Proposal would require health plans, doctors to cut appointment wait times

California soon may become the first state in the nation to set a maximum number of hours a health plan enrollee may wait before getting in to see a doctor.

Under the proposed regulations that are six years in the making, a patient needing an "urgent" appointment for a service not requiring prior authorization must be seen within 48 hours. For urgent appointments requiring prior authorization, they must be seen within 96 hours.

Patients would be allowed to speak with a doctor on the phone or receive a "triage" call back from a health professional–not answering service personnel–within 10 minutes, no matter what time of the day or night they call.

Read the full story by HealthLeaders Media’s Cheryl Clark.

Is healthcare better without doctors?

In all the talk about creating a medical home for every American, it's important to realize that increasingly, consumers are getting their healthcare outside of the traditional physician-based healthcare system. And that may very well be a good thing.

"Access to healthcare does not necessarily mean going to the doctor anymore," says health consultant Mary Kate Scott of Scott & Co. In her report for the California HealthCare Foundation released last week, Scott points to the rapid expansion of drugs and devices to test, monitor, and treat medical conditions without the physician office visit that defined access to healthcare a decade or two ago. In fact, a physician isn't required in the process at all.

"We're going to see an explosion in medical devices, and over-the counter drugs," as well as telemedicine applications for their use, Scott says.

"Consumers can purchase more than 700 over-the-counter medications whose ingredients and dosages were once available only by prescription," she writes in her report. "And in the last 15 years, numerous over-the-counter devices have become available" enabling oneself, or a non-physician to diagnose, monitor and treat a medical condition.

And that is the wave of the future, she predicts. "It's not like consumers love going to the doctor. They actually don't."

Read the full story by HealthLeaders Media’s Cheryl Clark.

Processing your MSP claims

CMS released a transmittal describing the formula it uses to determine its liability on claims when Medicare is the secondary payer. It is important practitioners accurately convey the primary payer’s group codes, claim adjustment reason codes, and associated adjustment amounts when sending claims to the Medicare contractor.

Effective date: July 1, 2009
Implementation date: July 6, 2009

View the transmittal
View the MLN Matters article
View the Job Aid article

Don’t delay because of Red Flags Rule delay

The Federal Trade Commission (FTC) pushed back its compliance date Thursday on the “Red Flags Rule” from May 1 until August 1, giving healthcare facilities considered to be “creditors” three extra months to implement an identity theft prevention program.

But that does not mean healthcare entities should delay implementing a program–especially when you’re dealing with the FTC, an organization known for harsh punishment and corrective measures.

“Don’t forget, this is a much different agency than [Office for Civil Rights] and CMS, the enforcement agencies for HIPAA, and if they do show up, the consequences will likely be severe,” says Kate Borten, CISSP, CISM, president of The Marblehead Group in Marblehead, MA.

The Red Flags Rule aims to keep the FTC away. It forces any organization considered to be a “creditor” to implement programs to identify, detect, and respond to patterns, practices, or specific activities that could indicate identity theft.

Read my full piece on healthleadersmedia.com.

HIPAA and the HITECH Act

Your patient access staff members can never know enough about HIPAA.

I authored a white paper analyzing the new laws in the Health Information Technology for Clinical and Economic Health Act (HITECH Act) – or Title XIII of the American Recovery and Reinvestment Act of 2009, signed February 17.

Visit our Revenue Cycle Institute to download the white paper, HITECH Act and HIPAA: Strengthen your HIPAA compliance and training programs; prepare for new laws under the American Recovery and Reinvestment Act of 2009.

I’ve also written some columns about the subject for our daily online healthcare news Web site — www.healthleadersmedia.com:

• No panic about HITECH
• HHS issues draft guidance on securing PHI

Thanks!

Dom Nicastro
Senior managing editor
Patient Access Resource Center

Centralized scheduling/online fax orders

I would like to network with hospitals that have Centralized Scheduling and Online Fax orders.

