 will become obligatory and all clinics and hospitals will have to code in ICD-10, either after fully adopting it or utilizing cross walking mechanisms.

A survey of more than 120 hospitals found: • 40 percent have not begun ICD-10 CM training for coding staff • 55 percent have not begun ICD-10-PCS training for coding staff • 47 percent have not begun document improvement education for medical staff • 31 percent do not plan to dual code prior to Oct. 1, 2014

Although individual physicians and small practices may be faring better, as indicated by certain surveys conducted by Medicaid, it is entirely within the realms of possibility that for about 10 to 15% of the practices ICD-10 might hit them like a hurricane.

AREAS TO CONCENTRATE WHEN TRANSITIONING TO ICD-10

1.  Denial Management:   As payers, like everyone else, move over to ICD-10 they may be forced to modify certain criteria for prior authorizations and referrals.  If the clinic is not fully aware of these changed parameters, either via the denial management team having a tab on payer reimbursements for ICD-10 coded claims, or a cross-walking mechanism, a clinic’s denial rates might spike to uncomfortable levels.

Your denial management team might benefit immensely by studying tools such as “General Equivalence Mappings” (GEMs)” developed by the CMS, which aids in the cross walking and thus can aid you in understanding the rationale behind the payer’s changed behavior patterns.  GEMs can be freely downloaded at http://www.cdc.gov/nchs/icd/icd10cm.htm.

2. Auditing:   As can be expected future RAC audits might focus on how compliant your clinic is with ICD-10 specificity coding.  Thus before an RAC happens and finds discrepancies either you or your medical coding vendor can conduct internal audits to ensure that no rules are flouted.

3.  Increased role of ICD-10 in ACOs:  If your clinic is looking to join the ACO stream, like many others, then it is mandatory that you become proficient in ICD-10 usage since it will be the mandated gold standard for ACOs and will be used by CMS for disease pattern tracking and resource distribution.

4.  Optimal Coding:   Coding accuracies will invariably be affected due to the 5 fold increase in codes and the fact that there will be a 1-to-1 match for only approximately 25% of the codes.  Rigorous monitoring of coding during the initial stages with continuing education will become mandatory if your medical coding has to reach ICD-9 accuracy levels.

The Survey:  Positives

1.  Most agree that the present state of healthcare is below par and ACO is a step in the right direction, both for patient accessibility and curtailing costs.

2.  Most physicians are driven by the goal of patient satisfaction.

3.  Clinical decision-making technologies that reduce redundancies are piquing physician interest.

4.  EHR adoption encompassing the entire clinical workflow including revenue cycle management is expected to increase.

5.  Connecting with patients using mobile technologies is expected to increase.

The Survey:  Negatives

1.  The autonomy of the medical profession may be at risk.

2.  Physicians are concerned about malpractice reforms.

3.  Many believe that Medicare and Medicaid payments may become increasing tough to secure.

4.  Solo physicians may be increasingly forced to integrate due to payment issues.

The NUMBERS

The numbers gleaned from the survey in general presents an ambivalent picture.  The one unifying point though is that almost all physicians, be it PCPs, surgical specialists, non-surgical specialists etc, consider  patient relationships and promoting individual health as the most satisfying part of their jobs.

a.  51 percent believe their income will dramatically fall over the next one to three years.

b.  90% of those worried about bundled payments believe the reimbursements will be inadequate and they will be made to pay dearly for factors beyond their control.

c.  0% of the specialists believed that the business angle contributed to any job satisfaction.

d.  57% of physicians feel that Medicine is in trouble.

e.  Nearly 80% believe it will cease to be an attractive career option in the future.

THE INFERENCE

The Deloitte 2013 survey results can be interpreted in many ways, but what can be readily seen is that physicians are less and less interested in spending time on the business aspects of their practices.

But sooner or later all of them will be forced to enter the ACO landscape.  Thus, the only panacea seems to be the one which has worked in the past, outsourcing your non-core activities to a medical billing vendor or a revenue cycle specialist.

