Compliance Solutions

Health Informatics Consulting (HIC) and Oscislawski LLC, through its OHC Solutions publishing arm, have joined forces to offer organizations an answer to successfully comply with the myriad of new and old privacy and security requirements.  

Weekly HIC EDU Topics

Legal HIE Blog From Helen O.  

Meaningful Use - Final Rule

Final Certification Rule

CMS Incentive Program Website

Industry News Feeds

Earlier this month, the Office of Civil Rights (OCR), which enforces the Health Insurance Portability and Accountability Act (HIPAA) and oversees health information privacy in the Health and Human Services Department, issued a memorandum to all patients reminding them that they have the right to receive a copy of their health record and encouraging them to do so.  Director of OCR, Leon Rodriguez said, "It was important to arm patients with something very easy to bring to their providers to say, in fact, the law requires you to give me my records."  These rights will also take a turn later this year when more legislation is finalized regarding HIPAA and patients' right to access their information. 

The final HIPAA Omnibus Rule is expected sometime later this summer and we anticipate a finalization on the Accounting of Disclosures (AOC) requirement under HIPAA.  AOC would allow patients to request and accounting from their healthcare provider of who has accessed their health information, what information was shared, and when it happened.  This is another way that patients are being encouraged to take a more active approach in their care. 

It is very clear that the Office of Civil Rights is making it a priority to educate consumers about their rights under federal regulation.  After all, the whole purpose of these initiatives (HIPAA, Meaningful Use, Patient Centered Medical Home, etc.) is to improve the quality of care that patients receive.  OCR even has a YouTube channel in which they post educational and instructional videos on consumer rights.  Along with educating patients on their right to access health information, and other rights under HIPAA, they are also educating them on how to file a complaint if they feel they are being deprived of their rights. 

The NLRB (National Labor Relations Board) rule, which required employers to post a notice of employee rights under the Act, has been delayed, indefinitely.  The delay was brought about because of conflicting federal district court decisions and would have applied to any medical office having a gross annual business volume of 250K or more.

CMS has issued a new rule to reduce regulatory burdens on healthcare providers by eliminating barring the enrollment of physicians for failure to provide a timely response to revalidation or other information requests.

The FSMB (Federation of State Medical Boards) has released "Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practices."  The guidelines provide physicians with advise on all aspects of social media and Internet activity. The FSMB guidelines also encourage state medical boards to use their authority to discipline physicians for online: inappropriate patient communication, unprofessional behavior, misrepresentation of credentials, violations of patient confidentiality, failure to reveal conflicts of interest, derogatory remarks regarding a patient, depiction of intoxication, and discriminatory language or practices. The guidelines are available at http://www.fsmb.org/pdf/pub-social-media-guidelines.pdf.

On April 16, 2012 the New Jersey Board of Optometrists readopted its rules with amendments regarding the issuing of prescriptions; releasing contact lens prescriptions, delegation to ancillary personnel and records retention.  

June 30, 2012 is the final day to submit for a hardship exemption request, or to report a minimum of ten E-prescribing claims to CMS in order to avoid a 1.5% reduction on all Medicare claims in 2013. Prepare your practice for the June 30 E-prescribing deadline.

The CMS HIPAA 5010 discretionary enforcement delay will end on June 30, 2012.  Medicare and other third party healthcare plans will begin rejecting non-compliant claims after that date.

The MGMA has released a new tool called the RAC Appeals Navigator, which helps guide MGMA members through the levels of RAC appeal, offers insight into strategies for the appeal, and highlights possible pitfalls the practice could face. 

A rule governing electronic transmission of laboratory test results to providers and carriers, including laboratory claims, under the New Jersey prompt payment of claims law, has been proposed by the New Jersey Department of Banking & Insurance.

The NJDCA (New Jersey Division of Consumer Affairs) adopted a rule authorizing its board and committees to waive specific regulatory requirements for reasons of undue hardship as long as the waiver is consistent with the underlying purpose of the DCA's rules and laws.  This was done to allow boards and committees to pursue measures to encourage compliance rather than to seek disciplinary sanctions for non-compliance.

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With the summer upon us, and Meaningful Use efforts in full swing (many providers are trying to take advantage of the decreased volume in their offices) one very important initiative is being slightly overlooked.  E-prescribing, or electronic prescribing of medication orders, is included as a core measure of Meaningful Use.  An eligible professional is required to E-prescribe forty percent (40%) of their prescriptions during the reporting period.  This includes prescriptions for all patients, plus refills.  However, the government is also still enforcing their e-prescribing initiative that is separate from Meaningful Use. 

