Effective in 2022, Medicare began accepting four new current procedural terminology (CPT) codes for principal care management (PCM) and discontinued two Healthcare Common Procedure Coding System G codes. Experts say the new codes, which are paid at a higher rate than the G codes, afford physicians the opportunity to improve outcomes while simultaneously generating additional revenue.

PCM is similar to chronic care management (CCM) in that both services are for patients who require ongoing clinical monitoring and care coordination. However, unlike its CCM counterpart, PCM only requires patients to have one complex chronic condition; CCM requires three or more.

For example, PCM could be appropriate for a patient with uncontrolled diabetes or uncontrolled hypertension or a high-risk patient with severe asthma who has frequent hospital readmissions, says Terry Fletcher, B.S., CPC, , a health care coding and reimbursement consultant. It could also be necessary for someone with hepatitis C, fibromyalgia, long-haul COVID-19 or a variety of other complex chronic conditions, she adds.

“Many practices are already doing this work to take care of these patients,” says Lori Foley, CHC, CMA, principal of compliance advisory services at PYC, P.C., a professional services firm specializing in health care consulting and certified public accounting. “They just need to capture the right information so they can bill for it compliantly.” That information includes details such as disease-specific care plans, adjustments in medication regimens, ongoing communication with specialists and more.

Physicians who treat a high volume of Medicare patients should definitely consider providing and billing for 

 care management services, including transitional care management (TCM), CCM and PCM because this population tends to struggle with at least one chronic condition and frequent hospitalizations, says Don McDaniel, CEO of Canton & Company, a health care growth and strategic services firm.

Consider a patient who is admitted to the hospital with uncontrolled hypertension. The patient may require TCM for 30 days after discharge, followed by PCM for an additional 30 days or more. If the patient develops an additional complex chronic condition that requires ongoing monitoring, they may even be eligible for CCM instead of PCM. Note that CCM is also a 30-day service for a patient with two or more chronic conditions expected to last at least 12 months that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline.

“PCM is one tool in a toolbox of different options (that) practices can piece together to support building the right kind of infrastructure and surveillance needed to support patients,” says McDaniel.

How can physicians provide PCM effectively?

Experts provide these five considerations for physicians who plan to offer PCM in the months ahead:

Not every patient with a complex chronic condition requires PCM. “Make sure you’re documenting that the condition is severe enough that the patient is at risk for hospitalization or was recently hospitalized several times due to that condition,” says Fletcher.

Fletcher audits CCM claims on behalf of various insurance companies and says the biggest reason for recoupment is that diagnoses for which CCM is performed don’t meet billing criteria or Medicare program integrity rules; she suspects the same may be true for PCM. For example, physicians can’t bill PCM for patients with a well-controlled chronic condition, she says.

Report CPT codes 99424 and 99425 when a physician or nonphysician provider performs the PCM, and report CPT codes 99426 and 99427 when clinical staff under the direct supervision of a physician or other qualified health care professional provide the service.

Fletcher says examples of clinical staff might include an RN, clinical psychologist or medical assistant. However, she cautions physicians to check with payers and state nursing boards before billing because every state is different.

And be sure to document that you’ve notified the patient that their coinsurance applies, says Foley.

4. Document who did what and for how long. 

“We promote a log that’s very clear: name, time spent, what they did specifically and their credentials,” says Foley. “The good news is that EHRs (electronic health records) have come a long way since 2016 when CCM rolled out, and many have integrated tools for time aggregation that facilitates the billing process.”

McDaniel agrees, adding that physicians intending to bill PCM should ask their EHR vendor whether it supports a care management workflow.

5. Determine whether you’ll outsource PCM. 

McDaniel says to ask these questions: What type of PCM services are you currently providing but not billing? Are you able to bill for those services and potentially cover the cost of hiring an additional staff member who might also be able to provide other types of care management services such as CCM and TCM?

“Do the research and find out if you can afford to hire someone,” says McDaniel. “If you find out you can’t do it, you still have the ability to hire a third party to support the activity.”

Principal care management billing criteria

To bill for principal care management (PCM), patients must have one complex chronic condition that meets the following six criteria:

Is expected to last at least three months.

Puts the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline or death.

Requires development, monitoring or revision of a disease-specific care plan.

Requires frequent adjustments in medication regimens, and/or the management of the condition is unusually complex due to comorbidities.

Requires ongoing communication and care coordination between relevant practitioners furnishing care.

Requires at least 30 minutes of PCM services per calendar month.

Articles

Four new codes have been put in place in 2022.  

New principal care management codes: What physicians need to know

Ransomware is perhaps the greatest cybersecurity challenge facing the healthcare industry right now. A 

 that 73 percent of health systems, including hospital and physician organizations, reported their data infrastructures are unprepared to respond to attacks. The survey estimated that healthcare providers with 500 or more records are a staggering 300 percent more vulnerable to data breaches.

Numerous hospitals and medical centers have had operations severely impacted, or even halted from attacks, which is challenging under normal circumstances, but nearly insurmountable in the midst of a pandemic. In the instances reported, files and systems became infected, forcing practitioners to use manual pen and paper systems to keep operations from shutting down completely.

