Practice Management

Keywords: Billing_and_Collections  CLIA  EMTALA  New_Practice  Physician_Owned_Facilities  Practice_Management  Practice_Marketing  
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 PRACTICE MANAGEMENT UPDATES

TMLT Practice Review:

  • 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... 

Web-based Training: 

PRACTICE MANAGEMENT TOOLS

MARKETING AND GROWING YOUR PRACTICE  
Would you like to increase your patient base? Need help with marketing? HCMS can help! For more...

DISASTER PREPAREDNESS  
To assist you in developing a disaster preparedness plan for your practice...

Other aids 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...   

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.

Another helpful tool is Physician's News Digest. 

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, medical records issues, documentation strategies, billing and OSHA compliance as well as many others.  For a list of other TMA resources, please click here.

The American Medical Association (AMA) also offers solutions for managing your practice.

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.)

 

TEXAS MEDICAL ASSOCIATION (TMA) INFORMATION

 

TMA KNOWLEDGE CENTER
The Texas Medical Association (TMA) has established a 'Knowledge Center' to provide members with rapid access to the association's accumulated expertise in coding, practice management, health care, health law, medical economics, public health, etc.   Visit the Knowledge Base, or call (800) 880-7955 from 8:15am to 5:15pm (CT) Monday through Friday to speak to a TMA information specialist, or e-mail the Knowledge Center at knowledge@texmed.org.

The TMA Knowledge Center also provides an e-mail alert service that allows members to keep abreast of new articles by subject.  This is done via searches that are first saved and then set to run automatically on a regular basis (daily, weekly, monthly, etc.).  The results of these searches are e-mailed directly to the user.  If you would like an e-mail alert on any topic of interest to you, the TMA Knowledge Center staff will set it up and have it sent to your e-mail.  To sign up for this service, click here.


TMA COMMUNITIES
TMA has an online interactive tool that provides a quick and convenient way for physicians and their office staff to exchange ideas, post questions, share best practices, access hot topics, and find resources and links.  Also, TMA experts post the very latest news concerning reimbursement issues, health plan updates, managed care, Medicare, and office technology.  Currently, TMA has two community pages: Office Technologies and Reimbursement.  For more information and to join, click here.

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.
Below are some E-Tips from TMA.  (More E-Tips are located throughout the Business of Medicine section.)

TMA PRACTICE MANAGEMENT ASSISTANCE
The TMA Practice Management section provides invaluable guidance to the physician's office in a variety of areas such as billing and collections, coding, risk management, human resources, regulatory issues, technology, and marketing your practice.

TMA POLICY & PROCEDURE MANUAL
TMA has prepared a HIPAA-compliant Policy and Procedure Manual that covers everything from privacy policies, to employee relations, to financial operations, and is a vital component to smooth-running office operations.  You'll receive both a hardcopy and a CD-ROM with over 150 policies, including sample forms and letters that are customizable to your office. Call (800) 880-7955 or (512) 370-1550 to order or click here to view a complete table of contents.

TMA PRACTICE MANAGEMENT PUBLICATIONS AND PRESENTATIONS
The Texas Medical Association (TMA) has produced a number of other practice management publications and presentations to assist with a variety of issues including fraud and abuse prevention, medical records, documentation strategies, billing and OSHA compliance, etc.  Many of these courses provide CME credit.

TMA SEMINARS, STUDY COURSES, LIVE COURSES and AUDIO SEMINARS
TMA also provides regular CME Seminars and Study Courses, and they hold various Live Courses and Audio Seminars throughout the year.  If you would like to receive an e-mail notification when a new practice management seminar or webinar has been developed, sign-up here.

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 DEPARTMENT OF INSURANCE (TDI) INFORMATION

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 Provider 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.
Click here for the link to download the credentialing form and to review the 'Frequently Asked Questions' about the revised form.
For more information, see  Texas Medicine, Sept 2006   Members Only box

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... 
  


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 HCMS Physician Newsletter, May 1, 2007

BILLING, COLLECTIONS AND DISCOUNTS        
Below are some strategies to solve billing and collection problems.  TMA's Reimbursement section, Texas Medicine, Physicians Practice and Physician's News Digest provide additional help.  TMA Practice Consulting also can assist by providing a billing & collections assessment.  

Billing and Collections: 


 

 

 

 

Discounts:

Can a physician give patient discounts? When is it appropriate? What are the the legal concerns? Below are some guidelines and laws to consider: 

 

CLAIM FORM - CMS 1500 (08/05) 
The National Uniform Claim Committee (www.NUCC.org) released the revised version of the 1500 Health Insurance Claim Form (version 08/05) that accommodates the reporting of the NPI.  This refers to paper claims only.  Electronic claims are under federal HIPAA 837 language.  (For more...)

