The new year brings new health plans, often with higher deductibles, and old bills that patients may be struggling to pay. According to 2018 data compiled by MedData, 83 percent of physician practices with fewer than five practitioners reported that their top collection challenge was slow payment among high-deductible plan patients.

In this landscape, physicians may have to get creative in order to increase their revenue. Experts suggest that the more payment options physicians offer their patients, the better the chance that bills will get paid. 

Patients are growing accustomed to an Amazon-like consumer experience, where they can click on a link and pay in an instant, ideally from their mobile phones, according to Deirdre Ruttle, vice president of strategy, for InstaMed, a healthcare payments network in Philadelphia, Pa. 

“We live in an always connected world. According to research, 75 percent of adults are online daily, and one in four adults report being connected all the time,” she says. 

Technology has made paying for goods and services incredibly convenient, Ruttle says, with options such as digital wallets, e-statements, and text reminders to pay balances owed, but it’s also increasing consumer demand for a variety of payment options.

The MedData study also found that 68 percent of consumers would prefer to pay their medical bills electronically, and 92 percent want to know what their patient responsibility is in advance of service.

As a result, Ruttle says, “Physicians should give patients multiple options with payment channels and payment methods so that you can really meet patients where they already are.” 

Assess your patients’ financial health

In order to determine what options to offer, physicians should adopt some tools for assessing their patients’ fiscal health, according to Kevin Fleming, CEO of Loyale Healthcare, a healthcare technology company in Lafayette, Calif.

Fleming breaks this assessment down into a series of measures:

“When patients aren’t paying, they’re already communicating strongly to you, in very real terms, that there’s a problem.”

And rather than treating that problem as a hassle, Fleming encourages physicians to work with the patient, because this can lead to a greater likelihood of receiving payments and a better patient experience. “The patients’ financial experience should be as good as, or even better than the clinical experience.”  

To streamline the process as much as possible, David Shelton, CEO of PatientMatters, a patient collections company in Orlando, Fla., recommends that all payment solutions be standardized and consistent. He recommends scripting conversations in advance so that front desk staff can engage easily with patients, and employing some sort of analytics or measurements on payment methods to see which ones are working best.

“It can all be incorporated into one presentation and the patient will have full satisfaction with the overall experience, not just the clinical side,” Shelton says.

When determining which payment methods to offer, physicians should consider that affording healthcare costs is not just a problem for the low-income, says Mark Spinner, president and CEO of AccessOne, a patient finance company based in Charlotte, N.C. “The majority of the country has a [healthcare] affordability problem now. People with jobs, with families, with mortgages and auto loans, people who are credit worthy.”

AccessOne is among many companies that offer “co-branded, personalized financing,” much like a store brand charge account that a person might get at Home Depot or Nordstrom. 

These accounts work much like a credit card, so physicians see their revenue, and the patients can pay down their balance in the ways that work best for them. 

There are multiple kinds of accounts, too within this framework. “Some accounts are built as part of deductible plans, some are built for catastrophic balances, some are built for partial charity or partial financial assistance recipients. Those different programs help the provider deliver a positive payment alternative for every patient that walks through their doors.” Patients can even obtain plans that offer zero interest for a set rate of time and the option to pay off their balances as needed.

Many physician practices offer standard payment plans, which Fleming says are only moderately successful in obtaining revenue.

He has seen physicians be successful with a prompt-payment discount for paying within a certain time frame. “You’d be amazed at what a simple discount of 10 to 20 percent will do to the psychology of the whole transaction,” Fleming says. “The patient is getting additional cash back in their wallet.”

A more common model is to break a bill down into monthly payments over a time period, such as a year, but there is still a financial risk to the physician.  He says that sometimes physicians have to be willing to increase the length of payment time. “When the patient just can’t afford say $200 per month, they might need three-year financing on something like an emergency room visit or cancer [treatment].” 

Additionally, he says, allowing patients to set the payment parameters can lead to better results, within reason. “When patients self-construct plans, selecting an amount and the period that works for them, they’re able to keep up their end of the bargain and pay.”

Another option is to pre-pay before a large and planned medical cost, such as childbirth or a big equipment purchase like hearing aids, according to Leonard Wenyon, BSBA, vice president of IKS Health, a practice management consulting company in Newark, Del.

Then, when the baby is born, or the equipment comes in, the patient doesn’t owe anything. 

If none of those options bring in prompt payment, Wenyon says, physicians can consider outsourcing to a collection agency.

When the patient’s deductible is extremely high, or if they don’t have insurance, Wenyon recommends physicians consider offering some basic services at a flat rate. “You tell the patient ‘this is the rate we expect at time of service.’”

