Tag: Doctors Pay

BREAKING: New CMS primary care payment model would affect 20K doctors

The CMS wants to pay practices a monthly fee to manage care for as many as 25 million Medicare beneficiaries in the agency’s largest-ever plan to transform and improve how primary care is delivered and reimbursed.

The Comprehensive Primary Care Plus initiative will be implemented in up to 20 regions and include up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians.

The regions are as of yet unidentified as the CMS plans to first assess interest by providers.

Provider practices will be able to participate in two ways. In Track 1, the agency will pay a monthly fee to practices that provide specific services. That fee is in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for care.

Providers currently perform a service and then submit a claim to Medicare for payment.

In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare fee-for-service payments for evaluation and management services, they will receive reduced Medicare fee-for-service payments and up-front comprehensive primary-care payments. This hybrid payment design will allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter, the agency said.

For example, practices might offer telemedicine visits or simply provide longer office visits for patients with complex needs.

Practices in both tracks will receive upfront incentive payments that they might have to repay if they do not perform well on quality and utilization metrics.

To be eligible for the incentives under the programs, practices will need to ensure:

• Services are accessible, responsive to an individual’s preference, and practices should offer enhanced in-person hours and 24/7 telephone or electronic access.

• Patients at highest risk receive proactive, relationship-based care-management services to improve outcomes.

• Care is comprehensive and practices can meet the majority of each individual’s physical and mental healthcare needs, including prevention. Care is also coordinated across the healthcare system, including specialty care and community services, and patients receive timely follow-up after emergency room or hospital visits.

• It is patient-centered, recognizing that patients and family members are core members of the care team, and actively engages patients to design care that best meets their needs.

• Quality and utilization of services are measured, and data is analyzed to identify opportunities for improvements in care and to develop new capabilities.

The CMS will accept practice applications in the determined regions from July 15 through September 1.

Story in progress…

ICD-10 Success for Large Practices, Problematic for Small

Several weeks following the implementation of the ICD-10 code set, the progress of the transition appears to vary according to size of the practice. While many large practices are reporting success with the transition, some smaller ones are reporting difficulty.

According to a blog post by the Coalition for ICD-10, many of the group’s members — which happen to be larger healthcare providers — are reporting great success with the transition. Many, like Centegra Health System, credit this success to the ample time for preparation they received.

“Centegra Health System was prepared for a smooth ICD-10 transition after two years of careful planning. Our information technology systems have been updated and our educational plans were deployed to help with the initial roll-out,” said Centegra’s Executive Vice President, Chief Financial Officer, and Chief Information Officer David Tomlinson.

Additionally, some coalition members stated that their success on October 1st is due in large part to their early implementation of the code set.

“Northwest Community Healthcare’s transition to ICD-10 has been smooth. This is due, in part, to our early clinical rollout of ICD-10 with our Epic Go-Live date of May 1, 2015,” said President and Chief Executive Officer of Northwest Community Healthcare Stephen Scogna.

Other members of the coalition, such as insurer Blue Cross Blue Shield of Michigan, reported a few bumps in the road amidst a generally smooth transition.

““BCBSM’s ICD-10 implementation went very smoothly. Call center volumes and overall inquiries are very low. Professional and facility claims are processing as expected. A few issues noted, which we are resolving, but nothing major to report,” the insurer said.

BCBSM also reported that it was the first private insurer to reimburse the hospitals it serves.

“Received kudos from our hospitals stating that BCBSM was the first payer to pay ICD-10 claims and these claims are paying as expected. Hospitals are not reporting any major issues. Other Payers (Priority, Cigna, Aetna) are reporting the same experience in that they are not seeing any major issues.”

However, this success is in contrast to what some other smaller providers are reporting. The impact of ICD-10 on smaller providers is a little bit more weary as these providers have fewer resources to work with.

For example, Linda Girgis, MD, FAAFP, told EHRIntelligence.com that due to how small her practice is — she and her husband are the only physicians in the family practice — its workload has grown much larger. This work includes changing patient problem lists from ICD-9 codes to ICD-10.

