EMR Adoption, Selection and Implementation Checklist, medical records

Insurers and Doctors Decline Marketplace Policies

by Nitin Chhoda PT, DPT | Jan 7, 2014 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

One of the major selling points for the Affordable Health Care Act was the ability for patients to keep the doctors they liked and the coverage they had. Individuals without insurance can now sign up for an insurance policy at the Healthcare Insurance Marketplace, but there’s no guarantee a particular doctor will be a participant in their patient’s plan.

Some insurance companies have changed or altered the criteria used for participating clinicians, a factor that’s led to the exclusion of many providers and facilities.

Many insurers have chosen not to participate in the Marketplace at all.

For patients, keeping the doctor with which they’ve built a relationship could mean purchasing a Marketplace policy they don’t want or losing their physician.

Controlling Costs and Profits

Insurers create their own networks of clinicians, specialists, hospitals and pharmacies with which they work to control costs.

If an individual’s current practitioner isn’t among the list of providers in the plan they purchase through the Marketplace, that patient will be forced to find a new primary care physician.

Medical professionals and facilities deemed as too expensive aren’t being included in the Marketplace plans by insurance companies. Much depends on the individual plan.

In California, Cedars-Sinai is one of the providers that aren’t covered in the state’s Marketplace policies.

Some of the insurance industry’s biggest players who offered Marketplace policies have since chosen not to participate in the Marketplace, even in states in which they already offer coverage.

That decision leaves patients with fewer plans and physicians from which to choose, and will critically impact those in rural areas.

Aetna, BlueCross, Cigna, Humana and United Health are just some of the providers that have announced they wouldn’t be participating in exchanges when a state’s regulators told them their rates were too high.

Insurers indicated the premiums they collected through the Marketplace would be insufficient to cover the cost of the services Obamacare requires them to provide.

Practitioner Protests

In many states, clinicians have begun turning away Medicare patients due to severe cuts in reimbursements and the practice is extending to patients with Marketplace policies.

In a study by the Medical Group Management Association, only 29 percent of the 47,500 respondents indicated they will accept Marketplace plans, citing new administrative and regulatory rules as the reason.

Eighty-five percent cited low reimbursement rates for Medicare and Marketplace plans as a reason for non-participation.

The number of insurance companies refusing to participate in the Marketplace and those limiting the providers in their network has the potential to reduce access to services ranging from primary care physicians and hospitals to labs, pharmacies and hospice care.

When purchasing a Marketplace policy, patients should make every effort to discover if their preferred practitioner is a participant in the plan. Unfortunately, provider directories are in short supply and locating the needed information can be a nightmare of website navigation.

Insurance Claim: How to Handle and Appeal

by Nitin Chhoda PT, DPT | Dec 30, 2013 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

When a reimbursement denial is received, medical insurance billers (MIBs) may need to initiate an appeal process to collect disputed funds for practitioners. In this informative article, Nitin Chhoda reveals the most common reasons for denials and the best strategies for handling claim disputes.

Each insurance claim goes through an adjudication process at a clearinghouse to check the data for errors before forwarding it to the appropriate insurance carrier.

An insurance claim examiner conducts another exploration of the claim and renders a decision. The examiner can choose to pay the billed expenses, reimburse at a reduced rate, or deny the insurance claim.

Insurance carriers usually deny payment for one of six typical reasons. Some of the factors are the following:

Carrier’s procedures
Medical necessity
Inactive policies
Out-of-network
Level of care
Pre-existing conditions
Pre-authorization

Unknown Carrier’s Procedures

MIBs should be aware of each payer’s procedures and policies for handling claims. Each insurance company has its own hierarchy and protocols for reviewing an insurance claim.

MIBs should also check the contract between the clinician and the insurance company to determine that all conditions have been met.

Medical Documentation is Necessary

When an insurance claim is denied on this basis, it’s up to the MIB to provide documentation, physical therapy documentation for example, that the appropriate diagnosis and procedural codes were employed. Sometimes a coding change and resubmitting the claim will result in a satisfactory resolution.

If the codes are accurate, a letter must be provided that clearly states why the treatment was necessary, along with any extenuating circumstances.

Patient’s Insurance Policy is Now Inactive

It’s essential that the MIB has proof that the patient has an active insurance policy at the time treatment was provided.