Cole Hauser:  Battlefield doctors decide who lives and who dies, it is called “Triage”.

Vin Diesel:  Kept calling it murder when I did it…

Among the many mystique terms that the Patient Protection and Affordable Care Act has sprung up, The Patient-Centered Outcomes Research Institute (PCORI) is a notable example.  The layman’s term for it though is “death panel” or “Triage” in which doctors or other decision-makers decide who lives and who dies.  This rather unflattering interpretation of PCORI can only be deemed as unsubstantiated gossip.   But there are other facets of the law which are not hearsay, but very much present in the 900 odd pages of the Act.

Some Facts About the ACA Act:

1.  The ACA will ensure or try to ensure that all Americans have access to quality and affordable healthcare.  On more realistic terms it will cover about 94% of Americans while keeping the healthcare costs under the $900 billion limit.  This is supposed to reduce healthcare spending deficits for more than a decade.

2. Eliminate annual limits on many policies.

3.  Dependent coverage will be extended up to age 26.

4.  Cover pre-existing medical conditions.

5.  By 2014 all states are expected to form health exchanges to enable coverage for all low-income and uninsured groups.

6.  Medicaid will expand; almost half the states are committed towards this, while about 17 are opposing this, and 7 still undecided.

7.  It is the individual’s responsibility too (including non-adults) to maintain basic medical coverage, else there are fines.

WHAT THIS MEANS FOR THE CLINICS:

While it may seem too early to exactly predict how all this will work out, what is certain is that Family Practitioners, Internists, PCPs, Emergency Room Physicians can expect their practices to burst at its seams with a huge influx of newer patients, most of them Medicaid and CHIP enrollees.

“The role of Medicaid as envisioned by the Affordable Care Act (ACA) is to make Medicaid an integral part of the nation’s health care structure and be the floor for all low-income individuals,” says Kathy Kuhmerker, former New York State Medicaid director.

It is estimated that ACA will increase Medicaid spending by about $420 billion between 2014 to 2019.  So, if you have not been accepting Medicaid so far due to lower payment rates, think again. Besides the sheer volume, ACA has increased Medicaid payments for E&M and Immunization Services to 100% of Medicare reimbursement.

This is to stimulate greater provider participation.  Also, coupled with the already relatively short payment cycle of 7 days, your clinic stands to gain a lot by seeking a medical billing vendor who understands the nuances of Medicaid Billing and is ready to put into place a dedicated team catering solely to your Medicaid Claims.

For a long while it was felt that the medical profession was one way or another prisoner to the so-called Parkinson’s Law, proposed by the scholar of public administration Northcote Parkinson in the early 1950’s, which stated something akin to “work expands so as to fill the time available”. 

Yes, about a couple of decades or so ago it would have been sacrilege indeed, if someone had suggested that physicians should devote an hour or so daily or weekly to come out of their self-imposed shells and interact with other members of the human race.  But as they say “change is the only thing that is constant”, and the medical profession, like any other field of endeavour came within the grasp of the information technology revolution, and needless to say it changed the face of it forever.

Medicine and Social Media:

Today’s medicine is so-called wired, just like many other fields of human activity, including interacting socially.  While on the public front medical records are now being stored and exchanged electronically via EMRs/EHRs, electronic health exchanges, and the like, on a personal front more physicians are coming together socially via social networking sites, collectively known as social media, to discuss recently published scholarly articles, render their opinions, interact with their patients, answer their questions, and to keep themselves abreast of the latest trends in a particular form of treatment.

Not surprisingly those trends these days become viral mainly through sites like Twitter, LinkedIn, Facebook, Tumblr, Yahoo, etc.