The NUCC Web site provides a helpful 55-page instruction manual with detailed descriptions of each item number on the claim form.  Changes/clarifications to the instruction manual also are posted on this site.

Also, the Texas Department of Insurance has 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)  Members Only box

CMS (Medicare) has published a Special Edition MLN Matters article that contains important information on the NPI and claim submission.  Please refer to SE0725.  Also, see SE0729 for 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...)

CLOSING A PRACTICE
If you are considering retirement or selling or closing your practice, TMA provides some helpful tools.  Please also review our Ethics section for more information.

CODERS / CODING CLASSES / CODING AUDITS
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 the Continuing Education section, provides a course in coding as well as other practical training courses for the medical office.

TMA frequently has seminars on coding.  Click here for a link to all current seminars and study courses.

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-mail TMA Practice Consulting.

CODING
Each year, as your new coding books arrive, it is imperative that you adjust your charge sheets to reflect changes to any of your frequently used codes.

To order the most current CPT Book, CPT Assistant, Coding with Modifiers and other coding guides, visit the American Medical Association's CPT products and services page.

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. 

To assist with coding, CMS has published the 2009 HCPCS Index in alpha-numeric format (pdf).

From HCMS Physician Newsletter:

E-Tips from TMA:

The TMA Knowledge Center can provide additional assistance with your coding questions.

CONSULTANTS (PRACTICE MANAGEMENT)
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.

CREDENTIALING
Please refer to the Texas Department of Insurance information section above for a link to the Texas Standardized Credentialing 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...   

ELECTRONIC DEATH REGISTRATION
The TX Dept of State Health Services (DSHS) oversees the online death registration system, Texas Electronic Registrar (TER). 

ELECTRONIC HEALTH/MEDICAL RECORDS and HEALTH INFORMATION TECHNOLOGY (HIT)
The implementation of electronic health/medical records (EHRs/EMRs) is becoming more widespread with increasing technological innovations.  Additionally, the use of EHRs has been encouraged with the rise in quality and performance improvement initiatives as EHRs serve as an excellent channel for reporting performance and quality of care data.  For more information about EHRs, please see the Health Information Technology section of this site.

For exceptions to the Stark Laws for electronic health records and electronic prescribing, please refer to information below.

One requirement of the 2009 federal economic stimulus bill is to notify patients and the US Dept of Health & Human Services (HHS) of "unsecured" electronic private health information (PHI) leaks or breaches.  This requirement is effective Sept 15, 2009.  For more from TMA...  

Prepare to meet "meaningful use" EMR requirement.  For more from AMA...  (AMA News, June 22, 2009 issue)   

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.  The Texas Medical Association has provided an EMTALA resource page to assist with the changing rules. Members Only box

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 details and to enroll for benefits, please click on the below links.

HEALTH INSURANCE FOR SMALL EMPLOYERS
The Texas Department of Insurance has provided helpful information and an online brochure to assist employers (and individuals) in making an informed decision when purchasing health insurance.  The site also has a complete list of companies licensed to sell small employer accident and health coverage in Texas.
(For Web site links to some of these plans, please see the Managed Care section of this site.)
Also, HoustonHealthChoice.com has been designed to help consumers make informed choices about health insurance coverage.

How much of your premium goes to health care? - How to find out... - HCMS Physician Newsletter, September 1, 2008 issue  

HIPAA RESOURCES
For assistance with the various rules and regulations of the Health Insurance Portability and Accountability Act (HIPAA), click here.

LEGAL ISSUES
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.

LIABILITY ISSUES
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:

MARKETING YOUR PRACTICE      new   
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... 
  • Practice Listings in the HCMS Roster

Other resources:

MEDICAL RECORDS
The Texas Medical Board is the state agency which regulates medical records.  For a link to all the Board's rules... 

For specific information such as requests for and maintenance and destruction of medical records, please see the Ethics section of this site.

Also, the Texas Medical Association has provided a Release of Medical Records: A Guide for Physicians that gives practical guidance to the physician's office. Members Only box

Of course, the privacy rules of the federal Health Insurance Portability & Accountability Act (HIPAA) also must be taken into account concerning the release of medical records.

From TMA and the Harris County Physician Newsletter (HCMS):

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.


 NPI NATIONAL REGISTRY (Look Up)
 For a link to the national registry to look up NPI numbers by individual or organization, click here.