He took advantage of such an opportunity while on vacation in Hawaii, when his daughter became sick and the local hospital did not take his insurance, but did offer a flat rate. The advantage is that the patient knows what they’re paying up front, and once it’s paid, there’s no bill to collect on. Sometimes, he says, commercial insurance or Medicare will cover it retroactively.

No matter what payment options a physician offers, front desk staff will play a crucial role in making them work, Ruttle says. “There is a great opportunity for providers to bring those financial conversations up at the beginning of the encounter, not the end,” she says.

She says taking the taboo out of talking about money up front helps to eliminate some of the fear and confusion that is so prevalent in healthcare payments today.

This requires training front desk staff to become comfortable talking about money and getting some form of payment at the point of service. It doesn’t have to be awkward, Ruttle says, comparing it to the experience of checking into a hotel, where the consumer knows in advance that they’ll have to provide a credit card upon arrival, but will only be charged for specific things. 

Fleming says patients want to feel cared for not just from a clinical aspect but from a financial aspect, too. Having these conversations when the patient checks in, he says, allows the patient relief from the financial stress or burden, and helps them focus on their clinical care they’re seeking. 

Shelton says that just asking patients about obstacles to paying has led to his clients’ point-of-service collections increasing by as much as 20 percent. 

“Our experience is that most people truly want to pay their bill,” Shelton says. “The challenge has always been whether the healthcare provider will have the conversation with them at the very beginning, taking into account their financial challenges or opportunities.”

If physicians are worried about the costs of adding any of these payment options to their EHRs or practice management software, Ruttle points out, “The overall cost is a very small percentage of what bad debt looks like. The return on investment (ROI) is very strong.” She recommends that physicians who feel overwhelmed by choices start with an online payment portal and e-statements and phase in other options over time.

Patients use smartphones for so many purchases it only makes sense that they want to pay for their healthcare that way. Now that patients are also shouldering a greater burden of their healthcare costs, the pressure is mounting on physicians to offer mobile and online payment options. 

Probably the easiest method for most practices is to create a payment portal to the practice management system, either accessible via the web or through a patient’s mobile device, says Craig Cooper, product manager for AdvanceMD, a medical practice management and EHR company out of South Jordan, Utah.

“This gives them the opportunity to receive a text saying they have a balance due and go make that payment.”

“When we offer more convenience to a patient, the more the patient will participate,” says Paul Gordon, manager of business development for Micro Office Systems in Cleveland, Ohio.

Gordon recommends that physicians take advantage of some form of online payment service, whether an app or a patient portal. “Whatever you use-the Square app, PayPal, or a bank’s basic shopping cart function, use it. You have to have a 24-hour, 365 day availability to take a payment in this day and age.”

However, the kind of mobile app or payment portal should be thoughtfully considered, Gordon cautions. “We recommend a tight integration between your payment app and your practice management system.”

Saya Nagori, MD, an opthalmologist in private practice in Bowie, Md. and CEO of Simple Health, a telemedicine platform for vision exams and birth control evaluations, sees the lure of cash payment apps. “The pro is their ease of use. We’re on our phones all the time, and the app interfaces are easy.”

However, she also cautions against tacking them on without thought. “Offices are complicated. There’s a billing system, an EMR, a scheduling system. A payment app like VenMo or Paypal [can’t be] integrated into those systems.”

Additionally, many cash apps don’t secure patient information like a payment portal does. Simon Greenberg, MS, product manager for MedManage, a medication management and pharmacist consult app, warns that they can also cause HIPAA violations, as some of them show the address of the physician’s office where a payment was made. 

Nagori’s practice offers patients the ability to pay online by embedding links into texts and emails. While for now that’s the only online payment she offers, she hopes that mobile solutions will become more integrative in the future. “Anything I can do to make the [payment] process easier and give the patient more options, I’m all for it.”

Another low-cost way to make payments convenient for patients that is not mobile, Gordon says, is to combine a credit card swiper in-office, with a “tokenization” process-a service that allows the practice to store the person’s credit card data securely for future use. A patient could then authorize payment over the phone using the stored data.

“The more convenience you can offer the patient, the more ease, the more info, the more likely they are to pay,” Gordon says. 

Articles

Strategies to increase your collection rate in 2019

The benefit of flexible patient payment options

Russell Libby, MD, selected his EHR system because it has the features and functions that best fit the needs of his practice.

He worries, though, that the features that make this EHR work so well for him and his practice colleagues could be eliminated if his EHR vendor merges with another-as so many other vendors have done.

“Not enough doctors pay attention to what’s happening with healthcare technology. But there are some who are worried, and they’re worried because they’re aware of the ramifications,” says Libby, president of the Virginia Pediatric Group and a board member of the Physicians Foundation.