What Social Media Can Do For Your Practice:

Consider that you are a fairly regular blogger on either your clinic’s blog or some other forum.  If your blog garners the attention of regular visitors, it means that your opinion is highly valued and patients and doctors alike consider you a pundit on a topic.  Besides showcasing your writing skills, earning goodwill, and learning something in the process, the most important result may be that you and your clinic are becoming the cynosure of all online eyes.

This can only benefit your practice immensely offline, and revenue curves may very well start heading north in a few months.  In short, blogging and social media interactions may be the best thing you can do to promote your clinic’s cause.

What Physicians Feel About Social Media:

David May, MD says:  “Twitter can function as large-scale doctors’ lounge.”

He also says, “The social media world is such an intense, immediately responsive place that you can have tremendous amounts of traffic pointing out the good and bad about an article itself technically, about the concepts that were put forward, and about potential flaws that were in a paper.”

A survey by the Journal of Medical Research revealed the following:  The survey was based on 485 responses received from 1,685 online surveys sent.

1. 85% of oncologists and primary care physicians used social media at least once a day or once a week.
2. 60% said that social media improved the care they rendered.
3. 24% utilize social media to investigate new medical knowledge.
4. 58% believe that social media can be a good place to come in touch with high-quality information.
5. 14% of them personally contribute to the medium daily.

How to Start Blogging, If You Have Not Already:

Although starting to blog should be fairly easy, even for those not particularly savvy about the online universe, the beginner may be faced with slight obstacles.  So, even though WordPress may be free, getting used to it may take some time for the absolute beginner.  Also, using some of its features properly like Publicize and the like may take still more time.

And if you are planning to append a blog to your clinic’s website (which might have been created in the previous century), it may require some site management skills.  But rather than seek the services of a web designing company, it would be prudent for you to seek your EMR support services or your medical billing vendor or medical coding vendor, who surely must have exposure to this.  And if they already perform this as a service to other physicians, that would be a real icing on the cake.

“It’s very frustrating; healthcare is the only industry where you don’t know what it’s going to cost until it’s done.”  So said a frustrated victim of heart palpitations, who ironically felt he was a bigger victim of a medical coding error, as he was made to pay more than $6000 out-of-pocket expenses as a result of this some time in the middle of 2012.

THE SIGNIFICANCE OF CODING ERRORS

It is an open secret that medical coding errors are at the core of many a billing issue that drive both providers and patients up the wall.  In big hospitals, as many as 250 personnel may be involved in the generation of a single medical bill.

Although this number might be reduced by a factor of almost 20 for very small clinics, it does indicate that the worlds of medical coding and medical billing often times appear as complex as the world of medicine itself.  “It all comes down to human beings being involved in a process that is very complicated,” says Kevin Theiss, a vice president at Summa Health System, headquartered in Akron, OH.  Mr. Theiss directly supervises an operation that generates close to a million medical bills a year.

An interesting study by a professor of health finance at the University of Minnesota found out that:

a.  40 percent of claim statements passed back and forth between providers and payers have errors.

b. Nearly 20% of the processed claims providers get back from insurance companies have errors.

c. 15% of all claims have fraud, negligence and abuse.

MACROECONOMIC IMPACTS:

A.  It was seen that in 2011, in Northern Ohio more than 2500 bankruptcy cases were filed by low-income groups, citing mainly medical debts as the primary culprit.

But the impact is not just on patients alone, as the below statistic shows:

B.  The AMA in 2011 claimed that it cost providers $17 billion in backend processes due to what it claimed dubious payer payment criteria, with a special focus on medical coding.

So, with such a huge economic impact, it is only natural that federal audits to smoke out medical coding errors are going to increase.  And of course the Patient Protection and Affordable Care Act will only intensify the focus.  So, although there are a zillion things that might be set right when it comes to medical coding errors, the journey of a thousand miles always begins with that first step, in this case 4 steps to be exact:

4 Crucial Medical Coding Pitfalls To Avoid:

1.  Errant Use of Modifiers:  These are 2-digit alphanumeric characters added to codes that inform the payer of extraordinary circumstances.  There are CPT modifiers and there are HCPCS modifiers; developed by AMA and CMS respectively.   Many reasons exist for their incorrect usage; it could be erroneous data, plain misunderstanding, or just a desire to get that crucial reimbursement.  But it is important to understand that a clinic’s medical billing staff may only be adding fuel to the fire by getting this crucial aspect of medical coding wrong.

