And while the article on Forbes focuses on one statistic, there is plenty of information in the report that should make it required reading among healthcare providers. The report is jammed with information that will be useful as well to patients, insurers, and federal and state governments.

The report contains one other statistic that should certainly raise eyebrows in the Obama administration. There are strong indications that early predictions regarding the mandatory insurance requirement may come true, namely that healthy young people will eschew insurance and for good reason–the actuaries found it will cost them more.

“The age-related premium policy established by CMS in its implementation of the Affordable Care Act will increase premiums for younger individuals and decrease them for older individuals purchasing individual health insurance,” the study found. “By analyzing the underlying costs per age for the population (both male and female) and comparing it to the new approach for individual coverage purchased in state-based exchanges, we found that premiums for individuals in their 20s will subsidize the cost of health insurance for individuals in their 60s.”

Keeping insurance prices affordable requires that healthy people buy insurance to offset the costs of those with chronic illnesses. But for young people, unless penalties for buying insurance have teeth the federal government will not be able to force them to spend more to subsidize the sick and the old.

Click here to read the full article on Forbes.com.

The post iPF on Forbes: Will One Statistic Sink American Healthcare? appeared first on insidePatientFinance.

In two committee hearings, in the House last week and the Senate on Tuesday, the consensus appears to be that the time has come to do away with fee-for-service and the Sustainable Growth Rate (SGR). At yesterday’s hearing of the Senate Finance Committee, Chairman Max Baucus (D-Mont.) said the time had come for both payment models to go. “We must permanently repeal this broken formula and we need to do it this year,” he said.

“We know this is not an easy task,” said Senator Orrin Hatch (R-Utah), “but physicians and patients deserve better. We must find a more stable foundation to pay physicians treating Medicare patients.”

The Senate also agreed with the Obama administration yesterday by ratifying the appointment of Marilyn Tavenner to service as director of the Centers for Medicare and Medicaid Services (CMS). Tavenner becomes the first permanent director since the last one resigned in 2006, and won her job by a 91-7 vote.

The love-fest in Congress pretty much ends there. The House today will vote once again to repeal the Patient Protection and Affordable Care Act. Depending upon who you ask, this is either the 37th or the third attempt to stop Obamacare. “Albert Einstein defined insanity as follows: doing the same thing over and over again and expecting different results,” said Senate Majority Leader Harry Reid (D-Nev.) yesterday on the Senate floor. “If his definition is true — and I won’t argue with Einstein — then House Republicans have truly lost their minds.”

House Republicans, who are sponsoring the vote, justified their decision to proceed by declaring that the ACA will “raise the price of health care, raise the cost of health insurance, reduce access to the American people and continues to get in the way of employers hiring new workers.”

Republicans believe the Democrats are vulnerable on the issue of healthcare reform, but at the same time the Democrats apparently have plans to make the Republican votes a major issue in the 2014 mid-term elections.

The post Congress Agrees: Change How Healthcare Providers Get Paid appeared first on insidePatientFinance.

Community health centers, which consist of some 9,000 locations that serve 21 million patients across the country, can apply for a grant to add staff, train existing staff, and conduct outreach and education, all with the purpose of making the uninsured aware of the new insurance options that soon will be available as a result of the Patient Protection and Affordable Care Act.

“Health centers will help consumers understand their coverage options, determine their eligibility and enroll in new affordable health insurance options,” according to an announcement by Health and Human Services Secretary Kathleen Sebelius. “Community health center staff will provide unbiased information to consumers about health insurance, the new Health Insurance Marketplace, qualified health plans, Medicaid, and the Children’s Health Insurance Program.”

The grant program will be administered through the Health Resources and Services Administration (HRSA). “Health centers work in communities across the country, giving them a unique opportunity to reach the uninsured in their communities and help connect them with the benefits of health insurance coverage under the health care law,” said HRSA Administrator Mary Wakefield in the announcement.

For information on applying for this grant, visit http://bphc.hrsa.gov/outreachandenrollment/.

The post Community Health Centers to Get $150 Million to Help Insure the Uninsured appeared first on insidePatientFinance.

The more data errors you have, the lower the quality of your data integrity. The lower your data integrity, the more consumer complaints you can expect. In this new healthcare climate where patient satisfaction is critical, these are not complaints you can afford.

