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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  

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.                          


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.


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.


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.  


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

Take an Active Role in Defining Your Payer Relationships Print E-mail
Written by Todd Rodriguez   
Monday, 24 September 2012 09:14

If you're not sure what your managed care payers want from you, maybe you need to tell them.

Many physicians are (understandably) complacent about taking an active role in defining in their payer relationships. Not surprisingly, managed care payers have had very little incentive or ability to negotiate special arrangements with a diverse and disintegrated physician practice marketplace. However, as the marketplace consolidates, larger independent physician practices may have an opportunity to begin to define their payer relationships.

Many physicians believe that insurance companies have exclusive access to the data necessary to define the specific cost controls and quality measures they will demand from the physician marketplace. In fact, while payers have historically had access to more utilization and quality data than the physician practices, with the implementation of electronic medical records and sophisticated IT systems, larger practices now have access to key data with which to define their quality, cost and utilization data. Very often when I talk to physicians about negotiating their managed care arrangements, they say that they don't know what their payers are looking for. Consider, however, that this may be because the payers themselves don't know what they are looking for.

Physicians are in a better position than virtually any other player in the healthcare marketplace to identify quality improvement and cost saving opportunities. With a reasonable amount of effort, most practices can identify at least a handful of areas where quality of care can be improved or significant/meaningful cost savings can be achieved. With this information, practices should consider approaching their payers to see if the payers will consider establishing reimbursement arrangements which reward achievement of specific goals surrounding these opportunities.

Here are a couple of tips practices can use to get started:

1. Establish a physician-lead managed care committee. This committee can be charged with identifying managed-care opportunities and exploring them with practice payers.

2. Identify high cost services offered by the practice and ways in which those costs can be reduced;

3. Identify the data necessary to measure cost and quality improvements and begin tracking them;

4. Identify achievable and measurable goals for quality and cost improvement for presentation to managed care payers. Note that payers may want to see empirical evidence of achievable savings and   or quality improvements before negotiating. Develop and document case studies which support your practice's proposals.
The only thing certain about the practice of medicine today is that change--in some form--is coming. We also know that cost, quality and convenience are and will continue to be the values that employers and payers are looking for in their health care providers. Physicians have an opportunity, perhaps now more than ever, to define the healthcare market and their role in it. The practices that will survive and thrive in the evolving health care market are likely to be those that take the initiative to not only adapt to change but to shape it.

For more information please contact: Todd A. Rodriguez at 610-458-4978 or

Last Updated on Monday, 01 October 2012 07:06
5 Vital Signs for Your Practice's Health Print E-mail
Written by M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC   
Friday, 31 August 2012 07:37

The phrase 'vital signs' makes most people think of patients, but did you know that your medical practice also has vital signs? And just like in the human body, these business vital signs are just as crucial to your existence. 

Here are the top five vital signs every practice should track every month:
  1. Collections: Keeping track of collections on a monthly basis can help you spot any trends as they begin to emerge. Healthcare experts maintain that revenue rarely fluctuates more than 10% so anything above that merits scrutiny.
  2. Labor Costs: These too don't vary unless you've had an unusual event that necessitated overtime or use of a staffing service. Monthly monitoring of the aggregate amount spent gives a quick reality check when one day of staff overtime starts to become a habit.
  3. New patients: Sometimes we get caught up in the day-to-day work and fail to notice any dramatic changes in the number of new patients. If they decline precipitously, you might want to look over your operations and assess any new competitors.
  4. Top 5 CPT Codes: Most healthy practices have a mix of E/M and procedure codes. However, too many Level V visits, for example, could prompt payor attention and claims review, and reveal the need for external audit and provider education.
  5. Top 5 Referral Sources: Knowing who refers you the most patients is helpful in cultivating strong collegial relationships and to express appreciation. Any significant changes in this area may clue you into environmental issues you may have ignored.
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  

Last Updated on Monday, 10 September 2012 07:10
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