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5 Questions: A Deceptively Simple Performance Evaluation Print E-mail
Written by ManageMyPractice.com   
Friday, 02 November 2012 00:00

"The point of the '5 Questions' evaluation is not to underline that the employee is often tardy or doesn't complete assignments on time. Those things should be dealt with outside of this process. Remember the old adage: 'No new news at the performance evaluation'. ...the idea is to dig under those things and see if the employee is dissatisfied, overwhelmed or under-challenged."

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Minimize Claims Issues with One Simple Step Print E-mail
Written by M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC   
Sunday, 28 October 2012 00:00

Most physician practices experience claims challenges, from denials and rejections to payment inaccuracies.  As frustrating (and costly) as those issues are, they are almost avoidable with one simple step:  verifying patient insurance eligibility.

For patients covered by Medicare, it may seem like a waste of time to verify insurance after the initial visit.  However, how can you be sure the patient did not knowingly or erroneously enroll in a Medicare HMO with which you are not contracted?  You would continue to see the patient and find out only when your claims are rejected that you, basically, volunteered your services with this patient.   

For patients covered by Medicaid, eligibility can vary, so it's crucial to verify that the patient is still enrolled in the Medicaid system for every visit.

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About the authors: M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC are principals at Coleman Consulting Group. The firm's services include:

· Risk Adjusted Reimbursement (MRA)
· Coding & Billing
· ICD-10-CM Consulting & Training
· EMR/Meaningful Use Attestation
· Credentialing & Contracting

For additional information about the firm or to request a complimentary no-obligation consultation, please call 954.578.3331 or email info@askccg.com.

Last Updated on Monday, 29 October 2012 09:26
 
HEDIS: Is Yours a Five-Star Health Plan? Print E-mail
Written by M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC   
Monday, 22 October 2012 16:22

To most patients, quality is amorphous; we know it when we see it. To a healthcare administrator, however, quality has a whole other meaning. It's measurable, measured and a measure of the congruence of several factors.  In managed care, quality is spelled H-E-D-I-S, which is a measurement of performance on criteria that support clinical excellence.  Using the Healthcare Effectiveness Data and Information Set, employers and patients can then compare plans on a level playing field and assess the value of their premium dollar.

HEDIS measures are refined every year, and include assessing successful diabetes and cholesterol management, in addition to several preventive measures, such as screenings for breast cancer, colo-rectal cancer, osteoporosis and glaucoma. HEDIS scores are reported as the percentage of patients who meet specific criteria.  For example, colorectal cancer screening includes services like fecal occult blood tests, flexible sigmoidoscopy and/or colonoscopy at certain intervals. Mammogram rates evaluate the percentage of females under the age of 70 who received the screening during the study period.  

Health plans conduct HEDIS reviews primarily by assessing the presence of specific CPT codes reported on claims and encounters. Chart reviews are also performed to glean additional information, and nurses have historically been integral to this effort.

CMS rates Medicare Advantage plans by assigning a 'star-rating' which adds HEDIS measures, member satisfaction scores and the results of a health outcomes survey to its own data. The stars, which range from one (poor performance) to five (excellent performance), correspond to bonus payments added to the funding that plans receive from CMS. The Henry J Kaiser Family Foundation reports that 91% of MA plans will receive a bonus payment in 2012; the value of these bonuses is estimated at $3.1 billion. One-third of the plans rated four or more stars. Nine percent of the plans received a score of two or less stars and consequently, have an incentive to work harder for the 2013 bonuses.

About the authors: M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC are principals at Coleman Consulting Group. The firm's services include:

· Risk Adjusted Reimbursement (MRA)
· Coding & Billing
· ICD-10-CM Consulting & Training
· EMR/Meaningful Use Attestation
· Credentialing & Contracting

For additional information about the firm or to request a complimentary no-obligation consultation, please call 954.578.3331 or email info@askccg.com.  

Last Updated on Friday, 26 October 2012 08:24
 
The Opportunities and Challenges of Telemedicine: Part 1 Print E-mail
Written by Vanessa Reynolds   
Friday, 28 September 2012 00:00

Telemedicine, or the use of technology/telecommunications for the delivery of healthcare services when the healthcare practitioner and the patient are not in the same physical location, is growing in popularity across the nation. The potential benefits of telemedicine include immediate/improved patient access, reduced service gaps, quality improvement; enhanced clinical support and increased patient satisfaction. Although telemedicine can offer significant benefits to local providers and their patients, all parties must be aware of the associated challenges and take steps to address the regulatory and common law issues that are specific to or may impact telemedicine services. Risk managers should work collaboratively with their facilities' quality, medical staff, compliance and legal professionals to reduce risk to the facilities and their patients.                          

