Senior Vice President of Client Development at VisiQuate

Podcasts

Physicians Practice® spoke with Terry Blessing III, Senior Vice President of Client Development at VisiQuate, about how practices can work to reduce the likelihood of encountering denied claims.

Avoiding Claims Denials in Your Practice

Though it might seem counterintuitive in a year that saw the U.S. healthcare system buckle under the strain of a pandemic-driven surge in demand, overall healthcare costs were down in 2020. New data from the Peterson Center on Healthcare and Kaiser Family Foundation show 

 declined roughly 2.7% last year as of December 2020, making it “the first time in recorded history,” that annual U.S. healthcare spending fell, the study authors write,.

It’s easy to understand why. Think about the appointments you or your loved ones canceled last spring and summer or the ones canceled by your providers. Then there was the care deferred—annual physicals, elective procedures, visits to specialists—because of quarantine measures and fear. These deferred episodes of care represent billions in lost revenue for healthcare providers.

The impact of COVID-19 on healthcare provider finances, however, extends well beyond 2020. The sharp decrease in costs has created an unprecedented financial forecasting challenge for Medicare Advantage (MA) physician practices submitting bids to the Centers for Medicare & Medicaid Services (CMS) for the upcoming plan year.

Confidentiality and consent considerations when treating minors

Fortunately, CMS appears to recognize that practices essentially are flying without radar in planning revenue for next year. The federal agency 

 the final rule for its MA and Part D payment methodologies for the 2022 contract year in January. In recent years, CMS has announced the Medicare Advantage and Part D rules four months later in May. This final rule, which will go into effect in 2021, and the timing of its announcement makes it clear that CMS considers this to be a transition year for both MA practices and beneficiaries.

CMS included several unexpected updates in the final rule, some of which address payment growth rate. Below are the biggest changes in the MA and Part D final rule for 2022 that could have a financial impact on physician practices. Understanding the implications of these changes will help physician practices improve efficiency and profitability.

During the pandemic, physician practices ramped up the use of telehealth to the point that 60% of Medicare beneficiaries with a regular provider said they 

 to telehealth appointments. Given that 91% of Medicare Advantage plan members 

 at least somewhat favorable telehealth experiences and 82% of seniors have high-speed 

, telehealth use is highly likely to increase.

Telehealth was such a huge success during the pandemic—even among seniors—that the Medicare 

 for virtual care enacted early in the pandemic have been retained in the 2022 MA final rule. This means CMS will continue to treat telehealth-permissible codes the same as in-person codes. Further, the virtual care encounter data can be applied toward risk scores.

After a year in which the pandemic created confusion over coding that resulted in disruptions to provider revenue cycles, the CMS decision to maintain continuity in telehealth coding means physician practices can continue to promote telehealth services to their MA members without worrying about code-related claims delays and denials.

In the rule’s Advance Notice, CMS estimated the effective payment growth rate for 2022 would be 4.55%. That jumped to 5.59% in the final rule, however, resulting in a 4.08% increase in revenue. For MA organizations, this is a promising sign because it indicates CMS is not anticipating a significant cost rebound after the major revenue decrease caused by deferred or foregone care.

Nonetheless, health plans cannot afford to remain complacent. Contract bids to CMS must be based on the most current and accurate Hierarchical Condition Category (HCC) data available. If plan members have been avoiding in-person care, such as their Annual Wellness Visits, for a year or more, the risk of new care gaps or chronic conditions increases. Member outreach and engagement efforts need to ramp up this year to close care gaps and identify any new health challenges that may have emerged in 2020. 

Payment growth will be higher than expected in 2022; however, for some payers, this revenue increase may be offset due to changes in the risk adjustment factor (RAF) score calculation. As announced years ago, the RAF score in 2022 will be based exclusively on data from the Encounter Data System (EDS) and fee-for-service claims rather than a blend of encounter data and Risk Adjustment Processing System (RAPS) data.

Once again, the challenge for MA plans is incomplete data to calculate an accurate risk score because members forego care, resulting in missing or overlooked HCCs. While the accuracy of these scores can be improved by encouraging members to seek preventive care or chronic condition management, MA payers should expect a small financial loss per member per year due to the EDS transition and incomplete data.

