Uncategorized

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

Years ago not many people would ever think to receive a flu shot from the place they fill their medications. CVS, Walgreens, and other retail pharmacy chains are trying to change patterns of receiving flu shots so they can make money on the flu shot as well as the visit for “other items” at their pharmacies. In many cases they only train their pharmacists on a few hour course. A medical assistant in a physician’s office whom administers vaccine has much more experience in giving vaccines to children than a pharmacist. Additionally, the physician can very there are no issues and if there are issues, they have the training to manage the situation in the best interest of the patient. The patient is also able to have the vaccine include with their medical record which is helps with continuity of care for the patient.

With that said, a flu vaccine provided by a medical assistant with a patient verification by the doctor, provides additional value than just a flu shot at a pharmacy. Patients need to be educated on this value so they understand the difference. If the patient is seen by the doctor, generally the coding should be a 99212, the code for the flu vaccine and the appropriate administration codes. As in any visit, the appropriate co-pay per the insurance company should be collected. The practice might consider policies to manage families with multiple patients. CPT codes for administration are accepted by most payers except for Medicare (Medicare has its own code). The administration code is based on the age of the patient, whether the physician counsels the patient or the patient’s family about the vaccine, and how the vaccine was administered. For children younger than 8 years old, CPT codes 90465 and 90466 are used to report/code vaccine administration when the physician provides education to the patient and/or the patient’s family. If the vaccine is intranasal or oral, codes 90467 and 90468 should be used for patients younger than 8 years old. If the patient is >8 years of age or no counseling provided to a patient 8 and under, then codes 90471 and 90472 should be used. 90471 is for administration of the first vaccine while 90472 is for administration of each additional vaccine. For vaccines administered via nasal or oral route and if the patient is >8 years of age or no counseling provided to a patient 8 and under, then codes 90473 and 90474 should be used. 90473 is for administration of the first vaccine while 90474 is for administration of each additional vaccine.

The ICD code most utilized is v04.81 for the flu vaccine alone. Seems like much to remember? No worries if using the physicianXpress system since the system is designed to automatically attach the appropriate diagnosis and CPT codes based on the coding rules described above. All an office needs to do is to attach a vaccine to the visit and the rest is managed by the system as well as the Doctor Office Management, Inc. billing team.

Once the billing policies are confirmed for flu clinics, the practice needs to plan how they will administer/manage their flu clinic. Questions to ask, how many patients do we expect to receive the vaccine? Should we have flu vaccine clinics? If so, how do we communicate the clinics? Voice broadcast? E-mail campaign? The physicianXpress system allows practices to use easily send out a voice broadcast and/or e-mail campaign to patients. For more information on the physicianxpress system go to www.physicianxpress.com

Some reference sites to gain further background on flu vaccine:

http://www.aafp.org/fpm/2007/1000/p35.html

http://www.cdc.gov/vaccines/recs/vac-admin/default.htm#guide

Continued from Part 1 of 2, listed below are some additional questions to consider when selecting a Pediatric EHR.

• Can broadcasting (via e-mail/voice) be done easily with the EHR System?

Pediatric groups have many needs for sending our broad cast messages. Examples include: announcement of a flu/H1N1 clinic, change in hours (e.g. summer hours), announcing a new provider. There should be a field for the staff to collect e-mail so that an e-mail announcement can be sent to all families whom provided an e-mail address. Does the system have the capability to send out the e-mail for no cost to the practice or does the list need to be loaded into another system/company that adds cost to the practice? For voice broadcasts, the practice should be able to download a list of the primary phone number and export to provide voice broad cast messaging. A direct link only to one vendor is usually not the best financial interest to the practice. For example, a cloud based voice broadcast company called ifbyphone has some very inexpensive options for voice broadcast; they have no contracts, a small monthly fee that can be cancelled at any time.

• Does the system have a balance in quality between the EHR and practice management/billing?

This is important. Some systems built an EHR because they want to maintain their practice management clients. If this is the case, how easy is the EHR to use? What is the cost? Does the system have complete integration? Others built an EHR with minimal knowledge of practice management and billing. There is extra cost and work for transitioning data between two systems. This can occur in a practice when the practice management do not want to change and ‘force’ the EHR on the providers or the other way around – the providers find an EHR they like to chart with but the system is ‘weak’ on practice management. A good indicator of this lack of balance is on a company’s web site. When you see that there are many links/alliances with EHR Systems, they probably have a very weak EHR but a solid background in practice management. When you see an alliance with a practice management company (e.g. Athena Health, Physicians Computer Company), usually a good indicator that they have weak practice management system.