Libby’s concerns are well-placed. The number of EHR vendors has dwindled in recent years following numerous mergers and acquisitions, dropping from 1,000-plus 10 years ago to approximately 400 now, according to KLAS Research, an Orem, Utah-based health IT review firm.

Libby and others say they expect more vendor consolidation in the future, a fact that could leave physicians with a host of problems, such as reduced levels of tech support, increased fees, and the need to migrate to a new system.

Health IT experts say physicians should keep an eye on EHR industry news and take steps to safeguard themselves to ensure practice continuity should their vendor merge with another.

“There’s only so much a practice can do about vendor consolidations, but physicians can be vigilant and make sure they do all they can to protect themselves and their practice. What they don’t want as a practice is to be unprepared and not know what their options are,” says Robert Tennant, MA, director of health information technology policy at the Medical Group Management Association.

The EHR market expanded rapidly in the past 20 years, with technology advances and government incentives spurring physicians and healthcare institutions to move from paper-based to electronic records. The percentage of physicians using EHRs jumped from 18 percent in 2001 to 57 percent in 2011 to 87 percent in 2015, according to the Office of the National Coordinator for Health Information Technology (ONC).

ONC figures from 2017 show that most physicians – or 64% -- use one of seven major vendors; Epic Systems Corp. and Allscripts lead the way with about 33% of the physicians as customers. 

But tens of thousands of physicians use EHRs from other vendors, from well-known makers such as Practice Fusion and eMDs to dozens of niche companies that cater to the unique needs of medical specialists or small independent practices.

However, consolidations in recent years have shaken up the market, as various vendors bought up others to gain market share, break into specialty practice areas or bolster their financial prospects, says Aaron Gleave, director of research for the ambulatory market at KLAS Research.

Much of the acquisition activity has involved small EHR vendors being bought up, but plenty of mid-size and larger vendors were acquired as well. For example, health IT vendor eMDs bought several tech assets, including EHRs, from McKesson Business Performance Services in 2016. And in 2018 Allscripts acquired Practice Fusion for $100 million.

Joel White, executive director of Health IT Now, a nonprofit group promoting the use of information technology in healthcare, predicts more consolidation in the future. He says EHR vendors are seeing fewer customers needing new implementations, as most physicians and healthcare institutions have EHRs by this point.

As a result, vendors are looking for other ways to grow their customer base and revenue streams while positioning themselves to compete. White says vendors are looking at acquisitions as one strategy to reach those objectives.

Gleave, White and others say small EHR vendors and those servicing niche markets are most likely to be targeted for acquisition, as they typically are weaker financially than the larger players in this market. But industry experts say even major EHR vendors could be bought by even larger companies within the health IT space as well as by large companies outside it.

“Everyone is making acquisitions of some kind, whether they’re adding additional EHR players to their portfolios or acquiring companies that would be considered ancillary products as a complement,” Gleave adds, explaining that an EHR vendor may see a strategic advantage to buying a company that makes patient outreach systems or a revenue management software vendor may want to buy an EHR vendor as a way to grow marketshare.

Many physicians are nervous about these market dynamics because they fear that consolidations could negatively impact their practice.

Physicians could see changes to the monthly fees charged by their vendors and tech support levels, Gleave says. Worse, they could see their EHR system phased out, forcing them  to migrate to another product.

Libby says some physicians worry that the functions they like in their existing EHR could change and that the niche offerings within their existing EHR might disappear. “That could really impact [the practice] and create some significant long-term problems,” he says.

Gleave says mergers among EHR vendors do not always lead to problems for the physicians using those systems; he says many vendors work hard to take care of their customers before, during and after the consolidations. However, he adds, even if a transition between vendors goes smoothly for a physician, such mergers still generally result in some changes to the EHRs, service level agreements, and fees.

Although physicians can’t stop consolidations, they can take steps to limit the potential for negative impacts to their own practices.

Gleave says physicians should have a good handle on their data –where it is and how to transfer it. “Make sure your data is ready to grab and go. Know very specifically what the process is to migrate your data from your existing vendor to another-what’s the timeframe for the work, what’s the cost, and what format is the database in,” he says, noting that each vendor has its own procedure and associated costs for transferring the data.

He says EHR vendor contracts typically spell out this information, so physicians should start by reviewing their contracts (on their own or with a lawyer) and then discuss with their vendor any details that remain unclear.

White says the federal 21st Century Cures Act, passed in 2016, could provide some help. He says the law incents vendors to make it as easy as possible for physicians to export their data out of the vendors’ systems-although other health IT experts say they’re not sure this new law will do much to reduce the challenges or costs of transferring data.

Gleave says physicians should have a list of a few vendors with products that could fit their needs so they can move quickly if they must find a replacement.