This can be accomplished through a copy of the individual’s medical card, a letter from their employer, or a statement from the insurer.

Out-of-Companies-Network of Physicians

Some carriers require patients to only see practitioners within the company’s network of physicians, but situations arise when an in-network clinician isn’t available.

A simple letter explaining, in detail, why the patient didn’t have access to the carrier’s network of clinicians can easily turn an insurance claim denial into a payment.

Having Too Much Level of Care

Insurance claim examiners may determine the level of treatment that was billed exceeded the usual care for a particular ailment. The culprit in insurance claim denial is usually a lack of documentation that fully explains why additional treatment or procedures were required.

Providing supporting documentation usually takes care of the problem.

The Most Common – Having Pre-Existing Conditions

Most insurance policies won’t cover treatment for conditions and diseases that patients were afflicted with prior to when their policy became active.

If treatment can be linked to any prior health problem, the need for an appeal is negated.

If it wasn’t related to a previous health issue, MIBs should provide a written explanation, accompanied in the insurance claim, as to why the ailment wasn’t related to a pre-existing condition.

Unable to Meet Pre-Authorization

A wide variety of treatments require pre-authorization for insurance claim reimbursements. MIBs can reverse a denial if they provide proof the treatment would have been approved, as in the case of an emergency.

A convincing argument can result in full payment and waiving of penalties for not obtaining the pre-authorization.

An insurance claim denial doesn’t always result in an appeal.

Providing documentation and a convincing argument as to why the denial was in error is essential when disputing reimbursement rejections. Clear and concise communications are critical elements of strategies to obtain payment for denied claims.

Does Obamacare Promote “Independence at Home” Over Physical Therapy?

by Nitin Chhoda PT, DPT | Dec 28, 2013 | Electronic Medical Records, Physical Therapy Documentation, Physical Therapy Software

Many physical therapists are concerned that Obamacare promotes its Independence at Home initiative over physical therapy and the answer at this point is yes.

The Independence at Home program uses technology at home (known as e-care) or community centers to identify problems and provide services to save money.

It’s difficult enough to persuade patients they need to visit their clinician’s office, especially the elderly and those with disabilities.

Obamacare’s program could make patients even more reluctant to leave their homes.

When patients can receive services at the local community center, they aren’t going to travel the extra distance to obtain the same treatments at their therapist.

Taking Healthcare To The Patients

The initiative is a new opportunity for clinicians to help patients through providing in-home physical therapy. Patients are less likely to attend sessions at a nearby community center or outpatient facility if the therapist is able to come to them.

The disabled, veterans and seniors will benefit most from in-home services and it provides the means for therapists to use Obamacare to their financial advantage.

Utilizing ACOs To Maximize Returns

One way clinicians can benefit is through becoming part of an accountable care organization (ACO). An ACO is a team of healthcare providers from different specialties that work together to manage patient care.

Obamacare rewards team members financially for good home care management that keeps patients out of hospitals and nursing homes, gets them better quickly, and saves money.

The Return of House Calls with Portable Technology

Many elderly patients have lamented the loss of an era when physicians and nurses made house calls, eliminating the need for them to leave their home.

Obamacare marks a return of those services through the Independence at Home program and with the assistance of the In Touch EMR, therapists can take their services on the road.

The software offers the ability to document patient encounters and treatment with tablet technology anywhere an Internet connection is available.

In Touch Biller PRO can be integrated with EMR technology to create and send reimbursement claims on the go. Both software systems provide practitioners with a new delivery method to increase revenues.

E-Care To Save Money

At-home monitoring is encouraged and it’s the direction in which healthcare is going under Obamacare.

Clinicians can monitor a number of chronic conditions and symptoms, ranging from blood pressure and heart rates to glucose levels.

Some monitoring devices use the Internet and EMR technology to automatically send data to the practitioner.

Other methods require an actual person to document information collected by a machine.

The Independence at Home initiative in Obamacare promotes therapy in the home or at community centers as a means of reducing overall healthcare expenses.

Therapists will be hit especially hard unless they find ways to utilize Obamacare for themselves. In-home services and ACOs offer clinicians with diversification options, but only if they’re willing to change and expand the way they treat patients.