“The doctors are doing it right now,” she says. “I’m doing it as I come across different patients, but definitely it’s adding time on to the workday.”

Smaller practices are especially affected by ICD-10 troubles because much of their revenue comes from the Centers for Medicare & Medicaid Services (CMS), and the agency has been reportedly unreachable throughout the transition.

“My biller tries to call every day. Since October 1, they have messaged that they are down due to technical difficulties so it’s impossible to get through to any person there,” Girgis said.

Not receiving CMS payment is problematic for small practices like Girgis’ because those payments may amount to almost 30 percent of hospital revenue. While a larger hospital, like those mentioned above, may be able to do without 30 percent of its revenue for a month or two, this kind of issue could be potentially detrimental for a practice like Girgis’.

“Big organizations, hospitals, and groups can go a few months without 30 percent of their reimbursement coming in. But for small practices, that can be devastating,” argues Girgis.

CMS set a timeline for rolling out ICD-10 payments, stating that those claims would be reimbursed within the first 30 days of the new code set. As that 30-day timeline draws to a close, small practices will be waiting to see if their claims are reimbursed.

ICD-10: 70,000 Ways to Classify Ailments

Doctors, hospitals and insurers are bracing for possible disruptions on Oct. 1 when the U.S. health-care system switches to a massive new set of codes for describing illnesses and injuries.

Under the new system, cardiologists will have not one but 845 codes for angioplasty. Dermatologists will need to specify which of eight kinds of acne a patient has. Gastroenterologists who don’t know what’s causing a patient’s stomachache will be asked to specify where the pain is and what other symptoms are present—gas? eructation (belching)?—since there is a separate code for each.

In all, the number of diagnostic codes doctors must use to get paid is expanding from 14,000 to 70,000 in the latest version of the International Classification of Diseases, or ICD-10. A separate set of ICD-10 procedure codes for hospitals is also expanding, from 4,000 to 72,000.

Hospitals and physician practices have spent billions of dollars on training programs, boot camps, apps, flashcards and practice drills to prepare for the conversion, which has been postponed three times since the original date in 2011.

Some coding experts warn that claims denials could double as providers and payers get used to the new, more specific codes.

Others are more sanguine. “We’re hoping it will be like Y2K,” when the switch to 2000 dates was expected to crash computers world-wide, says Robert Wergin, president of the American Academy of Family Physicians. “Everybody will worry, and the claims will go through fine.”

The real upshot won’t be apparent immediately. “Any problems that crop up will be far more evident on Oct. 15 than Oct. 1, because it takes that long to process claims,” says William Rogers, an emergency physician who is the Center for Medicare and Medicaid Service’s ombudsman for ICD-10 conversion.

ICD codes are an international system for recording diseases, injuries and other conditions set by the World Health Organization; federal agencies developed the far more elaborate version for the U.S. To get paid, doctors submit such diagnosis codes along with separate procedure codes that describe the service performed. Private and government insurers scrutinize the ICD codes to judge whether the service was medically necessary.

The new coding system is needed, many health-care experts say, because modern medicine has outgrown the old one, adopted in the U.S. in 1979. The ICD-9 doesn’t differentiate between Type 1 and Type 2 diabetes, for example, or distinguish Ebola from “other diseases spread by viruses.”

ICD-10 will help researchers better identify public-health problems, manage diseases and evaluate outcomes, proponents say. Over time, it will create a much more detailed body of data about patients’ health—conveying a wealth of information in a single seven-digit code—and pave the way for changes in reimbursement as the nation moves toward value-based payment plans.

“A clinician whose practice is filled with diabetic patients with multiple complications ought to get paid more for keeping them healthy than a clinician treating mostly cheerleaders,” says Dr. Rogers. “ICD-10 will give us the precision to do that.”