Meanwhile, physicians who find themselves with a vendor being bought by or merging with another should contact their vendor immediately to ask several key questions, Tennant says. These include how the merger will proceed, the timeline for consolidation, and what support the vendor will provide during any transition from one EHR version to another.

In addition, they should ask how fees, service and support will change as well as what features, functions, templates and other user interfaces could change and when. And physicians should work with their existing and new vendor representatives to determine whether changes resulting from the merger would impact any of the new EHR’s integration with other systems.

White says mergers among EHR makers could bring many positives to physicians. “When I think about vendor consolidation, I’m thinking about products becoming more usable, more functional and more customer friendly,” he says.

He says the consolidations could yield economies of scale for vendors, giving them more capital to invest in developing innovative capabilities. He predicts vendors will want to focus more on developing additional functions and more user-friendly features to better compete in the marketplace moving ahead.

“The vendors will need to compete in delivering value,” he adds, noting that as EHR vendors have seen a drop in the number of new customers implementing EHRs for the first time they now must compete on better usability to retain and attract customers.

Libby, too, says market consolidation could yield benefits such as increased interoperability among physician office systems as there will be fewer systems with unique integration requirements. 

But Libby says consolidations could bring challenges for physicians. Physicians who have to switch to a new EHR as a result of a consolidation may face unexpected costs as well as lost productivity as they learn to navigate a new system-both of which are particularly hard blows to small practices struggling to survive financially. And physicians could lose the strong relationships that they built with their vendors, should they be acquired by bigger companies. 

Those negative impacts could hurt practices, Libby says. “Those ripples [from EHR consolidation] can become waves that overwhelm practices,” he adds.

Gleave likewise says market consolidation could hurt practices, as acquiring EHR vendors could raise fees, change service levels and eliminate features that individual physicians rely on.

“Support is a big concern, particularly for small practices. They don’t have deep pockets and they feel vulnerable in the marketspace,” he says.

Libby also says there’s the possibility that market consolidation could lead to near monopolies, which have traditionally meant lower levels of innovations and higher rates charged to customers.

“That’s a fear that many of us have,” he says.White, too, says he sees potential for consolidations to create difficulties for physicians, such as when their EHRs are discontinued following mergers. White says the government entities should oversee consolidations to ensure such scenarios are kept in check and to ensure a near monopoly doesn’t emerge in the EHR market.

“There’s no guarantee that this will all be positive; I think there’s risk of harm to the consumer with consolidation. That’s why we need oversight,” White says. “But my expectation is we’ll see a lot more innovation as a result and that’s good for doctors and, more importantly, it’s good for patients.” 

What does the shrinking market mean for physicians?

EHR market consolidation and the impact on physicians 

Lowering the cost of a medical education 

Few would disagree that the cost of medical school is high as Aaron George, DO, explains in “We must address the rising cost of medical school” (The Last Word, November 10, 2018 issue).

But, as an alternative, why not combine medical school and college into a five-year program instead of the traditional eight? After all, much of what is learned in college is of questionable value for practicing physicians, especially those in primary care.

I remember sitting in my organic chemistry class and wondering what organic chemistry had to do with being a doctor. Not to mention calculus and physics; and trying to understand the Krebs Citric Acid cycle.

While browsing in a bookstore ­recently, I pulled an MCAT prep book off the shelves and paged through it. The questions about osmosis, semipermeable membranes, osmolality and the Krebs Citric Acid Cycle were still there.

Now after 43 years of practicing primary care I wonder even more.

In 1910 the Carnegie Institute commissioned Abraham Flexner to investigate medical school education. He was appalled at the lack of full time teachers with any scientific knowledge.

His report sparked a revolution in medical education. The result was an over-emphasis on basic science and full-time professors. But, years later Flexner lamented that medical schools had gone too far in their focus on science. Which may explain the why so many students take residencies in specialties and so few in primary care.

If the costs of medical education are worrisome, the overemphasis on science is just as worrisome. It’s not a matter of education, it’s a matter of common sense.

Nurse practitioners are critical providers of patient care

Your article (“The value of nurse practitioners to medical practices”, August 8th) correctly cited the number of nurse practitioners (NPs) is on the rise. While more patients are choosing NPs as their provider, conducting over a billion visits annually, the article misses the mark on a handful of key points.

NPs have been providing primary, acute and specialty care to patients of all ages and walks of life for nearly half a century. NPs’ abilities to assess patients, order and interpret diagnostic tests, make diagnoses, and initiate and manage treatment plans, including prescribing medications, make us neither mid-level nor an extension of our physician colleagues, rather a critical provider of patient-centered care.

