The Circus Is In Town:  Will TMB Walk The Tightrope?

Thank You To Our Sponsor: Viztek
     

Click on graphic or here to visit their website!

[top] [back to eConnect archive page]

Maryland Court Upholds Physician Self-Referral Law

In a January 2011 decision, the Maryland Court of Appeals upheld that the state’s patient referral law prohibiting group practice providers from referring their patients to other members of their group for certain tests and services.¹ In Potomac Valley Orthopaedic Associates v. Maryland Board of Physicians, the Maryland Board of Physicians (the Board) issued a Declaratory Ruling that the state’s self-referral law does not exempt in-house physician referrals of magnetic resonance imaging (MRI) scans when the "referring physician has a financial interest in the performance of that scan."² In reaching their decision, the Board addressed three specific exceptions outlined in the legislation.³

The Maryland Self-Referral Law expressly prohibits healthcare practitioners and their agents from referring patients to a healthcare entity in which that healthcare practitioner, or his/her family members, have a financial interest.⁴ However, the statute provides certain exceptions to the general prohibition, three of which were addressed in the Board’s decision: the "group practice exception;" the "direct supervision exception;" and, the "in-office ancillary services exception."⁵

Regarding the "group practice exception," the Board stated that, based on case studies, the exception was meant to allow the transfer patient care from one physician to another within a practice, not to allow the referral of "services or tests."⁶ The Board further ruled that the "direct supervision exception" was intended to parallel an American Medical Association (AMA) regulation that permits referrals for services and tests to outside entities where the practitioner directly preforms or supervises the service, but not in-office referrals.⁷ With respect to the "in-office ancillary services exception," the Board found that MRI, Radiation Therapy, and Computer Tomography (CT) scan services were expressly excluded.⁸

In reviewing the case, the Court of Appeals looked to guidance from the Attorney General, which had previously opined that interpreting the law’s exceptions to include the in-house referral from one physician to another for services such as MRIs and CTs would negate the meaning of the in-office ancillary services exception.⁹ Finally, the Court noted that proposals to include MRI and CT services exceptions have been suggested numerous times, and every time the state legislature failed to adopt such proposals. The Court further highlighted that "legislative inaction" may be as significant as legislative action when bills are repeatedly introduced, and repeatedly rejected.¹⁰

While the Patient Protection and Affordable Care Act permits the Secretary of the Department of Health and Human Services to waive compliance with federal Stark Laws for Accountable Care Organizations (ACOs), there is no indication of how physicians and hospitals seeking to align themselves with one another in the coordination of patient care will comply with state self-referral laws, such as the one upheld by the Maryland Court of Appeals.¹¹ As the national focus on integrated care grows, and ACO programs become more prevalent, state legislatures will likely be forced to address regulatory issues, and potential conflicts, going forward.

11 "Patient Protection and Affordable Care Act" Pub. L. 111-148, March 23, 2010, p. 277; "Written Comments of the California Hospital Association for the Federal Trade Commission, Department of Health and Human Services, Centers for Medicare & Medicaid Services Workshop Regarding Accountable Care Organizations, and Implications Regarding Antitrust, Physician Self-Referral, Anti-Kickback, and Civil Monetary Penalty Laws Public Workshop" California Hospital Association (October 5, 2010), Accessed at http://www.ftc.gov/os/comments/aco/100927cha.pdf (Accessed 2/14/11).

[top] [back to eConnect archive page]

Healthcare Reform: Impact on Physicians

The Patient Protection and Affordable Care Act (ACA) and the Health Care and Education Reconciliation Act (Reconciliation Act), collectively referred to as "healthcare reform," will implement numerous changes impacting physician providers. Several of these provisions affect primary care physicians and specialists separately, while other provisions will impact all physician providers with an increased focus on the coordination of patient care.¹

PROVISIONS AFFECTING ALL PHYSICIAN PROVIDERS

Over the next ten years, $250 million has been dedicated by the ACA to fund the expansion of fraud and abuse compliance. Beyond government "policing," the ACA requires physicians to actively identify possible Stark Law violations through the Health and Human Services (HHS) designed self-disclosure protocol. Under this provision, physicians who voluntarily disclose potential Stark violations may receive reduced penalties if violations are in fact found.³ Additionally, disclosure under the Physician Payments Sunshine Act, passed within the ACA, requires companies (e.g., pharmaceutical and medical device firms) to record any physician payment over $10 in 2012 and begin reporting these amounts on March 31, 2013.⁴

Beginning in 2011, CMS will launch the "Physician Compare" website, which is designed to disseminate provider quality measures reported through the Physician Quality Reporting Initiative (PQRI).⁵ From 2011 to 2014, participation in the PQRI will be voluntary and CMS will provide Medicare incentive payments (one percent in 2011 and 0.5 percent from 2012-2014) for providers who participate in the program. However, beginning in 2015, failure to participate in the PQRI will result in a 1.5 percent reduction in Medicare payments.⁶