The multitude of codes for external causes of injuries have gotten most of the attention to date. Hurt in a prison swimming pool? That’s Y92.146. Crushed by a human stampede while resting or sleeping? That’s W52.04. But insurers and Medicare officials say that, in most cases, they won’t require doctors to include such external-cause information for billing, although it is useful for research purposes.

Clinicians will need to document enough detail about patients’ conditions to support the new codes, including what side of the body is affected, how severe the problem is and whether it has occurred before.

ICD-10 also offers different codes for ailments depending on myriad circumstances, such as whether respiratory diseases are due to tobacco use and whether obesity is due to consuming excess calories or some other reason. In many cases, doctors readily know such information; in other cases, it could require more discussion and longer visits.

Medicare officials say they won’t deny claims solely for lack of specificity for the first 12 months, as long as providers supply the correct general category of illness. But that doesn’t apply to hospital procedure codes, and most commercial insurers aren’t offering such a grace period.

To what extent insurers will require doctors to use the most specific codes, or use them to adjust reimbursement rates, isn’t clear. “In the first few months, the goal is simply to get the ICD-10 codes into the system and make sure providers are using them,” says Clare Krusing, a spokeswoman for the America’s Health Insurance Plans.

Cost estimates for the ICD-conversion vary widely. Dueling studies have estimated the cost from less than $10,000 to more than $225,000 for small practices. Some large hospitals systems say they have spent millions on training and other preparations.

“This affects literally every single system in a hospital, except maybe the cafeteria,” says Ed Hock, managing director of revenue cycle solutions for the Advisory Board Co., a consulting firm that has warned its hospital clients to expect their accounts-receivable days to increase by three to five, on average. “That can mean millions of dollars in cash flow.”

ICD-10 codes will affect Medicare payments for some conditions because the added specificity moves them to a different severity tier, which changes how they are reimbursed. For example, in ICD-9, there is only one code for hepatic encephalopathy, a severe brain disorder that can occur with liver failure, which is considered a major complication. ICD-10 asks whether the patient is in a coma and if not, the condition is downgraded to a regular complication and the hospital is paid, on average, $2,800 less, according to an analysis by the Advisory Board.

But ICD-10 does give providers and health plans a chance to increase payments by recording patients’ conditions in more detail. In Medicare Advantage and other plans that receive per-member, per-month fees to provide care, payments are adjusted to reflect the severity of patient illnesses, so the more secondary diagnoses providers record, the more they may be paid.

“Hospitals leave millions of dollars on the table today through incomplete documentation or coding errors,” says Mr. Hock. “There’s a revenue opportunity in doing this right.”

Some patients will be affected, too. Those getting regular tests or infusions at outpatient centers will need to bring new orders bearing ICD-10 codes starting Oct. 1, says Kevin Lenahan, chief financial officer at Atlantic Health Systems, which owns five hospitals in New Jersey.

Atlantic plans to have personnel armed with ICD-10 code books stationed at every registration desk that day. “We won’t turn patients away. We’ll either call their doctor, covert the code for them or, in the worst case, we’ll put the bills on hold until we get the right information,” says Mr. Lenahan.

Insurers will have to work with both ICD-9 and ICD-10 codes for months or years until all the claims for tests, treatments and doctor visits before Oct. 1 are cleared. “If someone had a service in August that doesn’t get billed until December, that will still have an ICD-9 code,” says Debra Cotter, director of ICD-10 implementation for Pittsburgh-based Highmark Inc. Insurers generally give patients two years to submit out-of-network claims. “If someone has stashed a bill in a shoebox, it might be a year or more before they realize they’re owed some money,” Ms. Cotter says.

How a North Carolina insurer posted what it pays providers on the Web

Until this year, it was impossible for healthcare consumers in North Carolina to find out the average out-of-pocket cost for medical and surgical procedures.

But in January, Blue Cross and Blue Shield of North Carolina unexpectedly launched an online site that allows the general public to see how much it pays particular providers for certain services. The insurer’s move was spurred in part by a state price transparency law.

