(1^st of a 3 part series on Vision, Mission and Core Values)             

Most doctors’ eyes will likely glaze over when forced into a committee meeting to discuss the vision, mission and core values of an organization.  Physicians intuitively know their own individual vision and mission when they don their scrubs and show up for work.  They do whatever needs to be done within the scope of their skills and training at the appropriate time.  Group practices or hospitals on the other hand need a concerted effort to develop a consensus toward a shared vision of the goals, mission and standards of the entity as a whole.          

Organizations, such as hospitals, group practices, a contract medical groups or partnerships, are made up of individuals, each bringing a different set of thoughts about what the organization should be about.  When an organization is formed, it takes on an identity of its own in a synergistic manner forming an image that is more than the sum of its parts.  Groups are known by this collective image. When names, such as Lexus, Ritz-Carlton or Nordstrom’s are mentioned, the image of quality and service is associated with those companies.  This is not by accident, but by design.          

As Tom Peters pointed out a few years ago in his “In Search of Excellence” series, the most successful companies in America had at that time one common theme; all employees had a shared vision about their own companies’ business.  The success of each company depended upon not the individual’s personal vision, but of a common, collective vision of its products and services.  Then, each person’s behavior becomes congruent with the vision, mission and core values of the company on a corporate basis.

As we approach the end of another year and the beginning of another, I have been reflecting on how these principles apply to our vision as a company.  The most recent business plan of MedaPhase states that its mission is to:

“Use industry knowledge to become an outstanding company providing innovative, quality-driven services and solutions to meet the ever-changing needs of providers in the healthcare industry.  To develop an organization whose business lines provide the best resources available for the needs of its clients and attract highly skilled, visionary people to the organization.”

My goal for the coming year will be to make sure that everyone in our organization is both aware of this vision and to encourage all of our staff to align day-to-day activities accordingly.  Leadership is the key to success in this endeavor to enhance this kind of thinking.  I encourage our clients and staff alike to help contribute to these efforts by identifying specifics areas for excellence and to work together to achieve them.  In this way, we can collaborate and align our efforts toward the mutual accomplishment of worthwhile, predetermined goals.     

CERT Changes 

What is CERT?

The Comprehensive Error Rate Testing Program (CERT) is the Centers for Medicare and Medicaid (CMS) contract process to monitor the accuracy of claims filed and payments made by the Medicare contractors. The method by which this is done involves a CERT review contractor(PSC) requesting and reviewing medical record documentation.

What are the changes?

The CERT program has recently changed their time frames for responses to notification. Prior to 11-06, providers had 90 days to return requested information. The time frame is now 60 days for an OIG letter to be generated and 75 days for the claim to be scored an error.

Why is important to respond in time?

If the information requested is not received in time, the carrier will automatically recoup from the provider the money paid for the claims.  

Where are these notices sent?

The original notice is supposed to be sent to the “pay to” address that was on the provider’s original Medicare application. If they do not get a response, they will send a notice to the provider’s practice address, which for hospital based providers is the hospital. Unfortunately, the hospital mail departments are not always good about getting mail to the physicians. It is important for providers to check any mail slots, files, etc. on a regular basis. 

If you receive a CERT letter at your home or at the hospital, it is important that you get a copy to your billing agent immediately so that an appropriate and timely response can be made. 

What is the process MedaPhase has put in place to handle these requests?

In addition to providing all of the medical record information requested for a CERT audit, Medaphase has all records audited by a coding supervisor. The audit record is included along with an analysis of cogent record contents in regard to the codes that were assigned. If it is required, the MedaPhase Medical Director includes additional clinical information that can help clarify physician documentation that may not be easily understood by an auditor.  

Medicare Provider Enrollment – Issues potentially impact all providers - This could mean YOU!  

What are the issues?

• NPI implementation – In preparation for the National Provider Identifier, Medicare contractors such as Trailblazer have been overwhelmed with testing for claims submission using NPI and matching and entering provider information into the PECOS database. All providers must have their NPI and use it for submitting claims by May 23, 2007.
• New Provider Enrollment – Due to problems with entering information into the PECOS system, staffing issues, etc., Medicare contractors are having significant delays in assigning Medicare Provider numbers. Time lags are typically over 100 days and often longer. Then, due to computer and staffing issues, even after numbers have been assigned it often takes 30+ days to get the numbers to the providers. This is especially problematic in Texas where electronic submission capabilities (EDI) and Medicaid applications both require Medicare number documentation prior to submission. 
• Revalidation - Previously enrolled providers will soon begin to receive notices confirming their current status at a hospital or with a group and requiring them to “re-enroll” in the Medicare program. These notices are very important as a non-response could cause Medicare to terminate the provider number and payment for services. Medicare will not pay for any services rendered during the interim while the new application is being processed (see time frames above for processing applications) It is CMS’s intention to have all physicians enrolled in the PECOS system some time in the future. 