Newer MA practices would be well-advised to consult partners with experience in the technical requirements to calculate accurate risk scores and avoid financial losses in the contract year.

A practical approach to work-life balance

Updates to the Part D Hierarchical Condition Category (RxHCC) model in the 2022 final rule may impact the bottom lines of MA practices. Risk score calculations, for example, will be based on 2017 diagnoses paired with 2018 drug data, each updated by three years. As is the case with the RAF score, the RxHCC will be based solely on encounter data, which may be lacking for most practices because members have delayed or foregone care.

 show an across-the-board risk score decrease for RxHCC, which translates into reduced revenue for MA practices on drug costs. Fortunately, plans can expect to recover those losses in the coming year as more members return to in-person care.

Under the 2022 MA contract, individuals with end-stage renal disease (ESRD) will be allowed to enroll in a plan for the first time. Although increasing membership is a primary goal of every MA practice, ESRD is an expensive condition to manage. One study showed that in 2016, the average beneficiary with ESRD cost 

 for the year. That’s six times more than the $10,182 cost per beneficiary without the condition. Costs for members with ESRD exceeded MA benchmarks in nearly 

Going into the contract bidding process for 2022, MA practices should ensure they have the most accurate and timely data available on new members with ESRD to avoid large and unanticipated financial losses.

The MA and Part D final rule for 2022 makes it evident that while CMS expects 2021 will be a post-COVID-19 transition year for MA practices and beneficiaries alike, the agency does not foresee a deluge of utilization after more than a year of deferred care. The biggest variable is the health status of MA members, which could impact the bidding submission process for physician practices.

We can expect many fully vaccinated members to resume in-person care this year, which will give MA plans a more consistent and reliable stream of data for their financial projections. MA practices that use the right data management, member outreach, and engagement tools will increase their chances for a smooth transition to 2022.

Articles

Good news on telehealth coding, but lifting of EFRD restrictions will present financial challenges.

Key Medicare Advantage plan changes practices need to be aware of

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Colin Carr, CEO of CARR Realty, discusses what practice owners need to know about lease renewals.

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Physicians in these five states made the lowest, on average, compared to their peers in other states in 2020.

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Slideshows

Physicians in these five states made the lowest, on average, compared to their peers.

, JD, MBA, advises clients on compliance and transactions in healthcare, cybersecurity, corporate and securities law, while representing plaintiffs in False Claims Act and Dodd-Frank whistleblower cases. She also teaches bioethics at Baylor College of Medicine in Houston. Rachel can be reached through her website, 

 stated, “The United States faces persistent and increasingly sophisticated malicious cyber campaigns that threaten the public sector, the private sector, and ultimately the American people’s security and privacy.” This Executive Order followed the May 7th 

, which underscored the vulnerabilities of the government and energy industry participants.

CMS 2021 Final Rule: What practices can do

 is likewise plagued by a myriad of cybersecurity-related attacks, including ransomware. First, let’s consider a recent 

, whereby Vikas Singla, a former employee of Gwinnett Medical Center (Lawrenceville, GA) who ran a network security company that offered services for the healthcare industry, was charged with the following:

Disrupting the hospital’s Ascom phone system;

Accessing Lexmark printers and a Hologic R2 Digitizer;

17 counts of intentional damage to a protected computer; and

Obtaining information by computer from a protected computer.

 went so far as to voice their displeasure with the hospital (GMC) for denying it had been hacked stating, “does GMC have control of this system. The answer is no. The last time we checked, we own their Ascom system and their data.” This arrogance is similar to that of many cybercriminals, including those that prompted CISA, DOJ, FBI, and HHS to publish 

Joint Cybersecurity Advisory - Ransomware Activity Targeting the Healthcare and Public Health Sector

(Updated October 29, 2020), in light of six ransomware attacks against hospitals across the United States. The primary tactics utilized to infect systems with ransomware for financial gain were Ryuk and Conti. The primary activities “include credential harvesting, mail exfiltration, cryptomining, point-of-sale data exfiltration, and the deployment of ransomware.”