Attackers use a wide range of techniques to break into systems, find sensitive data, deploy encryption tools to lock data, and then demand a ransom in exchange for retrieving encryption keys. By employing the measures outlined below, healthcare practitioners can help protect their business, their patients, and their data from ransomware attacks in 2021 and beyond.

One key thing that makes a healthcare system an easy target is an understaffed IT department. For all the advanced medical technology and expertise hospitals and medical centers have in spades, they are frequently less prepared in the IT department. Technical staff and security funding tend to be in limited supply, and bad actors will schedule their attacks on weekends or off-hours, when they know IT staff is scaled back from the regular workweek.

Investing in a professional IT staff will ultimately save practices valuable time and money. Organizations need to shift to a “prepare and prevent” mindset, rather than “deal with the cleanup after-the-fact.”

Another reason healthcare systems are easy targets is because they tend to have a mix of older, legacy equipment and systems, as well as cutting-edge technology. If the older systems are not properly maintained, updated and/or patched, they become vulnerable.

Older medical devices, such as MRI machines or machines with databases built into them, have vulnerabilities that are well known to seasoned ransomware attackers, such as password-related backdoors due to weak manufacturer-set passwords or poor password security practices.

Future-proofing information systems and the application infrastructure against ransom attacks is essential whether or not the practice has suffered an attack. Practitioners must assume that the precursors to the next attack are already inside the system. Once inside a system, ransomware and associated malware are designed to look like normal operations. This is how they are able to dwell inside networks for weeks and months, executing undetected.

Advanced cybersecurity solutions enable visibility into essentially every application function during runtime, with real-time insight into performance. The aim is to stop exploits as soon as they occur, before any significant damage is done. These solutions designed to detect and stop any code that deviates from normal.

All employees, from doctors to front office staff, must be on high alert. Cyber criminals are using increasingly manipulative exploits during the global health crisis. It’s important for every practice to educate their staff about phishing email and other potential risks to avoid. Research states that nearly 93 percent of attacks infect systems from a phishing email with a malware-laced link. “Drive-by downloading” is another method where a user accesses an infected website and becomes infected.

Particularly with an increase in remote work, medical networks are even more vulnerable, and staff need to be extra cautious. Oftentimes medical staff need to access critical data from remote laptops, some of which may be personal laptops or devices that have users other than the employee. Without remote work, server workloads would mainly only be exposed to private networks. Now they are exposed to remote workers’ unsecured devices, further exposing practice networks.

Staff should enable two-factor authentication on network devices and systems and follow a password management policy that enforces regular updates and strong passwords. Implement a reliable backup and recovery system protected from network access. Regularly update all software, operating systems and anti-virus solutions. These small steps in everyday practice workflow can ultimately be the first barrier of defense from a ransomware attack.

Regardless of how much practices prepare, hackers will continue to hack successfully. The question healthcare systems face now is whether their network is prepared to handle better and more frequent attacks without shutting down completely. Healthcare organizations are critical infrastructure, providing essential services for the public. Their many vulnerabilities leave them exposed, but by implementing these key steps to protect their organization, practitioners can strengthen and fortify their security stance.

Willy Leichter is the VP of Product Management at Virsec, the industry leader in application-aware workload protection. He has over twenty years of experience in product marketing, product management, outbound marketing, communications, digital marketing, and demand generation.

Ransomware is perhaps the greatest cybersecurity challenge facing the healthcare industry right now.

The ransomware threat: 3 steps to protect your practice

As a physician, I’m frequently asked to make referrals to specialists by friends, family and patients. It certainly helps that I know who is good and who is not from direct working relationships, as well as being able to contact trusted physicians elsewhere for recommendations in their fields and geographic areas. This type of benefit extends to financial consulting as well.

Traditional reasons for hiring a fiduciary financial planner include to receive a review of one’s financial situation, obtain advice on the best ways to avoid financial mistakes and learn how to attain financial independence. An ongoing relationship with an experienced planner provides all this as well as long-term strategies for increasing wealth in a diversified and disciplined manner.

But a good financial advisor brings much more to the relationship in the form of the other professionals they know and work with. A seasoned planner usually will have a large team of consultants that they can tap for information and advice on behalf of their clients. These consultants have been vetted and found to provide the best fiduciary advice and help, as opposed to those who recommend risky, sales-driven tactics.

The field of life insurance is rife with agents trying to persuade young physicians to buy various types of expensive whole-life insurance products that they don’t need. I see it over and over. Closely aligned are annuity salespeople cramming expensive and underperforming products into portfolios to line their own pockets.

A good financial advisor will align with a great insurance agent who knows that most families just need some term policies that expire as financial independence is achieved. A great agent will also know the underwriting personnel and practices of various life insurance companies, which will, in turn, guide the best choice of policies for an individual in terms of cost and coverage. When necessary, a great agent will offer guidance on actions to take before applying for coverage, such as clearing up a resolved medical issue that is still on your records.

All this is true for having a great agent when purchasing disability insurance. The great agent knows the underwriting proclivities of the different companies and can help guide the young physician through the intricacies of applying. Such an agent knows that adding a catastrophic rider is a good value and that expensive extras like “return of premium” riders usually are not. In short, the great agent knows that getting maximal coverage in one’s early years is the overriding goal.