Who is affected?

While this issue primarily affects physicians new to a practice or hospital, the NPI issue impacts all providers, and requests for revalidation and/or re-enrollment could impact any provider.  

What should you do?

Please watch for any notices from Medicare, Trailblazer, or any other Medicare carriers and make sure they are forwarded to MedaPhase immediately for processing. It is imperative that physicians monitor their mail slots or files at the facilities so that important messages are conveyed in a timely manner.

Physician Documentation Tips

• Be specific:  coders cannot assume a diagnosis from laboratory findings
• Specify acute /chronic or “acute exacerbation”
• Specify adverse effects of a drug or treatment
• Specify the nature of the effect and treatment
• Specify complication cause ex:  postoperative, mechanical failure, drug induced
• Use qualifiers for secondary diagnosis:  “due to”, “secondary to”, “with”
• Specify if heart or renal disease is “due to hypertension”
• Document legibly

Diagnosis Tips

• Asthma:  Was it status asthmaticus?
• Burns:  What degree?  Document the percentage of body surface burned as well as each body site
• Diabetes:  “Controlled” or “Uncontrolled”?  What type?

If a patient presents to the ED with an acute problem, always document the final diagnosis  as “acute”.  This would include diagnosis of chronic conditions such as bronchitis, sinusitis, low back pain, angina, sickle cell disease, angina, schizophrenia, etc.

If a patient presents to the ED with worsening of chronic condition, document the diagnosis as “exacerbation”.   For example, the COPD patient with severe shortness of breath, would be documented as an “acute exacerbation of COPD”

What percentage of patient mail sent out is returned to your office or billing company due to a bad address?  Who is tracking and responding to this increasing and potentially adverse issue that can affect sustained cash flows?  With the continuously increasing self pay volumes along with rising insurance based deductibles, copays and expansion of health savings / reimbursement accounts, there are more patients falling into practice billing cycles.  To this extent, there is typically a direct proportional increase in non-billable addresses or return mail that must be addressed.  All too often, many hospital based physician groups get their demographic information from transferred hospital registration information.  Furthermore, they transmit statements with this information detailing patient responsibility accordingly. There are a few things that physicians should ask or know what to ask about return mail percentages as a part of their comprehensive billing efforts. 

First of all, in most circumstances a returned mail percentage above five percent deserves attention in the form of an assessment or evaluation.  A returned mail percentage can be calculated by taking the average monthly number of returned mail pieces divided by the average monthly number of patient correspondence sent.  Although a goal of a less than five percent returned mail rate is desirable, this can prove to be a varied challenge depending on factors such as hospital staff/relationships, demographics, payer-mix and connectivity limitations to hospital computer infrastructures.

There are solutions available that can reduce the amount of return mail and assist in maintaining higher levels of valid billable addresses.  The first technique is ensuring a thorough process for returned that includes revalidation of hospital systems at least 30 days after the date of service.  Many times, in the case of hospital physicians, patients contact their original place of service to offer updated demographic information necessary for insurance and patient billing.  The more consistently and frequently this information is attained by the downstream physician group or billing company, then the better addresses and less returned mail that will be experienced.  This can entail a technical solution where established interfaces allow for notification of updated information, or manual transfers of the information as necessary.  Naturally, hospital relationships and staff communication play a vital role in achieving maximum results. 

It may be necessary to involve key physician personnel if it is determined that higher percentages of bad addresses derive from the initial hospital patient registration.  In this case, it is important to know your return mail percentage and evaluate the root of the problem.  The hospital may not be actively working on the problem of bad information if they are unaware of the affect on the physician group.   

Skip tracing or performing address searches on patients, is the another effective method used in locating valid addresses.  It is important for physicians to understand whether skip tracing on patients will be performed prior to writing off balances for collection agency work.  The difference can mean as much as 30%-35% of the collected payments depending on the collection agency contract.  Again, this is a good question to ask in regards to return mail processing.

In summary, physicians should know to ask the following key questions in regards to returned mail:

1. What is my group’s returned mail percent?
2. Is the return mail address being revalidated against the hospital system within 30 days?
3. Is skip tracing done prior to collection activity work?