Five Meaningful Use Audit Preparation Tips

Preparing to attest for meaningful use of an EHR? Be sure to have all records in one place.

CMS announced last month it would conduct another round of payment audits for up to one out of ten physicians and other healthcare professionals attesting for meaningful use.

These “prepayment audits,” announced by the CMS Office of E-Health Standards and Services in March, come on top of post-payment meaningful use audits initiated in the summer of 2012, the American Academy of Family Physicians (AAFP) reported. 

According to CMS, between 5 percent and 10 percent of all eligible professionals attesting for meaningful use will be selected for prepayment audits and selections will be made both randomly and also based on protocols that identify suspicious or anomalous attestation data. Post-payment audits will affect another 5 percent to 10 percent of physicians and other healthcare professionals, the AAFP reported.

So how do physicians prepare for the audits? A number of experts have weighed in.

1. Put someone in charge: Practices should designate one person to regularly check that all responsible parties are complying with meaningful use attestation guidelines, suggests health IT consultant Beverley Caddigan of BevTek Solutions. Practices should also make sure their data and documentation is securely backed up. “Secure back ups are those that are saved and re-written regularly on physical or cloud servers with fail-over and redundancy built in,” said Caddigan. “Every practice should have two-way data information practices in place, and use good firewalls.”

2. Look at reports before you submit. “When you attest, just don’t do anything crazy,” wrote EMRAdvocate president Jim Tate in his weekly e-mail dispatch. Specifically, Tate advised providers not to “report different numbers of ‘unique patients’” for different meaningful-use measures. “Don’t claim you have a certified EHR unless you really have one. Don’t say you have performed a security risk analysis unless you can produce it. If you have multiple EPs in your practice it is probably not a good idea to report the exact same numbers for every provider during attestation.”

3. Be ready to respond immediately: Physicians selected for an audit will receive a letter from Figliozzi & Co., a certified public accountant firm based in Garden City, N.Y., and selected by CMS in April 2012 to conduct audits associated with the programs. Any physician who receives an audit letter should respond to the request immediately because the bonus will be held until the physician passes the audit review, a CMS spokesperson told reporters last month. Healthcare providers will have two weeks to produce necessary documentation.

4. Retain supporting documentation: All providers attesting to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program should retain all relevant supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses, states CMS. Documentation to support the attestation should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes, the agency said.

5. Prepare to Share Screen Shots, accommodate a visit: Physicians should be prepared to capture dated screenshots — copies of what appears on a computer screen — that document, for example, a test exchange of patient data with another clinician or any other software function that Figliozzi wants to verify, according to MedScape. After an initial review of the submitted documents, auditors may request additional information and even visit a physician office to see a demonstration of its EHR system, according to CMS.

Finally, practices should check out the meaningful use audit FAQs put out by CMS. These give a little more detail in terms of how practices should prepare. We’ll provide more guidance as it becomes available.

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April 18, 2013 admin No comments
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NP, PA Recruitment Trends Medical Practices Should Watch

Every medical group has a different approach and philosophy when it comes to the use of advanced practice clinicians (APCs), but we’re seeing more and more companies adopt a model that includes physician assistants and nurse practitioners as an integral part of a comprehensive care team.

To help you weigh whether to expand your clinical team to include APCs, here are some trends we’re seeing in the recruitment marketplace: 

1. Portable skill sets and expanding roles
There is pressure in the market to find APCs with the skills and experience required to deliver care within specialties beyond primary care. For instance, we’re seeing growth in new positions in support of surgical practices, including orthopedic surgery and neurosurgery. 

The skill sets for APCs are more portable across healthcare settings and specialties than those of physicians. This pays dividends when your organization is trying to quickly fill positions in diverse departments. During the initial candidate screening process, you can probe the experience and preferences of each individual and fill positions accordingly. 

2. Increasing salaries and full benefits
Over the last five years, we’ve not only seen increased hiring of APCs, we’re also seeing a big increase in salaries. The median compensation of a nurse practitioner is $96,372 and $100,452 for a physician assistant. Standard compensation packages also include full benefits and relocation assistance.

3. Higher turnover, but shorter time-to-fill positions 
The average turnover rate for APCs is almost double that of physicians, which likely reflects the competition for their skills within the community. On the other hand, time-to-fill is much shorter than physician search, reflecting the larger pool of APC candidates. As a result, you may have several qualified candidates to choose from when filling a nurse practitioner or physician assistant opening.

4. Recruiting Physicians and APCs together
In most cases, the recruitment of APCs and physicians is not centralized within the same office — but a majority of administrators we work with think that this recruitment should be coordinated. APC recruitment is sometimes managed by the human resource department and included with nurse and allied health staffing, while other organizations take their APCs through the physician channel — including vetting, licensing, and on-site interviews.

Do you think recruiting APCs and physicians together helps build a cohesive care team? What has been your experience with APC recruitment?