The good financial advisor knows who the good accountants are. Many accountants, however, are not much better than using a software program like TurboTax. Fortunately, there are still great accountants with deep experience, knowledge and creative ideas. A good financial planner has found and worked with these professionals, and the planner’s clients benefit greatly from this.

Working with attorneys on estate planning issues, contract reviews and even in litigation (malpractice or other) can be a scary crapshoot. It is difficult to know which attorneys are the best in their field and for your situation and personality. A good financial planner has worked with many attorneys over many years and can be extremely helpful when it comes to making the appropriate choices.

So having a relationship with a good financial planner brings a best-of team of advisors to help you achieve your life goals. Think of your own experience in medicine: When a relative or friend asks you to recommend a physician, you often know exactly whom to steer them to and whom to have them avoid. Having a guide to the best financial and legal advice is just as valuable.

Steven Podnos, M.D., MBA, CFP, is founder and principal of Wealth Care LLC in Merritt Island, Florida. He can be reached at

Having a relationship with a good financial planner brings a “best of” team of advisors to help you achieve your life goals. 

Why physicians need a good financial adviser

A private practice physician’s career, as with many other professionals and entrepreneurs, is focused on growing their practice and serving their patients. Considering when and how they will inevitably exit their careers and, more importantly, create a “strategic exit plan” doesn’t tend to be the highest priority.

Certainly, focusing on serving patients is to their credit, but many doctors over time slip into a “die at the desk” mentality. Their practice is who they are, and their last day in the office has a greater chance of ending with their being carried out than exiting gracefully with a retirement party.

During their lifetime work, doctors do everything in their power to keep patients healthy, but they also know more than most that life is not always predictable; yet, successful practitioners often don’t make any preparation for ending their practice if their lives end earlier than expected.

If we have learned anything during the COVID-19 pandemic, stuff happens — many times outside of what we planned. Doctors and other medical professionals were frequently exposed to danger. What happens if we don’t make it to the office tomorrow? Our patients, staff and a lifetime of work dissipates into the air?

Having a contingency plan isn’t a planning option. It is a necessity.

Whether you are a solo practitioner or part of a large, complex medical group, a “buy-sell” arrangement is a must-have for private practices to protect their family, employees and patients. Your family deserves the economic value of your life’s work, your employees deserve the assurance they will remain employed and your patients need to know that their medical needs will be met.

We encourage our clients to have a buy-sell agreement that addresses the five Ds:

: Premature death is the most common item in a buy-sell, whether a solo practitioner or part of a group.

: If you can no longer perform in your area of practice, disability insurance may cover a portion of your income and overhead, but what if you can never return to the practice of medicine? Make sure your agreement covers this possibility.

: In the event of a partner’s divorce, the shares of the practice cannot be left in jeopardy of going to the person who divorced a partner.

If partners can’t agree on major business decisions, a clause must be exercised to settle the agreement and potentially divide the practice.

: If one doctor decides to retire while others want to continue, what is the valuation method and payout structure for the doctor who is retiring?

I have had the privilege in my 17-year career in financial services of working with many family medicine groups, dental practices and specialized doctors such as aestheticians. What I have found is that many are great businesspeople and certainly highly educated. But most don’t realize the inherent value of the practice they have created. It’s also important to recognize the value of the after-tax income the business produces — and that it may be your largest asset.

It’s critical to plan the eventual exit of your medical practice, just as you would a business. The appropriate time, attention and team are necessary to ensure maximum value.

Ben Soccodato, CFP, ChFC, RICP, CExP, ChSNC, AIF, can be reached at bsoccodato@barnumfg.com or at 914-372-2929. He is a registered representative of and offers securities and investment advisory services through MML Investors Services, LLC. Send your financial questions to medec@mjhlifesciences.com.

Creating a strategic exit plan from your practice is an important step that many physicians put off.

Buy-sell agreements: Why you and your practice need an exit plan

“So, you want to be a doctor?” my pre-med preceptor asked, cocking an eyebrow. “My advice, kid? Don’t do it. Go to business school instead — anything else.” But I was 18, and like most teenagers, I knew better. “He’s just jaded,” I thought. “It won’t be like that for me.”

Thirty years and a global pandemic later, I find myself reflecting more than ever on that conversation. I feel privileged to be a physician, and I love my relationships with my patients (most of the time), but the daily aggravations often feel like death by a thousand paper cuts. And even though I’ve escaped much of the reimbursement rat race by converting to direct primary care, I still find myself frustrated daily by nonsensical demands, such as prior authorizations for generic medications and prolonged peer-to-peer phone calls to get necessary tests approved.

And, of course, add COVID-19 into the equation. Even before the pandemic, doctors were reporting high rates of burnout, with almost half making active plans to leave the profession. Tack on more than a year of full hospitals, social isolation and emotional angst, and some doctors have simply had enough.

But at our first in-person county medical society meeting in nearly two years, I found a balm for my jaded thinking, and it came straight from the Collier County Medical Society’s Physician of the Year, nephrologist, Mark Russo, M.D. His words of wisdom were just what I needed to hear.

