Author Archives: Vignesh Eswaramoorthy

How is Chronic Care Management Evolving?

The Centers for Medicare and Medicaid-recognized the importance of including a sustainable practice to manage care for patients suffering from multiple chronic conditions in the year 2015.
Medicare leveraged Physician Fee Schedule (PFS) options for CCM services offered to patients ailing from chronic conditions.

It’s been over 2 years since the implementation of Chronic Care Management services for patients.
CMS has closely observed the outcomes of those initiatives and has come up with plans that will increase the focus and funding towards the existing Chronic Care Management programs.

Let’s Understand CPT 99490

To be able to differentiate the purpose of the old codes from the new codes, one must understand the conditions for billing under CPT 99490. Chronic Care Management Services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements:

Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
Comprehensive care plan established, implemented, revised, or monitored

Assumes 15 minutes of work by the billing practitioner per month

What’s new in Complex CCM codes?

The primary limitation of CPT 99490 is the consulting time of 20 minutes, most practices felt the need to increase the consultation time for a patient.
Though CCM services resulted in positive outcomes, the results were far short of objectives.
Thus, they decided to increase the consulting time of CCM with new Complex CCM codes that can be used to provide 60 minutes of consulting in a calendar month and the duration of 60 minutes is billable.

Complex Chronic Care Management services, with the following, required elements:

1. Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
2. Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
3. Establishment or substantial revision of a comprehensive care plan
4. Moderate or high complexity medical decision making
5. 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month

How does the billing work?

A patient must be billed either for Complex Chronic Care Management codes or the already existing Chronic Care Management code.
The same patient should not be included or billed under both the codes, that way there’s more organized workflow for billing and reimbursement.

Reporting Expectations

Chronic Care Management codes CPT 99487, 99489, and 99490 are reported only once in every calendar month by the practitioner who carried out the care management, no more than one claim per month was allowed.
In the case of Complex Care Management, each month a practitioner is expected to review patient’s health condition and classify whether the patient would still be under the procedures of Complex Care Management or the existing Chronic Care Management codes.

This is a crucial practice to establish the health outcome of the patients given the importance and assistance for chronic conditions, in addition to that practitioners are expected to meet the quality metrics that are recommended by CMS.

Implementation of Comprehensive Care Plan at a practice level

New Chronic Care Management codes stress the necessity and induce the interest in creating an individual care plan for each of the patient’s for achieving better health outcomes.
It is important for the healthcare provider to record and assess patient health information at regular intervals.

An electronic form of secure patient information needs to be generated, based on which a physician can come up with a care plan that is required for the patients.
With technology companies extending their influence in healthcare, remote patient monitoring and real-time patient data can be gathered and put to best use. Creation and execution of care plan is one of the primary responsibility of the provider to adhere to quality metrics expected by the CMS.

HealthViewX is in the business of Healthcare IT, we offer a suite of comprehensive IT solutions from Referral Management, Chronic Care Management and a holistic Care Management Platform.

5 Healthcare Trends To Watch Out

The past year was a year of change for the healthcare industry. From the news by late 2016 about how a staggering 95% of US hospitals have participated in Medicare EHR Incentive Program to the ever-increasing cyber-attacks on hospitals systems to CMS rolling out new regulations and rules to further the industry’s transition from fee-for-service-based to a value-based payment model.*

What changes will happen in the industry this year around? The first month of a year is the best time to ponder that question.

Here are 5 trends that we think will create ripples in 2017.

1. Blockchain Will Be Put to Work

Blockchain made a lot of noise last year. So what is blockchain? And, how does it work?

A blockchain is a distributed database that can store any values without repetition even after multiple updates. It stores information in blocks (in databases called records) and each block will have timestamp and link to a previous block.

For example, every time a transaction is made, the transaction data/information will be stored in a new block rather than updating an existing information, and the new block is added to the existing blocks forming a blockchain.

Basically, once data is created, it cannot be altered. The system will encrypt all the data stored and it is impossible for hackers to break into the system.