In light of the heightened awareness and the increased proclivity of attacks, the National Institute for Standards and Technology (NIST) published 

, which includes quick steps persons can immediately take to reduce the threat of a ransomware attack:

Block access to ransomware sites by installing the appropriate software and services;

Allow only authorized apps on computers, tablets, and smart phones;

Use standard user accounts versus accounts with administrative privileges whenever possible;

Avoid the use of personal apps and website on company or work computers; and

Train the workforce to be aware of unknown sources, social engineering, and be sure to run an antivirus and/or look at links carefully.

Every person has an obligation to do his or her part to protect corporate IT systems. With remote working scenarios, many companies and individuals were lacking to ensure appropriate technical, administrative, and physical safeguards. In sum, and as a reminder, failing to take relevant precautions, can lead to government enforcement actions, class action lawsuits, and potential criminal cases.

, JD, MBA, advises clients on compliance and transactions in healthcare, cybersecurity, corporate and securities law, while representing plaintiffs in False Claims Act and Dodd-Frank whistleblower cases. She also teaches bioethics at

in Houston. Rachel can be reached through her website,

Recent attacks encouraged new guidelines from the National Institute for Standards and Technology (NIST).

Cybersecurity and ransomware: Tips, tactics, and updates

 at Ob Hospitalist Group, which connects OB physicians with hospitals across the nation.

I’ve always loved traveling. When I first took my OB/GYN job in Maine, I told my clinical partner not to take my position out of the classified ads because it wasn’t going to be a lifetime gig for me. Somehow, ten years flew by; it was suddenly 2019 and I was immersed in the day-to-day medical practiceseeing patients, charting clinical data, performing deliveries. Yet, the travel bug was still there, strong as always.

When an old friend brought up an interesting opportunity to work in labor and delivery rooms across the country, I took it as an inviting sign to make a change. As part of the 

, I now work with hospitals in multiple states to supplement existing staff and provide leadership in a variety of different settings. Starting in the summer of 2019, continuing through the pandemic and into the present day as a traveling OB physician, it's been an incredibly rewarding and eye-opening experience.

While COVID-19 halted some of the airline routes available at the local airports and made getting to destinations a bit trickier than before, it did little to deter the need for physicians that could fill critical roles in hospitals. For those in a career rut or who may have put their own desires to pursue a travel position on hold, here are some of the common misperceptions and realities about the travel physician role:

Duties to Give to Your Medical Practice Administrator

Misperception 1: Traveling positions are for young physicians who aren’t tied down with family.

Coming in as a physician with twelve years of work experience and a former department head put me at a significant advantage to establish myself credibly as a partner within the hospitals where I was placed. For my particular role, clinical experience was required, as I would be fulfilling an outstanding leadership need.

Additionally, the role was attractive to me 

I had a family and the arrangement gave me more time and flexibility—not less—to spend with them. One of the main advantages of moving into the hospitalist role was that I was not taking administrative work home with me like I often did when I was leading a department. Hospitalists work hard in a clinical setting and when we’re off, we’re able to focus on our life outside of that. For me, that includes hobbies like gardening, disc golf, and parenting a sixteen-year-old who now knows how to drive!

Misperception 2: Travel physicians are not in locations long enough to make a difference.

Though I didn’t realize it until I was in the OB Diplomat Program, moving between health systems helped with being able to identify and share best practices. During the early stages of the pandemic when hospitals were still waiting for further guidance from the federal level, I was able to work with hospital leaders from multiple systems to gather the most up to date information and establish early protocols for protecting patients and providers.

Moving between health systems also provided an opportunity to implement processes that have proved effective in similar settings. For example, I worked with a less resource-rich program to establish simulation training. This helped staff to practice scenarios so that we would be prepared in the event of an emergency situation. Our team ran through a simulation for postpartum hemorrhage, and right after we had conducted the drill that day, the real thing happened. The process went almost exactly as we had practiced, and we were able to help the patient as a result. Had I not seen the potential of simulation training to transform patient care in previous settings, the outcome may have been quite different.

Misperception 3: Travel physicians challenge the autonomy of private practice providers.

Especially when we launch a new hospitalist program, there is sometimes a misguided fear that the hospitalists are there to take the job of the community physicians or take their patients. However, the community physicians and staff usually see the benefit of adding hospitalists to the team within the first couple weeks. It also transforms the ability of the care team to triage effectively by having a physician on-hand 24/7. As an OB hospitalist, my role is to support the private practice physicians. Since I can spend more time with the patients on face-to-face interactions, and to take on unassigned patients, the whole team benefits.