Before he became a physician, Russo started working at the bottom rung of the hospital system. “I was a patient transporter, nurses’ aide and psychiatric attendant, and one of my jobs was to walk around and light the patients’ cigarettes,” he said.

This made me think about my own days of volunteering in hospitals and clinics to boost my medical school application. I remember how excited I was when a nurse let me check a patient’s blood sugar—I even wrote about it my diary. That pre-med student would be thrilled to know she would one day not only routinely check blood sugars but help patients manage their diabetes.

Take a moment to consider who you were before you started medical school. What motivated you to want to become a physician? What did you write on your medical school application personal statement? Most likely, you talked about wanting to help, to heal and to make a difference in someone’s life. I bet you’re doing exactly that.

Russo obtained a doctorate in molecular biology but found himself urged to attend medical school by his research mentor and discoverer of the Philadelphia chromosome, Peter C. Nowell, M.D.. Recollecting the early days of his medical career, he pointed out how much medicine has improved in the past 20 to 30 years. “Isn’t it great to be practicing medicine now?” he asked. “We have been blessed with improved treatments for cancers, hepatitis C, immunosuppressants [and] mRNA vaccines. We have better diagnostic tools.”

As a nephrologist, he is ecstatic about research on xenograft transplants. “We may even put dialysis out of business in our lifetime,” Russo said. This outlook resonated with me. Although we’ve struggled with COVID-19, the mRNA technology perfected to prevent the disease may change the trajectory of vaccines for many diseases and even cancer. Although it’s often automatic to think about the negatives when we are dealing with disease, practicing cognitive reframing to focus on how far we’ve come can change your outlook.

As physicians, we truly do make a difference in the lives of our patients, but we make an impact in other ways, too. Russo talked about the three years he spent working as a wrestling coach before medical school, and he recalls this as one of his favorite jobs. “I was able to help kids become outstanding citizens in their respective communities by instilling the discipline they needed, and they still call or write me, thanking me for teaching them,” he said.

It’s easy to focus on our shortcomings. Instead, take a moment to think about all the people you have helped and inspired over the years. Maybe it was through your work as a doctor, but maybe it was just through a kind word or deed. Know that you make a positive impact on the lives of others every single day.

Oftentimes, just being there for someone is enough. “Sometimes we cannot cure or treat. All we may have is our human touch.” Russo said, noting that medicine has been moving away from touch over time. “It’s OK to hug. It’s OK to just hold their hand and comfort them.”

An entourage of family members accompanied Russo to celebrate his award, and his family’s pride truly touched me. “Mark is the smartest person I know,” his older brother said. “The kid always had his head in a book. I remember the rest of us had to be quiet because he was always studying for some kind of test.”

Rather than focusing on people who don’t matter, such as social media trolls or anonymous reviewers, let’s give our attention to the people who really matter. Remember that we all have our own cheering section of friends and family who want to see us succeed and will be proud of us no matter what.

“My entrepreneurial spirit began when I was around 13 years old,” Russo said. “Everyone in the neighborhood was getting an allowance of $2 to $3 per week, so I asked my dad if I could have an allowance, too. My dad thought about it for a while and finally answered, ‘Yes. I’ve decided I’m going to allow you to continue to live here.’”

So Russo started his own business with his friends, mowing lawns and making $20 to $30 per week. He continued his entrepreneurship as a physician, opening a solo practice, Naples Nephrology, in 2002. In 2007, he added a partner “who is like a sister to me.”

Russo encourages physicians to take a chance on self-ownership, and I couldn’t agree more. After 15 years of employment, opening my own practice was the best thing I ever did. I never thought I could run a business but having physician mentors like Russo helped me realize I could—and you can, too. Talk to colleagues who have opened practices or check your state medical society for resources. As Russo says, “Follow your dreams!”

“During the pandemic, I was saddened to see mostly politicians speaking about the illness. I yearned to see more physicians,” Russo said. “Many of us answered the call and educated our citizens, leading us to have a strong response to [COVID-19], but when we tried to stand up and guide our leaders, we were pushed aside.” In addition, doctors who tried to speak up were harassed, heckled, and even threatened and abused, which I experienced firsthand when I attended county commissioner and school board meetings on behalf of our medical society.

“What I learned is that we need more voices. We need to be louder. We need to be tougher and stronger,” Russo said, offering to get out his wrestling whistle to motivate physicians. “We need to take back control. This is our lane. This is our automobile. We know how to drive it, not the politicians.”

Russo reminds us that as physicians, we all trained at top-notch, highly competitive universities. “We bring special skills and experience from these tertiary centers into our own communities. We must continue to recruit new physicians to meet the needs of the community,” he said. Consider precepting medical students or residents and taking newer doctors under your wing to show them the ropes and provide support. Russo also challenges physicians to serve the community outside of medicine. Volunteer work has been shown to lead to improved physical and mental health, and also allows us to be a part of molding the community we want to live in. “If we don’t do it, someone less qualified will,” Russo said.

Rebekah Bernard, M.D., is a family physician practicing in Fort Myers, Florida, and is the author of “How to Be a Rock Star Doctor.”

At our first in-person county medical society meeting in nearly two years, I found a balm for my jaded thinking.

