In a recent case in Georgia, the Grady Health System reached a settlement in a case for approximately 3 million dollars. Grady was sued by the state for allegedly using inaccurate medical coding to turn more of a profit. The Grady Health System and the State of Georgia have since reached a settlement for 2.95 million dollars and no admission of wrongdoing.
Cases like this are only becoming more common as tougher laws are being enacted to stop healthcare fraud. Under the Affordable Care Act (ACA) and the Health Insurance Portability and Accessibility Act (HIPAA), strict standards for medical coding and billing must be adopted to ensure that proper methods are being followed and patients are being protected.
Healthcare Fraud
One of the main goals of both the ACA and HIPAA is to help safeguard patients from healthcare and insurance fraud. This is accomplished through ensuring that all patients have access to affordable healthcare and through the implementation of stringent medical billing and coding standards. In the case of the Grady Health System, it was suggested that Grady did not follow proper coding standards, allegedly by inflating costs or inaccurately coding.
HIPAA, ACA, and Medical Billing
HIPAA and the ACA also set standards for the medical billing process. They mandate the use of a standard codex to be used by any healthcare provider taking any part in a public health program. The codex used for the purpose of standardizing the medical billing process is known as the Current Procedural Terminology (CPT).
The CPT is a list created and maintained by the American Medical Association (AMA) and refers to procedures and services rendered, rather than diagnoses, in order to standardize the way insurance companies are billed. Failure to adhere to these standards can lead to issues with how or if the healthcare provider is fully reimbursed for services and how much the services will cost the patient.
The Importance of Accurate Medical Billing
With the increasing amount of laws pertaining to healthcare and specifically medical billing, it is critical that healthcare providers are knowledgeable and up-to-date regarding coding standards. Failure to adequately adhere to the standards or properly code for services rendered has the potential to cost a firm millions of dollars.
For this reason, it is often helpful to turn to companies like Quest National Services that specialize in medical coding and billing. They will help ensure that businesses are compliant and educated when it comes to new laws and policies.
The Affordable Care Act (ACA aka “Obamacare”) calls for every citizen of the United States to be covered by some form of health insurance by the end of the Open Enrollment Period (OEP) in February 2015. Because of the nature of the mandate, a Special Enrollment Period (SEP) was opened to add a grace period for those who did not realize that failure to comply by the end of the OEP would result in a fine.
While the federally-funded web portal healthcare.gov only signed up a small amount of would-be violators, the states of California and Washington recently blew past that number when they opted to allow SEPs for their insurance marketplaces. These states dedicated much effort to spreading the word through advertising and social media about the SEP and the fact that non-covered persons would be responsible for a fee taken from their tax refunds. The coverage provided under these two SEPs outstripped by far the coverage provided by the federal marketplace and healthcare.gov.
What Is a Marketplace?
A marketplace is defined under the ACA as an organization that facilitates the purchase of health insurance policies that comply with the regulations and guidelines under the ACA. In order to be considered covered, and thus avoid a fee, eligible persons must purchase a plan for coverage by the end of the Open Enrollment Period for each year. In this case, the marketplaces provided by the states of California and Washington performed much more productively than the virtual federal marketplace, healthcare.gov.
Open Enrollment Period
In order to incentivize coverage, there is a deadline each year by which individuals and families would need to be covered in order to avoid a fee. This is known as an Open Enrollment Period and the most recent one ended in February 2015. The fee is to incentivize people to seek coverage earlier rather than later. However, because of the complexity and novelty of these provisions, a grace period was allowed to those who missed the original OEP.
Special Enrollment Period
Since so many people remained uninsured despite the closing of this year’s OEP, a Special Enrollment Period was made available through healthcare.gov and most recently, through the marketplaces of California and Washington. This SEP was opened in order to allow those who were unaware or unable to purchase a policy by the OEP to seek coverage and avoid paying the fee. When California and Washington opened their SEPs, they signed up record numbers of people and far and away performed better than the healthcare.gov system in terms of number of policies sold.
As healthcare evolves and improves with technology, both patients and care providers look for better ways to prevent and diagnose illness, and to identify and reduce health risks. Maintaining and reviewing health records is the way to accomplish this, but paper records are the method of the past. Electronic records have a foot planted firmly in the present and are becoming the future.
Which Offers Better Patient Value, EMR or EHR?