The Backbone of Obamacare — Health Insurance Exchange 101

by Nitin Chhoda PT, DPT | Dec 26, 2013 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Open enrollment at the Healthcare Insurance Marketplace began Oct. 1, 2013 and continues through March 31, 2014. It’s estimated that the majority of Americans will have signed up and be covered by an insurance plan by that time. Those who don’t will be subject to penalties and fines on their income tax returns.

The Marketplace is the backbone of Obamacare and will determine how healthcare insurance will be delivered.

The Marketplace provides consumers with a central location to purchase the healthcare that best fits their individual needs.

Prices vary and are dependent upon the applicant’s annual income and geographic location.

Purchasing A Plan

There are four types of coverage that consumers should be aware of and with which clinicians should be familiar if they’re to talk with patients about their plans.

The Marketplace offers a Bronze, Silver, Gold, Platinum and Catastrophic policy, each with its own set of parameters.

Bronze and Silver plans can cost up to 9.5 percent of an individual’s income.

Gold and Platinum policies can be 12.5 percent of the applicant’s yearly income.

Samples prices and coverage can be viewed on the Marketplace website, but the only way to ascertain actual costs is to apply.

Catastrophic plans are available for those under the age of 30. Individuals over 30 who have received an exemption are also eligible for the coverage.

These types of plans typically cost less but have very high deductibles. In 2014, the maximum out-of-pocket for any Marketplace plan is $6,350 for individuals and $12,700 for families.

Many consumers will be eligible for federal subsidies to help them pay for insurance on the Marketplace, but consumers need to examine a plan’s monthly premium, co-pays and deductibles carefully before committing to an insurance policy.

Costs are expected to change and many predict they will go higher. Clinicians need to understand what’s offered if they’re to advise patients on costs and options that will best fit individual health needs.

Facing Fines

People who don’t qualify for Medicare, Medicaid or an employer plan must enroll in healthcare coverage at the Marketplace.

Those who haven’t enrolled or received an exemption will be fined on their income tax return through Obamacare’s Individual Mandate Tax.

In 2014, the fine for no insurance will be $95 per adult and $47.50 for children, or 1 percent of taxable income.

Those amounts increase to $325 per adult and $162.50 on children, or 2 percent of income in 2015.

The penalty for non-compliance in 2016 jumps to $695 for adults and $332.50 for children, or 2.5 of taxable income.

After 2016, fines will be adjusted upward for cost of living increases.

To remain current on Obamacare and be able to advise patients, clinicians will need the In Touch EMR and In Touch Biller PRO.

The integrated systems can be used to educate patients about their healthcare insurance and the core preventative services provided, while facilitating quick turnarounds on reimbursements.

The Marketplace is the backbone of Obamacare, changing how healthcare insurance in the U.S. is purchased, determining how care is delivered, and redefining the role of clinicians.

How Obamacare Attempts to Tackle Overutilization

by Nitin Chhoda PT, DPT | Dec 22, 2013 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

The skyrocketing cost of healthcare was one of the motivating forces behind the passage of the Affordable Health Care Act. Known as Obamacare, one of the legislation’s goals is to reduce costs and it attempts to do that with a multi-faceted approach that seeks to reduce overutilization of healthcare services.

Too Much Care

Supporters of Obamacare claim that healthcare costs have soared due to demanding patients requesting unnecessary tests and clinicians that are prolonging patient treatments.

Obamacare assumes that patients are overindulging in expensive treatments, tests and medications, and attempts to address that through limiting the use of services deemed as too costly.

Luxury Services And Care

Dr. Ezekiel Emanuel was a primary advisor and architect of Obamacare. He called for scaling back on what he viewed as luxury services, conveniences and self-indulgent excess to curb costs.

He included comfortable waiting rooms, convenient parking and access, and the privacy of examination rooms as needless amenities that would reduce costs.

To curb costs, elderly patients will receive many services at home instead of being admitted to hospitals or making multiple visits to their physician.

Technology will be used to monitor, track and transmit patient data to healthcare providers.

The Obamacare model relies more on lower paid support staff and less on clinicians.

Less Is More

Obamacare addresses cost reduction through paying less to providers and bundling services that were previously billed separately.