The cure for the jaded physician

The end of the 2021 session of Congress saw what has become an annual last-minute scramble to stem massive cuts to Medicare reimbursement. Although the reprieve was welcomed by physician organizations, at some point, cuts will have to be made to achieve the required budget neutrality. In addition, telehealth changes are likely coming whenever the public health emergency is lifted, and physicians can also expect more prior authorizations and other cost-saving moves from payers.

“People are wondering, ‘How much will I get paid for this or that?’ The answer is: It’s never enough,” says Mark Bethke, FSA, managing director of Deloitte Consulting LLP. “They are never going to cover your underlying costs that you need to get.”

Bethke adds that the congressional scramble around Medicare will probably continue each year and that fee schedules are not likely to increase by significant amounts. “At some point, people need to think about getting off the hamster wheel of fee for service and think of alternative ways to collect revenue.”

What follows are the reimbursement challenges that physicians face for 2022.

In mid-December, Congress averted what would have been a devastating cut to physician payments in Medicare, which were scheduled to be reduced by 9.7% across several areas. Physician payments were scheduled to see a 3.75% reduction to meet budget neutrality requirements, but because of COVID-19, Congress opted to delay all but .75%.

Physicians can also look forward to a slow reinstatement of the Medicare sequester. “The sequester is not completely going away,” says Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA). “It will be phased back in 1%, in March, and the 2% will be phased back in in July.”

Gilberg says that 4% of the original 9.75% of Medicare cuts originates with Congress not offsetting money that was appropriated as part of the American Rescue Plan Act from early 2021.

“So what happens when Congress spends money and doesn’t offset it?” asks Gilberg. “It triggered statutory pay-as-you-go requirements, which would have resulted in 4% cuts.”

All told, physicians saw a .75% reduction to the Medicare conversion factor Jan. 1, which is a carryover from 2021. The other cuts — other than the phased-in 2% sequester — will be prevented through the end of 2022.

The challenge with Medicare reimbursement is when the program makes changes to its relative values that result in spending increases, it triggers budget neutrality requirements that reduce the Medicare conversion factor to offset increases in the relative values. Congress stepped in with a short-term solution of providing about $3 billion to fund the 3% of the scheduled 3.75% in cuts.

“But that was only for one year,” says Gilberg. “At some point, there will be a day of reckoning when the budget neutrality requirements will be implemented. That’s a requirement by law. The medical community has been successful in delaying this, but ultimately Congress is not going to repeal budget neutrality requirements, so we may have 3% of this to deal with in 2023.”

To permanently eliminate it would cost $30 billion or more, and Gilberg says he doesn’t see Congress being willing to do that. At some point, Medicare is going to have to square its books to meet the budget neutrality requirements. They were delayed in 2021 and this year because of the pandemic, but as 2023 approaches, will Congress be willing to do it again?

“Medicare doesn’t pay a lot, and oftentimes practices use their commercial contracts, which tend to be higher than Medicare, to offset what they lose on the Medicare side of their book of business,” says Gilberg. “But at some point, if rates go below a certain point and they can’t offset the losses that they incur by seeing Medicare patients, then they have to make tough decisions about whether they could still see Medicare patients.”

Bethke says that leaving Medicare probably isn’t a long-term solution to a practice’s problems, noting that commercial payers are dealing with the same challenges as the government and can’t keep raising rates at an increasing pace. “You don’t want to move away from Medicare because that is still where a lot of the money is; that’s still where a lot of services are; that’s where a growing percentage of the population is,” Bethke says. “And there is a lot of opportunity to still improve care, improve chronic conditions and focus on wellness and improving the quality of life and outcomes.”

If payment cuts are so severe that physicians start a mass exodus out of Medicare, it might force Congress to come up with a better solution. Gilberg points to the since-repealed sustainable growth rate. “It would have cuts looming over physicians every year in Medicare, and it destabilized practices; it caused them not to invest in new technology. It’s obviously hard to plan and project out in the year if every December Congress is deciding whether or not your reimbursement could be cut significantly.”

Because Congress got rid of the vast majority of cuts this year, it does show they are aware of the potential damage to the Medicare program. “Hopefully, this is more short term and not the long-term problems we had for at least a decade going up to 2015 with the SGR (sustainable growth rate formula),” says Gilberg. “But these cuts were largely a result of Congress overspending and not offsetting legislation that was completely unrelated to Medicare. We don’t know, for example, what may or may not happen with various infrastructure legislation, so it could happen again — that these cuts are kind of hanging over the head of physicians and Medicare.”

Does telehealth reimbursement have a future?

When the pandemic hit and many patients were in lockdown or simply afraid to go to a doctor’s office, telehealth filled the gap. Many practices invested in the technology to remotely talk to patients, and reimbursement was boosted to match that of an office visit. Everyone seemed to love the concept of expanded access and the convenience, except for one group.

“There’s still some degree of skepticism about telehealth, at least in Washington,” says Gilberg.

Prior to the pandemic, Medicare only covered telehealth services in rural areas — and with restrictions on which technology a doctor could use to talk to a patient. Those restrictions were lifted as part of the public health emergency. When the emergency is over, the rules will revert to existing law and Medicare will not cover telehealth in most cases.

