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Certification of Health IT will provide assurance to purchasers and other users that an EHR system, or other relevant technology, offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria established for a given phase. Providers and patients must also be confident that the electronic health IT products and systems they use are secure, can maintain data confidentially, and can work with other systems to share information. Confidence in health IT systems is an important part of advancing health IT system adoption and allowing for the realization of the benefits of improved patient care.The Health Information Technology: Initial Set ofestablishes certification programs for purposes of testing and certifying health information

Eligible professionals and eligible hospitals who seek to qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs are required by statute to use Certified EHR Technology. Once certified, Complete EHRs and EHR Modules would be able to be used by eligible professionals and eligible hospitals, or be combined, to meet the statutory requirement for Certified EHR Technology.

Learn more about the RuleFact Sheet

Additional InformationIn collaboration with ONC, the National Institute of Standards and Technology (NIST) is developing th functional and conformance testing requirements, test cases, and test tools to support the proposed Health IT Certification Programs. These conformance test methods (test procedures, test data, and test tools) will help ensure compliance with the meaningful use technical requirements and standards.

A local hospital might have a large enterprise EHR system. The system designed to be a ‘general’ system for all areas of Medicine. This requires many fields and the providers to mold to the system. This system can be difficult to use since the system is not designed around a specific Medical Specialty. Pediatricians have much different day to day patients than Cardiologists. The EHR sales representatives might call the practice and provide concerns that if they do not use their system, the practice might have a challenging time working with the hospital system. The physicians and other providers might have entered a few hospital orders in the EHR system in the hospital but not seen 20-30 patients in a day in their office (big difference). For some of these reasons, there are practice owners that believe they need to use the same system adopted by their local Hospital.

The government was concerned about interoperability in the health care system and provided a solution that allows a physician practice to choose the appropriate EHR for their practice and not be forced to choose the Hospital EHR system. Through the HITECH act, the Health and Human Services are funding the ability for states to have Health Exchanges. Hospitals in the state as well as laboratories will connect to these Health Exchanges. This means that any EHR system can connect to the exchange to share data (lab data, hospital data, etc.). Once the exchange is built, the practice only needs to connect to the exchange and will be able to send and receive appropriate data for any hospital in the state. This provides the practice the flexibility to choose any EHR system (assuming the EHR company has the experience/technology to link to the exchange) while not giving up function. Practices should choose an EHR system based on the quality of the product and the service.

I have visited in hundreds of Physician Offices and seen a wide range of billing operations. Physicians have a very difficult job to stay current on diseases as well as medical treatments. The world of medical/insurance claims and practice management changes daily with new rules for rejecting claims as well as changes on how to bill (e.g. see article on “billing options for flu clinics”). Insurance companies invest in ‘scrubbers’ and software products that reject claims based on certain rules. These rules change constantly. There are vendors that create software for Insurance Companies with these claim edits. I have met and seen these systems at the vendor display area of the American Health Insurance Plans (AHIP) annual conference. Sales representatives for software vendors with this claim logic system sell to insurance company executives the amount of money their system can save an insurance plan. Insurance executives are very aware that many billers for Physician Offices do not resubmit claims. Insurance companies utilize these systems and some have probably denied what most would consider appropriate claims. For example, the courts provided a judgment in 2010 against United Healthcare for using a software system that rejected many insurance claims that should not have been rejected.

Unfortunately, many owners of practices are losing thousands of dollars each year due to their billing system. Worse, most are not aware that they are missing this revenue. For example, a practice that generates $1,000,000 in total yearly revenue might feel that they are doing well. Usually, I would ask a physician partner or practice administrator, “What is your collection rate of the contract insurance amount?” Many practices are unaware what their collection rate of the contract amount. Benchmarking organizations like the Medical Group Management Association (MGMA) consider collecting 95% of the contract amount for all claims to be ‘good’. This would mean that if the practice brings in $1,000,000 per year in receivables that the practice is unable to collect $50,000. This $50,000 is usually insurance claims and/or patient statements that poor billing systems/operations miss. At Doctor Office Management, Inc, using the PhysicianXpress system, we have a system that benchmarks to 99% of the contract amount. So far, we have been able to achieve this benchmark for our billing clients.

