PRACTICE MANAGEMENT UPDATES
Aetna UCR Class Action Settlement
A class action lawsuit was filed against Aetna regarding payment to out-of-network medical providers for covered healthcare benefits. The lawsuit claims that Aetna paid inadequate reimbursements for these services by using the Ingenix database and other methods to determine the amounts paid. The settlement provides up to $120,000,000.00 to be distributed in accordance with the Settlement Agreement. Claims can now be filed by physicians. Please click her to learn more.
EHR Stark exemption continues New
The U.S. Department of Health & Human Services (HHS) Office of the Inspector General (OIG) and the Centers for Medicare and Medicaid Services (CMS) have extended the Stark exemption for EHRs.
The exception/safe harbor was scheduled to sunset on December 31, 2013. HHS has extended the time physicians can accept donated EHRs under this exception/safe harbor through 2021. The extension of the sunset through 2021 brings welcomed relief for physicians as they continue to adopt EHRs and struggle with the high cost of implementation. The rules also made several other notable changes:
- Excludes labs from the types of entities that may donate EHRs
- Updates the definition of what type of software is considered interoperable for the purposes of donations
- Clarifies the requirement prohibiting any action that limits or restricts the use, compatibility, or interoperability of donated items or services
- Removes from the exception the requirement related to electronic prescribing capability
HHS accepted the argument made by several others that labs should be removed from those types of entities permitted to donate EHRs to physicians due to concerns that EHR donations are being used to secure inappropriate referrals. The AMA, however, advocated that a preferable approach would be one that focused more on the need for better education around the limits of the safe harbor and exception for EHR donations.
Texas Workforce Commission (TWC)-Free Workplace Posters New
Various laws require employers and Workforce Solutions offices to display certain posters at the workplace. Click here to go directly to TWC's "Posters at the Workplace" website to access the free poster.
Health Insurance Marketplace New
The Affordable Care Act (ACA) requires individuals to have health insurance by 2014. Each state had the option of creating a state marketplace or participating in the federal marketplace. On July 9th, 2012, Governor Rick Perry announced that Texas would not implement a state exchange. Therefore, Texas will participate in the federal marketplace. The marketplace enrollment is scheduled to start on Oct 1st, 2013 and the marketplace is scheduled to open Jan. 1st, 2014.For more information visit Health Insurance Marketplace.
Revised CMS-1500 Claim Form New
Medicare is revising the CMS 1500 paper claim form and will begin accepting the new form on January 6th, 2014. As of April 1st, 2014 Medicare will only accept the revised form. This means that any physician that files paper claim forms to Medicare must be able to comply with this requirement by the April 1st date. The National Uniform Claim Committee (NUCC) has revised the CMS-1500 claim form. The revised CMS-1500 form will give physicians the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes. ICD-9 codes must be used for services provided before October 1, 2014, while ICD-10 codes should be used for services provided on or after October 1, 2014. CMS encourages physicians to check with their vendor to determine when they will be ready to switch to the new claim form.
Additional resources and tools:
Law mandates marketplace notice to employees by Oct 1, 2013 New
Although there have been some delays in implementation of the health insurance exchanges, a major piece of the Affordable Care Act (ACA), federal law is still requiring all employers, regardless of whether or not they offer health care coverage, to provide their current employees with a health insurance exchange notice no later than October 1, 2013. The notice must inform employees of the existence of the exchange, the services offered, and contact information, allowing them to make informed decisions about health insurance.
The purpose of the notification is to inform employees about the new health insurance exchanges and subsidies that will be available to individuals effective January 1, 2014, and to provide information about the employer’s current offerings to employees.
The open enrollment period for the state and federal health insurance exchanges begins on October 1, 2013. The new exchanges will offer a place for individuals and small businesses to compare and select coverage options via an online marketplace.
The notice must be given to all employees, regardless of plan enrollment status, or of part-time or full-time status, but does not need to be issued to dependents or other related individuals who are, or may become eligible, for coverage under this plan. For employees hired after October 1, 2013, the notice must be provided upon hire (which the U.S. Department of Labor (DOL) has indicated means within two weeks of their start date).
The DOL is providing model notices for employers offering insurance coverage to employees, as well as for those not offering coverage.
Model notice for employers that offer coverage to some or all of their employees
Model notice for employers who do not offer a health plan
Additional Resources regarding the Insurance Marketplace:
Effective August 17th, 2013
Availity will no longer be sending free batched claims transactions to government and non-sponsored health plans. However, you can continue to submit each individual claim for free through the Availity Web Portal.
For additional information, view the Availity Advanced Clearinghouse FAQs and the list of available clearinghouses.
New AMA Study: Patients Responsible for Nearly One-quarter of the Medical Bill -June 17, 2013
Patients are responsible for nearly one-quarter of the medical bill, according to the findings released today from the AMA’s sixth annual check-up of health insurers and their patterns for processing and paying medical claims.
For the first time, the AMA’s National Health Insurer Report Card examined the portion of health care expenses that patients are responsible for through copays, deductibles and coinsurance. During Feb. and March of this year, patients paid an average 23.6 percent of the amount that health insurers set for paying physicians.“Physicians want to provide patients with their individual out-of-pocket costs, but must work through a maze of complex insurer rules to find useful information,” said AMA Board Member Barbara L. McAneny, M.D. “The AMA is calling on insurers to provide physicians with better tools that can automatically determine a patient’s payment responsibility prior to treatment.”