2. Choosing the Wrong CPT Procedure Code:  There are greater than 75,000 CPT codes; and a billion rules governing their usage.  Anyone can do the math that this is a recipe for disaster or at least major errors most of the times.  So anyone may get confused; but when you add to it the add-on exacerbating factors of incomplete encounter forms, incomplete medical records, or EHR malfunction it only increases the probability of a wrong code being chosen.  Thus the coder needs to be always focused and the clinic always needs to get those supplemental factors working.

3.  Wrong Usage of CPT code 99211:  It has been made abundantly clear that services like allergy shot, venipuncture, etc should not be billed as nurse visits but should be bundled into injection codes.  Vital signs monitoring by nurses before and after such services are considered part of the payment for such administrations but not a separate service by a nurse, capable of being billed as 99211.   Only established patients for whom there is a medical necessity for vital signs check, e.g. a hypertensive patient, may be billed as 99211.

Also there may be instances where usage of 99211 is appropriate than higher level E/M codes; 99212-99215; e.g. an internist performs a very simple service, which does not fulfil the criteria of the higher level E/M codes.  Only a knowledgeable medical coding workforce may get the above right at all times.

4.   Proper Linkage of Diagnosis Codes (ICD-9/ICD-10) to CPT Codes:  The medical claim should make it very clear to the payer as to why a particular service was rendered; more so in circumstances where multiple unrelated services are done.

E.g. a patient visiting his physician for spirometric tests for asthma might undergo a routine abdominal ultrasound for GERD.  In such an instance the PFTs done should be linked to asthma while the ultrasound linked to the GERD.  Else the chances of claims rejection are high.

The above is just the tip of the medical coding iceberg; and if a clinic finds out that their medical coding workforce may be too inexperienced to get the above right at all times, then it may be high time that they seek out the services of a dedicated medical billing or medical coding vendor.

It was believed that the EHR-Healthcare marriage would mature over time with both developing an appreciation of each other.  But surprisingly the following statistics gleaned by AmericanEHR Partners, an organization founded by the American College of Physicians or ACP points to the contrary.

a.   A survey of 4,279 clinicians found EHR satisfaction declined from 39% in 2010 to 27% in 2012.

b.  Those who were “very dissatisfied” rose from 11% to 21% during the same period.

c.  2590 primary care practitioners in the Dept of Veterans Affairs received an average of 63 alerts per day through the EHR system.

d.  86% said this was excessive and 70% said it was more than they could manage.

e.  It took on average 5 years for a physician or clinic to become familiar and become comfortable with the workings of an EHR.

REASONS FOR DISATISFACTION:

Though the meaningful use statute has provided adequate fillip for doctors to start using EHRs more effectively there have been umpteenth reasons for the above dissatisfaction.  The chief among them are:

1. Rushed implementations when trying to meet meaningful use deadlines.

2.  Many EHR vendors trying to rush up to deliver products to the burgeoning market, the victim sometimes being usability.

3.  One size-fits all approach by many EHR vendors which resulted in products which could not adapt well to the physicians’ workflow and failed to meet expectations.

4.  Last, but perhaps the most important, physicians and clinics themselves not assessing their needs adequately before homing in on an EHR product, this frequently resulted in mismatch sending the dissatisfaction levels high.

What’s the Solution?