BCBS of North Carolina assembled the guts of its online price transparency tool in 2012, said Dr. Brian Caveney, the insurer’s medical director. Members were able to log on, find providers and see a detailed estimate of how much they would owe out of pocket for particular services.

The online, searchable database was made available to the general public in January. It covers 1,200 nonemergency procedures, showing the average total of how much the  insurer pays particular providers for an episode of care. The figure is drawn from the insurer’s claims data and includes all costs —the discounted payment, physician fees, facility fees, drug and medical supply costs, as well as consumers’ cost-sharing.

For example, the average cost of knee replacement surgery at providers in Raleigh, N.C., ranges from $20,300 at North Carolina Specialty Hospital to $31,542 at Rex Hospital. The average payment to providers in the Charlotte area for a screening colonoscopy ranges from $791 at Queen City Gastroenterology & Hepatology to $9,555 at the practice of Dr. Bryan Blitstein at Carolinas Medical Center-University.

An unexpected group pushed BCBS of North Carolina to expand its price transparency efforts. “Physicians desperately wanted it,” Caveney said. Doctors sought more transparency because it would help them as they enter value-based contracts. Internists, for instance, could use the price information to change their referral patterns by looking for high-quality labs or physician specialists offering lower costs.

The North Carolina Blues effort comes amid a wave of transparency tools developed by entrepreneurs, health insurers and states to give patients and employers more ability to shop around. In February, the Health Care Cost Institute launched a website called Guroo, which enables consumers to search for average prices for 70 services in more than 300 cities. Prices are drawn from medical claims for 40 million Americans covered by Aetna, Assurant Health, Humana and UnitedHealthcare. Consumers can identify the low, average and high prices within each market, including all services to treat certain conditions.

But useful price information for consumers remains unavailable in many parts of the country, with some price transparency tools showing only the retail prices providers charge, not the actual amounts paid by insurers.

Ray Desrochers, chief marketing officer at HealthEdge, a software company that works with insurers on backend tasks, said that not only should health plans give their members price data, but they also need to ensure consumers actually use the information effectively.

Last year, Priority Health, the health insurance arm of Spectrum Health in Grand Rapids, Mich., launched a price transparency tool for its members. The tool shows them the average market rates for area providers for 300 procedures and how the costs will affect their out-of-pocket payments. In July, Priority Health started a rewards program to steer members to lower-cost providers and settings. They can earn a Visa gift card worth up to $200 if they select a provider offering a below-average market price. “We really want engaged members,” said Joan Budden, chief marketing officer at Priority Health.

Caveney said BCBS of North Carolina’s transparency tool helped expand the insurer’s membership base, particularly on the state’s insurance exchange. People were able to see the prices of in-network providers before they made a final enrollment decision. The insurer has more than 380,000 exchange members, accounting for three-quarters of the state’s total.

The insurer’s price data release drew criticism and questions from some high-cost providers and even from some consumer advocates, who said the pricing data weren’t adequately explained. Caveney said the criticisms led to good discussions with providers and members to “check the integrity and accuracy of our databases.”

Now, the insurer hopes to improve the transparency tool by offering additional data on utilization and outcomes patterns for particular providers because price alone doesn’t reveal whether a provider delivers value. “Maybe Hospital A is $100 cheaper for an MRI, but doctors at Hospital A order a heck of a lot more,” Caveney said. “We don’t know whether every one of those was appropriate or necessary.”

Ohio physicians to team up for group purchasing, risk contracts

Five large, independent physician groups in Ohio are collaborating to ensure their survival against the growing employment of physicians by health systems.

Members of the Ohio Independent Collaborative are looking at collaborating on group purchasing, national risk-based contracts and possibly malpractice insurance in an effort to ensure their financial sustainability. The group’s founding members include Community Health Care, Northern Ohio Medical Specialists, Pioneer Physicians Network, Premier Physicians and Unity Health Network.