Administrative Burden Index
The AMA today also unveiled its new Administrative Burden Index (ABI) to rank commercial health insurers according to the level of unnecessary cost they contribute to the billing and payment of medical claims. The AMA found that administrative tasks associated with avoidable errors, inefficiency and waste in the medical claims process resulted in an average ABI cost per claim of $2.36 for physicians and insurers. Cigna (CI) had the best ABI cost per claim of $1.25, or 47 percent below the commercial insurer average. HCSC had the worst ABI cost per claim of $3.32, or 41 percent above the commercial insurer average.The AMA estimates that $12 billion a year could be saved if insurers eliminated unnecessary administrative tasks with automated systems for processing and paying medical claims. This savings represents 21 percent of total administrative costs that physicians spend to ensure accurate payments from insurers.“The high administrative costs associated with the burdens of processing medical claims annually should not be accepted as the price of doing business with health insurers,” said Dr. McAneny. “The AMA is a strong advocate of an automated approach for processing medical claims that will save precious health care dollars and free physicians from needless administrative tasks that take time away from patient care.”
Other Key Findings
Since 2008, the AMA’s National Health Insurer Report Card has examined the claims processing performance of the nation’s largest health insurers and provided an objective and reliable gauge of denials, timeliness, accuracy, and transparency. Key findings from six years of data generated by the report card include:
Accuracy-Error rates for commercial health insurers on paid medical claims have dropped significantly from nearly 20 percent in 2010 to 7.1 percent in 2013. While dramatic improvements have been made in accuracy during the last three years, the AMA estimates that more than $43 billion could have been saved if commercial insurers consistently paid claims correctly since 2010. UnitedHealthcare (UHC) led commercial health insurers with an accuracy rating of 97.52 percent. Regence trailed all insurers with an accuracy rating of 85.03 percent. Medicare led all insurers with an accuracy rating of 98.10 percent.
Denials-Medical claim denials dropped 47 percent in 2013 after a sharp spike in 2012 among most commercial health insurers. The overall denial rate for commercial health insurers went from 3.48 percent in 2012 to 1.82 percent in 2013. Among all insurers this year, Cigna (CI) had the lowest denial rate at .54 percent, while Medicare had the highest denial rate at 4.92 percent.
Timeliness-Health insurers have improved response times to medical claims by 17 percent from 2008 to 2013. Humana (HUM) had the fastest median response time of six days, while Aetna (AET) was the slowest with a median response time of 14 days. Medicare’s median response time of 14 days has gone unchanged since 2008.
Transparency-Health insurers have improved the transparency of rules used to edit medical claims by 37 percent from 2008 to 2013. Reducing the use of undisclosed payer-specific edits unlocks the flow of transparent information to physicians and reduces the administrative costs of reconciling medical claims.
ICD-10 Tools from TMA - For tools to help implement ICD-10 in your practice click here...NEW
2013 Psychiatric codes and guidelines - The current CPT 2013 codes and guidelines in the Psychiatry section have been revamped to more accurately reflect and differentiate the work performed by physicians and other qualified health care professionals, including the shifts of site fo service from the hospital to the office setting and treatment of single disorders to the management of multiple medical comorbidities. For more information, click here...
Patient privacy protection: What you need to do - The federal gov't is conducting a national HIPAA audit pilot program and Texas has passed a patient privacy law (HB300) that increases protection of electronic PHI beyond HIPAA. To learn more, please see the Aug 15 issue and Sept 1 issue of the HCMS Physician Newsletter. For a summary from Texas E-Health Alliance on the Texas Patient Privacy Law...
HCMS Compliance Calendar through 2014 - HCMS has developed a Compliance Calendar to help physicians and their staff keep track of all the various government agency deadlines and key health policy issues that impact their practice.
Delivery and Payment Models - For info, resources, fact sheets, and more, please refer to our Delivery and Payment Models Web page.
DPS answers controlled substance certificate renewal questions and how to check your renewal status...
HCMS PAYMENT ADVOCACY PROGRAM
HCMS has a program to assist our members with payment issues. For more information, please see ourPayment Advocacy Web page
HCMS PHYSICIAN NEWSLETTER
The Harris County Physician Newsletter (HCMS) publishes Business of Medicine articles on a variety of topics. For a link to the complete Physician Newsletter archives, click here. (Other Newsletter articles are located throughout the Business of Medicine section.)
-- You CAN negotiate a health plan contract - Feb 1, 2013
-- Your Web site-A resource and marketing tool - Jan 15, 2013
-- Choosing a new billing company - Dec 15, 2012
-- Watch for service provider billing mistakes - Dec 1, 2012
-- Get your office ready for 2013 - Nov 15, 2012
-- Improve collections - Better patient payment - Nov 1, 2012
-- Innocent mistakes can be costly (President's Page) - Oct 15, 2012
-- 2013 ICD-9 codes effective Oct 1 - Oct 1, 2012
-- First impressions matter - How to gain and keep new patients - Oct 1, 2012
-- Compliance protection? Only your P&P know for sure! - Sept 15, 2012
-- Update privacy policies now! - (TX Privacy Law) Sept 1, 2012
-- Patient privacy protection: What you need to do - (HIPAA and TX Privacy Law) Aug 15, 2012
-- Meeting with your billing company - July 15, 2012
-- Creating a practice brochure - June 15, 2012
-- Generate patient referrals - May 1, 2012
-- Identify claims filing issues - April 15, 2012
-- Emerging payment options - What to do? - April 1, 2012
-- Evaluating your billing company - March 15, 2012
-- Let your Web site work for you - March 1, 2012
-- Promote better patient payment - Feb 15, 2012
-- Perform an internal billing audit - Feb 1, 2012 (Flyer-How to perform an internal billing audit)
-- Webinar explains modifier 25 - Jan 15, 2012 (hot topics)
-- Be creative with patient scheduling - Jan 15, 2012
-- Do you have a business plan - Nov 15, 2011
-- Health coverage for small businesses - Oct 15, 2011
-- Prescribing data-Physician Data Restriction Program (PDRP) - Sept 15, 2011
BELOW INFORMATION AND RESOURCES LISTED ALPHABETICALLY:
AFFORDABLE CARE ACT (ACA)
How will the ACA affect you and your practice? For a summary...