In order to increase quality and lower costs, healthcare reform encourages the coordination of patient care. Many provisions of the ACA hope to achieve this integration between providers by changing the way in which physician practices are structured. Beginning in 2011 and beyond, the ACA provides for the implementation of various demonstration projects and new delivery models to test the effectiveness of various reform initiatives, including Accountable Care Organizations (ACOs) and bundled payment structures.⁷ For more information on ACOs and bundled payment, see Health Capital Topics Vol. 3, Issue 8: Emerging Healthcare Organizations: Accountable Care Organizations, and Health Capital Topics Vol. 3, Issue 10: Emerging Healthcare Organizations: Bundled Payments. If these small scale endeavors prove successful, the law provides for the extension and expansion of the programs on a national scale.⁸ Industry experts are urging physicians and small group practices to align themselves with other healthcare enterprises now in order to best position themselves to take advantage of the benefits offered by the Medicare Shared Saving Program, which are scheduled to take effect in 2012.⁹

PROVISIONS AFFECTING PRIMARY CARE PHYSICIAN PROVIDERS

Healthcare reform is also addressing the looming shortage of primary care providers. To encourage more medical students to concentrate on primary care, healthcare reform provides for expanded funding for scholarships and loan repayments for primary care providers working in underserved areas beginning in 2011. To supplement workforce shortages, reform initiatives will also expand primary care and nurse training programs, such as the Medicare Graduate Medical Education Program, beginning in July 2011.¹⁰ Primary care providers (pediatricians, family physicians, and internists) will also receive increased Medicaid payments starting in 2013, gradually increasing to Medicare payments levels by 2014.¹¹

[top] [back to eConnect archive page]

Thank You To Our Sponsor NBP: Understanding the New Models that Redefine Roles and Responsibilities in Insurance and Healthcare Delivery

Q&A with Nancy Moore
President, National Billing Partners

Q: What is the key to a physician practice’s long-term success?
A: With the primary practice’s income obtained through reimbursement, mastering thorough control and on-going maintenance of revenue cycle management is vital to long-term survival.  Understanding the processes from scheduling the initial appointment through final adjudication of the claim is imperative to building a profitable practice.

There are several components that make up the revenue cycle. It is important to have a firm grasp on each piece of the process in order to master revenue cycle management and achieve profitability. Some of the key components include:

1. Billing and collections: Physician practices must maintain a current knowledge base of changes in coding, Correct Coding Initiative edits, documentation requirements, carrier behaviors and appeals processes – all of which can effect reimbursement.
2. Eligibility and verification of benefits: Even though patient treatment decisions should not be dictated according to reimbursement, it is important, and in the best interest of the patient to understand the options and financial impact to both the practice and patient. Ensuring a knowledge base in this area will allow the practice to be more efficient in the long-term.
3. Time of service collections: In general, greater than 50% of the financial burden for an office visit is shifted to the responsibility of the patient. As such, time of service collections are critical. Not collecting correct when the patient is in the office significantly decreases the chance of collecting for those services.
4. Credentialing: Credentialing and contracting play a vital role in the equation of a practice’s profitability. It is important to contract strategically with managed care plans. Yearly evaluations of these contracts are imperative to maintain for each practice.
5. Marketing to patients and referring physicians: It is critical to maintain relationships with referral sources (a specialty practice providing episodic care must maintain a strong new patient population to grow and remain a viable source).
6. Patient service: Customer service is key in any industry and the medical industry is no exception to this rule. Once a patient walks through a practice’s doors, how well are they being served? Do they want to return and tell their friends about how wonderful the experience was?

"In order to run a medical practice you need expertise in many diverse areas. Employee relations, credentialing, contracting, HIPPA and OSHA compliance, the list goes on and on. Outsourcing our billing to NBP allows me to concentrate on all aspects of the practice and provides me with the security of knowing cash flow will remain steady. We have used other billing companies in the past but NBP's level of service outshines all others. Not only do we have a billing company that handles the claim and receivable transactions in a correct and timely manner, we have someone that takes time to understand our practice thoroughly from both a business model and a philosophical perspective. And yes, our revenue did move upwards. Once we signed on with NBP we experienced a 20% increase."

- Cindy White, Practice Manager of Central Texas Pediatric Orthopedics

Q: What is the first step a practice should take in order to understand the revenue cycle?
A: A thorough analysis and an objective assessment of the practice should be conducted so opportunities for improvement can be immediately identified and addressed. Recognizing who the customer or patient is, what the product is, and where the revenue stream flows from should be the first steps. Once initial benchmarks are established a strategic plan can be developed and implemented that identifies the desired goal and incorporates a practice’s unique needs. In order to maintain long-term success and truly strengthen the revenue cycle, regular review and tracking against measures outlined in the plan will guide and assist in maintaining focus on the desired outcomes as well as providing a measure of success.