Electronic record software comes in two main types, Electronic Medical Record (EMR) and Electronic Health Record (EHR). The American Recovery and Reinvestment Act of 2009 (ARRA) provided incentive funds to stimulate the adoption of these software systems by hospitals and physicians. The acronyms EMR and EHR are often used interchangeably, but there are distinct differences between the two software services. According to the National Alliance for Health Information Technology (NAHIT), EMR and EHR are defined as follows:
EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.
EHR: The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care.
The key functional difference between the two is the EHR provides a more comprehensive scope of a patient’s medical history, by pulling data from additional electronic health systems, creating long-term and aggregate health information. This allows doctors, hospitals, and clinical decision makers to anticipate health maintenance requirements. On the other hand, EMR software keeps records of a single diagnosis or treatment, essentially a replacement for paper charts and records, and is more likely to be used by a specialist.
Why Haven’t I Heard of EHR?
With most EHR software, the patient can log onto their record and review their personal health information, which is a cultural change for most patients. EHR is the industry standard, but the market term for the electronic record industry is EMR. Analyzing Google Trends data shows far more searches for “electronic medical record” are performed than “electronic health record”, but the gap is slowly closing.
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With the rising healthcare costs in America, and specifically prescription drugs, many seek relief by purchasing prescription drugs online. People have turned to cheaper online alternatives for clothes, books, hotel reservations, and more; online prescription drug purchases are quickly becoming a solution for pharmacy needs. Some health insurance programs even offer buying prescription drugs online through national pharmacy chains.
Online Prescription Safety
Several safety precautions should be taken before purchasing prescriptions online.
Talk to your doctor. You should only take medications prescribed to you by your doctor. They will determine if a specific drug is safe for you, or if a better treatment option is available. Only use websites that require prescriptions.
Use a licensed pharmacy. The National Association of Boards of Pharmacy authorizes licensing for online pharmacies. Some websites also carry the seal of approval from Verified Internet Pharmacy Practice Sites, gained by maintaining state licenses and allowing inspections by the National Association of Boards of Pharmacy. Using a licensed pharmacy will also help guard against receiving a counterfeit drug with no active ingredients.
Compare Prices. Check the prices at your local pharmacy or drug store for perspective when shopping online. If the price sounds too good to be true, it probably is.
Require access to a registered pharmacist.
While some online pharmacies have conventional physical locations, any chosen online pharmacy should provide access to registered pharmacists to answer any questions or concerns you may have.
Canada’s Cheap Drugs
Canada has long been known for cheaper prescription drugs, compared to the US, and is at the forefront of the online pharmaceutical industry. Canada’s ability to sell cheap drugs, compared to the US, is in part to the Canadian government implementing price controls, capping the amount drug companies can charge drug distributers and pharmacies. The chances are high that your recent online prescription purchase will come from Canada.
The Future of Drugs in America
The increase of online prescription purchases has forced a legislative discussion within the federal government. The U.S. is the only industrialized nation without caps on the price pharmaceutical companies can charge. Proponents of this capitalistic practice hold that it promotes innovation, and encourages the development of best, safest, and most effective drugs. Some argue that introducing price controls on pharmaceuticals would limit the supply for consumers and ultimately decrease the average life span in America. Time will tell, as change is already here and sure to impact prices. Patient and consumer education is critical for purchasing prescriptions online, just as it was for online dating and online shopping during that shift in culture to a cheaper and convenient alternative.
A new study has found that diagnostic errors are the single largest source of successful malpractice claims. Furthermore, the study concludes that diagnostic errors have the unfortunate distinction of being the most dangerous, costly and common type of medical mistake.
Study Finds High Costs
The study encompassed malpractice reports from a 25 year period, between 1986 and 2010. Researchers made use of data from the National Practitioner Data Bank. They analyzed 350,706 paid malpractice claims in order to ascertain the specific cause of patient allegations.
According to the study’s findings, diagnostic errors were the cause of 28.6 percent of all malpractice claims between 1986 and 2010. Furthermore, paid claims resulting from diagnostic errors represented the largest portion of malpractice claims from a financial standpoint. Diagnostic errors accounted for $38.8 billion in malpractice payments between 1986 and 2010, representing 35.2 percent of all medical malpractice compensation over this period.
Diagnostic Errors and Mortality Rate
A second worrisome finding from this study concerned the link between diagnostic errors and accidental death. As a whole, malpractice allegations were linked with patient mortality in 23.9 percent of cases. However, in the specific instance of malpractice allegations stemming from diagnostic errors, death as a result of malpractice was linked in 40.9 percent of cases.
