There has been an evolution of the services provided in Pharmacies over the past few decades. Pharmacies started as a local pharmacist that spent time teaching their clients, families and providing extra counseling care. Pharmacies also had some over the counter (OTC) medications available for patients. The pharmacy evolved into a “mini-grocery store” driven by high volumes of Prescriptions. Counseling at the Pharmacy changed today to providing more patient handouts to a point that most patients pick up their medications without speaking to a pharmacist. No physician would ever sell or consider selling tobacco products at or close to a Medical Facility. Pharmacies sell tobacco products including cigarettes. How can a pharmacy try to be a medical facility and/or treat patients? Here are some conflicts that Walk-in clinics found in Pharmacies have with good Pediatric Care:
1. Obtaining care at a walk-in clinic disrupts the continuity of care provided in the Pediatric Medical Home. Solid Pediatric Management principles minimize the chance that Patients over use Emergency Rooms, Medications (such as anti-biotics) as well received duplicate care.
2. The Pediatrician insures that the patient is up to date on their vaccines and does not receive duplicate vaccinations. Some continuity of care issues can occur with walk-in clinics including: the clinic providing an additional vaccine that the patient received on their last visit to the Pediatrician, disruptions in flow of information – the walk in clinic forgets to identify the primary care practice or the patient does not provide this information so the information is not in the medical record.
3. The Nurse Practitioner (NP) usually has a broad knowledge but limited knowledge in Pediatrics. The NP might not have the skill to identify a significant health issue that appears during an encounter in the pharmacy. She/he does have training and oversight by a Pediatrician in a Pediatric office. They might be performing this work as weekend work.
4. The walk in clinic does not know the history of the patient to provide optimal treatments. For instance, the NP at the clinic would not be aware of the number of visits to an Allergist for a patient’s asthma and if a patient has the tendency to move from mild coughing to severe asthma. The NP might in this case only provide a beta agonist and cough syrup vs. an anti-inflammatory Medication.
5. The Walk-in clinic might over prescribe certain Medications (like antibiotics) which are not necessarily in the best interest of the patient (good for a pharmacy though).
When a patient is on vacation outside of their home town is probably an appropriate example of when a patient might need to leverage a walk-in clinic. If a walk-in clinic is a health care facility, then they should accept all insurances including Medical Assistance as well as not be located in a pharmacy that sells tobacco products. As large institutions test and try to make money with walk in clinics, it is unclear on the future these pharmacy clinics have in the health care system.
pediatrics
Why Pediatric Patients should not obtain Routine Medical Care at Pharmacy Clinics like The Minute Clinic (CVS), Take Care Health (Walgreens), and other walk-in clinics.
Getting Paid Faster By AmeriHealth Administrators PPO
AmeriHealth PPO has joined forces with InstaMed in order to offer ERA’s and EFT’s. This includes getting paid faster, having claim payments directly deposited into your banks account and the ability to view remittances and details through a secure portal. There is an easy to fill out one page EFT enrollment form and you just need to attach a voided check and fax the information to them. Yes, it really is that easy!
Items to Consider when Selecting a Pediatric Electronic Health Record System
How do I select a Pediatric Health Record and Practice Management System? There are many questions to ask when looking for a Pediatric E.H.R. and Practice Management System. Some items to consider include:
1. Identify a company that focuses solely (preferred) in Pediatrics or primarily in Pediatrics. Don’t be ‘fooled’ by the companies that try to provide the impression that they are focused in Pediatrics via their Pediatric-Specific advertising when they are actually an Internal Medicine/Family Practice System (look on their web sites and see what other specialties they implement their system). Just like kids are not ‘small adults’, a Pediatric E.H.R. is not just some Pediatric Templates. A properly designed Pediatric Specific E.H.R. system should be simple and intuitive to use so that you are able to see 30+ patients a day and have your charts completed within 30 minutes of seeing your last patient. The system also should have Pediatric Specific billing rules and be updated at least monthly.
