B. Harney, Esq.
Brendan P. Harney, Associate General Counsel Mr. Harney joined MTBC in 2010 as an Associate General Counsel. His practice mainly focuses on healthcare compliance regulations including HIPAA and state privacy laws.
Posts by B. Harney, Esq.
Affordable Care Act Rules to Prevent Fraud: How Increased Vigilance Will Affect Your Practice
Aug 17th
If you are wondering how the new healthcare law – the Affordable Care Act – will affect your practice, you are not alone. Providers across the country are trying to understand the implications that this new law will have on reimbursements and the practice of medicine. Well, because the public is clamoring for my opinion on this matter, I will embark on a series of blog posts dedicated solely to the different provisions of the Affordable Care Act. You’re welcome.
One of the most important features of the Affordable Care Act is the increased measures designed to weed out fraud and abuse in the healthcare system. Whatever your opinion on this new law is, we can all agree that prosecuting and preventing healthcare fraud is a noble goal. In keeping with the spirit of preventive care in the Affordable Care Act, the anti-fraud measures of the law focuses on the prevention of fraud by identifying and remedying the sources of abuse. We have yet to see the law in full action but a reading of the statute appears to combat fraud with a broad stroke. For example, the law includes the following:
More detailed credentialing process- CMS will be scrutinizing Medicare, Medicaid and the new Children’s Health Insurance Program (“CHIP”) provider applications a little more closely to prevent fraud from even occurring. To this end, CMS states that certain types of providers (read- DMEs and “Pain Management”) will receive special attention.
New enrollment process for Medicaid and CHIP- Each individual State will be responsible for screening providers for enrollment in Medicaid and CHIP. The States will be on the lookout for providers who have been excluded from Medicare or another State’s Medicaid program. If this evidence is discovered, the provider will be barred from enrollment in Medicaid and CHIP in any State.
Temporary stop of enrollment if patterns of fraud are detected- Medicare will be borrowing new strategies from the credit card industry to identify patterns of fraud. If a pattern is discovered, all provider enrollment will be stopped until the fraud is remedied. Providers can be affected due to their geographic location or type of practice.
Payments stopped during investigation- If there is a “credible allegation of fraud”, CMS will stop all payments to a provider during the investigation process. The investigation process could take several months and would be a disaster for a practice alleged to have committed fraud.
Although these features of the new healthcare law are designed to prevent wide scale abuse of the healthcare system, they are broad and aggressive enough to potentially affect honest providers. Remember that laws are like cobwebs, which may catch small flies, but let wasps and hornets break through. Therefore, it is wise for your practice to understand these new anti-fraud countermeasures and how they could potentially affect your practice.
Thanks for reading and be sure to continue to follow my posts on the Affordable Care Act.
If you would like more information, check out CMS’s website at http://www.hhs.gov/news/press/2011pres/01/20110124a.html.
Brendan P. Harney, Associate General Counsel
Mr. Harney joined MTBC in 2010 as an Associate General Counsel. His practice mainly focuses on healthcare compliance regulations including HIPAA and state privacy laws.
ICD-10 Info Series Part 2
Aug 9th
Welcome back! I hope that you enjoyed my last post about an overview of ICD-10 implementation. Well get ready, because today’s post covers the basic steps to comply with ICD-10 implementation as detailed by CMS.
To CMS’s credit, there is no under exaggeration of the complexities and challenges that ICD-10 implementation will create. To this end, CMS suggests that planning for the transition to ICD-10 from ICD-9 should occur well advance of the October 1, 2013 deadline. Now if you are anything like me, you may feel that because the transition date is more than two years away that it is too soon to start any compliance plan. A lot can happen in two years, right? No. I cannot emphasize enough CMS’s seriousness of the October 1, 2013 deadline. At least starting to think about a plan today will avoid your practice many headaches in the future. Please don’t call me on September 30, 2013 asking to help you update your superbill.
Let’s get down to the basic steps your practice can take to comply with the ICD-10 implementation.
- Identify the current systems and work processes that use ICD-9- Makes sense, right? You must first identify the areas of your practice that will be affected before you can implement a compliance plan. According CMS, some of these areas may include clinical documentation processes, practice management software, electronic health record systems and of course the ubiquitous superbill. Furthermore, you may feel that some of these processes need to be adjusted or outright abandoned to comply with ICD-10 implementation. Identifying these processes now will allow a more educated compliance plan.