Q: Why is it important for physicians to create attainable goals?
A: Establishing goals that coordinate with the budget enable physicians to be aware of where the practice stands with spending vs. revenue. As surprising as it is, physicians are often unaware of what is going on with their costs, budgets, spending and revenue. This is many times due to staffing turnover, poor records management and for many physicians, taking on too much of the back-end management while trying to provide quality patient care. Setting realistic goals, identifying best practices and then implementing streamlined processes will allow a physician group to immediately increase revenue and put in place lasting revenue cycle management systems to ensure long-term success.

Additionally, it is important for practices to reassess revenue and budget goals as systems are put in place. Once true progress is achieved, practices can stay on top of managing the revenue cycle by increasing goals and continuing to strive for enhanced results.

"The processes NBP placed in our practice increased our time of service collections by 33%." - Jim Heitz, Practice Administrator, Cardiovascular Associates of East Texas

Q: What should be addressed or evaluated first: top or bottom line costs?       
A: The initial analysis will evaluate both top and bottom line processes to determine any gaps. In many instances, physician groups are quite adept at providing quality patient care (top line) but often pitfalls come into play when protecting the group’s bottom line. Outsourcing practice management support to address and correct any problems on the back-end will both quickly and efficiently protect a practice’s bottom line.

Q: What are the common mistakes that are made in revenue cycle management and how can they be avoided?
A: Poor management, improper staffing and turnover are common problems that undermine revenue for many physician practice groups. It goes without saying that employed staff is the outward face and a direct reflection of the physician practice to the public. Well managed, well trained, competent staff is a must for proper cash flow success. Staff that are trained and cared for often stick with a practice for the long haul, which in turn creates stability and increased productivity.

Q: Any suggestions for improving reimbursements?
A: Yes, it’s important for practices to maintain a current knowledge base of changes in coding, Correct Coding Initiative edits, documentation requirements, carrier behaviors and appeals processes – all of which can affect reimbursement. It is vital for physicians and staff to stay on top of changes as they arise and re-set goals where needed to ensure timely and efficient billing and collections management.

Q: What can a physician group gain from outsourcing practice management support?
A: A comprehensive Centralized Business Office (CBO) has the ability to bring expertise, superior technology and unparalleled customer service to medical billing, collections and overall practice management. For physician groups that would prefer to practice medicine and let someone else deal with back-office management, outsourcing practice management support is a cost efficient way to effectively manage the revenue cycle.

“NBP is extremely conscientious and knowledgeable in many facets of insurance billing, coding and reimbursement. They provide outstanding personal customer service and ensure that I get the highest level of reimbursement.” - Thomas C. Vinson, M.D. of  Round Rock Cardiology, P.A.
[top] [back to eConnect archive page]

TOA Legislative Advocate's Update

By Michelle Wittenburg
Texas Orthopaedic Association Legislative Advocate

BILL FILING DEADLINE – Friday, March 11^th, was the deadline for filing bills.  Fewer bills were filed this session than last.    

BILL FILING STATISTICS
*There are reserved numbers which is why the
total count doesn't match the last number

SENATE – The Senate passed SB 321 by Glenn Hegar (R-Katy), which prohibits employers from restricting their employees from storing legally owned firearms in their locked vehicle in the parking lot of their workplaces.

On Thursday, Lt. Governor David Dewhurst asked Senate Finance Committee Chairman Steve Ogden (R-Bryan) to form a new Subcommittee on Fiscal Matters charged with finding up to $5 billion in savings and non-tax revenue to balance the budget.  The subcommittee, which will be chaired by Robert Duncan (R-Lubbock), will evaluate cost-savings proposals, explore non-tax revenue alternatives, and review unspent fund balances held by governmental entities before making their final recommendations to the Senate Finance Committee.  Lt. Governor Dewhurst said, “We need to conduct a thorough review of the budget and look closely at every cost-saving alternative before there is any further discussion about tapping into the Rainy Day Fund.  Texas taxpayers cannot afford for the Legislature to leave any stone unturned.”

Total number of bills reported out of Senate Committees this week:         108

Total number of bills passed by the Senate this week:                                  68

Total number of bills passed on the Local and Uncontested calendar:       47

HOUSE – Election Contest in House District 48 – The House Select Committee on Election Contests held a hearing on Tuesday.  The attorneys for Republican candidate Dan Neil and Representative Donna Howard (D-Austin) made presentations to the committee.  Representative Will Hartnett (R-Dallas), the Master of Discovery, summarized his report on the election contest.  The committee went into executive session to discuss the issues presented.  Upon returning from executive session, Chairman Todd Hunter (R-Corpus Christi), made the motion that the contestant (Neil) failed to establish by clear and convincing evidence that the election contest outcome was not the true outcome.  The motion was unanimously adopted.  Dan Neil, who has now received adverse rulings from Special Master Hartnett and the Select Committee still, has the option to take the matter to the full House of Representatives for a vote.  He has not yet made an announcement on that decision. 

For the rest of the update, please click here.
[top] [back to eConnect archive page]