2. Obtain a demonstration from the Vendor. Is the system ‘simple’ or ‘complex’? Don’t let a seasoned sales representative whom knows how to navigate your obstacle cloud your judgment on what is simple. From your years of experience, you know what is a simple/easy to use and a better design for you as a Pediatrician. Keep in mind that it is very difficult to design a system that is simple while still being complete. Some of the ‘dated’ systems are complex since that was the old model in technology as well as the old thinking around design. In the defense of vendors that are trying to maintain the ‘old’ technology, it is very expensive to redesign a system so many companies just keep adding on to their base system developed over a decade ago. In the programming world, a decade is forever (think what has changed – smart phones (e.g. IPhone), Facebook, Twitter, I Pad, etc.). One of our advisors (an executive in the Technology field), is shocked at how ‘dated’ some of the technology companies are in the Healthcare space. Interesting that some of the vendors with ‘dated’ technology is proud to answer ‘how many installs’. This is a ‘weak’ argument. Consider that there are probably more ‘tube’ TVs (old technology) than Plasma/LCD (new technology) – would you purchase a ‘tube’ TV today based on number of installs of the dated technology? Electronic stores do not sell ‘dated technology’ in TVs but E.H.R. companies continue to sell systems that were built in the pre-plasma TV/IPAD days. Their fear is that customers will see the new technology – which is better, easier to use and lower cost to the practice than the ‘dated’ technology.
3. Does the vendor provide options to customize the system? What are the costs? Some companies will not provide small customizations at a nominal to no cost (especially if they did not develop their own software but paid an outside company to develop their software). Your Pediatric Practice, in most cases, is not a ‘cookie cutter’ of the beta site for which the vendor developed their product. What can be changed and customized? Find out the cost and time frame to make changes? Ask if the company employees full-time developers or if they outsourced their development (this will provide an idea of their level of technical expertise)?
4. Does the vendor have ‘fair’ and ‘reasonable’ pricing and contracts? I am shocked at the variation of contracts by Vendors. Some vendors will have an initial cost and maintenance cost for a client server system which requires the customer (practice) to incur all the costs of a server, backups, IT team to maintain the server while providing a high maintenance fee to the practice. Many vendors make it ‘difficult’ to provide access to your data (including vendors of client-server systems). They might ‘fool’ a practice owner that they are ‘safer’ with a client-server system, but the actual occurrences in the field show that this is not true. For example, some companies do not have an export feature of their client server system so that if you want your own data out of the servers that you have paid to maintain with your own IT people, you need to pay thousands of dollars to the vendor to extract the data. The contract should state the data is yours and that you can obtain your data with a nominal fee (spelled out in the contract) or no cost. The form should be a continuity of Care Record (CCR) or similar format. If a client wants to leave our service, they will receive their data in CCR form (in our current agreements).
5. Customer Service – can you actually speak with a technically knowable person during business hours? Some companies provide either ‘leave a voice mail’ or a customer service line managed by individuals whom have strong phone skills but minimal technology skills. Call the customer service line during the day and see how long it takes for the vendor to return your call.
6. Updates – What updates are included in the price? How often are the updates? Some client-server systems only update 1-2xs per year! Many cloud systems, update continuously with this cost included to the customer. This is how this should work.
7. After your demonstration online, take a test drive for yourself of the system. Is the system easy to use? Can you call and obtain feedback and answers to your questions from team members of the vendor prior to buying? Try to schedule and see a few patients. Ask how the practice management system is integrated with the E.H.R.. What Pediatric-Specific Billing rules are in the system? Does the system have a “Pediatric Specific Scrubber” for claims? How often is this scrubber and coding system updated? 1-2xs per year is definitely not acceptable to optimize the revenue cycle.
8. Ask yourself when evaluating the options for a Pediatric E.H.R. and Practice Management System: What is the worst that can happen and best that can happen if you choose this vendor? Consider cost, how current is the technology, ability to transition to other systems, focus in Pediatrics and how much ‘hazel’ will the system be for me (e.g. there is a cost in time and effort to buy servers, maintain servers, back-up data). For example, if the vendor provides a five year agreement without a clause specifying the data format if you leave, you might be in for a costly ride. Ideally, the E.H.R. Vendor should have a one year contract with a 90 day out clause at any time after that. The vendor should also provide the data back to you in a CCR format so that all the digital data can be converted into another E.H.R.. With this contracting, there is only the risk of not liking the system since you as a practice owner can always move the data to another system without having to move through the paper to data conversion again. This is how we word our contracts – minimizes the risk to the customer (practice) and assures that the contract favors us performing continuously.
