pediatrics

Is “ObamaCare” good or bad for children and Pediatrics?

October 24, 2011 in Blog by support Team  |  1 Comments

There is much discussion related to “ObamaCare” especially with the debates heating up. Was this change in our healthcare system good or bad for your Pediatric practice? Like all changes, there are positive and negative aspects of the change.

Let’s take a look at some of the positive aspects:
*Reduce co pay cost for well checks. No co-pay provides an incentive for parents to seek the recommended Preventive appointments by a Pediatrician. Invest in the prevention of diseases or catching diseases early is great for the children of our country. Overall, Pediatricians are very focused and dedicated to preventative healthcare.
*Potential higher reimbursements for Medicaid. There is a significant gap in payments between Medicaid vs.
Medicare. The government pays for both of these programs- pediatricians need to make a living so many cap the number of Medicaid patients or do not accept Medicaid payments. With potential increase in Reimbursements in a few years, I would anticipate more Pediatricians accepting Medicaid. This could lead to less use of the ER and/or hospital by Medicaid patients. Theoretically, the healthcare system would save money since paying for outpatient visits is on average, much less cost burden than the hospital. This should also increase the revenue for Pediatric practices – alignment of incentives for patients to use the most cost effective treatment.
*Requirement for insurances to cover vaccines and preventative services. The lower the cost of
service to patients the more they will seek out preventative medicine. Preventing a condition is much
more cost effective than treating, in general.

Some of the negative aspects of the changes:
*More patients moving into some of the Health Insurance plans that do not raise their reimbursements to practices each year but increase the profitability of the insurance company significantly. The busy Pediatrician is trying to pay their bills, their staff, and make a reasonable income, are they able to monitor and appropriately manage the insurance carriers? Are the partners watching the reimbursement by carrier and identifying carriers that a contract negotiation or termination is needed? Some of the carriers are reasonable each year which others are unreasonable.
*The increase costs on businesses due to ‘children’ now being covered until they are 26 years old (many 18 year olds are working full time – should their parent’s employer receive the cost burden of their adult children?). This
increase cost to businesses may trigger lay offs to reduce cost or an employer to remove coverage. We
are considered adults at 18 years old….this means an 18 year old should be on their own plan, an employer’s plan or a plan purchased by a student at a college vs. a higher burden on an already fragile economy and over burden businesses.

As the debate heats up over the next year related to the healthcare system changes make sure to evaluate
the proposals from the perspective of what is the best approach to optimize pediatric patient management. Neither the emergency room nor a pharmacy is the right place to manage the optimal grow and maturity of the
children of our great nation. Primary care pediatrics is both cost effective and clinically effective.

Some links related to ObamaCare:
http://www.whitehouse.gov/healthreform

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The Differences between Teaching Pediatric Medical Billing and Managing the Revenue Cycle for a Pediatric Practice

October 19, 2011 in Billing and Collections by support Team  |  Comments Off on The Differences between Teaching Pediatric Medical Billing and Managing the Revenue Cycle for a Pediatric Practice

While in college and graduate school I wondered why it was rare for a professor to have experience
managing companies.  After accumulating over two decades of experience in healthcare in various roles I have the perspective to understand why this is:  teaching is a different skill set than managing.  Similar to this, there are companies and businesses that fail because they move outside their core skill set.  For example there are many software companies that have no experience in medical billing but have experience selling software.   One of these companies started as an EMR system about 10 years ago.  Although they developed their software using the most current technology at the time, they were providing a general software solution for any specialty.   This company then moved to provide their software and medical billing for 7% of revenue.  This company lasted less than 2 years with this offering.  The leaders of the company probably realized that they were not familiar and did not have the proper resources to manage the revenue cycle (I am sure their customers voiced their concerns).  The revenue cycle is filled with daily management issues and challenges.   I am sure the company leaders realized that the systems, processes and skills needed for providing both software and medical billing services is much different than providing a general software offering.
  
   The Healthcare system in the United States has many disconnects.  When a company only provides the software the disconnects become the management issue of the users (for example, if an insurance
company has a different coding logic than the standard – in this case, they need to identify the issue and then develop a process solution).  We have interviewed billers that were hired to clean up the issues of a publicly traded stock company whom claim to be the model in practice management/revenue cycle management.  I have also learned from other Pediatricians examples of poor collection and revenue cycle management from a number of companies that provide the service in the industry.   

