Providers beware: computerized physician order entry (CPOE) is set to create headaches for the healthcare community. In fact, the threshold requirements for providers to achieve Meaningful Use (MU) under Stage 2 have many concerned that they will encounter similar problems to the ones they experienced during Stage 1 attestation, just more of them.
CPOE is proving difficult for the entire industry. Research conducted by the University of Florida found that only 13 percent of hospitals that intended to participate in the incentive program received an incentive payment in 2011. Fifty percent of organizations that did not successfully attest reported that meeting CPOE was their primary challenge. The report also indicated that unlike some of the other Stage 1 criteria, CPOE presented a host of technological, cultural and organizational barriers that are expected to grow as the threshold requirements increase.1
According to CMS’s Stage 2 requirements for CPOE, eligible providers (EPs) must reach a 60 percent threshold for electronic medications, up from 30 percent with Stage 1. But as providers are well aware, that may be the easier measure to achieve. They are not looking forward to the criteria surrounding laboratory and radiology orders, which have been added as a core measure. EPs are required to reach a 30 percent threshold for both radiology and laboratory orders, with one exception: Any EP who writes fewer than 100 radiology or lab orders during the 90-day reporting period is exempt.
Perhaps the greatest challenge for physicians to overcome is the disruption that electronic orders are expected to have on workflow. While software developers will attempt to make it as easy as possible for providers to create electronic orders with multiple labs and radiology centers, the truth is that this electronic capability is simply not one that practitioners have typically dabbled in extensively. Providers can spend the remaining time in 2013 to familiarize themselves with their Electronic Healthcare Record’s (EHR) radiology and lab modules in readiness for Stage 2. And they should not be afraid to check with their vendors if they experience any difficulties on the road to MU compliance.
Challenges aside, providers should be encouraged by the fact that they can increase patient safety and ultimately streamline billing and claims activities with cleaner, more accurate electronic laboratory and radiology orders and results.
 Healthcare IT News. “CPOE biggest barrier to meaningful use, study finds.” September 28, 2012.
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Quality is king in healthcare, a fact that is best demonstrated in emerging coordinated care models that reward physicians who achieve positive clinical outcomes. There is no better way to realize high quality care delivery than with analytics designed to track practice performance. With meaningful information at their fingertips, providers can identify areas for improvement and optimization and create a solid foundation for moving forward. As more and more practices are looking to take advantage of incentives offered through participation in new models of care, benchmarking solutions are becoming widespread.
However, many physician offices still lack the tools necessary to help manage patient populations or easily modify administrative procedures. Fortunately for organizations ready to make the leap, there are powerful analytics that help practices turn large amounts of raw clinical and financial data into useful information. Extracting data from patient records, physicians can gain insights into their performance on several clinical quality measures such as immunizations, cancer screenings or nutrition counseling provided for certain populations. And with technology to track their patients’ chronic diseases such as asthma or diabetes over time, physicians will be in a better position to offer preventative services and clinical interventions that lower overall healthcare costs.
With analytics that provide insights into their practice’s clinical performance, physicians also have the opportunity to drive additional practice revenue from emerging care delivery models that reward quality improvement, including patient-centered medical homes (PCMHs), accountable care organizations (ACOs) and the Centers for Medicare and Medicaid Services (CMS) Bundled Payments Initiative.
Practices that have successfully leveraged analytics tools to track performance and collaborate with diverse care teams are able to not only reap the benefits of financial incentives and improved outcomes, but they are also in a better position to participate in incentive programs such as the CMS Comprehensive Primary Care (CPC) initiative. The goal of the CPC is to foster collaboration between public and private payers and primary care physicians, creating a funding stream for resources that allow practices to better coordinate care1. Programs like the CPC give practices that are ahead of the curve access to additional funding and resources to better coordinate care for their patients.
As healthcare organizations move away from traditional fee-for-service payment arrangements and into quality-based, shared savings models, it has become evident that benchmarking data will be a vital tool for change. With an enhanced understanding of both clinical and financial performance, practices will be able to better coordinate care for all their patients, improving clinical outcomes at a lower cost.
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Final article in a 4-part series designed to offer small practice providers tips on improving their administrative and clinical operations.
It is not a stretch to say that payer relations are paramount to the success of your practice. And, fortunately, there are ways you can improve how the reimbursement process works with a handful of tactical strategies that will create a more inviting place setting for health plans, while keeping business courteous and retaining your position at the head of the table. Here are some tips for enhancing your payer relations:
It is important for small- and medium-size practice managers to know the policies and fee schedules of health plans to ensure they are being paid correctly. Most coders and billers are not aware of the agreed upon rates for procedures, or whether the contract is paid by relative value unit (RVU), flat rate or some other fee structure. Knowing contracts means you can ensure the practice is getting paid what it deserves and that codes, RVUs and prioritizations are aligned. And when the contract is up for renewal, don’t show up empty-handed. You will want to have concrete data at your fingertips that shows cost of services and profits from care provided to patients.
Denials eat up time and resources. The first step in finding a fix is to determine what types of denials you are getting most often from the top two or three payers, such as bundled services that were billed separately or incorrect codes, for example. By tracking these patterns, you can go back and change habits through education (physician documentation, coding errors, etc.) or decide if a denial was inappropriate and appeal the decision. If you disagree with a policy change or denial, bring it to the attention of your representative. If it needs to be escalated, contact the plan’s medical director. Whichever direction an issue takes, claims resolution takes time, so it’s a good idea to appoint a lead to chart, pull and review the documentation for the least amount of disruption.
Close the Communication Gap
When it comes to improving payer relations, there is no substitute for direct communication. Get to know your representative. Issues that are addressed quickly tend to remain manageable. Your health plan contact can answer questions quickly or put you in touch with resources that can help. Moreover, learn to speak the payer’s language. Delivering information on clinical outcomes, profitability and service volume will earn you respect, lay the groundwork for dialog and make clear the goals you want to achieve.
Having a solid understanding of the industry by being armed with data, whether to negotiate a contract or settle a dispute, and clearly communicating expectations and goals will keep the reimbursement process running smoothly. Likewise, these actions will set the table for future business and partnerships with payers.
Whether it’s arming your practice with claims rejection data or helping to improve the accuracy of your claims submission, Emdeon simplifies the everyday tasks of physician office staff, enabling you to create claims online or submit them through a practice management system. Our reporting and analytics dashboard allows you to track claims from submission to payment, identify and correct rejections, and be made aware of the top reasons for rejections so that future claims can be submitted accurately—and help you get paid faster.
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We have recently added the following payers:
• Health Alliance Medical Plans (HAMP) - ERA
• Mediture - Claims
• Medico Insurance Company - Claims
• Wellcare - Claims
• North American Benefits Network ((Cleveland, OH) - Claims
• Trellis Health Partners - Claims
• CNIC Health Solutions Inc. - Claims
• AmeriChoice of New Jersey, Inc. (Medicaid NJ) - Claims
• CareOregon, Inc. - Claims
• Blue Cross of Arkansas - ERA
• MED3000 CMS TITLE 19 REFORM - Claims
• Hawaii Medical Service Association (HMSA) - ERA
• Merchants Benefit Administration - Claims
• Cook Children STAR Plan - Claims
For a complete list of the payers in our network, visit our website at www.emdeon.com/payerlists/
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