What are the total costs?

It is extremely important to compare total cost. When evaluating a system built on client server technology, make sure to obtain cost for maintaining the server and backup. Servers have a life span of a number of years (some use 4-6 years). Evaluate current costs, maintenance, reoccurring costs, set-up costs. The system adopted should reduce total costs for the practice.

• How up to date is the company and their systems?

Some companies have been around for years and unfortunately have not changed their technology for years. Being locked into Microsoft technology was an asset in the 1990s while today, I believe, it is a liability. When the internet was young, client server was the most appropriate choice. There are many draw backs with maintaining a server – software that needs to be updated on each server (this is how things go out of date), cost to maintain the server, time spent on the server, need for VPN when there are multiple offices. Using a system build on “cloud computing” means your practice usually has an IT team with degrees and experience in Systems and Engineering and/or Computer Science maintaining backups, data and software means that the office only needs to maintain a connection to the internet. I use the word ‘usually’ because one of our competitors has a CIO without a Computer Science Degree or an Engineering or Systems Engineering Degree (unsure if he ever graduated from College). If a practice uses a system built on cloud computing, the practice can use low-cost IT support like “The geek squad” to maintain the internet connection as well as computer set-up. Does the technology easily allow a physician to pull up charts on the iPad, mobile phones? It is either very difficult or can’t be done for an EHR system built on ‘old technology’ to be usable across these different platforms. Other costs to consider: training, e-prescriptions, interfaces with Lab companies, reporting/practice management, cost to customize. Note: our CIO has 8 years of programming experience and a degree in Computer Science.

• Is the product designed specifically for Pediatrics?

Pediatricians have special needs not found in other specialties. Kids are not small adults. In a Pediatric patient, there is a higher utilization/visit amount by the younger patients than the older patients. An EHR sales person will state that ‘we have a large amount of Pediatricians’ using our system. This does not mean the product is designed and easy to use for Pediatrics (might just mean that the company has a strong sales force). For example, a practice needs to verify the system has coding linked into the template for each of the well visits type. Is there an integrated vaccine management system as well scheduling logic based on Pediatrics? Does the organization understand “Denver Development” and “Bright Futures” and how to incorporate these approaches into their system?

• How easy is the system to use and can we customize?

Many EHR systems are set-up with small boxes with many commands to learn. Some systems appear to be “Excel-like” spreadsheets with difficult operational interfaces. These systems might have been designed an older technology for a number of reasons including: the cost is too high for the organization to start over, the CIO/staff does not have the skills in the new technology, the technology team is not well integrated with what the user needs. If you see the opening scene for the 2010 Wall Street Movie, Michael Douglass is given back his large phone from the 1980s that no one uses today. You would not by a cell phone made in the 1980s or 1990s, why would you purchase an EHR system built on the technology of the past? The system should be easy to learn. A demonstration of the system is a must. Ask a practice that adopted an EHR system you are interested in how the physician, nurse/MA, front desk like the system. Recommend you either call a physician partner about the system or if possible, spent a ½ day at a practice.

• Does the system receive lab results as data elements directly into the E.H.R.?

Some of the systems advertise that they have a method to record lab results in the EHR. There is a free EHR known as “Practice Fusion” which shows the EHR can accept a PDF file. This does not meet the requirements for meaningful use per the Health and Human Services Requirements. The real question to ask them is do they have an HL-7 interface with the ability to receive lab results directly into the EHR. If they can answer yes and show you an example in the demonstration, they have the ‘right’ lab interface.

• Does the system have direct connection to Surescripts for both sending electronic prescriptions as well as receiving messages on formulary status?

All electronic prescriptions are routed to the pharmacy via an organization established by the large Pharmacy Benefit Managers known as Surescripts. Surescripts will allow EHR/E-prescribing vendors to link directly to their system. To do this, a vendor needs to be able to build all the systems to appropriate route the prescription as well as receive refills. Surescripts can send formulary status of patients as well. Some organizations choose to not invest the resources (they might not have capable enough programmers or enough programmers) and time to build the formulary link. A ‘short-cut’ is for a vendor to use an e-prescribing vendor to help them so that the when a physician wants to receive a formulary message the message/request is sent from the EHR vendor (e.g. Dr. first). There are two ways to identify if a vendor does this, ask them and look on their web site to see if there are partnerships with Dr. First or similar organization.

For further questions to ask, please read article “What are some questions I should ask when looking for a Pediatric Electronic Health Record (Part 2 of 2)?”