pediatrics

Technology evolves at a rapid pace. Moore’s law states that processors double in speed about every 18 months. This concept with the computer chip allowed manufacturers to develop personal computers at a low cost. IBM and other large companies focused their sales groups on high profit main frame computers. Businesses learned that they could save money by adopting personal computers. Businesses then Adopted servers with wired connections to personal computers (PC) and installed the software they needed on the server. Businesses that use servers need to pay for the software, the server, and have have IT individuals install firewall protection, conduct back up, maintenance, etc. The high speed Internet now provides a means for businesses, including physician practices to lower their costs and reduce their administrative work via cloud computing (see article related to what is cloud computing?).

Interesting to note the Wall Street Journal article on Monday, July 26, 2010 titled “microsoft, Google Vie to Sell US Cloud Mail”. The author of the article (Amir Efrati) shares two interesting confirmation of using cloud computing for business and government: (1) the General Services Adminstration certified that Google’s cloud-based “e-mail and word-processing service, known as Google Apps, meets security requirements to qualify for use by the agency”. If a large government agency that requires high security of information uses cloud-based solutions, shouldn’t small businesses? And (2) the estimated number of users would be about 15,000 government employees. Note that “the GSA often helps shape how other agencies acquire technology”.

The government understands that cloud-based computing can save money for US taxpayers. The WSJ article states “a report from the Obama administration’s chief information officer says the concept could help trim the federal government’s $76 billion annual budget for computer equipment and software”. The government would pay a set fee per user per year and would only need to maintain an Internet connection.

If the government is moving toward cloud computing with thousands of employees, should any physician practice with less than 100 employees adopt EHR systems based on the practice needing to buy and maintain a server?

A practice should verify their contract terms and fee schedule with the managed care organizations once a year. I was interested to see how long it would take to request this information from the top five payers of one of the practices we managed the billing and collection. Since each company has their own processes and systems, the customer experience varies between the insurance companies. In most cases, it takes time to obtain a representative. Once you are able to make contact with a Customer Service Representative the representative will usually provide you another name and number to call to obtain the information. For this particular practice, my experiences were with Aetna, Highmark, Independence Blue Cross, Cigna and Highmark and are as follows:

1. For Aetna, I called the main number (800)624-0756 and spent 4 minutes moving through the menu options until I requested “Customer Service”. After obtaining a customer service representative, she informed me that I needed to speak with our “Network Account Manager”. She provided me a name and phone number. I called the person. She answered! Unfortunately, she was the person for Hospitals and not physician practices. This representative then informed me that I need to contact the Network Account Manager for Physician Groups in our County. I called the number that she provided and received a message stating that the number has been disconnected. I called the person back whom provided the number (less than 2 minutes) whom did not answer so I left her a message. She called me back and provided me an updated phone number. Fortunately, I was eventually able to speak with the person in our area whom is the Physician Network Account Manager. I stated that we are requesting a current copy of our contract and fee schedule. She stated that the practice does not have a contract but a “Service agreement” for over six years implying that we did not need the information. I needed to state to her that we needed a current copy of the agreement again and she agreed to send the information (stated would take three business days and she would send via e-mail).
2. For Independence Blue Cross (IBC), I called the main number (800-Ask-Blue) and was able to speak with a Customer Service representative whom stated I needed to place this request with the Network Coordinator for PCPs. She provided me her direct phone number for which I left my name, reason for calling, name of the practice, tax id, return phone number and e-mail. I am unsure how long it will take this person to return my call.
3. For Highmark, I called the main phone number (866)975-7290 and was able to speak with a Customer Service Representative very quickly. I informed her of my request and she stated that she needed to fill out a form with the request and would send to the Provider Relations Representative. She was unable to provide me the phone number or other information for this person (was able to provide the first and last name) and stated that the provider relations representative would call me back in 1-2 business days.
4. For Cigna, I called the main number (888)992-4462 and after moving through a few menus obtained an option for “contracting”. The first Customer Service Representative stated that she needed to transfer me to contracting then the second person stated we could obtain the information by sending a fax request to Provider Solutions and Services at (866)463-6175. He stated that I needed to provide the name of the providers, practice name, tax id as well as stating that we need a copy of the contract and fee schedule and the department will follow-up via e-mail (with PDF file) or Fax. After the call I drafted a one page letter as he recommended and sent via fax to the number provided.
5. For United, I called the main number (877)842-3210 at 4:40 pm. When I spoke with a Customer Service Representative, she stated that I needed to call another number and make the request. The number provided [(800)791-2067] is a voice mail box that states to leave the information you request. I left a voice mail providing my name, practice name, the information requested, the practice tax id, my phone number and e-mail. Unsure when or if I will receive a call back as well as the information since there is no person working the line or a name of a person at United to call if there are issues.