The E-prescribing initiative has been around for a few years now, but over the recent past, CMS has been enforcing a one percent (1%) penalty on Medicare fee schedules who fail to meet the requirements.  Those requirements include sending ten (10) medication orders electronically during office visits with Medicare patients by the end of June, and sending an additional fifteen (15), for a total of twenty-five (25) by the end of the calendar year.  Most providers who have electronic health record systems (EHRs) have little trouble in meeting those numbers, however the reporting still needs to be done in order to get credit and avoid the penalty.  Although EHRs collect data on E-prescribing for Meaningful Use purposes, prescriptions that are sent electronically for the Medicare E-prescribing incentive need to be identified with a CPT code in the claim for the office visit.  The code is G8553 to be exact.

This month we are detailing two Meaningful Use Measures related to your patients' medications: Meaningful Use Core Measures #4 and #5.

Meaningful Use Core Measure #4- Electronic Prescriptions

Objective:

Measure:

-More than 40% of all permissible prescriptions written by the Eligible Professional (EP) are transmitted electronically using certified EHR technology.

Tips from the Experts:

-"Permissible prescriptions" doesn't include controlled substances, so prescriptions that can't be sent electronically will not count against you.

-If you write less than 100 permissible prescriptions during the reporting period, you're exempt from the measure.

-Ask your vendor about receiving electronic refills directly from the pharmacies.  This can save your staff an extraordinary amount of time usually spent processing faxed renewal requests.

-Medicare Providers remember to select the G8553 code on your superbill whenever you send a prescription electronically for a Medicare patient.  This code will help you avoid the payment adjustment to your Medicare Physician Fee Schedule (Medicare Electronic Prescribing Payment Adjustment).

Meaningful Use Menu Measure #5- Medication List

Objective:

-Maintain an active medication list.

Measure:

-More than 80% of all unique patients have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data.

Tips from the Experts:

-You are not required to update the med list at every visit.  Providers are asked to use their own clinical judgment when determining how often updates are required.

-A clinical staff member can enter a med list so long as the provider reviews everything entered into the chart.

-When you write a prescription using the EHR, it is generally automatically added to the patient's med list.

-If the patient isn't taking any meds, make sure you document this in the EHR.  There will generally be a button in the med list screen to document "no current medications."

-Ask your vendor about using a Pharmacy Benefit Manager (PBM) to download your patients' prescription histories.  This works through your EHRs electronic data interchange connection, which is the same connection used to send your electronic prescriptions.  This will also help you satisfy Menu Measure #7- Medication Reconciliations.  

Tune in next month for some tips on medication reconciliations and transition in care summaries.

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EHR/PM Selection and Implementation Services: Call us today for a free consultation.  Stick with the experts who have completed countless implementations throughout the tri-state area.  Don't do it alone. Hire an HIC specialist to ensure you are making the right investment for your business.

Privacy and Security: It is not just about Meaningful Use; it is about a federal mandate to have a compliance program in place.  HIC performs full privacy and security risk assessments, mitigation plans and remediation assistance.  We also have a one of a kind updated manual with state law overlay, Meaningful Use directives, and HIE considerations.  We even have packages to make it affordable.

E/M Preventative Chart Review (RAC): It has been mandated that every provider have ten charts reviewed per year as part of their billing compliance program.  This is in addition to your internal auditing process.  HIC provides this service that must be performed by a Certified Professional Medical Auditor (CPMA) to help if you are audited by RAC.  We also have a billing compliance manual to complete your program.  Our auditors are experts and provide the coding re-training and outcome reporting you need.

Human Resources: HIC has a comprehensive Employee Manual that has been legally reviewed.  Whether you need a new manual or updating your current one, we are Certified in Human Resource Management, and can assist with all aspects of your HR needs.

Meaningful Use: HIC is proud to have helped over 100 providers reach their goal of obtaining their Stage 1 MU funding of $18,000.  We have packages that make it affordable.  Stick with the experts and let us help you get there with confidence.

IT Services: Are you in need of some IT help for your practice or organization?  Call HIC and ask us how we can help you manage this critical part of your business.

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PIP Coverage

In this month's edition of PIP law, I would like to take time out to examine the pre-certification and appeals processes.  When caring for a patient that is covered by PIP, one must pre-certify care according to the insurer's Decision Point Review Plan (DPRP).  Pre-certification is a process in which a provider must request treatment prior to performing the same treatment or will be assessed a penalty.  Pre-certification is not necessary on the initial consultation or during the first ten days post accident, as that time is deemed as an 'emergency window'.  Only after the provider receives the DPRP does the provider have to comply with the pre-certification requirements.  It is important to read the DPRP because every DPRP is different and tailored to that insurer's mandates.  So what must be pre-certified by one insurer may not have to be pre-certified by another.  