The group, composed of more than 400 physicians of varying specialties serving over 450,000 patients, is hoping to take advantage of its heft as a large organization while still remaining independent. It’s an effort to stand up to big clinically integrated networks like Cleveland Clinic and Cincinnati-based Mercy Health, said Gary Pinta, president of the collaborative and a leader with the Uniontown, Ohio-based Pioneer Physicians Network.

“We felt that the winds of change are coming and this may be the thing that stops independent practice from continuing in Ohio,” Pinta said. “We believe we have individualized care (and) patient-centered philosophy, as opposed to the corporate world.”

Pinta said insurers have lobbied physician groups to collaborate so that payers have lower-cost alternatives when they go to form networks. To engage in those contracts, he noted that the physicians will also need to work together on data analytics.

The founding members of the group are based in northern Ohio, but Pinta said the group is working with contacts in Cincinnati, Columbus, Dayton and Toledo as well, and the goal is to cover the entire state. They’re starting with the bigger physician networks, and then working toward individual practices.

On Yelp, Doctors Get Reviewed Like Restaurants — And It Rankles

Dental patients really don’t like Western Dental. Not its Anaheim, Calif., clinic: “I hate this place!!!” one reviewer wrote on the rating site Yelp. Or one of its locations in Phoenix: “Learn from my terrible experience and stay far, far away.”

In fact, the chain of low-cost dental clinics, which has more Yelp reviews than any other health provider, has been repeatedly, often brutally, panned in some 3,000 online critiques — 379 include the word “horrible.” Its average rating: 1.8 out of 5 stars.

Patients on Yelp aren’t fans of the ubiquitous lab testing company Quest Diagnostics, either. The word “rude” appeared in 13 percent of its 2,500 reviews (average 2.7 stars). “It’s like the seventh level of hell,” one reviewer wrote of a Quest lab in Greenbrae, Calif.

Indeed, doctors and health professionals everywhere could learn a valuable lesson from the archives of Yelp: Your officious personality or brusque office staff can sink your reputation even if your professional skills are just fine.

“Rudest office staff ever. Also incompetent. I will settle for rude & competent or polite & incompetent. But both rude & incompetent is unacceptable,” wrote one Yelp reviewer of a New York internist.

ProPublica and Yelp recently agreed to a partnership that will allow information from ProPublica’s interactive health databases to begin appearing on Yelp’s health provider pages. In addition to reading about consumers’ experiences with hospitals, nursing homes and doctors, Yelp users will see objective data about how the providers’ practice patterns compare to their peers.

As part of the relationship, ProPublica gets an unprecedented peek inside Yelp’s trove of 1.3 million health reviews. To search and sort, we used RevEx, a tool built for us by the Department of Computer Science and Engineering at the NYU Polytechnic School of Engineering.

Though Yelp has become synonymous with restaurant and store reviews, an analysis of its health profiles shows some interesting trends. On the whole people are happy — there are far more 5-star ratings than 1 star. But when they weren’t, they let it be known. Providers with the most reviews generally had poorer ratings.

Of the top 10 most-reviewed health providers, only Elements Massage, a national chain, and LaserAway, a tattoo and laser hair removal company with locations in California and Arizona, had an average rating of at least 4 stars.

Western Dental did not return phone calls and emails seeking comment.

Dennis Moynihan, a spokesman for Madison, N.J.-based Quest Diagnostics, said the company has more than 2,200 patient service centers around the country and had 51 million customer encounters last year. He said all feedback is valued.

“While one negative customer experience is one too many, we don’t believe the numbers presented are representative of the service that a vast majority of our customers receive every day,” he said.

For years, doctors have lamented the proliferation of online rating websites, saying patients simply aren’t equipped to review their quality and expertise. Some have gone so far as to threaten — or even sue — consumers who posted negative feedback.

But such reviews have only grown in popularity as consumers increasingly challenge the notion that doctor knows best about everything. Though Yelp’s health reviews date back to 2004, more than half of them were written in the past two years. They get millions of page views every month on Yelp’s site alone.