This initial process of contacting these five carriers took about an hour. Anticipate that I will need to follow-up with these insurance companies in two days if I do not receive confirmations that they will be sending the information requested.

Healthcare is a very complex field. After attending college and Medical School, physicians invest years of time and effort to learn the focus of their specialty. Pediatricians spend three (3) years in Residency after Medical School. Pediatric residency includes rotations in NICU, PICU, ER, Cardiology, Pulmonary, office practice as well as other areas related to Pediatrics. This is much different than a Surgery, Ortho or Radiology Residencies. Similar to the Medical training in Pediatrics, the coding in Pediatrics is differs from other specialties. There are routine updates to the CPT and Diagnosis codes as well as the scrubber logic/systems at insurance companies. This requires continuous learning and improvement by the entire billing team and providers.

The revenue cycle is comprised of the front end and back end. Traditionally, a practice labels the back end of the revenue cycle as the “billing team”. This is only half correct. The front desk and providers (front end of the revenue cycle) are a critical component of the revenue cycle to insure that the proper procedures/codes are captured at the time of the visit as well as to appropriately check in the patient. A well designed system can optimized the revenue cycle for Pediatrics by attaching code automatically (e.g. when a vaccine is added, the administration codes added automatically). The back-end billing team needs to submit & resubmit (as needed) the claim to the insurance companies, print patient statements and follow-up on the claim. The back end billing team should also have communication with the front desk and providers related to appropriate update/changes in billing practices and/or a certain claim.

There are many variables in the revenue cycle including: patients/families with various types of insurance (HMO, PPO, H.S.A.) as well as numerous insurance companies each with their own payment structure and systems. The front desk team needs to be trained on how to intake insurances for verification. Additionally, the front desk team needs to be monitored and provided feedback on their work performance. The Pediatricians and/or providers also need some initial training on coding and monitoring to provide feedback on what they are doing well as well as what they can do to improve. I have seen some providers be able to identify all appropriate billing opportunities while others have a small range of variability in their coding.

Think for a minute of the range of codes in a Pediatric visit: a simple sick visit with one diagnosis and one CPT code (e.g. 463 – DX code, 99213 – CPT Code) to a complex well/sick visit that includes multiple vaccines (e.g. greater than the eight diagnosis codes and more than 6 CPT codes). If a provider averages 80 patient visits a week for fifty weeks a year, the provider see approximately 4000 patient visits a year. This Pediatric provider might have 25,000 to 35,000 CPT/DX codes attached to these visits. A well designed system as well as trained providers, front desk and back-end billing team utilizing a system designed for Pediatrics built on today’s technology should optimize the revenue cycle for the practice. The system should automatically attached procedure CPT codes when a procedure is selected. Also, when a vaccine is given, the system should automatically attached administration codes. Well check coding is very similar for each visit with the variables being the procedures, vaccines and/or if the patient is also sick and should have sick codes. The practice should have a clearly written policy on how they manage the fall flu injections. This policy needs to be shared with the front desk and back-end billing teams.