“A lot of private payers also cover Medicare or follow Medicare-type payment policies, so I would expect a contraction in coverage for telehealth as well,” says Gilberg. “It would be both a contraction in coverage as well as a reduction in the amount paid for telehealth services.”

He says that Congress has concerns that if the originating site restrictions are lifted to allow telehealth outside of rural areas, then Medicare spending might increase significantly, perhaps by billions. The idea is that easier access would promote greater utilization. In addition, there are concerns about privacy, fraud risks and the quality of services when physicians can’t actually lay hands on the patient.

“All of those things need to be sorted out before we would see a permanent telehealth expansion in Medicare,” says Gilberg. “My best prediction on this is after the public health emergency, I do see a residual demand for telehealth, but I don’t see Congress just permanently extending all this indefinitely.”

One possibility is that Congress will keep the expansion for a couple years to study the overall impact to Medicare. Private payers are also somewhat skeptical of it having a negative impact on their bottom lines.

“Private payers do like telehealth, especially for primary care services, (because) they can make sure that certain preventive care is delivered,” says Gilberg. “But that doesn’t mean that they’re necessarily going to just pay physicians in their network the exact same amount for telehealth visit.”

Bethke says he expects telehealth will remain in some form. “I don’t see how it makes sense to back off of telehealth and technology and evolving our care model,” he says. “It just seems like a backward approach of not helping evolve and transform out industry.”

The strategy some payers are using is to buy a telehealth company and only reimburse for telehealth if the patient uses their in-house service. “I’m a little contrarian about telehealth and that they’re just not going to open up the floodgates for telehealth on the public or private side,” says Gilberg. “They’re going to kind of assess the situation and then move forward based on findings.”

Payers and consumers create reimbursement roadblocks

Surprise billing legislation intended to protect consumers could end up hurting the reimbursement of practices that negotiated good deals with payers. “The way CMS (Centers for Medicare & Medicaid Services) implemented some of the criteria using benchmark rates could have a very negative effect for those practices that have negotiated contracts above benchmark rates that would be set as a result of surprise billing regulations,” says Gilberg.

In addition, payers have reinstated different utilization management techniques, such as prior authorizations. Gilberg says MGMA members have reported a significant uptick in prior authorization usage, as well as expanding into different areas. For example, some prior authorization requirements now restrict where a patient can get services, so if the insurer deems the patient could receive the same service in an outpatient setting, they will only cover it being done outside the hospital setting.

These increasing payer demands are putting more pressure on practice staff, which has been exacerbated by the shortage of workers, costing practices more money in talent searches, training and time.

Bethke says it’s all part of payers’ attempts to focus on their premiums and what those are made up of. “Yes, it’s their admin costs, but it’s also utilization and unit prices, and they’re getting aggressive about how to manage that. They’re realizing they need to do more than just the old way of utilization management — prior authorizations and hammering fee schedules. They’re still doing that, but (they’re) also realizing they have to focus more on the provider relationships and the consumer experience because (those) ultimately (are what create) their network and those are the people who are buying their product.”

To be successful with payers, practices are going to have to not only improve outcomes, but also the consumer experience. This means understanding what the practice does well and marketing that to both payers and patients, Bethke says.

“That doesn’t mean you have to be the cheapest provider or the least expensive because if you think about that in retail, that’s not always a good thing,” Bethke says. “You don’t want to be the most expensive, but you want to create a brand and market to the individuals that you want to come to your practice.”

That same information used to promote the practice to patients can be used to show payers where the practice fits in the market and how it adds to the overall patient experience when it comes time to renegotiate, according to Bethke.

Many practices with value-based contracts fared better than those on fee-for-service deals, mainly because many of the value-based ones offered a monthly fee per month for payment or a set amount of money to manage a patient population. As a result, value-based practices saw less disruption to their revenue.

“Where it’s become a little tricky with value-based care in the middle of the pandemic is that a lot of quality measures and measures of cost are based on benchmarks,” says Gilberg. “And because of the disruptions that we’ve seen as a result of the pandemic, the benchmarks have a lot of anomalies or aberrations in the benchmarks. It’s always tricky, for example, if volumes went down significantly in 2020, only to rebound in 2021.”

As the country emerges from the pandemic, value-based measures may have to deal with some anomalies as care returns to more normal levels. Practices probably won’t see a huge surge in value-based contracts, at least for now. “The measurement of both costs and quality has been affected by the pandemic,” says Gilberg. “It’s hard to envision a situation where you are going to see significant growth in value-based care until we emerge from the pandemic and kind of normalize the benchmarks for cost and quality.”

Smaller practices and reimbursement challenges

With so much economic pressure hitting smaller practices harder than most, can an independent practice with limited resources survive in a post-pandemic health care world with so many reimbursement obstacles?

Bethke says without scale, smaller practices will have a challenging time keeping up with the demands of the evolving health care industry. “That doesn’t mean those small shops have to close and go join the biggest system,” he says. “There are ways around that — they can join clinically integrated networks, and there are other ways to collaborate.” A smaller practice may have to join an accountable care organization or similar group to help with the logistical challenges and the data many payers now require. But being small can be a good thing too.