The challenges of managing both software and medical billing services include:
-The company leaders need to provide the proper technology strategic direction.  Are the leaders still holding onto ‘yesterday’s technology’?  Are the leaders familiar and able to develop a team that moves toward the future versus holding on to the dated technology?

-The company needs to have qualified and up to date technology team members…some questions to ask are there staff with computer science and engineering degrees?  Has the company been able to link
directly with Surescripts for both formulary advice and sending/receiving prescriptions?  

-The company needs to be able to benchmark their billing performance and use continuous improvement to optimize the systems/processes as the market changes. Ask the company to provide their billing performance for their pediatric practices versus national averages provided by the Medical Group Management Association (MGMA).  If they are not familiar with MGMA benchmarks and can not provide the mean performance as well as minimal/maximum…..run away from this option!
-The company needs to be able to identify, develop and maintain billing team members whom achieve
performance for the practice.   Ask how often and the sources of training.  Our billing team participates in quarterly training provided by the American Academy of Professional Coders, the American Academy of Pediatrics and/or the Medical Group Management Association (this takes time and keeps us ‘humble’ since the rules are constantly evolving).
-The company needs to have expertise/focus in Pediatrics – we wouldn’t select a pickup truck for street racing so why do pediatric practices select an EMR system designed for geriatrics?  Because of the high cost of developing and marketing software, companies will provide a general system and leverage their sales and marketing channels to optimize the revenue for each segment.  The field of Pediatrics is too small for a company to become a large company if they focus solely in Pediatrics.  I met a few users of ‘general’ Electronic Health Record Systems this weekend at the American Academy of Pediatrics National Meeting in Boston, MA that are spending 2-3 hours a night completing their charts.
-The company needs to manage the ‘right’ type of technology to optimize medical billing and software
EMR/practice management for a practice.  Client server systems are not the optimal solution – this is why the largest player in general medical billing (AthenaHealth) uses cloud computing and start up capital is ‘chasing’ cloud solutions and not client-server solutions (strong Venture firms have the ability to forecast the future and are able to abandon the past/dated technology) .

Our company meets these challenges by leveraging the PhysicianXpress system:  a cloud-based system for Pediatric Offices to manage the Revenue Cycle, their electronic Health Records as well as their practice.  We maintain a qualified billing team that receives quarterly training in Pediatric coding, we continuously benchmark the performance of the practices we manage, as well maintain a qualified technology team.  We are committed to help Pediatric practices increase revenues while decreasing operating costs as well as administrative burden to the practice.   Practices that implement the PhysicianXpress system do not need to spend time or extra money on maintaining a server or a database/data.  When you go to sleep tonight, do you know that your practice is collecting at >99% of the contract amount?

Hidden Costs and Reliability Issues of Client-Server EHR systems

March 14, 2011 in EHR Selection by support Team  |  Comments Off on Hidden Costs and Reliability Issues of Client-Server EHR systems

While traveling to a potential customer, I met an individual that has 10 years experience as an IT consultant.  He worked at Accenture, then the Government and for the past three years works at an IT outsource company managing a department.  This IT professional reminded me, through his position and experiences, the issues that customers face when an application has multiple copies and versions.  He described the higher operating cost for the client-server systems and the difficulty at times identifying the issue due to variation of version, install, and local equipment (their team needs to travel occasionally on site to correct issues).

He expressed to me the advanages of cloud-based systems:  more consistent access for the IT support team to correct issues, continuous updates and lower operating costs.   He was familiar with the change from ICD-9 to ICD-10 and the impact on vendors of EHR/EMR and billing systems.   We discussed with client server systems, updates would need to be completed and verified with each location.   This is extra work for the vendor of client-server EMR systems as well as their clients.  Will client-server vendors use the ICD-10 changes as an opportunity to pass a cost on to their clients?  Well designed cloud-based EHR systems provides pediatric practices routine updates at a lower operating cost compared to client-server EMR systems.

The Future of Medical Billing for Pediatric Practices

March 7, 2011 in Billing and Collections by support Team  |  Comments Off on The Future of Medical Billing for Pediatric Practices

The credit card machine changed the methods that vendors collect bills due from customers.   Prior to the credit card, the customer had to have enough cash on hand, have a check or receive store credit.   Only a few generations ago, businesses needed staff and resources to collect on this store credit.  Once credit cards became available, businesses accepted credit cards for which the business would pay a percent of the charge to cover the costs associated with the credit card company collecting from the customer.   These businesses were able to eliminate or reassign the staff that managed the store credit. 