The small business health care tax credit is an aspect of the ACA that is helpful to a physician's practice. For eligibility info and how to claim the credit....
AMERICAN MEDICAL ASSOCATION (AMA)
For links to helpful information on the AMA Web site:
--How to perform a physician practice internal billing audit
--Legal Issues for Physicians
--Next Generation Physician Payment and Delivery Models
--Practice Management Center
--Solutions for Managing Your Practice
ASSIGNMENT OF BENEFITS
In Texas, if there is an assignment of benefits signed by the patient, the health plan is required to pay the physician, in- or out-of-network. For addt'l info, see Assignment of Benefits Form- a sample form (members only)
BILLING, COLLECTIONS AND DISCOUNTS
Below are some strategies to solve billing and collection problems. The Texas Medical Association's (TMA) Billing & Coding and Reimbursement sections,Texas Medicine, and Physicians Practice provide additional help.TMA Practice Consulting also can assist by providing a billing & collections assessment.
Billing and Collections:
HCMS Physicians Newsletter articles/issue:
- Choosing a new billing companyDec 15, 2012
-Meeting with your billing company July 15, 2012
- Evaluating your billing company March 15, 2012
- Promote better patient payment Feb 15, 2012
- Perform an internal billing audit and How to perform a physician practice internal billing audit (AMA) Feb 1, 2012
- Take steps to boost your collections July 2011
- It's the law and all doctors must know it! April 15, 2011
- How to reduce denials April 1, 2011
- Collection tips April 1, 2010
- Document, document, document! Sept 1, 2009
- "Source of injury" exclusions May 1, 2008
- Producing good claims April 15, 2008
- Telephone collections plan April 1, 2008
- Establish a collections policy April 1, 2008
Texas Medical Association (TMA) and other articles:
-Billing Disclosures Required - TMA
-Collection Practices - TMA Board of Councilors Current Opinion
-Fee Issues - TMA Board of Councilors Current Opinion
-Answers to billing & collections questions most commonly asked of TMA
-Precall plan improves telephone collections - TMA
-Write off or collect from the patient? (secondary payer) - TMA
-Tips for choosing an outside billing service - TMA
-TMA Practice Consulting offers collection tips - TMA
-Maximizing collections in your practice - TMA
-Don't lose revenue with an outdated fee schedule - TMA
-How to perform a physician practice internal billing audit - AMA
Can a physician give patient discounts? When is it appropriate? What are the the legal concerns? Below are some guidelines and laws to consider:
-- It's the law and all doctors must know it! The offense of waiving copays and deductibles,not disclosing out-of-network services, etc. - HCMS Physician Newsletter, President's Page, April 15, 2011 issue
-- New Laws Require Billing Disclosures by Physicians- from TMA
-- Billing Disclosures Required- from TMA
-- Discounts for Patients- helpful tips from TMA
-- Waiving Copays- could it affect your managed care contract? from TMA
-- Can I waive copayments or deductibles for my Medicare patients?- from TMA Knowledge Center FAQs
-- Write Off or Collect from the Patient?- when a secondary payer is involved? from TMA
-- Financial Hardship Patients- what needs to be considered when a patient is experiencing financial hardship? from TMA
-- Texas Insurance Code- refer to Chapter 1204, Section 1204.055 concerning 'contractual responsibility for deductibles and copayments'
-- Texas Insurance Code- refer to Chapter 552 concerning 'illegal pricing practices'
-- Texas Administrative Code- refer to Examining Boards, Part 9 Texas Medical Board see Chapter 164,Rule 164.3 concerning 'misleading or deceptive advertising'
CLAIM FORM (Paper) - CMS 1500
The National Uniform Claim Committeewww.NUCC.org1500 Health Insurance Claim Form accommodates the reporting of the NPI. This refers to paper claims only. Electronic claims are under federal HIPAA 837 language. The NUCC Web siteprovides a helpful instruction manual with detailed descriptions of each item number on the claim form. Changes and clarifications to the instruction manual also are posted on this site.
Also, the Texas Department of Insurance updated the "submission of clean claims" information to correspond with the revised claim form. See Commisioner's Bulletin #B-0030-07(of July 17, 2007) and information concerning fields 17a and 17b.
Elements of a Clean Claim - the Texas Administrative Code provides a 'field by field' description for CMS-1500 (08/05)
Color-coded CMS-1500 form - a helpful reference indicating the required and conditional fields (from Texas Medical Association)
CMS (Medicare) published a Special Edition MLN Matters article that contains important information on the NPI and claim submission. Please refer to SE0725. Also, seeSE0729for addt'l info about the testing and implementation phase.
CLIA (CLINICAL LABORATORY IMPROVEMENT AMENDMENTS)
The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory testing (except research) performed on humans in the U.S. through the Clinical Laboratory Improvement Amendments (CLIA). The objective of the CLIA program is to ensure quality laboratory testing. All clinical labs must be properly certified to receive Medicare or Medicaid payments. For details...
-- Updated CLIA brochure (pdf) advising why it is important, how test methods are categorized, enrollment information, and the five types of lab certificates
-- Must CLIA Labs Give Patients Test Results?- E-Tip from TMA
CLOSING OR SELLING A PRACTICE
If you are considering retirement or selling or closing your practice, please see our Ethics section for the rules and requirements of the Texas Medical Board (TMB) and helpful tools from the Texas Medical Association.