“I think the advantage that smaller practices have is that they’re nimble and they can adapt quickly,” says Gilberg. “And we are seeing a positive trend in terms of their ability to recover. If we can get beyond some of these near-term staffing shortages, then I think that will be a very positive thing. The fact remains, and most studies show that, especially either independent practices or just practices that are smaller in size, they tend to be able to deliver more personalized care and also at a lower cost than some of the larger institutional systems.”

For the best financial results, practices need to decide how they want to be reimbursed and then build from there. “Don’t focus on how you’re currently reimbursed; focus on what you think it should be,” Bethke says. “Once you’ve determined that based on the data, your history, where you believe you are valuable to the system and thinking about that part differently — maybe in the past you were in the fee-for-service world — then and only then can you think about what the right payment model to live in is.

“Change the order of operations about how you think about payment models.”

Physicians get a temporary reprieve from Congress, but payment challenges loom.

Getting paid in 2022

You’ve received a request for medical records from a payer, who is going to conduct an audit on your claims. Your Electronic Health Record (EHR) system is excellent, the notes are voluminous, your providers are well-versed at coding. If anything, you under code! You provide excellent care for your patients and achieve great outcomes. No one has ever given you any trouble before.

Several months pass, and you get a letter from the payer. It’s the results from your audit. You open it up, and see:

“…medical necessity not supported…”;

“…records include conflicting data.”

an astronomical amount of money due to “overpaid claims”, and they are putting you on pre-payment review until things improve.

What just happened? Why are they doing this? Can they even legally do this? Welcome to 

 where black and white is often eclipsed by gray. Where the “obvious” is rarely so, and where sometimes, less is more.

Below are recent trends in medical audits and what physicians can expect with the the U.S. Centers for Medicare and Medicaid Services’ (CMS) changes in 2021 to the documentation of 

Most providers have an EHR system where they fill in pertinent patient information, as prompted by the EHR system. Is there anything they need to be on the lookout for?

An EHR system is supposed to make your life easier. It provides accurate, up-to-date information about the patient. Its purpose is to facilitate coordinated access and information sharing among physicians. It helps providers more efficiently diagnose patients, reduces errors, provides safer care, facilitates quality. And, by the way, it does a bang-up job of capturing essential billing elements. Pop in the right template, maybe tweak it a little, and you’re good to go.

So, where do things go astray? Well, to understand how something like this can happen, you first need to understand how the patient’s medical record influences medical necessity. Per CMS, medical necessity is the overarching criterion for payment. Inaccurate information in the chart, especially when carried forward from a previous service date or entry without necessary editing, often does not afford an auditor the ability to understand if you needed to see that patient, perform that test, order that script, etc.

Often the information obtained from a patient has not changed from the prior visit. So, what is the potential problem with just carrying information forward?

Auditors across the nation, both private and public, love to deny claims based on allegations that the provider simply copied and pasted prior notes. “Copy/paste” type operations that occur without needed modifications to content is a process infamously known as “cloning’’. And that doesn’t just refer to the entire progress note as a whole; it can refer to 

 of a progress note that are inaccurate. Those pieces could be integral to billing a distinct procedure, or a crucial element associated with an office visit code. If one or more pieces never, or 

 never, change from one visit to the next, the auditor doesn’t know if the information simply didn’t change, or may have changed but just wasn’t edited.

Lately, auditors seem to assume the latter.

Is there anything else that auditors look for when they believe a note is cloned?

The presence of conflicting information is another giant red flag. If the history indicates the patient has severe dementia, but the review of the systems template indicates “All systems were reviewed and negative”, well, that could be a problem. One error of this nature can lead to a reviewer to cast aspersions on the integrity of your note. “What else could be wrong with this chart?”, thinks the auditors.

Truth be told, these are usually just innocuous mistakes that do not represent any intent to commit billing fraud. The payers don’t see it that way. They don’t know if you forgot to revise that review of systems because you’re up until 11:30pm signing off on your notes, or if you’re trying to pad the record with billing elements. All they know is there is a conflict or redundancy which 

Are there any other potential pitfalls that are low-hanging fruit for auditors?

Another pitfall that may come back to haunt you is the overstuffed progress note. This occurs when the sheer quantity of the displayed items seems wildly disproportionate to the nature of the presenting problems.

Taken at face value, it would seem that a single, self-limiting medical condition would not normally warrant a complete review of past medical, family, and social history, a full review of systems and comprehensive exam. Although there may be times when circumstances do require a more intensive evaluation than meets the eye, the payers expect this would be the exception, not the norm.

All of this leads to a presumption that the information in your charts is questionable. Once that notion is planted in an auditor’s head, it colors their perspective. If you happen to be a “high volume” provider with disproportionately more billing of any particular code or modifier, the notion that there “must” be something disingenuous going on becomes solidified. This thinly veiled ethical challenge can be insulting and infuriating to hard-working providers who would never, in a million years, intentionally submit an unsupported health claim.

Will providers have to completely change the way they document Medical Necessity?

A gift horse arrived on January 1, 2021, by the name of the new 2021 E/M guidelines. These are new rules, created by the AMA and adapted by CMS and other payers, for outpatient office visit codes (codes 99202-99215 only).