It rewards clinicians who get patients better faster and prevent hospitalizations.

Obamacare rewards physicians who increase efficiency and productivity within their practice to accelerate the number of patients treated.

The legislation calls for patients to be responsible for a greater financial amount of their care through increased co-pays, deductibles and premiums; restricting tests to only those that are absolutely essential and utilizing low-cost tests whenever possible; and bringing prescription costs more in line with those of other countries.

Prevention And Patient Accountability

Consumers are tasked with improving their health and working to prevent disease and healthcare problems before they arise.

Obamacare encourages employers and insurance companies to promote improved health with incentive programs that reward individuals who meet specified guidelines.

In the Obamacare economy, clinicians will need to focus on outcomes and be able to prove it with tools like those in the In Touch EMR and In Touch Biller PRO.

The software improves efficiency, productivity and reimbursements.

The current trend in healthcare is toward prevention, getting patients better quicker, and doing it with the least amount of testing and medication, all of which will be instrumental in changing the way healthcare is delivered.

The Problems Obamacare is Trying to Solve

by Nitin Chhoda PT, DPT | Dec 14, 2013 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Obamacare was designed to solve four problems within the healthcare arena. The legislation sought to increase access, benefits and efficiency, while reducing costs. It’s a law that will affect virtually every American and will certainly affect each healthcare provider.

Obamacare sought to extend benefits to an estimated 45 million patients with no healthcare plan, but an estimated 26 million still won’t have coverage under the new law.

The poorest segment of the population is the most likely not to have insurance.

To remedy the problem, Obamacare expanded the overall Medicaid program, but many states chose not to participate, further limiting access to those who need it most.

Other Medicaid patients found themselves without coverage when Obamacare changed income eligibility guidelines.

For practitioners to compete effectively in an era of Obamacare, clinicians will need to review the type of insurance they accept, and the way they treat patients.

EMR technology and billing systems must be employed to increase efficiency and secure timely reimbursements.

Gaining Access

Obamacare provided access to healthcare to more people by prohibiting insurance companies from denying coverage to those with pre-existing conditions and allowing children to remain on their parent’s policies until they’re 26.

Medicaid eligibility was expanded and federal subsidies provided to help patients purchase insurance.

The downside to providing increased access is more patients flooding into an already overcrowded system.

Multiple surveys of clinicians indicate a full 40 percent will sell their practices because they won’t be able to survive financially.

Reducing Costs

Obamacare wants to reduce the overall cost of healthcare with a goal of saving more than 700 billion between now and 2022. To do that, Obamacare reduces Medicare reimbursements, establishes accountable healthcare organizations (ACOs) and reduces hospital stays.

It’s also leaning more toward home healthcare solutions.

There will be serious repercussions for private practices.

To survive, clinicians must be more efficient through the use of EMR technology, hiring better people and getting more referrals. Billing systems are essential for the little guy to get paid quickly and accurately.

Increasing Benefits And Services

Obamacare gives patients a large range of free screenings, tests and services for free and closes the donut hole for seniors on Medicare.

It limits the amount people can put in their flexible spending account (FSA) and focuses on prevention rather than treating.

Patients will now know how much their healthcare actually costs and makes them responsible for a greater out-of-pocket amount. Consumers are already seeing the difference through higher co-pays and deductibles.

Obamacare assumes that if individuals are aware of and responsible for more of the financial burden, it will end the over utilization of services. Essentially, patients will have to accept responsibility and penalties for taking control of their health and using preventative services.

Increasing Efficiency

The overall delivery of healthcare must change to be more efficient.

It can be done by using an EMR to streamline patient encounters and by using billing systems that get clinicians paid faster.

Practitioners will have to change the way they accept insurance, treat patients, document and bill. They’ll also face greater marketing challenges.

The use of ACOs marks a departure from traditional care models. ACOs are teams of healthcare providers that work together as a group to provide and manage patient care.

If ACOs become the standard for healthcare delivery, clinicians will have to be in one to survive.

No one knows if Obamacare will produce a nation of healthier patients, but it’s the law of the land. Practitioners have to accept that and look for ways to work within the Obamacare system. It’s far better for patients’ lifestyle, and less expensive to focus on prevention rather than spending money, time and effort on a cure.