CODERS / CODING CLASSES / CODING AUDITS
Start your billing and coding career here by researching schools that offer billing and coding programs, and learn more about this growing field at http://www.medicalbillingandcoding.org/
When looking for a qualified coder or someone who can perform external coding audits for your office, look for someone who has received a certification in coding. The American Academy of Professional Coders ; the American Health Information Management Association ; and Practice Management Institute test and certify coders. The Practice Management Institute (PMI) offers training to prepare for their exam. In addition to coding, PMI also provides programs for Certified Medical Office Manager and Certified Medical Insurance Specialist.
The Houston Community College, under theContinuing Education section, provides a course in coding as well as other practical training courses for the medical office.
The Texas Medical Association (TMA) frequently has seminars on coding. Click here for a link to all current seminars and study courses and refer to TMA's billing & coding section for additional assistance.
TMA Practice Consulting has certified professional coders who will review your coding and medical record documentation to determine whether your practice is following payers’ guidelines for appropriate billing. The analysis will include evaluation of CPT and ICD-9 coding and related documentation, and review billing documents such as encounter forms, claims, and the corresponding explanations of benefits. Ten patient records (per provider) representing a mix of payers will be reviewed. Recommendations to correct any problems will be included in a written report within 30 days. Contact TMA Practice Consulting to request a Coding and Documentation Review proposal for your practice at (800) 523-8776 or e-mailTMA Practice Consulting
Each year, as your new coding books arrive, it is imperative that your office adjusts your charge sheets to reflect changes to any of your frequently used codes. For a link to the CMS summary tables... To assist with coding, CMS also publishes an Alpha-Numeric HCPCS Index. To order the most current CPT Book, CPT Assistant, Coding with Modifiers and other coding guides, visit the American Medical Association's AMABookstore. AMA also offers an online CPT code/Relative Value Search look-up tool. You can perform CPT code searches and obtain information about Medicare's relative value payment anount associated with the codes. The tool also provides citations for relevant AMA CPT Assistant articles.
Unraveling Modifier 25
When UnitedHealthcare (UHC) researched its appealed claims, it found the absence of modifier 25 from the initial claim frequently was the reason the claim had been denied. Also, Texas emerged as the #1 state in appealed claims due to the missing modifier 25.The Texas Medical Association (TMA) regularly receives calls and emails related to the proper usage of modifier 25. For that reason, TMA has teamed up with UHC and the American Medical Association to offer a free webinar on using modifier 25 correctly. The 38-minute, archived presentation applies to all payers, not just UHC.
Below are a few reminders about using modifier 25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service):
-- Use modifier 25 with E&M codes only.
-- Modifier 25 is not restricted to a specific level of E&M service.
--Do not use modifier 25 to report an E&M service that results in a decision to perform a major (i.e., 90-day global period) surgery.
--You may use modifier 25 to report a problem-oriented E&M service you provide on the same day as a preventive-medicine E&M service.
--The E&M service may be prompted by the symptom or condition for which you performed the other service or procedure. Different diagnoses are not required for reporting the service or procedure and the E&M service on the same date.
If you need more in-depth training on this modifier's use after viewing thewebinar, contact TMA Practice Consulting at (800) 523-8766 firstname.lastname@example.org. Having trouble appealing a claim dealing with modifier 25 — or any other reason? Report your problem email@example.com and HCMS will help resolve it.
E-Tips from TMA:
--Make Modifiers Work for You
-- Coding a Cancelled Procedure
-- Guidelines for Documenting E&M Services
-- Is This a New Patient or an Established Patient?
-- How to Document E&M on the Basis of Time
CONSULTANTS (PRACTICE MANAGEMENT)
TMA Practice Consultingprovides full-service practice management consulting to help physician members meet operational challenges. Services include: new practice set-up, operations assessment, billing and collections assessment, coding and documentation review, embezzlement risk review, technology readiness assessment, etc.
The Texas Department of Insurance provides help and general instructions for completing the Texas Standardized Credentialing Application form.
Texas House Bill 1594 (HB 1594), effective Sept 1, 2007, provides for expedited credentialing for certain physicians joining a medical group already contracted with a health plan. For more info...
Note: The CAQH Universal Provider Datasource (UPD) service provides a location for physicians to store their data used in credentialing, claims processing, quality assurance, etc. Physicians may enter their information free of charge through an interview-style process. The data is stored in a secure, centralized database housed in the U.S. Physicians then can access, manage and revise their information as needed. For more information...
DELIVERY AND PAYMENT MODELS
Physicians are working to position themselves for a coming wave of delivery and payment innovations designed to reign in healthcare cost growth while also improving the quality of patient care. Physicians also are considering entering into employment or other contractual relationships with hospitals, group practices, and other heath care delivery systems. For information and resources on ACOs, bundled payments, capitation, cash-based practices, fee for service, pay for performance, physician employment, shared savings, and more, please see our Delivery and Payment Models Web page.
To assist you in developing a disaster preparedness plan for your practice...
--TMA/TMLT Web Seminars - for live and recorded Webinars, many for CME credit and TMLT discount, please see TMA's Distance Learning page.
--BlueCross BlueShield of Texas - offers Web-based training available to you in the convenience of your office. These interactive courses are a combination of a conference call and on-line training and have been tailored to meet specific needs of the physician's office. For more info, see BCBSTX Provider Training...
-- Availity - offers training Webinars. For more info and to register, log into the secure Availity Portal and select FREE TRAINING from any page.
ELECTRONIC DEATH REGISTRATION
The TX Dept of State Health Services (DSHS) oversees the online death registration system, Texas Electronic Registrar (TER).