The Difficulties of Diagnostic Errors
Although this study serves as a reminder of the dangers that can accompany a diagnostic error, it also shines light on the difficulty that accompanies addressing diagnostic errors. Within the scope of this study, both surgical errors and treatment errors also represented a large portion of malpractice claims. However, the study’s authors posited that these types of malpractice issues were more easily addressed due to the greater degree of immediacy accompanying an error. While the results of an unsuccessful surgery may be quickly apparent, incorrectly diagnosing a serious condition as something relatively innocuous is often slower to cause harm.
Due to the significant burden that diagnostic errors place on both the health of patients and the livelihood of health professionals, the authors of this study call for an increased focus on diagnostic errors as a critical health policy issue.
Emergency room visits cost insurance providers a fortune, and quite often they’re unnecessary.
In an age where scrutiny of the healthcare system is perhaps at an all-time high, there’s some less-than-great news being reported from the folks that keep score. According to a new scientific study, 71 percent of all emergency room visits by patients with employer-sponsored health insurance are essentially unnecessary.
The Claim
The study, which was performed by Truven Health Analytics, set out to look at the emergency room habits of people with employer-sponsored healthcare. In debates about healthcare in the US, those who use government-sponsored forms of healthcare are often receive blame for congesting emergency rooms and putting stress on hospital resources. Yet the results of this most recent study suggest that employer-insured individuals are just as likely to visit the emergency room in situations when they don’t really need to.
The Dirty Facts
In order to establish a proper context for this study, the researchers focused on data from 6.5 million emergency room visits made by employer-insured patients during 2010. Their findings were somewhat sobering. Of all of these emergency room visits, only 29 percent resulted in emergency treatment being administered. In a perfect world, a full two-thirds of all emergency room visits by commercially-insured patients in the US could have been avoided in 2010.
Of the 71 percent of patients who didn’t require medical care, 24 percent didn’t require immediate care. A full 41 percent were administered care that could’ve been performed in a setting other than the emergency room. Additionally, six percent of commercially-insured patients who visited the emergency room were treated for issues that would have been avoidable if they had received proper primary care to begin with.
The Dirty Cost
Emergency room visits are hardly cheap, and the excessive misuse of the emergency room has come with a big price tag attached. The authors of this study estimated that if only 10 percent of unnecessary emergency room visits were avoided, it would result in a net savings of $18.68 for each of the 24 million insurance enrollees included in the span of the study. That may not seem like much per person. But all tallied up, that’s equal to a savings of $461 million dollars each year!
The Biggest Offenders
When breaking down the study into demographics, the researchers found that women are more likely than men to visit the emergency room, and are also more likely to visit for what turns out to be non-emergency level reasons. However, the most common scenario of an unnecessary emergency room visit involved tomorrow’s leaders – 82 percent of all visits to the emergency room by children 12 months or younger resulted in a non-emergency diagnosis!
New research suggests that adding a personal touch to the doctor-patient relationship after discharge from the hospital may help to lower readmission rates of patients. This information comes courtesy of a trial program put together by three non-profit hospitals located in the Bronx, NY. Montefiore Medical Center, Bronx Lebanon Hospital Center and St. Barnabas hospital all reported significant drops in readmission rates after installing a few new but basic follow up procedures to their post-discharge practices.
Methods of Personal Contact Post-Discharge
The new personal contact methods laid out in this study were quite straightforward. Prior to discharge, patients selected for increased personal contact attended an information session aimed at educating them on proper behavior upon leaving the hospital. Additionally, care transition managers set up a follow up appointment for these patients, scheduled to occur within 14 days of their discharge. Finally, patients received up to four follow-up phone calls within the next 60 days. During these phone calls, care transition managers checked in on the health of patients and made sure that they had attended their follow-up appointment.
Testing the Success of Personal Contact
In order to develop a framework for testing the success of personal contact post-discharge for lowering readmission rates, these three hospitals first used a predictive modeling system to identify a group of patients considered likely to be readmitted. This group of patients was then divided into two groups. The first was a group of 500 who received additional personal contact following discharge. The second was a group of 190 individuals who received the standard treatment following discharge.
After 60 days, 26.3 percent of patients who received standard care had been readmitted to the hospital. However, only 17.6 percent of patients who had received a more thorough level of personal contact had been readmitted. The hospitals involved in this study concluded that if their new personal contact initiatives were extended to all patients at high risk of readmission, they could reach approximately 9,300 patients within the local hospital system. They estimate that this change in policy could save the local hospitals $5.5 million annually.