- Talk with your practice management system vendor/billing service/clearinghouse about accommodations for both Version 5010 and ICD-10 codes- This is a very important step to take because there is always an assumption that your revenue cycle company/software vendor knows what they are doing. However, this may not always be the case. Be sure to ask the vendor if they are planning any updates and the schedule when the updates will be included. Additionally, review your service contract to see if all of the updates are included or if they are extra services that you will have to pay for. Don’t assume a thing.
- Contact your major payers to determine if ICD-10 will cause changes in your reimbursement contracts- CMS points out that because ICD-10 is so much more detailed than ICD-9, payers might modify payment schedules and contracts. Be careful to understand how the payers are reacting to ICD-10 because inevitably their response will affect you.
- Assess staff training needs- Your staff is very important to your practice and will have the most interaction with many of these new codes. Identifying the appropriate staff members that need ICD-10 training is key. Consequently, inherent in new training is cost and creative budgeting will be necessary. If you have a small practice you may be able to hold joint training sessions with other practices to increase the cost effectiveness of training sessions. You can also ask your billing service provider to provide training if it is offered. CMS suggests that new training should be completed six months prior to the implementation date of October 1, 2013.
- Conduct 5010/ICD-10 submission tests with all payers and clearinghouses- Last but not least, this step is one that can be embarked upon relatively soon. As I Mentioned in my previous article, the deadline for 5010 compliance is January 1, 2012. Most, if not all, payers and clearinghouses are currently accepting test submissions to ensure compliance with 5010 standards. As for ICD-10 submissions, you may have to wait a little bit to send a test file but it would be in your interest to remain in contact with your payers and clearinghouses to find out when ICD-10 test submissions will be accepted.
There is no harm in starting your compliance plan early, just don’t start it now and forget about it come 2013. A consistent and measured approach to ICD-10 implementation will allow you to focus on what you do best- care for your patients.
For more information, please feel free to visit https://www.cms.gov/ICD10/05a_ProviderResources.asp#TopOfPage.
Brendan P. Harney, Associate General Counsel
Mr. Harney joined MTBC in 2010 as an Associate General Counsel. His practice mainly focuses on healthcare compliance regulations including HIPAA and state privacy laws.
ICD-10 Info Series – Part 1
Aug 3rd
An old saying goes that “laws are like sausages, it is better not to see them being made.” The decision to transition from ICD-9 to ICD-10 by the Center for Medicare and Medicaid Services (CMS) is no exception to this saying and most likely the finished product will not be appetizing to most healthcare providers either.
To first comply with this regulation you must first know what it actually means to your practice. ICD-10’s goal is to assist providers in adapting to the changing and more detailed world of modern disease diagnosis. To accomplish this feat, ICD-10 will include almost 69,000 diagnosis codes compared to 13,000 ICD-9 codes. Many of these new codes reflect changes in medical diagnosis but the majority attempt to provide a more specific and in depth classification of existing aliments.
This transition will inevitably mean more cost to healthcare providers who must now find the regulation, understand it and implement a training regime so that their practices are in compliance. This burden is especially heavy on smaller practices that do not have the administrative infrastructure that larger practices and hospitals currently have in place.
Now you may believe that your practice is not subject to the new 1CD-10 codes or that you are immune because you receive reimbursement from only commercial insurance payers. Denial is always present when uncomfortable change is developing. Please take heed though, that all “covered entities” under HIPAA are subject to ICD-10. This includes healthcare providers, all payers (commercial and governmental) and other entities such as software vendors and billing companies. Denial is a necessary step to acceptance and eventually compliance.
CMS has set several deadlines for providers to comply with the new regulation. First, all electronic claims must conform to HIPAA transaction 5010 standards by January 1, 2012. This change establishes the technical groundwork for the use of ICD-10 codes, which become mandatory on October 1, 2013. If you are not a big believer in bureaucratic efficiency and believe that these dates will inevitably be extended (as they already were extended for 2 years in 2009), please note that CMS is adamant that there will be no further extensions to these deadlines.
To further buttress this point, CMS has even begun sponsoring training events such as the sardonically named Code-a-thon in April of 2011. CMS is also providing national provider conference calls and training materials to attempt a smooth transition from ICD-9. All evidence is pointing to CMS’s seriousness in this transition. Developing a plan for your practice now will blunt any of the hardships that will arise once full implementation of ICD-10 occurs in October of 2013. Because as with anything coming out of Washington, the devil is always in the details.
This is just Part 1 of my discussion on ICD-10 implementation.
Be sure to read my next blog post in which I will discuss the steps your practice can take to comply with 1CD-10.