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Vanessa Reynolds is Of Counsel in the Fort Lauderdale office of Broad and Cassel. She is a member of the Firm's Health Law Practice Group.

Last Updated on Friday, 26 October 2012 08:23
 
The Opportunities and Challenges of Telemedicine: Part 2 Print E-mail
Written by Vanessa Reynolds   
Thursday, 27 September 2012 00:00

Telemedicine has been a boon to patients and providers, but can expose the parties to risks that are unique to this area.  Managing the parties’ expectations and establishing their respective obligations through clear communications, regulatory compliance and written agreements are important first steps in minimizing those risks.

Informed Consent

One way providers can manage patient expectations and reduce risk is through the informed consent process.  Prior to a telemedicine consultation, the patient should be given information about, and should acknowledge understanding, of:

·         The limitations of and alternatives to participation in remote consultation or care;

·         The telemedicine practitioner’s inability to perform a physical examination and the need to rely on information from on-site provider(s);

·         The possible presence of non-medical, technical personnel during the telemedicine encounter;

·         The patient’s right to withdraw his or her consent to the telemedicine encounter at any time; and

·         The availability of follow-up care with a local provider.

Licensure

Providers that contract with or refer to telemedicine practitioners should also ensure that the practitioner is appropriately licensed or certified, and that the telemedicine services comply with state law.  Most states, including Florida, require that practitioners engaging in telemedicine be licensed in the state where the patient is located.  Further, Florida law prohibits practitioners from providing treatment recommendations or prescribing medications without a documented patient evaluation, including history and physical examination, dialogue between the practitioner and the patient regarding treatment options and the risks and benefits of treatment, and maintenance of contemporaneous medical records. 

Privacy and Security

Telemedicine providers are bound by the provisions of HIPAA’s privacy and security rules, as well as more stringent state laws, to the same extent as any other health care provider.  Because the use of electronic communications provides additional opportunities for unauthorized uses or disclosures of protected health information, telemedicine providers and the entities with which they contract must be extra vigilant about the privacy and security of patient images and information – both during and after the telemedicine encounter.

Credentialing

Practitioners who provide services to hospital patients must be credentialed and privileged by that hospital.  In 2011, the Joint Commission and CMS issued new rules to address the credentialing of telemedicine practitioner by hospitals contracting for telemedicine services from remote telemedicine sites. Hospitals are free to credential and privilege remote telemedicine practitioners through their usual processes.  They also can make credentialing and privileging decisions using credentialing information from the remote telemedicine site, if the remote telemedicine site is accredited by the Joint Commission and the telemedicine practitioner is licensed in the state in which the patient is located.  Alternatively, hospitals can adopt the credentialing and privileging decision of the remote telemedicine site if the remote site meets Joint Commission and CMS criteria.  In deciding whether to delegate credentialing to distant site telemedicine entities, hospitals should be mindful that they may be liable for the negligent credentialing of a practitioner who provides services to the hospital’s patient. 

Contracting and Insurance

Hospitals that use remote telemedicine services are required to have a written contract with the telemedicine provider, which must meet Joint Commission standards.  Even those entities that are not required to have written agreements should nonetheless reduce their respective expectations and obligations to writing.

Providers contracting for telemedicine services should verify that the telemedicine practitioner’s professional liability insurance will cover telemedicine encounters.  It is also important to verify that the telemedicine practitioner’s professional liability insurance will cover claims in the patient’s or local provider’s state.  This is particularly true for offshore telemedicine providers, who may be unable to purchase coverage for claims in the United States.  In those cases, the parties may want to consider alternative risk vehicles, such as a captive insurance company.  

Conclusion

Telemedicine can offer significant benefits to local providers and their patients if all of the parties are aware of its challenges and take steps to address the regulatory and risk issues associated with telemedicine services.

Vanessa A. Reynolds is Of Counsel in the Fort Lauderdale office of Broad and Cassel. A member of the Firm's Health Law Practice Group, she is an industry veteran with more than 20 years of experience in Health Law.  Reynolds has extensive expertise in institutional and individual health care provider operations and licensure, as well as in health care litigation, Medicare and Medicaid reimbursement, and multi-hospital public health care system representation. She is  Board  Certified as a specialist in health law by the Florida Bar and can be reached at (954) 764-7060 or vreynolds@broadandcassel.com.

 
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