Medical billing is moving through a similar path.  Prior to the 1990s change to managed care, offices had individuals that prepared the bill and collected from the patient.  If the patient had insurance, the patient would take a receipt from the doctor’s office and submit to their insurance.   As managed care began the process of “In-network”;, offices utilized their billers to submit to managed care companies.  This process started simple (via paper) until the managed care plans invested in computers, software, and coding scrubbers.  Insurance companies learned that the skill of the ‘average’ office as well  as flaw in billing system/methods were not sophisticated enough for their systems.   The managed care plans were able to post strong profits.

Many offices still maintain medical billers.  Some invest well in training, people and Technology, others do not and/or do not know how.  Maintaining a medical biller is very difficult for smaller practices since they do not have enough revenue to justify the cost of a qualified biller as well as appropriate systems.   Even if a practice has the level of revenue to support a medical biller, many are not able to set up and
maintain a medical billing team with appropriate skill sets.   Practice Managers and practice consultants have a portion of their job dedicated to coaching, mentoring, hiring and training medical billers.  Is this
the best model?  Having a medical biller in the office has direct costs, indirect costs as well as an
additional burden to manage.  Interesting that many large Dow 30 companies outsource functions (such as payroll)…..shouldn’t physician practices?

Practices that adopt physicianxpress for EHR and medical billing achieve, to date, 99% collection rate
(contract amount) at a cost that is within the range of benchmarks for backend billing processes.   These practices can audit the claims for their practice real time and they do not need to invest in the cost of a biller, management of the biller, cost of training and retraining.   The medical billers at Doctor Office Management receive quarterly training from various sources (AAPC, AAP, MGMA).    It is much easier to be an auditor and ‘Monday morning quarterback”; than to hire, train, manage and audit a billing team on a continuous basis.  Since payers are becoming more complex to interact with, medical practices will see the benefits of moving the billing operation out of the office.

The advantages of Auto Formulary Advice in Pediatric Electronic Health Record Systems

March 1, 2011 in EHR Selection by support Team  |  Comments Off on The advantages of Auto Formulary Advice in Pediatric Electronic Health Record Systems

Let’s face it; parents are much busier today than a generation ago.  Kids have more activities at a younger age.   There are more medications today than a generation ago with varying degrees of managed care coverage.   If there are three asthma medications in the same therapeutic category, prescribing the ‘on-formulary’ medication saves time for parents.    

A Pediatric office accepts health insurance from multiple plans each with differences in formulary coverages.   A ‘typical’ drug formulary is three tiers.   Tier 1 is the generics tier, tier 2 is the preferred branded tier, and tier 3 is the non-preferred branded tier.  Each plan has a range in cost to the patient.  For example, tier 1 usually ranges $5-$10, tier 2 is $15-$35, tier 3 is $35 and up.  Since the formulary status of medications at plans changes routinely, staying up to date would be a full time job for a busy Pediatric practice.   This is where a well-built system that uses auto-formulary advice can save a practice time, lower costs to patients, and increase the adherence to a managed care plans formulary.

E-prescribing vendors and Electronic Health Record vendors have different options when they design and develop their systems.   Surescripts/Rx Hub maintain the data on products on formulary for each plan.  Many vendors link directly to the source (All Scripts, Nextgen, Physicianxpress) while others choose an indirect route via linking to another vendor (Dr. First).  Either source is dependent on the Internet to check formulary and send the prescription (another reason to choose cloud-based system).   When there is a problem with formulary advice:  a vendor with a direct connection to sure scripts needs to only diagnose their own system and communicate with sure scripts while a vendor that connects to another vendor whom connects with Surescripts has three systems that there could be a problem.

Reliability Engineering confirms that more systems in a series lead to more chances of failure/error.   Six sigma concepts also support less steps in the process.  When selecting an EHR, ask if the vendor if their system has directs links and achieved certification directly from sure scripts for formulary advice and sending scripts/refill requests.

Over the next two years there will be some significant branded drugs that lose patent protection.  This change in the market place will motivate managed care plans to further change and control formularies.   Pediatric practices that routinely use the formulary advice feature of an ‘optimal’ system should reduce their administrative burden while reducing costs for patients and payers.