-- TMB electronic death record update- HCMS Physician Newsletter, Oct 15, 2011 issue
-- Law requires electronic death registration- (Note: penalities for non-compliance start at $500) HCMS Physician Newsletter, June 2010 issue
-- Death Issues- TMA Board of Councilors Current Opinion
EMTALA (EMERGENCY MEDICAL TREATMENT & ACTIVE LABOR ACT)
The federal Emergency Medical Treatment & Labor Act (EMTALA) requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests an exam, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition. EMTALA affects on-call physicians.
Some EMTALA resources from the Texas Medical Association (TMA):
-- legal article on EMTALA from the TMA Office of the General Counsel
-- EMTALA final rule...
Some EMTALA resources from the American Medical Association (AMA):
-- EMTALA Quick Reference Guide for On-Call Physicians...
-- EMTALA changes (under Medical Staff Topics)...
--SECTION 1011 OF THE MMA - UNREIMBURSED CARE TO UNDOCUMENTED IMMIGRANTS
Texas physicians who provide emergency services to undocumented residents may receive federal funding under Section 1011 of the Medicare Modernization Act. These payments are designed to ease the financial burdens on physicians, hospitals, and ambulance services that comply with EMTALA and the Medicare bill's border health provisions.
For more Section 1011 info and to enroll for benefits, please click on the below links:
Novitas Solutions- the designated Section 1011 contractor- for enrollment forms, news & updates, customer service, claims processing
Section 1011 Payment Under EMTLA(TMA Web page) - info for physicians from the Texas Medical Association
HEALTH INFORMATION TECHNOLOGY (HIT)
For information on electronic health/medical records, e-prescribing, Version 5010, and ICD-10-CM, please refer to our HIT Web section.
HEALTH INSURANCE FOR SMALL EMPLOYERS
The Texas Department of Insurance provides information about health insuranceandconsumer guidance on health care coverageto help individuals and employers make an informed decision when purchasing health insurance. TDI also has a complete list of companies licensed to sell small employeraccident and health coverage in Texas. (For Web site links to some of these plans, please see the Managed Care sectionof this site.) For info about Federal Health Care Reform, the Affordable Care Act, FAQs, and federal and state resources, please see the TDI Federal Health Care Reform ResourceWeb page.
TexHealth Harris County 3-Share Plan The 3-Share Plan is an affordable health plan for small businesses whose cost is shared among employers and their employees and is subsidized by one or more sources of local, state or federal funding. The Harris County 3-Share Plan is an inititative of the Harris County Healthcare Alliance to address the health care coverage needs of the working uninsured. Participating businesses must be small employers (2-50 employees) who have not offered group health insurance to their employees in the past 12 months. For more info, eligibility requirements, plan benefits, and rates, please visit their Web site or contact them at 713-368-1336.
-- Healthy Texas Online is a statewide private/public health insurance program designed for small businesses and their employees.
-- Texas Health Options has additional resources for finding health insurance coverage.
-- Houston Health Choicehelps consumers make informed choices about their insurance coverage.
For assistance with the various rules and regulations of the Health Insurance Portability and Accountability Act (HIPAA), click here.
Many hospital systems in the Houston area provide direct Web portal links for physicians to access their patients' clinical and billing information.
The Texas Medical Association has gathered a number of legal articles and papers, as well as information concerning court cases/decisions, regulatory requirements, etc. in the Legal Information section of their site.
The Texas Department of Insurance (TDI) has a list of licensed professional (medical) liability carriers. The helpful 'Medical Liability Insurance Shopping Guide' from TDI provides practical information when choosing or renewing a plan.
Articles and legal information involving liability and charity care:
-- Volunteer Protection Act of 1997 Federal Law
-- Limiting Liability for Providing Charity Health Care
-- Consent Form for Charity Care(revised April 2006)
MARKETING YOUR PRACTICE
HCMS can assist you with marketing and growing your practice and increasing your patient base.
--With the Patient Base Development Program, HCMS offers many services that can aid you in growing your practice. We can help you to create your personal patient development plan by reaching out to thousands of physicians practicing in the Greater Houston area. To learn more...
-- Medical Practice Listings in the HCMS RosterLet colleagues know more about you and your practice.
-- Thinking of creating a brochure for your practice? - For some of the benefits (TMA)
-- Designing an effective practice brochure - To create an effective, professional brochure (TMA)
-- Practice brochure templates - Helpful guides to create your own practice brochures (TMA)
-- Marketing your practice - Stay compliant with Medicare marketing rules, advertising board certification, and more (TMA)
-- Patient/customer service - Tips and articles on how to improve customer satisfaction (TMA)
-- Practice Listing - Let colleagues know more about you! - HCMS Physician Newsletter, Nov 15, 2011 issue
-- Marketing your practice using your member benefits - HCMS Physician Newsletter, Sept 15, 2011 issue
-- Patient base development - What can HCMS do for you? - HCMS Physician Newsletter, March 15, 2010 issue
-- Marketing on a shoestring - HCMS Physician Newsletter, Nov 1, 2009 issue
-- Tool for promoting your practice - HCMS Physician Newsletter, Nov 1, 2009 issue
To encourage your patients to establish a "medical home," HCMS has developed flyers in English and Spanish for posting in your office.English(pdf) and Spanishpdf)
Please refer to the HCMS Ethics-Physician web page for information on medical records, as well as information on Closing, Selling or Departing from a Practice.
NATIONAL PROVIDER IDENTIFIER (NPI)
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for health care providers. The National Provider Identifier (NPI) was adopted as this standard. For more information, please refer to the HIPAA section of this site.