Many software systems used for Medical Billing are difficult for a physician partner to answer these simple questions. Additionally, ‘drilling down’ or ‘spot checking’ might not be possible for a physician partner to view specifics on a claim as needed. I have been in physician offices for which the providers are very knowledgeable on Medical diseases, treatments and have invested much in their facilities and equipment but their billing systems that are based on technology from the 1980s or 1990s. Since insurance rules change, in some cases, monthly, using a ‘dated’ system places the complete burden on the billing staff and practice managers. Even if the billing staff and practice managers for a practice are top in their field, they would not have the time & resources to stay current with the insurance claim edits.

Speaking of billers and practice Management, there are many questions a physician partner needs to insure if they choose to perform billing and patient statements with their own staff. Some of these questions include: Do the billers and management have the depth of skills for today’s insurance climate? Can all the billers explain the difference between a 99213, 99214 and 99215? Are there formal SOPs in the practice which includes an audit system? How much redundancy occurs in the operation? Does the practice check the billers work and provide feedback? If not, how much revenue is being lost that the practice owners are unaware of? Does the practice management have the skills to interview and constantly check on the performance of the billers? Is the practice able to bring in new talent that utilizes the latest or is there a system to improve the skills sets for the billers? Does the practice establish benchmarks for ‘good’ performance? What type of feedback loop does the billing team use to communicate with the other stakeholders and influencers of the revenue cycle (providers and front desk)?

There has been a dramatic shift in design of insurance policies in the last twenty years. Billing and patient statements were very predictable when most of the insurances were 80/20. Today, most insurances are PPOs/HMOs with <5% that pay the entire billed amount. More and more patients have high deductible plans as well as plans that limit the number of well checks per year. The revenue cycle is constantly changing. Benchmarking is difficult to do with one physician office. MGMA has a strong benchmarking history in practice management. In some of the highly regarded revenue cycle courses they provide benchmarks. One important benchmark is how many days of Accounts Receivable (AR) does the practice have outstanding. If the practice bills on average $1000 (evaluate over 1 year of time) and the practice has $60,000 in AR then the AR days are 60. MGMA sources show that 60 is the average for a practice and better the 40 is ‘good’. Using the PhysicianXpress system, Doctor Office Management, Inc. benchmarks 30 AR days as ‘good’. This is 25% higher benchmark than MGMA groups provide.

From a cost stay point, a physician office needs to be able to identify the salary paid to the biller, the time needed per month for management (whether the physician partner manages or a practice manager), benefits, taxes, office space, training and time for hiring replacements if the biller leaves, is sick for extended period of time or underperforms. Additionally, there is a cost for postage, maintaining the computer, office area, phone lines, and supplies of the biller. There are many articles by the Business Process Outsourcing (BPO) groups that provide further background and depth related to Medical Billing Outsourcing as well as how to determine if a practice should outsource. One good article I found on the subject is http://www.globalservicesmedia.com/BPO/Industry-specific-Processes/Should-Your-Practice-Outsource-Medical-Billing/23/29/9739/GS100618688470

Situation A: a mother and daughter have lunch at a high-quality restaurant that includes a musical, two lunches and dessert for a total of $215. When the check arrives, the mother and daughter leave the restaurant without paying.

Situation B: a mother and daughter visit their Pediatrician so the daughter can obtain a check up/physical, the Gardasil vaccine, have her vision and hearing checked, and have forms completed for sports camp and school. The mother has a high-deductible plan; she receives a patient statement for the entire visit and does not pay.

Ask a few individuals how they feel about situation A vs. B. In both situations, the mother (Guarantor) must pay the bill. The restaurant will insure they collect their money, but will the physician office?

There has been a dramatic shift in design of insurance policies in the last twenty years. Most patients/guarantors pay their patient statements timely. However, there are patients/guarantors who do not pay their patient statements. Per their insurance policy, they are required to pay the portion that is “Patient Responsibility”. A practice needs a consistent policy to manage all patient statements as well as how to manage patient accounts that do not collect.