Mary Scholz Barber is Senior Executive Vice President of Marketing at Cejka Search, a nationally recognized physician, healthcare executive, advanced practice and allied health search firm providing services exclusively to the health care industry for more than 30 years.

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Mitigating the Financial Impact of the ICD-10 Conversion

In August 2012, the HHS announced that the implementation of ICD-10 was going to be delayed from October 1, 2013 to October 1, 2014. Two of the greatest concerns associated with the conversion are the impact on the revenue cycle and accurately detailing the condition to meet the ICD-10 requirements.

As a starting point, physicians and hospitals alike should ask three crucial questions:

1. Is our knowledge of the pre- and post-ICD implementation costs adequate?

2. Is our awareness of the training, productivity, contractual, documentation, and revenue issues adequate?

3. Is there adequate cash-on-hand and cash reserves prior to the ICD-10 deadline to ensure liquidity post-compliance?[1]

In order to assess these areas, a good starting point is accounts receivable (A/R). Because various studies and the experience of other countries has demonstrated that there is a significant potential of a shortfall in net revenue (i.e., a 250-bed hospital could face $1 million to $2.5 million in the months following Oct. 1, 2014; and Australia and Canada found that coder productivity will increase 50,000 hours in the first month of implementation alone).[2] Hence, coding errors, payment denials, inadequate understanding of mapping to ICD-10, and the impact on contracts are all significant landmines to be aware of and navigate during the preparation process.

Let’s look at a clinical example – esophageal hemorrhage.[3] Currently, it is identified as a major complication or comorbidity (MCC). ICD-10 has no equivalent code and one mapping identified ICD-10-CM Code K22.8 (other specified disease of the esophagus). This is problematic on two fronts: 1.) the MCC, which receives a higher reimbursement rate, is lost; and 2.) it does not provide the most specific code available. The more appropriate code, K22.11 (esophageal ulcer with bleeding), would still capture the MCC, provide the more accurate condition description and maintain the higher-weighted Medicare severity-adjusted DRG (MS-DRG). Therefore, ensuring that “cat” does in fact spell “cat” and not another animal.

In light of this, physicians should look at ways to mitigate the financial impact of the ICD-10 conversion. Suggestions include:

• Training coders and increasing their vocabulary and understanding of anatomy, physiology and procedures;

• Utilize the “80-20″ Rule — assess the most frequently billed or highest dollar claims and curtail mappings, education and clinical documentation to meet these needs;

• Educate clinicians to use the more specific language and, like a contract, place it at the top of the notes, so coders can reduce the amount of time they have to spend scrolling through a medical chart;

• Evaluate contracts with IT vendors and payers to make sure everyone is on the same page and who absorbs liability in the event of an error that has a significant impact on the revenue cycle; and

• Make sure the HIPAA-required Business Associate Agreements are in place.

By focusing on these suggestions now, providers can mitigate the projected adverse impact on the revenue cycle and potentially capture previous inefficiencies in ICD-9 claim related submissions.

[1] L. Newell and J. DeSilva, “Dollars and Sense- Mitigating Budget Risk for ICD-10,” Healthcare Financial Management, pp. 78-81 (Feb. 2013).

[2] Ibid at 79 (citing ICD-10: A High Stakes Transition, presentation by The Advisory Board Company and faculty for Johns Hopkins University, American Health Information Management Association ICD-10 Summit, 2011).

[3] B. Levy, ICD-10: “5 Steps to a Comprehensive Financial Impact Analysis,” Healthcare Financial Management, pp. 122-126 (Mar. 2013).

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EHR Rules Compete With Medicine’s Grassroots Nature

Rules and regulations are important. Society could not function without them. Consider sports. The very essence of a game is that it has a set of rules. The rules define the game — different rules, different game — no rules, chaos.

In the philosophy of Aristotle, the golden mean is the desirable middle between two extremes, one of excess and the other of deficiency. There is no clearer application of the golden mean than the rules intended to regulate EHR — too little regulation, apparent chaos — too much regulation, dictatorship, and stagnation. Finding that golden mean is, and has always been, the challenge.

Some people are drawn to organizing groups, making rules, and enforcing them either for love of power or from feelings of powerlessness. Others simply want to be let alone. Since nature abhors a vacuum, the rule-makers have a natural advantage over those who want to be left alone. There is, it seems, always some problem for which the “obvious” solution is to make another rule. It takes great wisdom and restraint to know when enough is enough — when the golden mean has been achieved.

At the moment, the country is caught in the grip of a rule-making frenzy — a situation that results when a number of “sharks” (organizers) fight over the same “prey” (perceived problem). Physicians and the natural evolution of EHR have fallen victim to this rule-making frenzy.

There is a defense. For all its “industrialization” and “corporatization,” healthcare is still a grassroots activity. The individual clinician has control over what they say and do during an encounter with a patient. They likewise have control over what they document and order, and what they leave undocumented and unordered.