NEW PRACTICE INFORMATION
Whether embarking on a new practice, expanding an existing one, or relocating to the Houston area, HCMS member physicians will find the New Practice Checklist an invaluable resource in the creation and maintenance of a successful enterprise.
If you are new to Texas or have recruited a physician from out of state, be sure to check out Texas Medical Association'sNew to Texas Resource Page. Also, HCMS can help you to grow your practice and increase your patient base! Please refer to the above marketing info.
NOTICES FOR POSTING IN OFFICE
The Texas Medical Association provides guidance on notices (for employees and patients) that should be posted in the medical office.
For your Employees:
The Texas Workforce Commission (TWC) requires any Texas and Federal Labor Law postings to be visible to the staff. The TWC's "Posters at the Workplace" section of their Web site is located athttp://www.twc.state.tx.us/ui/lablaw/posters.html. The US Department of Labor (DOL) provides an overview to help determine which of their posters are required for small business and other employers. This "elaws Poster Advisor" and the needed posters can be found on the DOL Web page at http://www.dol.gov/compliance/topics/posters.htm.
For your Patients:
Both the Texas Medical Board (TMB) and the Texas Department of Insurance (TDI) have notices that must be posted in your office where patients can easily read them. (Both notices are in English and Spanish.)
The TMB's Notice Concerning Complaints advises patients who have a complaint against a physician of the TMB's address and telephone number. The current notice can be found athttp://www.tmb.state.tx.us/professionals/hcpres/compost.php.
The TDI's Notice to HMO Patients advises HMO patients of the steps they should take if they have a complaint against their HMO plan. The current notice can be found athttp://www.tdi.texas.gov/hmo/documents/hmonote.pdf.
PHYSICIAN RATINGS BY HEALTH PLANS
For information about the rules health plans must follow when rating physicians as well as a TMA guide to assist in reviewing and disputing a ranking, please refer to the Managed Care section of our site.
Physicians now have the opportunity to help patients with pre-existing conditions obtain affordable and comprehensive health coverage. The Pre-Existing Condition Health Plan (PCIP) has changed its guidelines to allow adults and children to submit a letter from a doctor as proof of a pre-existing condition to enroll in PCIP. PCIP is a federal program and is administered by the Government Employees Health Association. To qualify, an applicant must: be a U.S. citizen or reside in the U.S. legally; have not been insured in the past six months; have a pre-existing condition or have been denied coverage because of a health condition.
ThePre-Existing Condition Insurance Plan (PCIP)rates are lower than the rates in the Texas Health Insurance Pool (THIP), which also is for patients with pre-existing conditions. Patients may apply for PCIP online atwww.pcip.gov. Forplan info and options...
For more information, call 1-855-TEX-CHAP or go towww.TexasHealthOptions.com.
For information from the Texas Department of Insurance (TDI)about Federal Health Reform, the Affordable Care Act, FAQs, and federal and state resources...
Requirements under other individual policies and insurance plans
Federal and state requirements affect how pre-existing conditions are to be considered under other individual policies and insurance plans. Information can be found at the federal Dept of Labor HIPAA site under FAQs, in the Texas Insurance Code and in the Texas Administrative Code.
From the Federal Dept of Labor -HIPAA FAQ:
How does HIPAA apply when changing from group health coverage to an individual insurance policy?
HIPAA also protects those who are otherwise unable to get group health insurance.
The law guarantees access to individual insurance policies and state high-risk pools for eligible individuals. They must meet all of the following criteria:
* Had coverage for at least 18 months, most recently in a group health plan, without a significant break;
* Lost group coverage but not because of fraud or nonpayment of premiums;
* Are not eligible for COBRA coverage; or if COBRA coverage was offered under Federal or state law, elected and exhausted it; and
* Are not eligible for coverage under another group health plan, Medicare, or Medicaid; or have any other health insurance coverage.
The opportunity to buy an individual policy is the same whether a person quits a job, was fired, or was laid off.
From the Texas Insurance Code -TIC 1201.151 - 1201.154:
SUBCHAPTER D. PREEXISTING CONDITIONS:
Sec. 1201.151. COMPLIANCE WITH SUBCHAPTER; PROHIBITION OF DEFENSE. Except as provided by this subchapter, an individual accident and health insurance policy may not include a provision that permits a defense based on a preexisting condition.
Sec. 1201.154. COVERAGE FOR CERTAIN PREVIOUSLY COVERED PERSONS.
(a) In this section, "creditable coverage" has the meaning assigned by Sec. 1205.004(a).
(b) A preexisting condition provision in an individual accident and health insurance policy may not apply to an individual who was continuously covered for an aggregate period of 18 months by creditable coverage that was in effect up to a date not more than 63 days before the effective date of the individual coverage, excluding any waiting period.
(c) In determining whether a preexisting condition provision of an individual accident and health insurance policy applies to an individual, an insurer shall credit the time the individual previously was covered under creditable coverage if the previous coverage was in effect at any time during the 18 months preceding the effective date of the individual coverage.
The Texas Administrative Code provides even more detailed information atTAC 3.3018 under the Policy Definition of a Preexisting Condition (TAC Title 28, Part 1, Chaper 3, Subchapter D, Rule 3.3018).
PRESCRIBING DATA / PHYSICIAN DATA RESTRICTION PROGRAM (PDRP)
The American Medical Association (AMA) created the Physician Data Restriction Program (PDRP) in 2006 to offer physicians the option to restrict their prescribing data from pharmaceutical sales representatives. The PDRP also allows physicians to register complaints against sales representatives or pharmaceutical companies who they believe are using their prescribing data inappropriately. Below are materials about this program and how physicians can make an individual choice about the accessibility of their prescribing data. For more information and to register for the PDRP, please see the AMA's PDRP Web page. (Note: This program is available to all physicians, both AMA members and nonmembers.)