Second, the assertion that NPs merely exist to free up time for doctors undermines the value that NPs bring to health care cost management. Numerous studies have documented that patients seen by NPs have lower readmission rates and are more likely to adhere to plans of care-two important factors in bending the cost curve and improving the quality of life for patients.

Lastly, there was no mention of the prevailing trend of states which have modernized their scope of practice laws to allow NPs to practice to the fullest extent of their licensure and training. As evidenced in recent analysis, nine of the top 10 best states for health care (as measured by outcomes, costs, and accessibility) have enacted such laws, known as full practice authority (FPA). Interestingly, nine of the bottom 10 still limit patient access to NPs by keeping collaborative agreements and other restrictive measures in place.

While we appreciate the interest in gaining perspective on the value of NPs to medical practices, it is these facts which matter most to your audience and patients alike-especially when considering choosing an NP for primary care. 

Joyce M. Knestrick, Ph.D., C-FNP, APRN, FAANP

President, American Association of Nurse Practitioners

Editor’s note: This was first published in the December 10, 2018, issue of 

 It contained errors and this is the corrected version.

Your voice: Lowering the cost of a medical education

Navigating the reimbursement landscape can be confusing for physicians because of the number of entities that exert influence on payments. For example, CMS uses the Medicare Physician Fee Schedule (PFS) to adjust Medicare payments, and sometimes these changes can have dramatic effects on doctor pay. Coding changes reward some types of care while de-emphasizing others through how much reimbursement is allowed for each. In addition, the MIPS program is pushing Medicare into value-based care, distributing bonuses and penalties to doctors depending on how well they meet various quality measures. 

Many private payers also use quality metrics, but often, these are somewhat different from those that CMS uses and from each other’s. 

And to top it all off, all these rules can change each year. So what reimbursement trends can physicians expect in 2019? 

For physicians using the “ignore it and hope it goes away” strategy for MIPS, 2019 might provide a rude awakening as bonuses and penalties based on 2017 claims data go into effect. “The concept of MIPS will not go away, and even if it did, it would just be replaced by something similar,” says Anders Gilberg, MGA, senior vice president, government affairs, for the Medical Group Management Association. “It is one of the few bipartisan-supported concepts in healthcare today.” 

The payment adjustments for this year are relatively small-2 percent is the maximum bonus and 4 percent the maximum penalty, depending on how a physician did on the performance measures in 2017. While that might not have much effect on a practice’s financial situation this year, those adjustments are scheduled to increase to 7 percent in 2021 and 9 percent in 2022 and beyond. “Practices have the opportunity to receive a higher increase in 2021 than previous years based on what they do in 2019,” says Gilberg. “But they could also see a significant penalty.” 

CMS reported that 93 percent of MIPS-eligible clinicians earned a payment bonus for 2019, but 2017 was a “pick your pace” year to introduce physicians to the program. As performance measures change-and cost containment becomes a bigger component of the score-fewer physicians are likely to qualify for a bonus, especially those not actively monitoring their progress.

“Practices should try to get good advice on how MIPS is going to affect them,” says Mark Friedberg, MD, MPP, senior physician policy researcher for the RAND Corporation. “It is a very complicated and changing payment model.”

Private payers and physicians are always haggling over reimbursement rates, and 2019 will be no different. But as the market on both sides continues to consolidate, smaller practices may find it more difficult to negotiate for the rates they desire.

From an insurer standpoint, the overall pie to pay physicians, hospitals, and other providers is fixed, says Mark Dietrich, CPA, member of the National Society of Healthcare Business Consultants. “The largest portion of the pie goes to provider entities that have the greatest amount of negotiating leverage. Smaller practices get what’s left.” 

Larger entities can not only negotiate better fee-for-service rates, but also more lucrative quality incentives for value-based care contracts, he adds. Physicians should expect the reimbursement challenges for small practices to continue. “Government policy is really designed to loosen the regulatory restriction on providers coming together,” says Dietrich. “The whole idea is that if they get more integrated provider groups along the continuum of care, they will get better data, better clinical options, and better outcomes.”

The result is that larger practices or those affiliated with health systems can extract significantly higher rates than small, independent practices, according to Dietrich. “It’s all about who has the biggest piece of the pie,” he says. “Like on the savanna, the big lion gets the most and the hyena gets what’s left.”

Small practices can help themselves in negotiations by having strong data that proves they are improving outcomes for patients, as ultimately, this lowers a payer’s costs. Experts agree that practices can expect to see more demands for data from CMS and private payers as the march to value-based care continues.

“Carriers are doing deals that generally reward physicians in value-based contracts, but minimize reimbursement increases if they are not involved in value-based benefits,” says Ken Goulet, former executive vice president of Anthem Inc. and current board member at OODA Health, which focuses on streamlining interactions between payers and providers. While he says fee-for-service won’t be completely eliminated, doctors can expect to see diminishing reimbursements in 2019 and in the future.