There are several important implications. First and foremost, the quality and ultimate utility of the information in the medical chart is only as good as the clinician chooses to make it. If you write a complete, thoughtful note it will have lasting value. If you abbreviate, skimp, cut-and-paste, or are less than complete, the information available in the future will be of low quality and it may adversely affect the patient if someone acts on it.

Second, the rules (and there are a lot of them) actually encourage thoroughness but they do not reward it. Each clinician must make a choice to do all that is required and expected, both to practice good medicine and to comply with the rules, or to do a slop-up job in order to “keep the numbers up.” If clinicians do right by each patient, their “productivity” may suffer but their quality and patient satisfaction will not. If they succumb to the stress the rules elicit in most physicians, then quality will suffer.

The defense against exuberant rule-making is to follow them to the letter and let those who made the rules, rather than the patients, experience the adverse effects. This has been called “work-to-rule” — when labor engages in an industrial action in which employees follow safety and other regulation precisely, understanding that the result may be a slowdown in production.

In the clinical context, work-to-rule can hardly be faulted. Presumably the rules were meant to be followed. It is always appropriate to take a full and complete history, do a complete examination, document everything in detail, and make sure that the patient understands their condition and the proposed treatment. If following the rules creates unintended consequences, those should impact the rule-makers, not the patients. It also means not staying in the office for two to four uncompensated hours every night to finish complying with the rules. You should finish each patient before going on to the next. If you don’t, your memory will falter, your documentation will suffer and, in the long run, so will the patient. If the regulations don’t seem to allow that, well — the rule-makers should have considered that before acting.

Quality care starts and ends right there during the encounter. Encounters that are cut short and documentation that is sloppy and incomplete because you feel time pressures will add up to poor performance of the entire healthcare system. Each clinician must decide whether to comply with the spirit, or merely the letter, of the rules. That is a grassroots decision that is each clinician’s to make.

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It’s Time for Healthcare Teams to Be Inclusive of All Providers

It seems that the past year has been a real turning point in the increased importance of the team practice of medicine. The Affordable Care Act, along with other things like quality standards in medicine tied to reimbursement, has elevated scrutiny of how to assist healthcare teams and organizations perform better. Physician assistants have been uniquely positioned and trained as high-level providers in physician-led team practice for decades.

I work in an inpatient setting, and over the past 18 months there has been an explosion of the number of providers other than physicians working at our hospital. There are higher numbers of PAs, nurse practitioners, and certified registered nurse anesthetists working at our community hospital than ever before, and more are being hired every month.

They are a critical part of the outpatient, inpatient, and surgical teams at our facility; although we could not deliver the volume of high quality care that we do at our hospital without the dedicated physicians and other providers who are credentialed to practice medicine.

As I began to work in medical staff leadership over the past three years, I quickly realized that there was a major impediment to team practice at our hospital — and that was that PAs, NPs, and CRNAs, although credentialed by the medical staff in the same manner as physicians, were not allowed membership in the medical staff. We have due process, and the ability to be assigned to committee (without a vote), but no real voice in the governance of our hospital.

That didn’t sit right with me or the other nonphysician providers, nor did it sit right with my practice partner, who currently serves as chief of surgery. We formed an exploratory group to look at the issue of our medical staff bylaws, and to come up with some suggestions as to how to better integrate and involve nonphysicians in the healthcare team.

There are a lot of good reasons to include all direct care providers in hospital governance and leadership. PAs, NPs, and CRNAs should be medical staff members to ensure:

• Rapid exchange of critical information on clinical issues

• Sharing of important information on medical staff policies

• Timely input on policies affecting their practice

• Participation in quality review programs

• Full participation on medical care and administrative committees as appropriate

• High-quality patient care by all medical providers

While I can only speak with authority about PAs, we believe in the practice of medicine on physician-led teams. This makes sense in private practice, as well as within an organization the size of our hospital. However, PAs, NPs, and CRNAs have a lot of expertise and experience that is invaluable to the collective governance of our hospital. Up until this point, all officers on medical staff are required to be physicians.

While this makes sense for chief of staff, vice chief of staff, and the medical department chairs, do the chairs of the quality, CME, and clinical practice improvement committees (all largely administrative committees) really always require physician leadership? Are we failing in our healthcare organizations to effectively use all the talents at our disposal to better govern the practice of medicine, and ultimately better serve the patients who rely on us for their care? We hope to change this also at our facility and allow PAs, NPs, and CRNAs a role in medical staff leadership.

While I’m a traditionalist in a lot of ways, I also want to find ways to better involve the healthcare team at my facility, and at every facility in the healthcare system. That requires that we don’t fall back on the way in which we have always done it, and look to develop better, more cohesive teams in medicine. Everyone benefits when we maximize the contributions of all members of the healthcare team.

I’m a realist when it comes to this sort of stuff, having been a veteran of many policy and legislative struggles over my long career. Although our team has the support of the chief of staff, as well as all the major department heads, we will see how this shakes out in the coming months.

This blog was provided in partnership with the American Academy of Physician Assistants.

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