--An overview of the Physician Data Restriction Program (PDRP) also discusses enforcement
-- Physicians discuss use of prescribing data the pros and cons of restricting data
-- Q&A on the Physician Data Restriction Program
-- Physician prescribing data - The choice is yours - How to register
-- AMA Therapeutic Insights program offers quarterly online newsletters with current treatment guidelines
PRESCRIPTIONS (RX) / PHARMACEUTICAL SAMPLES
For some information and requirements involving prescription medications and providing free pharmaceutical samples to patients, please click on the links below:
--Drugs - TMA Board of Councilors Current Opinion
--To register for FDA alerts as soon as they are issued (through HCNN).
--TMF Health Quality Institute has a project to promote Part D drug safety.
--TDPS requirements for Schedule II-V controlled substances; and DPS notification of July 7, 2008.
--Q&A from the TSBP concerning substitution laws and rules.
--Health insurance plan requests for DEA numbers; and TDI bulletins on appropriate use.
--Drug registration info: TX Dept of Public Safety; DEA Office of Diversion Control.
--Prescription pad requirements for controlled substances (schedules II through V) (info from the TX Controlled Substances Act, TX Dangerous Drugs Act, and the rules of the Texas Board of Pharmacy).
--For Medicaid requirements on prescription pad and drug claims, please refer to the Medicaid Section under Prescription/Drug Claims and Medicaid.
--Writing valid prescriptions - what makes a "valid" prescription? (info from the Texas Secretary of State Web site).
--Over-the-counter drugs/items that require a prescription for a patient to be reimbursed under a tax-deferred health benefit plan.
--For electronic prescribing resources, please see our E-Prescribing Web page...
Pharmaceutical samples to patients:
Below are statutes/rules from the Texas Medical Board about providing free pharmaceutical samples to patients and record keeping:
Statute Sec. 158.002. PROVISION OF FREE SAMPLES:
(a) This chapter does not prohibit a physician from supplying a pharmaceutical sample to a patient free of charge if, in the physician's opinion, it is advantageous to the patient, in adhering to a course of treatment prescribed by the physician, to receive the sample.
(b) A pharmaceutical sample provided under this section must be: (1) provided to the physician from the manufacturer free of charge and delivered to a patient free of any direct or indirect charge; (2) prepackaged by the original manufacturer and not repackaged; and (3) marked on the immediate container to indicate that it is a sample or recorded in records that indicate it is a sample.
(c) Each state and federal labeling and recordkeeping requirement must be followed and documented. A record maintained under Subsection (b)(3) must be accessible as provided under state and federal law.
Rule 169.7 RECORD KEEPING:
(a) The following provisions relate to dangerous drugs:
(1) A licensee shall be presumed to have complied with record keeping requirements for dangerous drugs (the Texas Health and Safety Code, Chapter 483) received as pharmaceutical samples if: (A) the licensee maintains a copy of each signed request form for samples required by the Prescription Drug Marketing Act of 1987, Public Law Number 100-293, 102 Statute 95 (21 United States Code 503(D) for a period of two years from the date of acquisition; and (B) the licensee makes appropriate entries in patients' medical records when a pharmaceutical sample is supplied to a patient.
(b) The following provisions relate to controlled substances:
(1) A licensee shall be presumed to have complied with record keeping requirements for controlled substances (the Texas Health and Safety Code, Chapter 481) received as pharmaceutical samples if: (A) the licensee maintains a copy of each signed request form for samples required by the Prescription Drug Marketing Act of 1987, Public Law Number 100-293, 102 Statute 95 (21 United States Code 503(D) for a period of two years from the date of acquisition; and (B) the licensee maintains records of pharmaceutical samples as required by the Texas Department of Public Safety under 37 TAC §§13.201 - 13.209 (Controlled Substances - Record Keeping).
PROMPT PAY / CLEAN CLAIMS / SB418
Please refer to our TDI Prompt Pay Rules & Proceduressection.
For information and resources involving health care quality, such as quality improvement programs, physician ranking, and patient experience, please see our Quality Web page.
RED FLAGS RULE - IDENTITY THEFT PREVENTION
For information on the Red Flags Rule, the regulations issued by the Federal Trade Commission (FTC) to protect consumers and prevent identity theft, please refer to our Red Flags Rule Web page.
Two Options for refunding overpayments:
Under Section 6402 of the Affordable Care Act, Medicare and Medicaid providers and suppliers are liable under the False Claims Act for failure to disclose and refund to Medicare or Medicaid any overpayments within 60 days after the date the overpayment is identified, or the date the next applicable cost report is due. However, many providers may not be aware there is an overlap between the CMS Policy and existing avenues for resolving overpayment liability under the Office of Inspector General (OIG) Self‐Disclosure Protocol (the “SDP”). To read more please click here.
To claim or report unclaimed property, please refer to the Texas Comptroller Office for Unclaimed Property. For answers tofrequently asked questions... For holder info andreporting unclaimed property...
RESOURCES FOR YOUR PRACTICE
-- If you are looking for resources for your practice (such as accounting, banking, billing, EMR, etc.), the Medserv/Practice Services section of our site can be a real help. Listings also include Friends of the Society who are organizations committed to serving the needs of our physicians and their staff. For Friends of the Society... For an index of practice services...
-- HCMS has developed helpful Practice Tool Kits-Administrative Efficiency to aid our members in starting, running and closing a practice.
-- HCMS has created grids and tables such as health plan contact information, search for an in-network physician who speaks another language, guarantee of payment, incentive bonus program, Web portals, and more.
