Competitive pricing is an essential part of nearly every industry across the nation. So why has healthcare managed to escape? Why is the cost of care rarely revealed or understood until it is time to pay the bill? Although healthcare is much more complex than going on vacation or getting an oil change, the truth remains that unexpected healthcare costs have been plaguing patients nationwide for decades. While a solution may be unclear at this point, it seems as though the issue may have finally been addressed.

In Jan. 1, 2019, the Trump Administration required all hospitals to post prices for their services. While many believe this was a step in the right direction, this has been easier said than done. The result has been confusion over deciphering the complex pricing information, it is not consumer friendly, and most believe it falls short of what is truly needed.

The Centers of Medicare and Medicaid Services have recently voiced their commitment to price transparency and released a new Medicare.gov tool that enables consumers to compare Medicare payments and co-payments for certain procedures in hospital outpatient departments and ambulatory surgical centers.  According to CMS, this initiative is just the beginning of their efforts to increase price transparency throughout the healthcare system.

Additionally, the issue of “surprise billing” and lack of price transparency continues to gain scrutiny from the White House and Congress. In fact, large hospital groups such as American Hospital Association, The Federation of American Hospitals, Catholic Health Association, and others have indicated they want to take part in addressing the problem.

Recently, the group sent a letter to Congressional leaders, calling for principles they would like lawmakers to consider as they work to address the issues of surprise billing. The following were some of their requests:

• Define “surprise bills”
• Protect the patient financially.
• Ensure patients access to emergency care.
• Preserve the role of private negotiation.
• Remove the patient from health plan/provider negotiations.
• Educate patients about their health care coverage.
• Ensure patients have access to comprehensive provider networks and accurate network information.
• Support state laws that work.

As the debate continues, and the answers remain unclear, the need for cost transparency in our healthcare system is more apparent now than ever before. The lack of accurate and timely healthcare price information prevents patients from having a clear understanding of fees until after a procedure, pharmacy visit, or physician appointment.

Cost transparency remains a key factor in the efficiency of our healthcare system, and why it is so different than any other industry in our nation. Once patients are in the driver’s seat with accurate quality and price information, they can see the complete picture and will be more empowered to take an active role in their healthcare while finding the best possible value, quality, and cost.

References:

1. KFF

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The transition to ICD-10 has come and gone and the final metrics were posted by CMS last month. Thus far, the shift has been seemingly smoother than most had expected. Making many wonder what all the hype was about, while others remain skeptical.

Healthcare experts are optimistically cautious about what is to come, saying it is too early to tell the impact ICD-10 will have on reimbursement. The outpouring of denials everyone anticipated was not the case for 2015, primarily due to the 12 month grace period granted by CMS. Claims are currently not being denied solely on the specificity of the ICD-10 codes provided, as long as the physician submits an ICD-10 code from the appropriate family of codes. However, some warn that while this concession makes sense, not to breathe a high of relief just yet. Providers may slowly start seeing more denials in the near future, as 2016 brings on a new set of reimbursement challenges.

So what can practices do in 2016? Stay updated on ICD-10, utilize the training and education received prior to the transition, code correctly, monitor progress, get services authorized and stay on top of denials.

ICD-10 Online Training

Due to the complexities and additional documentation requirements of ICD-10, MedSafe has created online training modules for most of the medical specialties. These modules provide an overview of the IDC-10 requirements and best practices. Each module also reviews the top ten to fifteen codes for that specialty and how the ICD-9 code converts to the ICD-10 code(s).

Specialties include: Cardiology, Emergency Medicine, Endocrinology, Family Medicine, General Surgery, GI, Internal Medicine, Neurology, Neuromuscular, OB/GYN, Pathology, Pediatrics, Pulmonary, Urology, ENT, Rheumatology, Hospitalists, Allergy, Behavioral Health, and Psychology.

