Summer 2015  
Will an Urgent Care Strategy Work For Your Health System?
By Johanna Epstein
Across the country, an estimated half a million patients visit the more than 22,000 urgent care centers on any given day. Addressing patients on an acute and episodic basis, urgent care centers are a viable alternative to the crowded emergency room. The wait time for a new patient visit with a primary care physician is more than six weeks in some healthcare markets. As such, more and more patients do not have an established relationship with a primary care physician. The traditional family practice in your town may have morphed into the local urgent care center in the strip mall a mile or two away.
Urgent care centers appeal to patients because they typically promote convenient, walk-in appointments to insured and non-insured patients. Emphasizing a view of the patient as a “consumer”, these centers are open late into the evening and on weekends. They tend to be a “one-stop” service center providing point of care laboratory testing, basic radiology services and an onsite pharmacy. Many urgent care centers provide services that traditionally would only be offered in the Emergency room such as intravenous hydration and complex wound repair.
From a patient’s financial perspective, the cost of receiving services at an urgent care center can be one- fourth that of the local emergency department for the same diagnosis. These lower fees have drawn the attention of hospital systems and health insurers both of which see the urgent care center as way to hold down costs and boost bottom lines. With more and more patients choosing and selecting insurance coverage through healthcare exchanges, the urgent care center provides not only an increased level of service, but constitutes big savings for the patient with a high deductible plan. Further, for those young, healthy patients who choose to be uninsured, an urgent care center is far more likely to provide bundled self-pay packages that are affordable and flexible.
From a health system perspective, an urgent care strategy can be an effective way of decompressing severely overcrowded emergency departments. These centers, if aligned tightly with an associated medical group and hospital network, can promote a patient’s continuum of care and compliment primary care rather than replace it.
There are a number of things to consider if your organization is thinking about developing an urgent care strategy. The following items should be thoroughly evaluated to ensure a successful implementation.
Corporate Practice of Medicine: Some states have laws that prohibit the “corporate practice of medicine”, which requires urgent care centers be owned by physicians. While this should not prohibit your organization from operating urgent care centers, for these states, unique ownership arrangements and contracts with medical groups may need to come into play.
Clinical Staffing Plan: Determine how your urgent care center will be staffed. Will you have board certified emergency room physicians working at the center? Do you prefer to staff your center with primary care physicians? Will you rely on mid-level providers such as nurse practitioners or physician assistants? Will your urgent care center use nurses or a lesser expensive medical assistant to perform patient triage?
Scope of Care: Will your urgent care center provide ancillary services such as point of care laboratory testing and basic radiology? If so, be certain to manage all of the regulatory requirements that may differ from state to state. Obtain CLIA licensure and radiology equipment certifications early in the process and ensure the development of detailed policies and procedures for these services in the event of an unannounced visit from the health inspector.
Pharmacy: Determine whether your urgent care center will dispense medication. Many urgent care centers (roughly two-thirds) have chosen not to dispense drugs at their urgent care centers. These organizations do not want to be burdened with the risk of housing drugs in their facility. Others have decided not to dispense narcotics. Those who do dispense, provide pre-packaged medications assuring that the contents are never handled by the staff at the center. Proponents of dispensing prepackaged medications site a considerable profit margin for the most frequently utilized drugs such as penicillin. Additionally, the increase in patient satisfaction is yet another reason to consider offering prepackaged medications in your facility.
Marketing: Develop a comprehensive marketing plan. Consider social media, direct mail pieces, and newsprint when opening your urgent care center. If your center is associated with a larger health system, use this platform as a way to promote downstream services offered by the larger system. Consider a strategy that engages your urgent care clinical staff with physicians in the network or community to ensure that your center is not looked upon as a competing entity.
Customer Service and Patient Satisfaction: Ensure your urgent care strategy includes the development of a culture of service and satisfaction. In addition to first class clinical care, be sure to consider amenities for patients that might include free wi-fi, television and refreshments in the waiting room, current reading materials, and clean and cheerful décor. Hire staff with warm and welcoming attitudes. Constantly review, refine and refresh your patient satisfaction initiatives.
Revenue Cycle: Evaluate billing methodology. Will your facility bill a flat rate for services? Will tiered levels of service be created? Will a facility fee be charged? Consider your payer mix and have an in-depth understanding of urgent care billing requirements by payer as they often differ from insurer to insurer.
In conclusion, the decision to offer urgent care services in your organization requires careful cultural, financial and operational consideration. Give yourself plenty of time for planning and implementation in order to quickly reap the many benefits an urgent care center has to offer.
Revenue Cycle: Getting It Right the First Time
By Michael Landers
Spotlight Article
There has been an increasing problem in Revenue Cycle performance over the last several years as a result of a lack of well-defined processes in physician front offices. These issues have arisen as a result of physician groups merging, creating mega sized physician groups and health networks. Furthermore, older, established physician groups have not completed operational reviews to address the problem of denials associated with front end operations. Finally, a rapid increase in the uninsured population, employee turnover, and downsizing in all organizations has contributed to this problem. As a result there has been an increased problem in the management of accounts receivable by billing office staff. Incorrect payer and patient billing and a greatly increased number of payer rejections have led to a dramatic increase in A/R days for many organizations. As a result, physician organizations have taken several steps in order to reduce issues in the billing back end. Most processes implemented were in the front office which is the gateway into the facility or practice.