EHRs are here to stay; medical records and other information are best stored in the electronic medium.  But then how can we improve satisfaction levels and also decrease the time it takes for physicians to become comfortable with EHRs.  Bruce Eckert’s, principal with Beacon Partners, a health care consulting group, insight on it is worth alluding to here:

“I have seen numerous implementations where the results met or exceeded everyone’s expectations, and I have seen numerous others where this was not the case.  My observation is that the difference between these, the ‘secret sauce’ if you will, is the quality of the EHR implementation, not the software. All EHR vendors have very successful, very satisfied users, and others who are not.”

Why Do Failed Implementations Occur?

Failed implementations can happen due a variety of reasons, some of which we have mentioned above.  “Meaningful use incentives created an artificial market for dozens of immature EHR products,” said Doug Brown, managing partner of Black Book Rankings.  This means you have to be careful in choosing your EHR product.  Good training of staff on a bad EHR product is not going to serve anyone’s end.  Also, what is paramount is to see if the EHR products caters well to your particular speciality.

It is interesting to note that primary care physicians are the most satisfied of all EHR users while the surgeons are the least.  This is certainly indicative of how the EHR market initially developed with just a general template, best suiting the primary care physicians, but optimized by other speciality practitioners to cater to their own needs.

The Solution:

EHR companies are basically IT companies that happen to focus on healthcare.  Although many of them provide good support during implementation and also post sales, the need of the hour is for clinics to also partner with someone who have already implemented and are using these systems.

Also, rather than joining hands for this sole purpose, it would be ideal if clinics could also combine their RCM needs into the package.  The only possibility that springs up then is the clinic’s medical billing or medical coding vendor, who already should be savvy about implementation, usage, and troubleshooting of EHRs.

The United States Department of Justice Considers The Following Three The Worst Form of Culprits, not necessarily in that order:

1.   Terrorists.

2.  Violent Crime Doers.

3.  Healthcare Fraud Perpetrators !!!!!!

Now, how and when the medical profession made it to the chart of ignominy is a moot point; but what is certain is that your practice stands a very good chance of hearing from your region’s RAC if the following does not happen in your clinic:

1.   At least a couple of audits for every E&M Code that you use.

2.  Doing the above at least two times in a year.

3. Getting the above rechecked by at least one outsourced certified coding consultant.

4.  Doing at least 5 audits for more frequently used codes like 99213 and 99214.

(If your practice’s code utilization happens to mirror the green and blue lines beware!!!!)

How It All Started And How It’s Going:

a. Despite a 2-year demonstration; the RAC Audit program was officially deemed to be applicable to all states in 2009.

b.  At that time Medicare was registering 1.2 billion claims per year or about 10,000 per minute.  These numbers have increased in the past couple of years.

c. About 96% of scrutinized dollars involved overpayments or in other words physicians needed to return the money to Medicare.

d. Only 4% involved Medicare paying the physicians some money for underpayment.

e. Medicare has recently approved audits of Level 4 and Level 5 E&M services; because of a 25-40% increase in the usage of the codes in the past decade.

f.  Medicare has given approval to extrapolate the audit results; that is if 30% of your charts are analyzed, and out of them around 20% are found to violate the guidelines, that 20% verdict is applicable to the remaining 70% of the charts the auditor will not check.

g.  According to a court verdict in Sep 11, 2012, there is no restricted time limit as to when your charts may be pulled and/or when you will penalized.  Yes, you will be living under the shadow of an audit all your life!!!!  Also, your old records are not safe from an audit!!!

WHY CMS WON’T STOP

If these audits had been lean pickings for the CMS, one could have theorized they would have lost interest in the so-called outlaws.  But no, the returns have been substantial.  Consider the following figures:

1.  CMS had received $4 billion dollars in 2011 in healthcare fraud cases.

2.   That was about $7.2 per every $1 invested or a ROI of 720%!!!

3.  Thus, they have invested a further $350 million to smoke out the violators!!!

WHAT YOU NEED TO KNOW AND DO

If all of the above is making you feel like a cat on a hot tin roof; don’t fret, there is light at the end of the tunnel.  Just keep in mind the following:

1. If you bill Medicare, then you can be certain there will be an RAC Audit, don’t let it take you by surprise.

2. Don’t bill Medicare until you are absolutely sure every service has been properly documented.

3.  Don’t jump into the frying pan when an RAC audit request arrives.  Remember you have 45 days; use it appropriately to set your records straight (if you haven’t already done it, that is).