In many ways, consumers on Yelp rate health providers in the same way they do restaurants: on how they feel they’ve been treated. Instead of calling out a doctor over botched care or a possible misdiagnosis (these certainly do happen), patients are far more likely to object to long wait times, the difficulty of securing an appointment, billing errors, a doctor’s chilly bedside manner or the unprofessionalism of the office staff.

Health providers as a whole earned an average of 4 stars.

But sort by profession and the greater dissatisfaction with doctors stands out.

Doctors earned a lower proportion of 5-star reviews than other health professionals, pushing their average review to the lowest of any large health profession, at 3.6. Acupuncturists, chiropractors and massage therapists did far better, with average ratings of 4.5 to 4.6.

Other providers, like dentists and physical therapists, are “actively seeking out customers to review them, whereas doctors have a lot of antipathy toward reviews and as a result have been trying to suppress reviews for many years,” said Eric Goldman, a professor at Santa Clara University School of Law and co-director of its High Tech Law Institute. He has written extensively about physician review websites and physician arguments against them, but did not review the Yelp data.

Doctor visits also tend to be more complex than visits to the dentist or chiropractor. A typical dental visit is for a specific service — a teeth cleaning, a cavity filled or a root canal. In general, expectations are clear, and ways to gauge success are easier than with a doctor visit.

Healthgrades, a site which focuses solely on health providers, also sees slightly lower ratings for doctors than for dentists and other health providers, though the differences are smaller than those on Yelp.

Unlike Yelp, Healthgrades, which says it has 6 million survey scores, has not allowed consumers to post comments. But Evan Marks, Healthgrades’ chief strategy officer, said the health rating systems are in their infancy. Soon, he said, patients could see different questions based on the type of doctor they see to provide far more useful feedback to those searching the site.

None of this has yet gained favor with physicians. The American Medical Association encourages patients to talk to their doctors if they have concerns, not post views anonymously. And those looking for doctors should be similarly skeptical, the group says in a statement. “Choosing a physician is more complicated than choosing a good restaurant, and patients owe it to themselves to use the best available resources when making this important decision.”

The AMA has called on all those who profile physicians to give the doctors “the right to review and certify adequacy of the information prior to the profile being distributed, including being placed on the Internet.”

In 2012, the group partnered with a company called Reputation.com to offer discounts to doctors for a service that monitors their online presence and tries to combat negative reviews.

Western Dental’s average rating of 1.8 stars on Yelp is well below the average of 4 for all dentists nationwide. About 1,250 of its 3,000 reviews used the words “wait” or “waiting” and about 15 percent of them, the word “worst.”

When patients leave angry comments, the chain’s “social media response team” often replies, inviting patients to call or email and citing a federal patient privacy law known as HIPAA for not responding in more detail. “Thank you for reaching out and providing the opportunity to improve our services. We hope to speak with you soon,” the notes say.

At least one patient gave a Yelp follow-up review of the social media response team’s performance: “I responded to the info in their response twice and got no reply at all … they are just attempting to minimize the PR damage caused by undertrained and rude, lazy staff.”

Periodically doctors, dentists and other providers threaten or even file lawsuits against people who post negative reviews on Yelp or against Yelp itself. Their track record is poor: Courts have ruled in favor of the company and various consumers.

In June, New Jersey resident Christina Lipsky complained in a 1-star review on Yelp that Brighter Dental Care had recommended $6,000 worth of work that a another dentist subsequently determined was unnecessary.

Within days, she received a letter from a lawyer who said he was retained by Brighter Dental “to pursue legal action against you and all others acting in concert with you.” The letter was signed by Scott J. Singer, an attorney whose office is in the same building as a Brighter Dental clinic. A man named Scott Singer was also listed in 2012 as the non-clinical chief executive officer of Brighter Dental. Singer did not return a call or email seeking comment.

After Lipsky took her story to local media, Singer sent her a letter saying Brighter Dental was dropping its legal pursuit. In an email to ProPublica, Lipsky said “People put a lot of trust into their health care providers, and if my review could help others make an informed decision regarding their treatment, then it was worth it.”


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