“Fee-for-service is going to last for a while, but it’s becoming less preferred by carriers,” says Goulet. “In 15 years, it will probably still be here, but there will be significantly higher levels of contracts in value-based care. Anyone still doing fee-for-service will find reimbursement not increasing much, so it will be less and less beneficial to be in those contracts.”

The challenge for primary care providers is that every payer has its own version of what value-based care looks like, with different measures for evaluating quality, outcomes, interaction with other physicians treating the same patient, and efficiency, says Goulet, adding that one model insurers favor is the Patient-Centered Medical Home (PCMH).  

“It’s fair to say that a primary care physician or primary care practice can increase earnings by 25 percent in bonus payments if actively engaged in PCMH,” says Goulet. “It allows them to increase quality, improve outcomes, and lower costs, therefore triggering bonus payments.”

The appeal to insurers is to identify patients with chronic conditions and pull them back into primary care practices, which can help them manage their conditions, says Goulet, who notes that it isn’t uncommon for insurers to have patients who visit the emergency department 35 or more times a year. The PCMH model was put in place not only to drive better outcomes, but provide smaller primary care practices a way to thrive in a value-based care market, so he says to expect continued emphasis on this and similar business models. 

While government policy may encourage provider consolidation, private payers don’t necessarily favor it, especially if small practices can work with them to improve outcomes. “Payers do prefer independent practices, and feel that working with them can keep costs down,” says Goulet.

Reimbursement in 2019 and beyond will require an increasing reliance on data from primary care practices proving to payers that they are meeting performance measures. “Reimbursement models will become more complex and also involve more and more measures,” says Friedberg. 

CMS created quite a stir in 2018 when it proposed consolidating E/M levels 2 through 5 into one payment rate. After listening to concerns from medical associations and others, the merging of payment levels has been delayed to 2021, and as currently proposed, will collapse levels 2-4 into a single payment rate, while retaining level 5 as a separate rate. 

“If equating a level 2 visit with a level 5, it could create a disparity in reimbursement for those with multiple chronic conditions,” says Gilberg. Part of the reason behind the delay was the short timeline between the final rule announcement and when it would have to be implemented.

 “It would be nearly impossible for all the software systems and EHR and payment vendors to get this up and running,” says Gilberg. So for now, E/M reimbursement levels remain unchanged, but expect to see further debate on what collapsing levels 2-4 would mean to physicians, says Gilberg.

Another significant PFS change for this year is the addition of codes for virtual check-ins, allowing physicians to bill for some evaluations done over the internet or phone. “It’s a little wonky in the sense that they don’t call it telehealth, but it is telehealth,” says Gilberg. “If physicians can now bill for the time spent talking to patients on the phone or internet, that will help alleviate the time taken away from other patients. From a financial standpoint, it allows reimbursement for common communications with patients.”

Nancy Enos, FACMPE, a professional coder, says physicians need to find out if their private payers will reimburse for these new codes. “Having the codes added to Medicare is a good first step, but it remains to be seen what private payers will cover them,” says Enos.

CMS may be adding new codes for remote consults, but Enos points out that physicians will miss out on many 2019 reimbursement opportunities if they don’t focus on the codes already in place, such as those for transitional care management (TCM) and chronic care management (CCM).

“Some docs use them, but don’t use them well,” says Enos, noting that common mistakes include not documenting patient discharge dates or noting phone calls within the required 24-hours of discharge. “If you are not using these TCM and CCM codes, you are really missing the boat on getting good reimbursement for time when you are not face-to-face with the patient.”

Another frequently-lost opportunity is the Medicare annual wellness visit. Enos says doctors often can bill for both the wellness checkup and for dealing with a chronic issue in the same visit provided they document it properly. “For some doctors, these extra codes are seen as either too much work, they don’t understand the details, or they think it’s only for a few extra dollars,” says Enos. “But those dollars add up.”

Enos says successfully capturing all the reimbursement a physician is eligible for requires a commitment by the entire office staff. “Assign a nurse to look at the patients who are due for physicals and coordinate screenings and the annual Medicare wellness check,” she says. “Call those that are overdue for appointments. Another person should be in charge of tracking patients that are in and out of the hospital and documenting what’s necessary for the care management codes.”

She advises starting with one code and working it into the office workflow. “If you say you are suddenly going to start tracking everything on Monday, by the end of the month, it’s all going to fall by the wayside,” says Enos. “You need some sort of reasonable, planned deployment to succeed.”

As Medicare moves toward value-based care and private payers add more incentives focused on outcomes, data becomes increasingly important for a practice’s reimbursement outlook.