-- An excellent resource for a medical practice is Physicians Practice. Assistance with such issues as reducing claim denials, improving collections, electronic billing, coding, budgeting, contracting, staff retention, office operations, and many other matters can be found here. The Tools section provides various financial calculators with worksheets to enter in your own data. Sample calculators are: Accounts Receivable Key Indicators; Denials Tracking Worksheet;E&M Coding Calculator; and Overhead Calculator and Benchmarking Tool. For a link to this invaluable resource, please click here.
-- The Texas Medical Association (TMA) has produced a number of practice management publications and presentations to assist with medical office policy and procedures, fraud and abuse prevention, TMB resolution, OSHA compliance as well as many others. Please see the TMA Store for a complete listing. TMA also has developed interactive tools and resources, including an EMR Product Evaluation Tool, a Student Loan Calculator, Practice Change Sample Forms, How to Perform a Physician Practice Internal Billing Audit, and more. Also refer to their Practice Operations Web page for more assistance.
--The American Medical Association (AMA) also offers solutions for managing your practice including How to perform a physician practice internal billing audit.
REVENUE CYCLE MANAGEMENT
The Harris County Medical Society Board on Socioeconomics, through its Subcommittee on Administrative Relief, has researched administrative Web portals that assist physicians with the management of their revenue cycle. For information about these companies and a detailed comparison chart of the services offered by the Web portals by payer, please refer to our HCMS Grids and Tablespage. HCMS is dedicated to assisting its members on getting practice administrative relief. If you have any ideas that you would like to share with HCMS on how you have saved time and decreased administrative burdens in your office, please fax them to 713-528-0951.
TheTexas Medical Board(TMB) answers frequently asked questions about telemedicine.
--What is the definition of a "face-to-face" visit? HCMS Physician Newsletter, January 2011 issue
--TMB rules on telemedicine - Part 1-General Administration HCMS Physician Newsletter, April 15, 2011 issue
--TMB rules on telemedicine - Part 2-Medical service provided HCMS Physician Newsletter, May 1, 2011 issue
--TMB rules on telemedicine - Part 3-Evaluation HCMS Physician Newsletter, May 15 ,2011 issue
For theTexas Medical Association (TMA) HIT section and mHealth (mobile health) technology...
TEXAS DEPARTMENT OF INSURANCE (TDI)
TDI Physician INfo & Advice
The Texas Department of Insurance (TDI) has gathered information of specific interest to physicians on topics ranging from prompt pay , to filing a complaint , to medical liability insurance under Physicians & Health Providers Resources. For assistance with filing a complaint and which agency oversees the various types of plans, please click here.
Texas Standardized Credentialing Form
To assist physicians with the credentialing process, the Texas Department of Insurance developed and implemented a single, standardized application for physician credentialing. For help and general instructions on the application and for the links to download the document pages and checklists...
Prompt Pay/Clean Claims/SB418
The Texas Department of Insurance (TDI) is the state agency responsible for overseeing and enforcing the Prompt Payment rules and procedures. SB418 is the current prompt pay/clean claims law effective for fully-insured claims. For info and helpful charts and links...
TEXAS MEDICAL ASSOCIATION (TMA)
TMA Support Center
The Texas Medical Association (TMA) has complied their most frequently asked questions in an easy to use Q&A format for members only. Find information on membership, advocacy, public health, practice management, and much more. For the Support Center...
TMA Knowledge Center (Ask TMA)
TMA has information specialists decicated to answering a wide variety of questions involving CME, claims, health care, health law, HIPAA, legal issues, medical economics, medical records, practice management, and more. Call the Knowledge Center at 1-800-880-7955, see the resources at Knowledge Center , or e-mail firstname.lastname@example.org
TMA Policy & Procedure Manual
The Texas Medical Association has developed a practical, easy-to-use, and customizable Policies and Procedures Guide that contains more than 200 up-to-date policies and procedures, tools, sample letters, and forms. Written by practice management and health law experts, this guide includes new policies on compliance, human resources, front desk and business office operations, safety, and more. For details and to order...
TMA Practice E-Tips
TMA has developed an electronic newsletter that offers brief, practical tips for managing a medical practice. TMA Practice E-Tips is published twice a month and provides helpful advice on coding, billing, reimbursement, office policies and procedures, practice marketing, etc., with useful links for additional information. Click here to visit the archives and to sign up to receive this e-newsletter.
TMA Practice Management Assistance
The TMA Practice Management section assists the physician's office in a variety of areas such as billing, coding, practice operations, technology, and more.
TMA Practice Management Courses and Publications
TMA provides regular seminars, Webinars and distance learning study courses, many of which provide CME credit. For a listing of publications, please see the TMA Store.
TMA Practice Consulting
TMA Practice Consulting provides full-service practice management consulting to help physician members meet operational challenges. Services include: new practice set-up, operations assessment, billing and collections assessment, coding and documentation review, embezzlement risk review, technology readiness assessment, etc.
TEXAS MEDICAL BOARD (TMB)
For information about the Texas Medical Board, it's rules and regulations, the Medical Practice Act, renewing your medical license, etc., please refer to the Ethics/Physician Information section of this site.
TEXAS MEDICAL LIABILITY TRUST (TMLT) PRACTICE REVIEW
A practice review involves an on-site evaluation by a TMLT risk management professional to help determine your risk exposure. The review will examine the office for physical safety concerns, review practice policies and procedures, evaluate medical record documentation, and provide follow up through a confidential, written summary. Practice reviews are free to all TMLT policyholders. For more info...
The state has developed a formula to assist physicians with calculating uncompensated care, including an example of how to do the calculation.