For more information or a free trial contact us at Toll-free: (888) MED-SAFE or visit our website at www.medsafe.com

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In this coding tip, we will review a few modifiers that specify which portion of the surgical package the provider is billing for.  The global surgical package includes payment for services that are a necessary part of a procedure.  For example, the global package includes not just payment for the surgical procedure itself, but also preoperative visits after the decision is made to operate, postoperative visits related to recovery, postsurgical pain management, supplies, and other miscellaneous services such as dressing changes, removal of sutures or casts, etc.

There are many occasions when more than one physician provides services that are included in the global surgical package.  For example, sometimes the physician who performs the surgical procedure does not furnish the follow-up care.  Let’s say a child from Florida is vacationing in Massachusetts and fractures their leg while sledding.  Payment for the postoperative care is split between two or more physicians of different groups, since there is a transfer of care when they return home.  When that happens, the following modifiers are used:

·         Modifier 54 – Surgical Care Only.  This modifier is used when the provider only performed the surgical procedure, but none of the preoperative or postoperative work associated with it.

·         Modifier 55 – Postoperative Management Only.  Use this modifier when the provider furnished postoperative services, but another provider performed the surgical procedure.

Both providers would bill the CPT code associated with the surgical procedure, and both would bill for the date of service of the procedure – the difference would be the use of the modifiers above to indicate which portion of the surgical package they furnished.  Be sure to also document the date of the transfer of care- that should be transmitted on the claim as well.

One exception to this would be for physicians who provide follow-up services for minor procedures performed in emergency department – they would actually bill an Evaluation and Management service (for example a 99203 new patient office visit.)  In that case, the physician who performs the emergency room service would bill for the surgical procedure without a modifier.

For more information about the global surgical package and use of modifiers 54 and 55, check out the Medicare Claims Processing Manual Chapter 12 Section 40.2.A.3 or this Modifier 54 Fact Sheet.

The post Coding Tip – Surgical Package Modifiers appeared first on MedSafe.

According to an article posted by PHIPrivacy.net, it appears the billing company, Goldthwaite Associates of Marblehead, MA, dumped an unknown number of patient records originating from Pioneer Valley Pathology Associates, P.C. in the trash section of a Georgetown transfer station. Goldthwaite had provided billing services to the pathology group, and had recently been sold to another company when the breach occurred.

Several Boston area hospitals (Holyoke Medical Center, Carney, Milford Regional, and Milton Hospital) all used Pioneer Valley Pathology Associates for pathology services. The hospitals were notified of the breach this past August, and are performing their own investigation.  According to PHIPrivacy.net, Holyoke, Carney and Milton had posted press releases at one point on their websites, but it appears they have since been taken down. The copies available on the PHIPrivacy website state that the records contained individuals’ full names, addresses, dates of birth, Social Security numbers, insurance information (including policy numbers), patient identification numbers, as well as protected health information such as diagnoses relating to pathology testing.

The question for the hospitals is whether they can be held responsible for a breach that occurred through a business associate of the pathology group. The answer may depend on the type of arrangement the pathology group had with the hospital, and whether they had established an “Organized Health Care Arrangement.” (For details, see my blog of 9/14/11, “Do Hospital-Based Physician Groups Need an OHCA to Comply with HIPAA?”)

Typically, hospital-based physician groups will contract with hospitals to perform services, but if they use standard transactions for billing, they are considered covered entities. They generally use billing companies–their business associates (BAs)–to perform the actual billing. Under the HITECH Act, covered entities must have business associate agreements in place with their BAs, and BAs are now subject to many of the regulations of HIPAA, including having their own HIPAA privacy and security policies and procedures. Covered entities and BAs share the responsibility of keeping personal health information (PHI) secured.

The Massachusetts Attorney General’s office is investigating this matter, and it remains to be seen who actually dumped the records, and whether charges will be brought against the prior or current owners of the billing company, the pathology group, or possibly the hospital.

Make sure your patients’ PHI is protected from unauthorized use or access. Does your organization utilize billing companies, do you have business associate agreements in place, and are you satisfied that they have, and are following, their own HIPAA policies and procedures?

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