Physicians in the MIPS program must track and submit data on a dizzying array of measures, and many private payer contracts have similar metrics that require data as the proof point. If a practice does not have the data to prove patients are achieving desired outcomes, reimbursement can take a substantial hit-up to 9 percent from MIPS alone by 2022. Combine this with private payer contracts that continue to incentivize value-based outcomes, and a substantial part of practice reimbursement could be endangered by a lack of performance data, experts say.

Accumulating and analyzing this data can be expensive, notes Ken Goulet, former president of Anthem Inc. and current board member at OODA Health. Consequently, Goulet says, doctors can expect to see more companies helping independent practices navigate the changing reimbursement landscape for negotiation and technology-support purposes, and  insurers investing more in helping practices acquire and evaluate their data.

Goulet adds that another change practices may see as early as this year is more customized arrangements for primary care, based on region or even ZIP code. “Carriers are all going to more cloud-based capability and moving away from significant legacy software systems to pay claims,” he says. Once implemented, these systems will allow for flexibility in value-based contracts, faster payments, and easier interaction between providers and insurers.

Here are the reimbursement trends physicians can expect in 2019.

Getting paid in 2019 

There are numerous reasons for claims denials but most of them come down to some form of documentation error, according to Karen Meador, MD, MBA, Senior Physician Executive and Managing Director at the BDO Center for Healthcare Excellence in New York, NY.

Furthermore, most of the claims she has seen that “rise to the level of dispute” have some sort of issue around medical necessity, she says.

Medical necessity, as defined by the American Medical Association (AMA), refers to healthcare services or products provided to a patient “for the purpose of preventing, diagnosing or treating an illness, injury, disease, or its symptoms.” This is in keeping with generally accepted standards of medical practice, that are clinically appropriate, and “not primarily for the economic benefit of the health plans and purchasers.”

One of the common problems contributing to poor documentation, Meador says, is a byproduct of EHRs. In a bid to save time, certain functions, such as copy and paste features and generic templates, can lead to a lack of specificity as physicians copy notes into claims.

“Notes can look very similar not only one day to the next for the same patient, but often among different patients,” Meador says.

She says physicians must take care to make sure that each note is “specific and unique to that patient” even when using templates.

“Physicians should routinely ask themselves ‘have I put uniquely identifying information regarding this patient, regarding his or her history, review of systems, exams, and the plan?’” she says.

In addition, the check-one-box function of many templates isn’t always enough to make the case for medical necessity; more complex notes are often required. “I can often review medical records and see that based on the vital signs, certain labs and the overall exam, this patient needed to be admitted, but the physician wrote a very brief plan, often following a template,” Meador says.

Another byproduct of EHR systems is that they allow for a physician to make an electronic signature instead of a physical signature. However, Meador says, some statements include language that says “signature not required.” An unsigned claim will cause a rejection from the payer.

In newer EHRs, “that language has since been changed to instead say ‘electronic signature,’” she points out. But not all EHRs are up to date.

The timeliness of a physician’s signature is also important, she says. “We do still see problems where the signature happens too long after the note was entered.” She says that can be problematic if a nurse practitioner or other mid-level practitioner wrote the note and then the physician signed it later.

“If that’s not done timely, that can be a potential opportunity for the payer to challenge,” she says.

To save a physician hassles in claims denials and appeals around medical necessity, Meador recommends they involve a third-party, either to do the coding, or to double check a physician’s coding.

Having a third party check the information that supports the documentation can avoid what Meador calls a common pitfall, which is where the physician, crunched for time, relies upon information in their mind from the physical exam and visit rather than confirming that it matches what was documented.

Having a coding expert or a coding team on board can also provide feedback to ensure that the code was appropriate for what was documented, she says. Such feedback might help physicians code appropriately to a higher level, as well.

She recommends physicians hire an outside group to come in annually and do a preventative audit of the records. “It can be very helpful pulling a random selection of records for each of the physicians and then getting an assessment of the accuracy of the coding, billing and thoroughness of the documentation.”

Oversight can only improve billing for medical necessity. “Physicians need to be reminded that one really has to think about how one communicates with the payer,” Meador says.

Jordan Rosenfeld is a contributing author. Send your financial questions to medec@ubm.com.

How to increase revenue by eliminating needless rejections

Eliminate claim denials for medical necessity

Opioid use has become a top priority, and, as part of that, CMS emphasizes that review of a patient’s opioid use should be a standard element of the Initial Preventative Physical Exam (IPPE) also known as “welcome to Medicare”, and the initial and subsequent Annual Wellness Visit (AWV).