There has been a trend over the past decade to attempt to “tighten up” and redesign front office operations to ensure that all patient information has been collected and verified prior to a patient presenting for his/her appointment. This has included holding front office staff more accountable for collecting accurate information on patients and having it verified days in advance of the scheduled appointment. In addition, many organizations are making an attempt to operate as efficiently as possible by using limited staff and automated systems to accomplish all required tasks. Quite often a front desk Registration clerk will be responsible for many tasks pertaining to Registration and Insurance Verification beyond the collection of the initial information at the time of appointment booking. Many large organizations have implemented a Central Registration Department where all of these tasks are handled.
In order to ensure that all patient billing information is collected and verified prior to the patient’s arrival, it is recommended that the following steps are taken in the front office of all physician offices:
  • Demographic/Insurance capture – Completed either at the time the patient calls to schedule an appointment with a given provider or via a call back from the office at some point prior to the appointment date. Some key data elements required include:
    • All address information for the patient, the guarantor and the emergency contact/next of kin
    • All pertinent telephone numbers (home and cell phone)
    • Any email addresses
    • All information for the subscriber (policy holder) including address, telephone contact and relationship to patient.
    • Any requirements (special needs) that may apply to that patient.
  • Eligibility Checking – An automated eligibility check is completed (generally within one week of the scheduled appointment). The eligibility check is an interface to the patient’s insurance company either directly or via a clearing house or other intermediary. This check completes a comparison of the information the patient has provided with the information on file in the payer’s database. This includes matches against the patient’s insurance Certificate number and the Effective Date of Coverage. This process has proven most helpful as it will catch differences in coverage dates as well as certificate number that may be different or may have changed since the initial information was gathered when the patient made the appointment. This allows the registration staff to contact the patient to discuss eligibility status or correct any data entry errors which are flagged during the matching of registration data to the insurance company’s information.
  • Patient Verification at time of Check In – All patient’s demographic and insurance is verified for a final time at the time of the appointment check in. The patient must present their insurance card along with a driver’s license or some other form of identification to ensure that the patient who presented is in fact the cardholder. With the increase in the number of uninsured people becoming a problem, insurance fraud is a distinct possibility. A Registration form is produced for the patient to review, sign and date. All of the aforementioned steps take place prior to the patient being seen by the provider.
  • Referral Management – Patients who require a referral in order to be seen by the provider should be notified (generally within one week of the scheduled visit) that a referral is required. This will allow ample time for the patient to contact their insurance company in order to obtain the referral. Steps should be taken by the physician’s office to ensure that the patient will be responsible for payment in the events that the patient presents without the referral or the referral is not obtained in a timely manner. A waiver can be signed by the patient stating they will assume financial responsibility for the visit. Referral tracking software (available in many practice management systems) can be implemented and used by specialty offices to monitor a referrals progress. Decrementing features can notify office staff when remaining visits are running out.
  • Once seen by the provider, patient charge tickets are completed by certified coders or go through a secondary review process if coded directly by the provider to ensure that the correct CPT and Diagnosis codes were used and that modifiers are selected when appropriate. In some cases coding is completed via an Electronic Medical Record system (EMR) which has been preprogrammed with specific coding scenarios. This is done to ensure that the billing process is done correctly to avoid having to extensive follow up, or resubmitting rejected claims due to missing or incorrect data.
If these recommendations are followed, the results will be a reduction in denials and overall improvement in AR days in most organizations. In addition, a reduction in back office staff creates cost savings for the organization as fewer Full Time Employees (FTE’s) are needed to complete follow up work since the majority of work has already been accomplished in the front office setting.
In summary, the increased focus of fine tuning the front office patient flow process will result in better first time billing processes, increased cash flow, a reduction in annual operating budgets, improved customer service and greater patient satisfaction.
Improving Population Health using Epic’s Healthy Planet
By Tiffany Weachter
Population Health Management isn’t a concept that is new to the healthcare industry however; efficiently managing high-cost and high-risk patients is becoming a necessity with payment models focusing on reducing cost and improving outcomes. With this, many organizations are instituting an increased focus towards population health management, participating as Accountable Care Organizations (ACOs) in order to more effectively identify, understand, engage, and track patient populations. An ACO delivering high-quality and low cost care will share in the savings that is achieved for the Medicare program.
Many EHR vendors, including Epic, are looking to provide tools to assist organizations in moving toward better and more coordinated care for individuals, greater health and disease prevention, and less healthcare expenditure. Healthy Planet is Epic’s solution for helping organizations achieve these goals. It allows clinicians to identify and address gaps in care with patient populations using tools within Epic – EpicCare Ambulatory, MyChart and Cogito - to take action on population health analytics, integrate care management and coordination, and engage the patient in their care.