Your patient financial services function is at the mercy of your data integrity. How many times have you heard from a patient who claims they never knew they owed you money until they received a call from your collection partner? And upon investigation, how often is it because someone keyed the wrong address or failed up to update the patient’s insurance?

The source can be human error or a programmatic flaw in the system or a combination of both. Many times the error can occur in a handoff of the patient record from one department to another. Finding the root cause of poor data integrity can be a challenge, but it is one that can be critical to your effectiveness. One of the best way to hunt down these data exceptions is to begin tracking them on a regular basis.

Tracking exceptions requires tremendous discipline, but the value can be immeasurable to your reputation. Your patient financial services staff will not like it because it holds them accountable and measures their accuracy. Your IT staff won’t like it because it may reveal flaws within the technology landscape that they may not be able to fix. And you won’t like it because exceptions require that you take action, and your plate is already full.

But by tracking exceptions you can find root cause or causes, and address them. By improving your data integrity, you will in turn improve the integrity and standing of your organization among your patients. It’s that simple.

The post Maintaining Your Integrity through Healthcare Data Integrity appeared first on insidePatientFinance.

But then Medicare pays it anyway. And while the provider has no idea why, they are grateful that they now don’t have to chase secondary insurer or the patient to collect.

In 2011 the Centers for Medicare and Medicaid Services (CMS) paid almost $750 million in claims with G modifiers, and the Office of Inspector General believes that was too much. “We found that vulnerabilities exist in how Medicare pays for these claims,” the report states. “When processing claims, contractors often do not consider the modifiers that providers use to indicate that they expect the services or items to be denied as not reasonable and necessary. Contractors also do not always consider the modifiers that providers use to indicate that services or items are not covered by Medicare. Although contractors have checks that affect some of these claims, such as determining whether the services and items met Medicare frequency limitations, they do not specifically check for claims providers expect not to be paid.”

The Inspector General has asked CMS to order it’s claims processing contractors to apply greater scrutiny on claims that use G modifiers, writing:

We are aware that CMS developed a GU modifier for providers to use on claims for items and services for which the routine use of ABNs is appropriate, such as for services that are subject to frequency limitations. This is one way to address the problem in that it would allow providers to use the GA modifier solely for other items and services that they expect to be denied. CMS would then need to instruct contractors to automatically deny or review claims with GA modifiers before paying them. To date, however, CMS has not issued any instructions about the GU modifier or how contractors should process these claims. CMS needs to either issue such instructions or develop other methods of addressing these program vulnerabilities.

In addition, CMS needs to ensure that all contractors are following its instructions to automatically deny claims with GZ modifiers. CMS also needs to instruct contractors to automatically deny claims with GY modifiers and ensure that contractors follow these instructions. Further, CMS should decide whether to implement the GX modifier for Part Bclaims, since providers are already using it. Lastly, CMS should ensure that contractors do not pay for claims with inappropriate combinations of G modifiers. OIG will continue to monitor claims with G modifiers and will undertake a review in the future if it appears that CMS has not addressed the problems presented in this report.

The post Inspector General Wants CMS to Scrutinize G Modifiers appeared first on insidePatientFinance.

The association released an analysis of ICD-11 that is full of contradictions and must have members wondering exactly in which direction the organization wants to proceed.

The federal government will require the healthcare industry to switch from ICD-9 to ICD-10 on Oct. 1, 2014. The AMA has opposed this switch, and until this new report, had thrown out the possibility that the government wait until ICD-11 is released sometime in 2015. That, however, is no longer the case.

“AMA harbors serious concerns and reservations with the significant burden of the ICD-10 mandate and will continue to convey these points to policymakers in Washington,” according to the new report by the organization. “However, given the even greater complexities and uncertainties with moving directly from ICD-9 to ICD-11, the Board of Trustees believes skipping ICD-10 and moving directly to ICD-11 is fraught with its own pitfalls and therefore, based on current information available, is not recommended.”

So is the AMA advocating that the federal government abandon the move to ICD-10 and ICD-11 and stay with ICD-9? Apparently not.

“ICD-9 is outdated today and continuing to use the outdated codes limits the ability to use diagnosis codes to advance the understanding of diseases and treatments, identify quality care, drive better treatments for populations of patients, and develop new payment delivery models,” according to the report.