2. Healthcare Consumerism is on the Rise

Patients fund their health care expenses. Patients’ nowadays act as real consumers and seek for high-quality service for the cost incurred. Earlier patients were pressurized with large deductibles and it turned the table towards hospital providers to provide better care.

The rise in consumerism also increases the digital transformation in healthcare. Patients are now demanding the type of service quality that they are familiar with from other industries. Though digital push rises the care cost, it improves the patient’s engagement levels. The investment made in technology will enhance the digital consumer experience by making it more viable.

3. Telehealth to Serve More

Value-based and patient-centered care has providers’ attention on telehealth technologies. Telehealth service has drastically reduced the readmission rate and the cost of Chronic Care Management.

In addition to that, it has also improved communication after patients are discharged. “The number of Americans receiving virtual medical care is forecast to double, from 15 million in 2016 to 30 million in 2017”, according to American Telemedicine Association.

4. Cloud to Get More Attention

Data storage is still an unsolved puzzle for many providers. Though some opted cloud to improve practice management there were a lot of security concerns. Despite all, most accelerated technology investment of healthcare is expected to be made on Cloud in 2017.

“It wasn’t too long ago that people were skeptical of cloud computing, but today, over 83 percent of healthcare organizations are using cloud technology, according to a HIMSS Analytics Cloud Survey,” says Morris Panner, CEO of Ambra Health.

It is also estimated that the health cloud computing market will grow to 9.48 Billion dollars by 2020, a new report from MarketsandMarkets.

5. Cognitive Computer with Ease Process

The process of healthcare transformation is increasing the number of tasks performed. In the coming years, much time will be spent on understanding and finding ways to leverage the advanced computing system to better the clinical operations. Cognitive computers ease the process of analyzing the unstructured pattern of data.

For example, IBM cognitive machine surfaces insights by analyzing masses of data- personal, medical, practical, pharmaceutical, etc. Adapting such innovative technology in healthcare helps hospitals function more effectively.

Healthcare always strives to deliver good quality of service at lower costs by including technology elements such as telemedicine, cloud, analytics, cyber security, remote patient monitoring and also by trying out newer technology solutions to bring out the better outcome.

* “Hospitals Participating in the CMS EHR Incentive Programs”- dashboard.healthit.gov

* “Ransomware: See the 14 hospitals attacked so far in 2016”- http://www.healthcareitnews.com

Problems With Medical Referrals in the US

During the last two decades, the number of medical referrals in the US has dramatically increased. The healthcare system has more specialists and specialties than before but unfortunately, no parallel growth can be cited for general health care quality or efficiency in patient management. The purpose of medical referrals is to ensure that the patients receive the right type of care from a specialist for a specific condition.

Here are the reasons why all those referrals are going down the drain, literally.

1. Inappropriate Referrals
2. Outdated Technology
3. Insufficient Data
4. Delayed care

Inappropriate Referrals:

It is estimated that nearly 20 million referrals are made in the US every year which are considered to be clinically inappropriate (according to an article that appeared in the HIT consultant blog -“19.7M Clinically Inappropriate Physician Referrals Occur Each Year”). Clinically inappropriate referrals are those referrals which are not made to the right Specialist. PCPs make inappropriate referrals due to the physician’s lack of information about the specialist, referring to offices about the lack of information on available specialists and personal relationships between the providers.

When an inappropriate referral is made the primary provider will have to re-refer the patient to a more appropriate provider or the patient will end up receiving care from an inappropriate provider; in either of the cases, the patient will get poor outcomes and increased cost.

Outdated Technology

Referrals made by a provider to a specialist sometimes could fall through the “cracks” in the referral process. This could vary from practice to practice; some due to faults in referral procedures or ambiguity of the processes.

One recurring problem with referral procedures is with the use of technology or lack thereof. HIPAA regulations have mandated certain standards for the use of technology to transfer patient data. For example, it is against the regulations to use providers’ personal email to send or receive patient data, HIPAA has also mandated against the use of fax which is vulnerable in the case of data theft.
On top of being insecure, these technologies are not capable of supporting modern healthcare requirements including instantaneous communication, secure chat and exchanging data.