 


TMA - NPI Resource Center  
For help with implementing the NPI, the Texas Medical Association has developed the NPI Resource Center.  Included in this resource center are links to the TMA NPI Look-Up Tool (with instructional video) and to the location where you can add your NPI information to this database.  (The NPI database is for members only.) 

NEW PRACTICE INFORMATION
Whether embarking on a new practice, expanding existing ones, 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.  Members Only box

If you are new to Texas or have recruited a physician from out of state, be sure to check out Texas Medical Association's New 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
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.)

TMB's Notice Concerning Complaints advises patients who have a complaint against a physician of the TMB's address and telephone number.

TDI's Notice to HMO Patients

Also, with the 'transparency laws' in effect, a medical practice is required to reveal specific billing information to patients.  Click here for a notice advising patients that the practice's billing and charity care policies are available for review.

PRE-EXISTING CONDITIONS         new
Federal and state requirements affect how pre-existing conditions are to be considered under individual policies and other 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.  Note info below:

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 at TAC 3.3018 under the Policy Definition of a Preexisting Condition (TAC Title 28, Part 1, Chaper 3, Subchapter D, Rule 3.3018).

PRESCRIPTIONS (RX)   
For some information and requirements involving prescription medications, please click on the links below:

PROMPT PAY / CLEAN CLAIMS / SB418
Please refer to the TDI Prompt Pay Rules & Procedures section.  

RECORDS
TMA Records Retention Program can be used as a guideline.   Members Only box 

RED FLAGS RULE - IDENTITY THEFT PREVENTION 
Physicians who regularly bill their patients for services (including copayments and coinsurance) will need to comply with Federal Trade Commission (FTC) regulations that require covered entities to develop and implement identity theft prevention programs. According to the FTC, programs must identify and respond to "patterns, practices, or specific activities-known as "red flags"-that indicate the possibility of identity theft."
The Federal Trade Commission announced that the Red Flags Rule is delayed until June 1, 2010.  For more information on the FTC's decision...  
Red flag rules delayed again - HCMS Physician Newsletter, Nov 15, 2009
For more info, resources, and sample policies and procedures from TMA...
For info from AMA....  (Note: AMA has been urging the FTC and Congress to not consider physicians as "creditors" and therefore not be subject to the rule.)  
And for a helpful guide, FAQs, etc., from the FTC...
 

REVENUE CYCLE MANAGEMENT         new
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 for a detailed comparison chart of the services offered by the Web portals by payer, please click on the links below:

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.

Clearinghouse Services
For a comparison of clearinghouse services, see the June 2009 survey report from healthcare executives and professionals through KLAS. 

STARK LAWS / PHYSICIAN OWNERSHIP 
The Stark Laws were originally passed to prohibit physicians from referring Medicare patients for certain designated health services to an entity with which the physician or a member of the physician's immediate family has a financial relationship-unless an exception applies. (See the Federal Register, Sept 24, 2004...)

However, the Federal government established two exceptions to the Stark Laws to allow protected donors to make certain nonmonetary donations of hardware, software and related training services to physicians for e-prescribing and for electronic health records purposes.  Please refer to the specific exceptions published by CMS.

Also, the TMA has provided additional help in this area: TMA Helps Physicians Navigate Stark and Antikickback Regulations.  TMA Action, April 2007

Medicare - Physician Self Referral and Hospital Ownership Disclosure
CMS has provided detailed information about referring Medicare patients to an entity with which the physician or the physician's immediate family has a financial relationship...  See CMS MLN Matters #6306 of March 6, 2009...  CMS has published a fact sheet of August 4, 2008...   Also, see the HCMS Physician Newsletter, September 15, 2008 issue...   

Texas law requires physicians who hold an ownership interest in certain specialized hospitals to submit a Notice of Ownership Interest in a Niche Hospital  to the Texas Department of State Health Services.  Also, if the physician or an immediate family member has a financial interest in a specialized hospital, the physician must disclose this fact to the patient, in writing, along with notice that the patient has the option of using an alternative health care facility.  (For addt'l info...)

The American Medical Association (AMA) Council of Ethical and Judicial Affairs (CEJA) also has an opinion concerning conflict of interest and health facility ownership by a physician. (For addt'l info...) 

USUAL AND CUSTOMARY RATES
If you are experiencing large reductions in your 'usual and customary rates'....  report it to the TMA -  HCMS Physician Newsletter, September 1, 2008 issue  

 

  

 


Last Updated 1/21/2010 - Print This Page

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