So if the AMA has concluded that ICD-9 is outdated, but moving to ICD-10 will be too expensive to implement and switching to ICD-11 (skipping ICD-10) will be too difficult, what does it want its members to do? The advice appears to be “stay tuned.” The report concludes with the following statement: “The AMA will continue to advocate for physicians on this issue and monitor the situation as new information becomes available.”

Advantages and disadvantages

The report contains an excellent summary of the advantages and disadvantages of waiting for ICD-11:

The following are advantages for moving from ICD-9 to ICD-11 (skipping ICD-10):

• Implementation efforts for ICD-11 will be significant and costly regardless of whether or not ICD-10 is implemented.
• Waiting to implement ICD-11 will give physicians and the health care industry more time to implement electronic health records (EHRs) and develop the electronic systems infrastructure for health information exchange, since resources will not be stretched between the two major implementation activities of ICD-10 and EHRs.
• Physicians will only have to go through one implementation period, instead of two to go from ICD-9 to ICD-10 to ICD-11.

The following are disadvantages of moving from ICD-9 to ICD-11 (skipping ICD-10):

• ICD-9 is outdated today and continuing to use the outdated codes limits the ability to use diagnosis codes to advance the understanding of diseases and treatments, identify quality care, drive better treatments for populations of patients, and develop new payment delivery models.

• The market will miss out on the improvements in the ICD-10 codes that align with today’s diagnosis coding needs, including the addition of laterality, updated medical terminology, greater specificity of the information in a single code, and flexibility to add more codes.

• Skipping ICD-10 will impede the ability of the industry to build on their knowledge and experience of ICD-10, which is expected to be needed for ICD-11. Learning the medical concepts, training efforts, and overall implementation efforts for ICD-11 will be more challenging if ICD-10 is not implemented first.

• Focusing solely on moving from ICD-9 to ICD-11 risks missing the opportunity to educate physicians and leaving them unprepared for the anticipated transition to ICD-10, which could result in significant cash flow disruptions.

• Implementing ICD-10 is expected to reduce payers’ reliance on requesting additional information, known as “attachments”, which could reduce burdens on physicians, but this opportunity will be delayed until ICD-11 is implemented.

• The timeframe to have ICD-11 fully implemented could be as many as 20 years, unless there is a strong commitment by the industry to implement it faster.

The post Head-Scratching Time: AMA Says Waiting for ICD-11 a Bad Idea appeared first on insidePatientFinance.

Reading between the lines of a recent report by the California HealthCare Foundation’s Center for Health Reporting that appears to be the conclusion. The article–”Medicare penalizes hospitals with high readmissions”–is not not an indictment of Medicare’s new standards for readmissions, but it makes a convincing case that safety-net hospitals may be unfairly victimized by the program.

“Several of the hospitals paying big penalties this year are scattered up and down the sprawling Central Valley, from Tulare to Oroville, a region known for chronic health problems such as obesity and diabetes,” writes the Center’s Deborah Schoch. “Others serve under-privileged Los Angeles area neighborhoods that also have health challenges and lack the medical networks of wealthier communities.”

Tom Petersen, executive director of the Association of California Healthcare Districts, which represents smaller hospitals, believes the Medicare readmission penalty is discriminatory. The patient population his organization’s members serve are often low income and are less likely to have the resources to follow doctor’s orders for diet and medication once outside the hospital. “The hospital doesn’t have the ability to control behavior outside the hospital,” he said.

“But we think the current construction of the program is unfair,” says Nancy E. Foster, vice president for quality and patient safety policy at the American Hospital Association.  “It puts hospitals serving low-income patients at risk.  We don’t think that’s right.”

The post Do Medicare Readmission Penalties Unfairly Target Safety-Net Hospitals? appeared first on insidePatientFinance.

Providers in Europe and other regions that already have switched to ICD-10 reported “considerable disruption,” and according to a new study published in the Journal of the American Medical Informatics Association (JAMIA), providers in the United States will encounter a similar result.

