pediatrics

It has been about three weeks since I contacted the top five managed care organizations for a customer of ours. The purpose of my initial call was to obtain their current agreement and fee schedule for their top five payers. I started as if I had no experience or contacts in the field to see how long it would take to obtain the proper information. Here is the update by managed care plan:

1. Aetna: The Physician Network Account Manager on 12/2/10 stated that I would receive the information via e-mail within 3 business days. I called at the end of the third business day to check on the status. She did not call me back until I called again and sent and an e-mail to her as a follow-up (10 business days after our original call). After some further back and forth via e-mail (few hours), I was able to obtain a copy of the agreement as well as fee schedule.
2. IBC: Independent Blue Cross (IBC) – the office had to request the information, sign a document, follow-up with the representative. IBC provided the agreement and fee schedule by 12/17/10.
3. Highmark: The most disappointing of the five carriers. After a few phone calls and e-mails the network representative provided a general mailbox (estprovcred@highmark.com) for contract and fee schedule requests. She stated would only take 1-2 business days. I followed up after 10 business days and still have no response or information. The Network Representative is out of the office from 12/23/10 until 1/3/11 due to the holidays. I left a message and will need to follow-up again in a few weeks.
4. Cigna: The representatives (888-992-4462) stated there is no provider representative and could only provide a fax for this information. Cigna would not expect a Pediatric Office to not provide the name of their doctors or not to provide the location of their doctors when they need help, why do they avoid their providers when requesting simple information related to contracting? The woman on the phone stated that we need to send an urgent fax (866-463-6175) and that there might be a provider representative that would call us back. We sent the fax, as instructed, 10 business days ago, no one called as of yet. Today, at the main number, they instructed me to send another fax to the same number.
5. United Healthcare: The Network Manager (obtained proper information by calling 877-842-3210) was good at providing the fee schedule and initial follow-up. He was available we I called or followed-up within a few days. There were a few additional codes missing from the fee schedule for which I requested the information and he was able to obtain after a telephone call.

The commitment to follow-up on contractual items is very inconsistent with the Health Plans (even if the representative states they will follow-up). Due to this, the burden of follow-up is on the provider’s office or the company that works for the provider’s office.

The HITECH Act has an Electronic Health Record (EHR) incentive program paid via either Medicare or Medicaid. Since Pediatricians do not have Medicare Patients, their opportunity to participate is via the EHR incentive program provided by the Medicaid program. The Medicaid program starts as early as 2011 and eligible providers in a Pediatric Group (MD, DO, NP) can each receive up to $63,750 over a six year period. Unlike Medicare, eligible professionals have until 2016 to implement a certified E.H.R. system and still qualify for the maximum incentive. The HITECH act has recommendations to the state of the threshold for this incentive money. A provider must have at least 20% of their total patient volume be via Medicaid/Managed Medicaid/Children Health Insurance Program (CHIP) Patients during a 90-day measurement period. If a provider has 20% Medicaid volume during a 90-day period, they are eligible for up to $42,500 over a six-year period. If a provider has over 30% volume during a 90-day measurement period, they are eligible for up to $63,750 over a six-year period. Note that the “up to” is dependent on maintaining these thresholds each year as well as implementing a certified EHR system to show meaningful use. The table below provides a summary by year.

Medicaid Eligible Professional (20% – 30% Medicaid/Managed Medicaid/CHIP vol.)

Medicaid, different than Medicare, is administered by the state. The state Medicaid programs are required to verify the eligibility of the provider as well as disperse the payments. Per the CMS.gov website: “The Medicaid EHR Incentive Program is voluntarily offered by individual states and territories and may begin as early as 2011, depending on the state.”

The question and answer section on the CMS website related to the Medicaid EHR program I found to be a useful resource (22 pages). One of the questions is if the State Medicaid program needs to verify the “installation” or “signed contract” of a certified EHR . The answer on the CMS website concludes that: “Thus, a signed contract indicating that the provider has adopted or upgraded would be sufficient.”

There are details to verify and implement to insure eligibility and then receive disperse these funds. I recommend that each office invest some time learning about the HITECH act. Also, having a knowledgeable EHR vendor and/or consultant should greatly reduce the detail knowledge needed within each office.

http://www.cms.gov/EHRIncentivePrograms/

https://www.cms.gov/apps/media/press/factsheet.asp?Counter=3793&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

Most in the medial field know the acronym EHR (Electronic Health Record) and EMR (Electronic Medical Record) but many do not understand the difference between the two. The National Alliance for Health Information Technology defines these two as follows (2008):

Electronic Medical Record: an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.

Electronic Health Record: an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff across more than one healthcare organizations. The United States government via Health and Human Services/Office of the National Coordinator provides incentives via the HITECH Act to move the nation toward adoption of Electronic Health Records. On July 13, 2010, HHS provided a clarification of the benchmarks providers must demonstrate to receive the incentive payments for adopting a “certified EHR”. This document is over 850 pages in length that highlights some of the details of meaningful use. Many thought leaders, providers, and policy makers believe that Moving away from a primary “paper-based” system to an “Electronic Health Record” will improve quality and reduce costs of the health care system. Making the transition requires time, money
and effort.