The American Academy of Pediatrics has a good selection of training courses for providers and back end billing team members. Providers should routinely take courses and/or obtain updates so they can appropriate select the ‘right’ code for the visit. Pediatricians and pediatric providers have much to manage in their practice. For even a highly skilled Pediatrician, managing all the details associated with a practice is very time consuming and challenging. Providers that do not have a strong understanding or interest in the revenue cycle of a practice might have unrealistic expectations on managing the details of the revenue cycle (e.g. variability of payment from different insurance companies, % of patients that pay). Organizations, such as the Medical Group Management Association, have tools and benchmarks for practices. These benchmarks include % of revenue collected to the contract amount as well as the average amount of accounts receivable waiting to be paid. A well design system should be able to provide reports to evaluate both the ‘big picture’ as well as to drill down on each detail. As the front end and back end billing team move to a steady state, a partner should invest a few hours a month to run the reports to see the status of the practice performance. If the practice is performing above the performance benchmarks, congratulate yourself and your team. If the practice is performing below the performance benchmarks, identify the issue: is it a revenue capture by the providers? Speed of being paid? Amount of $ in Accounts Receivable? Is it patient collections?

There are numerous articles written on why practices should outsource their billing operation (the attached link is an example http://www.softwareadvice.com/articles/medical/medical-best-practices-advice/when-should-you-outsource-your-medical-billing-1032610/ ). The providers still need to optimize their check-in procedures as well as select the procedures when outsourcing their billing. Many outsource billing organizations have limited transparency. The practice should be able to audit the back-end billing team ‘real time’ as needed. The back-end billing operation should have a written audit process for which billers audit each account. The back-end billing team should also have coverage when the primary biller or billers are on vacation or sick leave. The providers need to have a resource in the back end billing team to ask or send questions/clarifications.

Although healthcare is a complex field, a well designed system and processes along with proper training can simplify the work for a practice, optimize the revenue cycle, and minimize the staffing cost to a practice.

Similar the field of medicine the field of electronic health records changes regularly. During the initial training of an electronic health record system, the providers and staff should have a basic understanding of how to register a patient, take the vitals, record the visit and if needed, send an electronic prescription. The initial training and initial use of the system will require the most work and effort to optimize the transition from paper to electronic records.

The initial training is only the start. I like to compare this as learning to ride a bike without training wheels. The first time a person is able to ride without training wheels they need to consciously think of how to balance, place feet, stop, etc. As the person spends more time riding the bike, the easier it is to increase the speed at which you ride the bike, increase the speed on corners. As the skill improve, the biker rides in a subconscious manner. Additional training should increase the ability of the biker.

Similar, when utilizing a new electronic health record system, the first few uses on the system is like the biker on the training wheels. Recommend there be 2 to 3 point people in the practice whom become ‘expert’ users. These can either be individuals that quickly move through the ‘training wheel’ phase and/or leaders in the group whom have a good affinity for computers and training. These individuals should provide training tips/updates to the practice (maybe during lunch) on a routine basis (every other month). The Health Information technology field is a dynamic and chaining field. You EMR system should be continuously improving and evolving.

Backing up multiple times per day provides data security and ‘peace of mind’. If your E.H.R. system needs to be maintained on a server within your office there is additional cost in time and money that practice needs to incur.

What if there is a power failure? Corruption of the database? Fire? How does your practice/system manage these scenarios to insure that at most the practice only loses a few hours of data? If the E.H.R. system your practice has in their office is client server then the practice needs to develop and execute a data back-up and recovery service. If your E.H.R. system is based on ‘cloud computing’ and maintained by the vendor, I recommend you ask some questions of the vendor. These questions include:

• How many back-ups does the system make per day?
• Does the main production server back-up to a redundant server?
• Does the system contain a data vault for daily back-ups of all production and redundant servers?
• Does the company have personnel with degrees in computer science and systems engineering?

If you receive some long pauses and non-direct answers on the questions above, ask to speak with a person from the company with a Computer Science or Systems Engineering experience. If they do not have any personnel with Computer Science or Systems Engineering degrees/experience, there might be further questions that you should ask to insure optimal data back-up and recovery.