ICD-9 does not map neatly into ICD-10, the study’s authors found. “Convoluted mappings indicate that multiple ICD-9-CM and ICD-10-CM codes share complex, entangled, and non-reciprocal mappings,” they wrote. After studying data from 24,008 patient visits in 217 emergency department, the researchers found that 36 percent of all diagnoses mappings were “convuluted.” Some areas, such as obstetrics and injuries, were convoluted in 60 percent of cases. According to the study:

From the proportion of convoluted mapping motifs, we determined that hematology and oncology are poised for easy transition, while obstetrics, psychiatry, and emergency medicine (poisoning) will be among the most challenged. Furthermore, 42% of infectious disease code mappings remain convoluted, which will impact most specialties. In addition, harder to transition ICD-10-CM to ICD-9-CM code ratios greater than five are found in musculoskeletal, injury, and poisoning clinical classes

“We establish that the meanings of a high proportion of the ICD-9-CM to ICD-10-CM mappings are entangled in complex mapping motifs that have the potential to induce inaccuracies and reporting errors,” they report. These convoluted codings represent 27 percent of treatment costs.

The solution? Double coding.

Because the relationship between ICD-9 and ICD-10 is not clean, coding staff will be challenged and automated coding tools will need to be replaced. “Memorized codes, training, and coding-support software need to start afresh,” the authors concluded.

The switch from ICD-9 to ICD-10 will be so complex that the authors recommend healthcare providers consider coding in both ICD-9 and ICD-10 in advance of the Oct. 1, 2014 deadline.

An alternative straightforward approach could be to conduct double coding (ICD-9-CM and ICD-10-CM) for the entangled ICD-9-CM codes and compare motifs in ICD-9-CM and ICD-10-CM in the final reports of the medical system or clinics, such as graph-pruning strategies to subsets offering reasonable coverage. However, dual coding is cost-prohibitive as coding to ICD-10-CM codes may require additional patient information that is available in patient charts but unobtainable from the historical ICD-9-CM claims. To mitigate the costs of double billing, we provide web portal tools, files, and charts to assess the risk profile per clinical condition, and to identify minimally affected ICD-9-CM codes.

Previously:

ICD-10 Migration: Everyone’s Behind, But Does It Matter?

Research Finds ICD-10 Projects Lagging: How Far Along Should You Be?

CMS Releases Tools and Recommended Timelines for ICD-10 Adoption

The post Mapping ICD-9 to ICD-10 ‘Convoluted,’ Experts Say appeared first on insidePatientFinance.

Beginning in 2005, Medicare Advantage added $122.5 billion to Medicare expenditures, representing almost 4 percent of total spending for the program during that period.

The study, published in the latest issue of the International Journal of Health Services, claims to be the first to examine and define the total cost of overpayments to Medicare Advantage and its predecessor programs since 1985.

According to authors Ida Hellander, David U. Himmelstein, and Steffie Woolhandler, private insurers have been “gaming the system” from the beginning by attracting relatively healthy seniors and discouraging seniors with serious illnesses from enrolling. “Medicare adopted a risk-adjustment scheme in 2004, but this has not curbed private plans’ ability to game the payment system,” the authors write, which they have done so to the tune of $122.5 billion.

The post Medicare Advantage Overpaid $123 Billion Since 2004 appeared first on insidePatientFinance.

At least as far as Senate Minority Leader Mitch McConnell and House Speaker John Boehner are concerned, that responsibility does not belong with the Independent Payment Advisory Board (IPAB), an independent panel created by the Patient Protection and Affordable Care Act. The technocrats who will serve on the panel do not deserve to decide the medical fate of Americans, they declared.

In today’s Inside Patient Finance post on Forbes.com, “Who Do You Want to Cut Medicare, Politicians or Technocrats,” I make the case that the decision has already been made for us. Healthcare already is run by both politicians and technocrats. The Republicans, therefore, are fighting against principles they acquiesced to almost 20 years ago.

That said, their politicizing of IPAB had been an effective tactic. As the Washington Post reported earlier this year, recruiting qualified medical professionals and economists for the panel has been difficult. According to the Post:

“It is supposed to be 15 members, with limited salaries who can’t do any outside work,” says Peter Orszag, the former director of the Office of Budget and Management under Obama who was a key proponent of IPAB. “It will be challenging to find top 15 health-care experts are who would want that job.”

“You’re joining an organization that has uncertain authority with the certainty of being deeply political and widely criticized,” says Bob Kocher, a former Obama health policy adviser. “It doesn’t make sense for current thought leaders in American health care to want this.”

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