Medicare has included the following languarge as part of the review of the patient’s medical history for IPPE visits and AWVs: “Medicare would like to emphasize that review of opioid use is a routine component of this element, including Opioid Use Disorder (OUD). If a patient is using opioids, assess the benefit from other, non-opioid pain therapies instead, even if the patient does not have OUD but is possibly at risk.”

The IPPE is covered for all Medicare beneficiaries once during their first year of becoming a beneficiary of Part B coverage, and the elements of the IPPE include:

Review the patient’s medical and social history

Review potential risk factors for depression and other mood disorders 

Review functional ability and level of safety 

Measurement of height, weight, body mass index (BMI), and visual acuity screening 

End-of-life planning (upon agreement of the individual) 

Education, counseling and referral based on the review of previous 5 components 

Education, counseling and referral for other preventive services, including a brief written plan such as a checklist 

Medicare covers AWVs for patients who are no longer within their first year of their Part B coverage, and who haven’t had an AWV or IPPE within the last 12 months.  The initial AWV is a once in a lifetime benefit, which means that Medicare only pays for this visit once per patient. The subsequent AWV is covered once every 12 months. The elements for the initial AWV are:

Establishment of a current list of provider and suppliers

Review of medical and family history Measurement of height, weight, BMI, and blood pressure 

Review of potential risk factors for depression and other mood disorders 

Review of functional ability and level of safety Detection of any cognitive impairment the patient may have 

Establishment of a written screening schedule (such as a checklist) 

Establishment of a list of risk factors 

Provision of personalized health advice and referral to appropriate health education or other preventive services

Subsequent AWVs include the following elements: 

Review of updated health risk assessment 

Update of list of current providers and suppliers 

Measurement of weight and blood pressure 

Detection of cognitive impairment the patient may have 

Update of the written screening schedule (such as a checklist) 

Provision of personalized health advice and referral to appropriate health education or other preventive services 

Physicians should update templates to include info on patients who are at risk or are using opioids.

Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your coding questions to medec@ubm.com.

Asking about opioid use now part of Medicare welcome and annual visits

Obesity, whether it’s on the list of medical concerns or a stand-alone appointment, is difficult for physicians to treat during the 15 minutes or so allotted for primary care visits.

Even with time constraints, it’s possible for primary care physicians to compassionately and effectively guide patients in decreasing their weight. Weight loss experts say obesity should have a treatment pathway in primary care settings like what was developed for smoking cessation and depression. Given the multi-factorial treatment approach, the key is individualizing care. 

An estimated 39.8 percent of U.S. adults over age 20 have obesity, with another 31.8 percent considered overweight, according to the 2015-2016 National Health and Nutrition Examination Survey. Obesity increases the risk for many medical issues, including hypertension, diabetes, sleep apnea, cardiac disease, arthritis, hyperlipidemia, and certain cancers. The U.S. spends approximately $190 billion annually, or 21 percent of healthcare dollars, on obesity and related conditions. 

“We need to start treating the largest disease in our country, as all other health issues go along with it,” says Craig Primack, MD, board certified in internal medicine and obesity medicine, and co-founder of the Scottsdale Weight Loss Center in Arizona. 

The first step is combatting two major false assumptions that many physicians and patients often have. They are that weight loss is a matter of “calories in, calories out” and that obesity is only due to patient behaviors, says Rekha Kumar, MD, assistant professor of medicine and attending endocrinologist at the Weill Cornell Medical College in New York City. 

The American Medical Association declared obesity a disease in 2013, but many doctors still don’t appreciate that and rely on stereotypes that patients with obesity are lazy or lack self control. 

Decreasing weight is more than just changing diet and exercise routines. While there may be a behavioral component, Kumar says “there are things that go wrong in the body that perpetuate weight problems. There is significant appetite dysregulation with hormones and neurotransmitters.” 

There’s no room for judgment when it comes to treating obesity, Primack says. “I take care of people who go to the gym five or six times a week and run marathons, and still have weight problems,” says Primack. “You don’t say a person with cancer is cancerous. A woman has obesity, she is not obese,” Primack says. 

Understanding obesity genetics is important for understanding how those with obesity issues may differ from those without. Hormone levels involved in body regulation signal if a person should be full or hungry, and these may not function properly in patients with obesity. Primack notes a landmark 2011 

Even with time constraints, it’s possible for primary care physicians to compassionately and effectively guide patients in decreasing their weight.

January 10, 2019 edition

The benefit of flexible patient payment options

EHR market consolidation and the impact on physicians

Your voice: Lowering the cost of a medical education

Getting paid in 2019

Eliminate claim denials for medical necessity

Asking about opioid use now part of Medicare welcome and annual visits

Treating obesity: How to individualize care

What primary care physicians can do about rising rates of obesity

Physician moonlighting doesn’t mean major travel burdens