9. Do I have options for the vendor to provide billing so that I can manage my practice with less staff and does the vendor have repeatable results? Many Pediatric offices would make additional revenue with less hassle by leveraging an expert in the Revenue Cycle Management. There are many obstacles in the revenue cycle to manage that require consistent processes and management systems in place. There is a major difference from developing, selling and training on software versus managing the revenue cycle. Some vendors are trying to ‘cash-in’ without their processes and systems designed from ‘day one’ to manage the revenue cycle for their clients. Contact analysts, venture capitalists and investors, they will all point to cloud-based systems where these leaders believe today’s technology and tomorrow’s is as well. Also, you will see that the outsourcing vendors in other industries usually leverage cloud based technologies. This is very important when selecting a company to manage your billing. Some questions to ask: What is the vendor’s collection rate? What type of report do they provide the practice monthly? What is their range in A/R days for their clients? How do they train their billers to obtain new information? How do they assure that your account has follow-up and resubmission of claims? Can you view your claims real time as they manage the revenue cycle?
Pediatrics in the Facebook generation, is your practice ready?
One of the benefits of Pediatrics is being surrounded by youths that adopt the latest technologies. Many of
Pediatric patients are very familiar with technology. Almost all teenagers cannot image not being connected to the Internet. They see the web as operating all the time to check Facebook, watch movies, play games, and interact with their school, teachers and friends.
Are their parents able to connect with your pediatric practice via web? The patient portal via the
physicianXpress system allows a practice to customize how a practice establishes and manages their web
interface. A practice can implement one, some or all of the options of the patient portal. These options
include:
-area to request for office to update demographics and insurance information
-request an appointment
-pay a patient statement
-provide patient education materials based on their conditions
-provide lab results
-select medical information such as vaccination list
Cloud based applications reduce costs and burden for Pediatric offices since the office does not need to
employ or contract an IT specialist to maintain appropriate security, back-up of data, system
performance. Does a pediatric practice care if the issue is the software or hardware? The old model of
the 1990s was client server. Over the last five years, inexpensive high speed Internet access as well as
wide spread use of smart phones (iPhone, android phones) provide multiple Internet sources for users.
Physicians can be free to complete their charts anywhere while being removed of the burden of managing
an IT infrastructure in the office.
Pediatricians can feel free today inline with their ‘Facebook’ generation patients by using a cloud-based Pediatric
specific EHR and practice management system.
HIPAA Version 5010 – Is your Pediatric Practice Ready?
There is much noise now about the file version called 5010. What is 5010 and what does this mean to my Pediatric Practice? Claims are transmitted in a file format from practice management/billing systems to insurance companies. The current format is known as 4010. Vendors of software need to be able to adhere to these standards to successfully transmit claims to clearing houses/insurance companies (so the practice can receive payments for services). New requirements in the Patient Protection and Affordable Care Act of 2010 should improve the functionality of sending claims via 5010. This file format change impacts insurance companies, practices, clearing houses and software vendors that provide software for Medical Billing. The goal/reason for the change is an effort to reduce the administrative burden on Physician Practices. Some of the projected benefits include:
• Creation of an electronics funds transfer (EFT) transaction standard as well as operating rules. This should help with matching ERAs and EFT transactions (there are many ‘holes’ in the current standard within the industry which makes tracking payments more challenging).
• Implementation of an electronic claim attachment standard and national plan identifier (NPID)
• Requirement for Health and Human Services to solicit input from providers on administrative items including whether the application for enrollment of Health Care Providers by health plans could be completed in an electronic method.
• Adoption of common approaches to administrative transactions by Health Plans.
• Clarification of a transaction standard.
Currently, authors of articles published in Connexion (a monthly magazine published by MGMA), site that there is inconsistent and non-uniform use of more than 1000 claim adjustment reason codes and remittance advice remark codes. ERAs have been sent by Health Plans for which adjustments are documented incorrectly. Many practices have a difficult time matching EFTs to the ERA files. The conversion to 5010 should help with some of these issues. PhysicianXpress is currently ready and certified for 5010 transactions (ahead of the 1/1/12 due date).
The revenue cycle is very complex which needs to be maintained and managed continuously for a practice to receive consistent and optimal revenue streams. Some billing companies have a low fee but they do not manage the revenue cycle (many only upload claims to the clearing house/insurance companies without follow-up on denied or underpaid claims). There is a major difference from uploading claims to managing the revenue cycle. This is why performance to benchmarks (e.g. collection rate to the contract amount) is so important.
What do you need to do as a practice owner related to 5010? If you use a revenue cycle management service by a professional team, very minimal. If your practice manages all the internal processes then there is a check list of 10+ items that need to be completed. These include: reviewing the processes of the practice, verifying that each component in the revenue cycle is 5010 ready (clearing houses/insurance companies/billing software) and validated, identify if the practice will incur extra cost in software, transaction fees and training from the practice management software, identify if time to switch systems for the practice and/or start on an E.H.R. system.