The practice leadership needs to decide the following: How many and when do we send out patient statements (initial statement, 30 day statement, 60 day statement)? How many telephone calls do the billers make to the guarantor during the patient statement process? Do we have a payment plan policy? Do we use a collection service? Does the collection service have adequate experience in the medical field?

These seem like tough questions. Many readers are probably thinking that “we have never used a collection service in the past and just wrote this off as bad debt.” In the past, this might have worked well. Billing and patient statements were very predictable when most of the insurances were 80/20. Today, most insurances are PPOs/HMOs with <5% that pay the entire billed amount. More and more patients have high deductible plans as well as plans that limit the number of well checks per year. The revenue cycle is constantly changing.

Please remember that a patient’s insurance policy does not mean “Insurance company pays all”. The insurance policy is an agreement for which there are obligations of the insurance company and the patient/guarantor. The guarantor who does not pay his patient statements might be the type of person who is paying his credit card, car payments, house, utility bills as well as other bills but places the patient statement as ‘optional’. This person learns through the system that for some bills there are no penalties, the organization gives him a ‘pass’. If a person does not pay his utility bill, the account goes to collection and the power can be turned off. A practice in the field of providing medical care to patients needs to balance the approach of how they collect (this is not ‘Joe’s Garage’). Issues occur with a small number of patients that they might need a payment plan or help to assure they can pay their bill. In many cases a payment plan for these select patients provides the flexibility they need to pay the bill. These patients usually answer the phone and respond to the patient statements. The patients that do not respond to the patient statements nor answer/respond to multiple phone calls are the ones that, unfortunately, need to go to collection. Many in collection become willing to work out a payment plan since they realize that they need to pay. Being consistent and collecting from everyone is fair to all patients.

For these reasons, I recommend that practices have a patient payment plan policy, extra fees for patient statements not paid within 30 days of initial statement as well as a collection policy in place. For clients that use the PhysicianXpress system, there is a collection option with a series of 3 letters and 10 phone calls to patients over a two month period. This is an ‘affordable’ option of only $6.75 per account that goes into collection. If the guarantor does not pay, there is a second level of collections that goes to the credit bureaus as well as other measures. Generally this last step cost 30% of the amount collected.

The CEO of the largest EHR company (Allscripts), Glen Tullman, has been very vocal that there will be a reduction in the number of EHR companies. I agree with his prediction since many companies that claim to be EHR companies are really not EHR systems that have e-prescriptions, lab results read directly into the EHR as well as the technology required by the government related to meaningful use. How many EHR companies will there be 10 years from today? I believe looking at other industries that have consolidated provide some good benchmark ranges. Businesses move through different business cycles from the growth stage to the mature phase. Generally, the buyer will always buy better technology/products if the products are better value/price than the previous offerings. This is true more in the growth phase of an industry (like iPads, new phones, EHR) than mature industry (like Automobiles).

If we look at the auto industry, a very mature industry, there are over 50 auto manufacturers that consumers have to choose from per Edmunds (there is even an auto company that launched a very successful IPO in 2010 – Tesla motors). The largest EHR company is Allscripts while the largest Auto company use to be General Motors. Allscripts, similar to General Motors (GM) during a certain time frame, is focused on making acquisitions. The most recent being the merger with Eclipsys. If Allscripts is investing much of its time and resources on buying companies, what will happen to their products? Will their fate be a similar path as General Motors – from top auto options for buyers of their products to one of the worse? GM went bankrupt due to bad management and large debt loads. The executives at the mature companies in the auto industry laughed at the Lexus and then Hydundai while the buyer did the right thing – evaluated the car on the quality of the product, service and reliability (a test drive plus the total cost were primary evaluation methods). Some buyers will only purchase Bentley’s and exotic cars due to their particular needs and desires. I believe the smart buyer will not be influenced by a CEO trying to increase their stock price/company value but by the product/service they need. If the EHR industry consolidates to the same as the Pharmaceutical Industry there will be >300 EHR companies (see MediLexicon for a list). If the consolidation is more like the auto industry, there will be approximately 50 EHR companies. Recommend practices choose an EHR system based on the quality of the product and the service.

Sources:

http://www.edmunds.com

http://www.medilexicon.com/pharmaceuticalcompanies.php