The guidelines effectively remove those pre-existing requirements to “quantify” the history and physical examination: you no longer need to worry about having “enough” of that ROS anymore. However, you should continue to document those aspects of history and exams that lend support to your clinical decision-making and any tests or treatments ordered. E/M coding has historically been associated with EHR misuse, in part due to the confusing and onerous documentation requirements imposed by the CMS.

The new rules allow physicians to document the most salient points relevant to the medical decision making, or time spent. It is coding, so there are charting nuances you still need to know, but this is an enormous step in the right direction.

Is there anything else providers should keep in mind when documenting Medical Necessity?

Another very simple rule to bear in mind is: 

. Your notes should always have an interval history of present illness (HPI). The history of the problem is what it is, but there is usually something unique to say about the patient’s status covering the period between the last appointment and the current one.

Also, make a point to label it “Interval HPI”, don’t blend it in with the other history because that combination of new and old data sometimes doesn’t sit well together. You want unique documentation for each encounter, and it should stand out in your progress note. Taking the Interval HPI concept one step further, understand that encounter-specific charting is king. With the E/M changes comes a flexibility that has not existed in many years.

The rigidity of cookie-cutter, awkward appearing templating is, from a billing standpoint, now 

 to an old-school 1985-ish free text paragraph or two (yep, I remember those).

Everything has come around full circle. Less is more.

This sounds like a good development that will benefit providers. Do these documentation changes apply to all Current Procedural Terminology (CPT) codes?

To be clear, the E/M documentation changes do not apply to all CPT codes. Certain services, such as wellness visits, chronic care, transitional care, etc., require more rigidity in capturing essential elements. However, you do want to infuse encounter/patient specificity into those templates too. Despite the redundancies, you still need to personalize those notes to render them unique to the patient. A little TLC goes a long way.

Any parting pieces of advice for providers going forward based on the changes to the E/M Guidelines?

Spend an extra five to 10 minutes proofing those notes before you close them. As my mom once said, “An ounce of prevention is worth a pound of cure”. The immense benefits of such diligence can truly be worth its weight in gold.

In the unfortunate event that you do receive one of those nasty overpayment demand letters someday, don’t acquiesce without conducting an analysis first. Let’s face it: they call them “procedure” codes because there are commonalities. Certain things may not change, or change much, from one service date to another. If you’ve changed the things that change, and still got dinged in an audit, there may be sufficient basis to challenge the results.

There is no requirement to rephrase verbiage in your charts just for the sake of making it look different. That’s a level of insanity we hope we’ll never arrive at.

Abdul J. Roberts, Esq. – Associate, Frier Levitt, LLC

As an Associate in Frier Levitt’s Healthcare Department, Abdul’s practice focuses on civil healthcare fraud litigation matters, government investigations, payor audits and overpayment demands, OIG exclusions and CMS revocation of billing privileges. Prior to joining Frier Levitt, Abdul was a criminal defense counsel in the United States Army Judge Advocate General (JAG) Corps handling trials for felony level Federal Criminal Offenses and appealing agency decisions on behalf of Soldiers. Abdul also served as a Trial counsel where he prosecuted Federal Criminal Offenses, and an administrative law attorney, where he advised senior level Commanders and agency heads on matters such as Freedom of Information Act (FOIA), Whistle Blower Protections, administrative investigations, and environmental law related issues.

Jim Tudor, PCA, CPC – Director, Coding & Billing Compliance, HealthCare Compliance Network, LLC

Jim is an expert in E&M auditing across all specialties, including professional and facility billing. He has designed and administered billing compliance and audit programs at the hospital level and for hundreds of provider physician organizations. He has extensive knowledge of federal regulations as they pertain to teaching settings and institutions, and in current billing guidelines for non-physician caregivers (“incident-to”). Jim has built coding database platforms for tracking, reporting, and productivity utilizing MS Access/Visual Basic. He has been a keynote speaker at several coding conferences and nationally broadcast webinars and has authored several articles for the AAPC 

Recent trends in medical audits and what physicians can expect.

Coding audits 101: How physicians can prepare

7 cures for the jaded physician in 2022

“So, you want to be a doctor?” my pre-med preceptor asked, cocking an eyebrow. “My advice, kid? Don’t do it. Go to business school instead. Anything else.” But I was eighteen, and like most teenagers, I knew better. “He’s just jaded,” I thought. “It won’t be like that for me.”

Thirty years and a global pandemic later, I find myself reflecting more than ever on that conversation. I feel privileged to be a physician, and I love 

 (most of the time), but the daily aggravations often feel like ‘death by a thousand paper cuts.’ And even though I’ve escaped much of the reimbursement rat race by converting to direct 

, I still find myself frustrated daily by nonsensical demands like prior authorizations for generic medications and prolonged peer-to-peer phone calls to get necessary tests approved.

And of course, add COVID-19 into the equation. Even before the pandemic, doctors were reporting high rates of 

, with almost half making active plans to leave the profession. Tack on more than a year of full hospitals, social isolation, and emotional angst, and some doctors have simply had enough.

But at our first in-person county medical society meeting in nearly two years, I found a balm for my jaded thinking, and it came straight from the Collier County Medical Society’s 

How physicians can use the new year to rediscover meaning in their careers.

Medical Economics February 2022