Sabine McNair
Director of Patient Financial Services
Hopkins County Memorial Hospital

Got a success story with HINNs?

Looking for a successful case study for an audioconference. If you have one and would like to speak to it in an audioconference with us, please let me know!

Thanks!

Dom Nicastro

National Appeal Process denial

Does anyone have a success story on getting a denial overturned by using the National Appeal Process after all levels of appeals for the insurance company have failed? Also, can someone provide that address?

Rosemary R. McLain, RN
Clinical Nurse Auditor
Providence Hospital

EMTALA in Georgia

We know the EMTALA guidelines for the ER log book. I’m looking for the State of Georgia guidelines. Can anyone help me?

Marianne Addison
Patient Access Supervisor
BJC Medical Center
Commerce, GA

Accurate edits return $$$

By Vince Arencibia and Julie Souder

Many companies offer various services and ideas on how to improve revenue. Most, if not all, concentrate their efforts on the front-end registration process, dealing with eligibility, making sure the patients have enough insurance coverage, collection of co-pays, etc. All these procedures are important, good practices to follow and are essential to a good revenue cycle program.

One vital step in the revenue cycle program tends to be ignored or is inadequate – proper setup and use of a scrubbing system. In order to have a clean claim, there are a few components dealing with systems and personnel that need to exist. A good, reliable scrubber system needs to be in place, the billers need to know how to use it, understand the information the scrubber provides, and, most of all, know how to resolve claims issues presented by the scrubber.

Companies spend hours on research and development concentrating on how well the electronic file is built so the insurance company will accept it. However, even though it is an important step as part of claim submission, how accurate is the information within the file? What if you do not have electronic file submission established for all the carriers, and paper claim submissions need to a review?

In addition to a good scrubbing system, there needs to be a good revenue integrity person at your facility keeping up with all the various scenarios relating to reimbursement. The revenue integrity person needs to understand the types of contracts the hospital has with a particular insurance company. 

Your facility needs to have solid background on what insurance companies look for and what the best practices are in the billing and coding arena. In our experience with many clients over the years, we have determined that in order to have a good revenue cycle program, there needs to be a synergy between revenue integrity, medical records, coding, billing, and compliance. A good “scrubber” system can help to ensure you receive the most appropriate reimbursement for the services you provide. 

Besides the front-end eligibility and compliance on file structure, what are the claims issues at a hospital? There are three components:

• Compliance
• Lost charges
• Payer-specific issues

There also needs to be a good understanding on how to build edits on your scrubber to look for certain edits dealing with areas such as:

• Outpatient Medicare
• Carve out
• Interventional radiology
• Drug administration
• User-defined

The question is – do you have a person in-house dedicated to reviewing claims before or after they are billed? Are you relying on the scrubbing system to do just that? Does your scrubber perform to your expectations?  Systems are supposed to be automatic, but we know in the healthcare environment, there are too many variations for a system to automatically pick up most coding errors.

There needs to be someone or some system in place to review particular claims either right before you bill them, and/or shortly thereafter.

Only with the synergy mentioned above, will your facility experience the expedience and accuracy of claims processing and reimbursement it deserves.

Vicente Arencibia is a chief information officer with Omega Technology Solutions. Arencibia leads a team providing all aspects of electronic technologies, including compliance, claim submission and revenue management. Arencibia is a qualified manager and holds a B.S. in management and marketing degrees from Florida Atlantic University.

Julie K. Souder, CPC, CPC-H, CPATI, is a business analyst for Omega Technology Solutions with more than 22 years in the healthcare industry. Her experiences have taken her everywhere from working on systems to collect patient information during emergency situations, to patient billing, to medical record audits. Previous positions have included the business office management of what was the largest private ambulance company in South Florida, to owning her own medical collections agency. Today, she is involved in research and development of claims edit systems that report compliance issues as well as alerts for potential lost charges/revenue. She is also involved in the charge description master products provided by OTS.