Insufficient Data

Primary care and specialist care are poorly integrated into a single system, the lead cause of this is lack of data. There are no means to transfer data between specialist or primary provider. The specialist is always making the fresh diagnosis without knowing the care history of the patient while the primary provider is unaware what kind of care his/her patient has earlier received.

Delayed Care

Referrals are (traditionally) a slow and time-consuming process. The primary care provider with limited information about the available specialists finds it hard to shortlist an appropriate specialist. The provider has to go back and forth to choose one out of the various specialists. Between the primary provider’s preference and the specialist’s availability, the patients experience long waiting hours and would finally decide to meet another provider out of the network.

The wait to see a primary care provider, the wait to get referred and the wait till specialists appointment plus the possibility that this process may have to be repeated leads to long delays to even receive most basic care.

Primary and specialist care coordination is an important aspect of the healthcare continuum. Providers should create and evaluate a referral process which would ensure maximum security of the information shared, minimum resistance to sharing patient data and possibly reduce the time delay in the referral process.

HealthViewX Referral Management Solution is a web-based, multi-channel referral management platform. Providers can send and receive a referral, share patient related information and track referral progress through one window making the referral workflow seamless and effortless.

Challenges Faced By The Rural Hospitals In The USA

The rural healthcare infrastructure which serves 15 percent of the country’s population has been showing signs of ill-health lately. According to USA Today, since 2010 more than forty rural hospitals have shut their doors and the rest are under enormous pressure. For millions of Americans, especially Medicare patients such institutions are often the only source of healthcare.

Though it is said that all the hospitals have been affected by the changing regulations and are vulnerable to external factors, the rural hospitals take the hardest blow. Here are the major challenges faced by rural hospitals:

Financial Factor:

The rural population is in most cases poorer and may be living with the help of federal or state support. Minority communities in rural areas are more likely to be categorized as below poverty level. The rural population is also likely to be uninsured. This financial disposition also indirectly affects rural hospitals as the institutions are less flexible to change.

Workforce Shortage:

The US Department of Health and Human Services in its 2012 report states that patient-to-primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas. This uneven distribution of healthcare providers leaves rural population more vulnerable.

Change in Healthcare Reimbursement Rules and New Regulations:

Change in reimbursement methodology has led to an overall reduction in reimbursement. Though this affects all hospitals alike, rural hospitals are more affected by the loss of revenue. In the recent years, hospitals are also required to abide by some healthcare IT innovations such as EMR implementation which is often too costly to implement for a cash short rural hospital.

A rural hospital can do the following to help themselves stop the trend from the current state and how HealthViewX Referral Management Solution can help them in recovering.

Better Management – Hospitals need to be managed according to their current revenue and resource constraints. This may include restructuring the organization to make it smaller and agiler. HealthViewX Referral Management Solution gives valid insights into the referral practices of a hospital. This could help in better prioritizing the practice goals and actions to the common medical requirements of the community they serve.

Join Hands With Other Health Systems – Rural hospitals can join forces with a larger organization in their region which will give them access to a larger market and better resources. Having a referral solution in place will help the user identify and track the process-follow of each referral. This will allow the hospitals to understand where the referrals are actually going and identify the actual number of referrals that end up in the network and the number that ends up outside the network.

Embrace Innovation – The changing regulations which aim to boost the use of healthcare IT in hospitals is only going to intensify. Many such software and solutions are expensive for a rural hospital and it is a challenge to find the right solution within the allocated budget and exceed patient experience at the same time.

Referral – What a PCP and Patient need to know!

Communication is a critical aspect of healthcare. Most healthcare providers across the country have systems, processes, and procedures implemented to ensure smooth flow of communication. However, such innovations are largely focused on improving in-facility communication, resulting in poor communication between facilities.

The ability to send and receive information between facilities can not only improve the patient healthcare outcome but also enhance healthcare efficiency. A referral management software would simplify procedures between primary care physicians and patients. It would also help PCPs to closely monitor the progress or the outcome of the patients who are referred to a specialist.