Many of our clients are part of an Accountable Care Organization (ACO) establishing integrated care teams made up of physicians, nurses and social workers that utilize the tools provided by Healthy Planet such as navigators, dashboards and bulk ordering and communication functions as well as MyChart to help manage the needs of their high-risk patients. Healthy Planet’s ACO functionality has been used to define ACO patient populations, complete patient questionnaires for risk stratification, track patient outreach, provide care management which includes documentation of medication compliance, care plans and goals, as well as interaction through MyChart.
Organizations have also begun to create team Longitudinal Plans of Care allowing other clinicians throughout their organization as well as other Epic organizations to see their care efforts in one concise place.
As a result, organizations have already begun to see the benefits of their Population Health Management efforts meeting the goals of:
  • Accurately and efficiently capture data for preventive care and disease management services
  • Monitor the performance of providers on closing care gaps for these services
  • Implement chronic care management workflows for care managers
  • Apply risk stratification models to your patient populations
  • Increase efficiency through bulk ordering and communication
  • Engage patients through MyChart
  • Improve transitions of care and patient engagement with a longitudinal plan of care
Through their care management teams, they have been able to better understand patient needs in areas ranging from transportation to doctor’s appointments and picking up medications to education regarding their clinical care. Reporting shows decreases in Emergency Room visits as a specific example and clients continue to gather data that demonstrates how critical care management is to overall population health. The successful implementation of tools such as Healthy Planet provide both short term and long term benefits that result in a more educated ACO and an overall improvement in the healthcare experience and general well-being of individual patients.
MU Negative Payments: Avoid the Penalties!
Carmen Bello
It’s not too late to avoid the CMS Stage 2 Meaningful Use negative payments for Program Year (PY) 2015 that will be imposed with payments issued starting in January, 1st, 2017.
On January 29, 2015, CMS announced its intention to issue a new rule in early spring 2015, which would change the Meaningful Use (MU) reporting period for Stage 2 from a full calendar year to a 90 day calendar quarter in 2015. This change is great news for Eligible Professionals (EP) that have not yet been able to implement all the requirements to meet MU Stage 2 guidelines. An important point to note is that CMS negative payments are imposed two (2) years after the calendar year (CY) in which the services took place. In early January 2015, thousands of EPs were surprised with the first negative payments for non-participation issued by CMS for services provided during Program Year (PY) 2013.
Providers have a great opportunity to implement the requirements needed to meet MU Stage 2 criteria for 2015 and collect the EHR data needed to meet the new 90 day reporting period during the last quarter of 2015, and most importantly; avoid the penalties. But they must be proactive and act now. There are a number of new requirements for MU Stage 2 that require implementation and planning in order to meet MU Core and Menu measures.
Some of the new requirements are, but not limited to:
  • Correct certified version of EHR software technology installed to track Stage 2.
  • Upgraded workflows and settings for the Patient Portal fully operational to meet higher communication thresholds for Stage 2.
  • Develop workflows and Implement the ability to incorporate lab results into patient charts.
  • Must have the ability to import imaging results and associated reports into the patient's EHR record.
  • Must have the ability to transmit using QRDA III, to CMS by 12/31/15.
In touching on the consequences of non-compliance, the penalties for failing to attest are considerable. Most importantly, penalties for each program and subsequent years are cumulative and could add up to a negative 17% in some cases. Below is a summary of current CMS Medicare Program penalties for non-participation.
  • MU incremental negative payments up to 5% in subsequent years
    • PY 2015 reduced starting with attestation in CY 2016, imposed in CY2017 – 3%
  • PQRS - All Groups and EPs - Negative Payment Adjustments
    • -2.0% Applied starting January 1st, 2017 for services during CY 2015
    • -2.0% Applied to each subsequent year
  • Value Based Payment Program – Groups 10 – 99 EPs submitting claims under a single Tax ID
    • -2.0 Applied starting January 1st, 2017 for services during CY 2015
  • Value Based Payment Program – Groups >100 EPs submitting claims under a single Tax ID
    • -4.0 Applied starting January 1st, 2017 for services during CY 2015
  • Value Based Payment Program – Solo Practitioners, first year this category will get negative payments
    • -2.0 Applied starting January 1st, 2017 for services during CY 2015
Note: All negative adjustments are cumulative by program and year.
For example, a solo practitioner failing to attest to all 3 programs during PY 2015, can expect to start receiving a negative 7% penalty applied to Part B reimbursements starting in 2017, and negative 9% for groups of >100 working under a single tax ID. This negative payment is in addition to any penalties for non-participation in prior or subsequent years and are not eliminated for compliance and subsequent years.
There is no question that these penalties can adversely impact the cash flow of any provider, especially those with a high Medicare patient mix. There is a very small window of less than 3 months to prepare, implement, test and successfully generate valid MU data for the last full quarter of 2015, however, time is of the essence, and for EPs that lack the in-house resources to comply with minimum requirements for MU Stage 2, this is the time to implement a plan and seek assistance to avoid CMS negative payments for Program year 2015.
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