4.  Don’t let any Tom, Dick, and Harry in your clinic handle this audit request.  Ideally it should be given to a dedicated medical coding vendor or medical billing vendor.

5.  You have the right to appeal RAC audit verdicts, remember that 1/3^rd of these appeals are successful.

6.  Or for that matter Medicare denials need to be appealed as well.  But sadly only 4% of these are ever disputed, even though nearly 60% of these disputes come out favourably for the providers.

All in All remember that RAC Audits are not Armageddons waiting to happen, but just speed breakers in your clinic’s path, which can be surmounted if you are careful and assimilate the essentials before meeting it head on.

Both of the latter mandates that a strong foundation of interoperability and security be laid first.  Was the healthcare industry any closer to these goals after HIMSS13?  Well, that could be a moot point depending on whether you consider your glass to be half full or half empty.

THE RECENT PHI SECURITY SITUATION:

a. From 2009 to 2012 there were 495 PHI breaches involving 21 million patient records.

b. The total cost incurred due to these breaches was in the region of $4 billion.

c.  Small private practices accounted for about 60% of these breaches.

d.  70% of the breaches were electronic.

e.  Annual Data Security Risk Analysis was more stringently conducted in hospitals settings than in private practices.

KEYNOTES SPEECHES REGARDING DATA SECURITY AT HIMSS13:

Some of the keynote addresses addressing PHI security had the following insights to offer:

1. “Providers need to identify and assess risks and threats to data in advance” offered Mr. Braithwaite, who is the chief medical officer for Equifax.
2.  ”We often find, when we take a look at physician offices, the technology is not where it needs to be to interface with a hospital.  They don’t have the security they need.   They have a server, but they don’t have things like “firewalls” and other necessary technology to set up a VPN or other tunnel“ said Mac McMillian, CEO of CynergisTek.
3. Mr. Mac McMillian also beautifully summed up the need of the hour in the following: “If I architect my network properly and I determine where that data needs to live, I have less of a footprint I need to encrypt.  I first need to figure out where I create my data and where I use it. And from there, I figure out what controls I need to have in place.” 

MEDICAL IDENTITY THEFT:

One of the gravest forms of PHI compromise involves what is now known as Medical Identity Theft; the overall costs for this type of breach touches a staggering $40 billion with nearly 2 million affected yearly.  Of course these breaches do not always happen due to lapses at the provider’s setup, but because of a large black market involving the active trading of medical records.

This market is deemed to be more powerful than the black market for social security numbers. What this theft pertains to is the usage of a person’s medical records and insurance information by the fraudster for undergoing illegal medical care or filing illegal claims.  In most situations the patients come to know of the mishap only by looking at the detailed EOB from the payer or when collection agents come knocking on their doors.

NO ONE-SIZE FITS ALL SOLUTION:

What could be reasonably concluded from the conference is that there is no tailor-made security solution that fits everyone, but one needs to envisage a package that depends on the size of one’s operation and what balance one desires between efficiency and security in day-to-day proceedings.   E.g. Tony Hudock, Director of Development and Technical Operations at Dignity Health spoke of how Dignity Health went for something called “Managed File Transfer” packages from Axway.

This was essentially a beefed up form of an FTP program, which ensured high security and audit trails.  Thus, the hackneyed solution of a networked enterprise EHR software was not the ideal one for Dignity Health.  They wanted something that would enable them to occupy a vantage point, such that all data flow could be viewed on a single plane.

So, if you are in a confusion as to what security solution best suits your practice, call up your EMR consultant or your medical billing vendor or medical coding vendor, who are surely bound to have a robust system in place.