According to a new report, Medicare patients are experiencing improvements in the end of life care that they receive. Specifically, beneficiaries who were chronically ill and in their last six months of life spent fewer days in the hospital in 2010 than they would have in 2007. Additionally, these beneficiaries spent more time in hospice care in 2010 than a similar cohort did in 2007.
This news comes courtesy of the Dartmouth Atlas Project. Researchers looked at over 1 million claims which were attributed to Medicare patients who died in the year 2010. When comparing these numbers to totals compiled in 2007, the researchers found that in just three years the number of hospital days logged by each patient dropped 9.5 percent. Additionally, the number of deaths that occurred among this cohort while at the hospital dropped by 11 percent.
These lower hospital stay numbers were mirrored by a parallel rise in hospice care usage. Compared to 2007 numbers, hospice care usage in 2010 was up 13.3 percent. The number of days spent in hospice care also increased by 15 percent.
Researchers attribute the changes in end of life care behavior to a greater focus on the wishes of dying individuals. They believe that increased hospice care might align more closely with the preferences of these Medicare beneficiaries, and that these numbers reflect medical professionals’ increased attention to patients’ wishes.
Although these new numbers generally bode well for the medical community, and may free up valuable hospital resources, not all of the researchers’ findings were positive. Medicare beneficiaries were equally likely to spend time in an intensive care unit in 2010 as in 2007. Additionally, the researchers found that Medicare beneficiaries in 2010 were more likely to see 10 or more doctors during the last six months of their lives than they had been in 2010.
A recent study released in The International Journal of Medical Informatics suggests that the inclusion of a psychiatric patient’s psychiatric records within their electronic medical record can result in a decreased likelihood of their re-admittance to a hospital following discharge. Within the scope of the study, the researchers concluded that psychiatric patients were 40 percent less likely to be readmitted to a hospital within a month of discharge when their mental health records were included in their EMR.
Carried out by Johns Hopkins University, this study involved the top 18 hospitals in the United States as they were defined in a 2007 U.S. News & World Report list. Of these top 18 hospitals, less than half of them included inpatient psychiatric records within inpatient EMRs. But even within the hospitals that included these records in EMRs, many did not make this mental health information available to non-psychiatric doctors. Overall, of the 18 hospitals surveyed, only 22 percent included mental health records in patient’s EMRs and made these record easily accessible to non-psychiatric doctors.
Standard Psychiatric Care
Traditionally, a patient’s psychiatric records have remained separate from the rest of their medical records. This practice has been in place in order to show respect for a patient’s privacy in matters of mental health. However, the preliminary findings of this study suggest that including the mental health history of a patient within their EMR aids doctors in successfully administering treatment. Since the prevailing goal of all medical disciplines is to successfully treat a patient so that they may enjoy good health, studies of this kind make a strong case for a higher degree of transparency within the medical field.
Proper communication between cooperating entities is a fundamental part of any business. This is exceptionally true within the field of medicine, where the clientele’s quality of life is at stake. Tools like electronic medical records and readily-available psychiatric information will help your business function more smoothly, but these practices are capable of even greater feats. They can help your patients’ quality of life. After all, that’s what you’re in the business for.
For any physician, the potential of having to address a malpractice claim represents a major area of concern. It is thus in the best interest of medical professionals everywhere to mitigate this risk wherever and whenever possible.
Reduce Medical Malpractice
A recent study in Massachusetts by Harvard Medical School has found a positive relationship between the use of electronic medical record software by physicians and a decrease in medical malpractice claims. In the study, 275 physicians were tracked and surveyed between the years 2005 and 2007. During that time period, 33 experienced malpractice claims. Of the total 52 claims that were filed, 49 took place before EMR implementation and only two were filed after implementation. Within the scope of this study, researchers estimated that the likelihood of experiencing a malpractice claim was reduced by 84 percent following electronic record implementation.
Although this research is limited by a relatively small sample size, it is nonetheless helpful when evaluating the effects of EMR on medical malpractice claim volume. The implication of this research is that contrary to the inference by some that EMR will increase the occurrence of malpractice claims, it can actually lower their number.
In addition to the ability of electronic medical records to streamline your medical practice from a functionality standpoint, they must also be considered within the context of lowering your exposure to malpractice risk. Not only is EMR implementation a formidable organizational tool, but it is also a way to bolster your practice’s security and valuable reputation.