A few insurance companies do not require pre-certification at all.  The reason for the pre-certification process is to give insurers notice of potential future care and not receive hundreds of thousands of dollars in the form of bills all at once.  If a provider is required to pre-certify treatment and fails to do so, the provider will be assessed a 50 percent pre-certification penalty if the insurer finds the treatment rendered reimbursable.  That is why the pre-certification process, once the DPRP is in the provider's hands, is a crucial step to maximizing reimbursement and profit.

To make the pre-certification process easier, the Department of Banking and Insurance (DOBI) created what is called the Attending Provider Treatment Plan (APTP), which is a universal form that must be completed and sent to the insurance company for review.  One can get the APTP off the Internet and one is usually contained in the DPRP.  Once your office has one, make copies because it is the same form regardless of the insurer.  Sending the APTP to the insurer is generally done by fax but can be mailed or emailed.  Faxing is the preferred method as you have a fax confirmation transmittal letter proving the insurance company received your request.  Why is the fax transmittal letter important?  Because an insurance company has 72 hours (three business days) to respond to your request or the request is automatically deemed medically necessary from the 72 hours post request up to the time the insurance company officially sends out its response and is received by the provider.  So if a surgeon, for instance, sends a pre-certification request on Monday and schedules and performs the surgery for Friday, and the insurance company responds the following Monday denying the requested surgery based upon medical necessity, the surgeon, hospital, etc. will all get paid regardless of the denial because it was not timely. 

If the surgery was scheduled for the following Wednesday and the denial was received on Monday prior to the surgery, even though the denial is beyond the 72 hour rule, arbitrators and judges have held that since the provider received notice prior to performing the service, the notice was still valid.  If one is a physical therapist, chiropractor, acupuncturist and sends in a pre-certification request and the same request gets denied two weeks into care, you are entitled to the treatment rendered for those two weeks prior to receiving the denial and all treatment post denial will have to be appealed and eventually arbitrated.

If a pre-certification request was denied, it is very important that the provider appeal the denial within the time frame and in the manner as described in the DPRP.  Again like the pre-certification process, every insurance company has a different appeals process.  Yours truly has taken issue with this administrative headache and DOBI is addressing the appeal issue.  DOBI is going to make the appeals process similar to the pre-certification process in that they want it to become uniform like the APTP.  Debate is ongoing as to the form, substance and rules associated with the new proposed uniform appeals process, but DOBI is to make a decision shortly and I anticipate within a month.  Once the decision is made, I will update you with the results.

The reason the appeals process must be strictly adhered to is that it affects a providers ability to bring a claim for services rendered and not properly compensated.  As discussed in earlier articles, a provider may obtain an assignment of benefits which allows the provider to step in the patient's shoes and sue the insurance company directly instead of having to go through the patient in order to be properly compensated.  However, many insurance companies have tied the validity of the assignment of benefits to the mandatory appeals process.  If a provider fails to appeal, the assignment of benefits is deemed invalid so the provider now must go through the patient if they want to challenge the insurance company's determination as to any reimbursement discrepancy.  The problem in relying upon the patient or the patient's attorney to properly bring the claim is that a patient has little to no legal training and if the patient is represented by counsel, his/her specialty is most likely in personal injury law, not personal injury protection benefit law.  There is a huge difference between the two with personal injury law focusing on making the patient whole through pain and suffering damages while personal injury protection law focuses on getting the patient's or more importantly the provider's bills paid correctly.  

While my firm represents individuals in personal injury matters, our focus is on the proper reimbursement and collection of health care providers claims or the personal injury protection aspect of claims.  Failure to appeal voids the assignment of benefits which takes the matter out of my or my providers' hands and leaves the providers claims and money in the hands of those that do not either care about the provider or are to potentially incompetent to handle same claims.  Following the appeals process guarantees your potential claim will be adequately represented.

Should you have any questions or concerns, feel free to contact my office at (908) 595-9900.

The above information is for informative purposes and should not be construed as legal advice.   

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It is with great pleasure that we congratulate Tim Pacek, Senior Consultant, who is receiving his CHP (Certified HIPAA Professional). 

We would also like to welcome Stephanie DiCarlo, our new administrative assistant!

Stevie