Problems With Conventional Referrals:

Physician refer patients but cannot follow up
Lack of communication between primary physicians and patients
Patients not meeting the referred specialist
It is impossible to send follow-up information

The existing problems listed above highlight the Complexity in current referral procedures. The root of these issues can be traced to the physician’s practice because they are the ones who initiate a referral.

Here are some key points that PCPs are expected to validate before sending out a referral to a specialist.

Get to Know Your Patients More

Knowing a patient is as important as knowing about the problems they have. The patient outcome should be foreseen before a referral is made. Most patients visit one PCP whom they trust to a great extent. If the referral process does not meet their expectations, the patients may seek alternative options.

In some cases, patients get the second opinion from another physician after getting suggestions from a specialist. This scenario happens quite often despite being a reverse process. This shows the importance of PCP in the referral cycle as it is their responsibility to ensure patients’ smooth transition and get the required care.

Do Patients Really Need Specialists?

Once a patient selects their PCP, they generally don’t see any other physician or specialist unless a need arises. Here PCPs are the generalists who take full responsibility for their patient. Before getting a patient to step into the specialist’s office they must identify a clear need for the specialist’s visit.

Also, general practitioners could solve many of the patient’s problems without the need for a specialist’s help. Only in some cases do physicians require additional visits to identify the problem. If after multiple visits they cannot diagnose the problem they will send patients to a specialist at the time of need as they are primarily liable for their patient’s care.

Managing the Referral

To avoid any delay in patient diagnosis, some physicians make referrals frequently. But referring more does not mean it is the optimal approach.

Most referrals happen within the network. Physicians send patients to specialists who are known to them and these specialists can easily follow up to them, which helps in closing the referral loop. When this process does not go as planned then the PCP will stop referring to that particular specialist as referral closure is important to identify the patient’s health status.

Key points a patient must be aware of:

Referral is an important process in healthcare
Referral success partially depends on patient cooperation
The referral will require some patient-related data transfer and some methods of data transfer are safer than others.

How Not to Share Patient Information For Referral

The medical referral process is an important part of ambulatory care in the US. Medical referrals have a direct connection to patient health outcome and the provider’s revenue flow. Patient-specific information and the need to keep it safe is even more important.
To protect patient information from falling into the wrong hands, healthcare providers use various procedures and processes to ensure maximum security but when it comes to referral workflow there are no standard procedures nor any secure technology to ensure information safety.

Gigabytes of patient records are compromised each year because providers do not have processes, the required technology or is unaware of HIPAA regulations. Here is how not to share patient information during referral.

Email Is Not What You Think It Is:

Many providers rely on emails to send and receive patient information instantly. Emails are easy and a lot faster than faxes but the problem with emails is that the files sent through with emails are generally un-encrypted when transmitted or when saved leaving patient information sensitive to theft. Using emails to share patient-related data is against HIPAA compliant and according to HIPAA, the provider is held responsible for any breach.

Beware Of Faxes:

Faxes are the most common format to send and receive patient information between practices. Regular faxes are affected by the problem of encryption; since these files are not encrypted, this information could be accessed by an individual with access to phone lines and basic knowledge of the system. Faxes are slow and time-consuming and do not support all type of file formats. Received faxes are usually kept in the machine for some time exposing patient information to unauthorized people. Faxes leave a paper trail of patient information which will practically result in making EMR/EHR systems useless.

Triplicate Form:

Although triplicate forms sound straightforward, practically triplicate forms transfer the process of referring a patient from provider to patient or patient’s skin. The patient is left with the challenge of coordinating between physician offices – calling referral coordinators, faxing files to specialists’ office. Often a patient will have to request an appointment with multiple specialists which means sending sensitive patient information to specialists office who may not be taking care of the patient at all.

Sharing patient information is crucial in the medical referral process, but the systems that the healthcare providers use are incompetent to do a fast transfer of patient file and transfer it securely to authorized providers.
Hospitals need to establish clear-cut procedures in case of sharing patient information. Such a procedure should be able to track the flow of patient data and establish standard norms and practices to minimize the possibilities of compromising data.