Misperception 4: Travel physicians don’t have the same support system in place as full-time physicians.

Unlike a locum position, my current arrangement provides benefits and continuing education opportunities more akin to traditional full-time employment. In most locum positions, there aren’t a lot of options that offer benefits such as medical malpractice insurance, or a clear organizational mission. As part of a hospitalist program, however, not only are we connected with clinicians across the nation, but we also interact with other physicians in the travel program on an ongoing basis to create a virtual support network. These forums give us a space to discuss trends in cases and best practices for our specialty, and share tips on hotel stays, airline specials, and other matters that come with being a travel doctor.

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Misperception 5: Travel physicians are at a disadvantage when it comes to connecting with patients.

One of the greatest parts of being a travel physician is that my shifts are scheduled for a set amount of time. Because of this, I can spend more time at the patient bedside. My patient mix is usually a combination of both assigned and unassigned patients. Among the more rewarding parts of my job is the ability to make connections with patients that previously have had little to no engagement with the healthcare system, including those that have gotten used to having low expectations when it comes to medical care. When they realize they now have access to a physician that is able to spend time with them at a critical moment, who isn’t rushing to move on to the next case and is willing to listen to their concerns in a non-judgmental way, it can be a life changing moment for that patient.

Travel positions can be a truly rewarding pathway for physicians wanting to get back to focusing on clinical work or practicing in a variety of settings. For experienced practitioners that are looking for a new way to make a difference, apply their leadership skills, and rack up serious airline points, the sky is no longer the limit — it’s the highway to new opportunities in clinical care.

Misperceptions and realities about the traveling physician’s role.

Shifting Careers: The sky (or sometimes the airline route) is the limit

 is a senior director of product management at 

, the nation’s largest health information network.

 around consumer-focused price transparency is causing a stir across the healthcare industry. But if you’ve been following the healthcare consumerism trend, it shouldn’t come as a surprise. Consumerism is built on the tenet that patients have full access to cost and pricing information to make decisions about their health, and these new laws are likely just the start of a series of regulatory initiatives designed to mandate pricing transparency. But these transparency laws are also a reminder that many of the tried-and-true practices associated with building and maintaining a patient population are about to be disrupted.  

Providers have traditionally built their practices on word of mouth or being in the right contracted networks. And while these are still valuable marketing resources, they are just a starting point. The ability to view costs before scheduling a visit gives patients a valuable tool when comparing one practice with another similar practice within a five-mile radius. If you want to continue to compete for patients in this competitive environment, you must focus on differentiation.

One of the best ways to differentiate is to build a patient-centered practice. While a concierge-health model may not be possible for high-volume practices that accept insurance, you can still adopt some of the principles that make those attractive to patients. Here’s how: 

Eight technologies practices are leveraging to deliver better patient care

Building trust with patients isn’t just about the interaction during the patient encounter; it’s also about what happens after the patient leaves. According to a recent 

, 30% of patients surveyed reported not taking their medicine as prescribed due to costdifficulty affording their medications. Your practice should have processes in place so that a care team member follows up to see if the patient has questions, ensure they are taking medications, following their after-care plan, and getting the financial support necessary to follow the care plan. This is especially important with chronic health conditions such as diabetes and heart disease. You should also proactively reach out to patients to schedule follow-up visits, rather than relying on the patient to remember.    

Building a strong physician referral network helps you coordinate care across all dimensions of your patients’ health. Whether they need a routine colonoscopy screening, physical therapy, or even mental health services, patients look to their physicians for help choosing specialized care services. Creating these referral relationships also has reciprocal benefits for your practice. 

Make it easy to do business with your practice

Everything about your patients’ administrative experience—from scheduling to appointment reminders to billing–should be a seamless experience. This means accommodating for the different ways patients prefer to communicate —phone, email, online, and text message. According to the 

, patients are increasingly open to digital communications. Sixty-three percent reported preferring appointment reminders through email, 53% were willing to receive emails about payments, and 43% were willing to establish online payment plans. Providers should offer convenient payment options and payment plans when necessary.

Even those with decades of experience in healthcare can find patient coverage difficult to decipher. Understanding the myriad of plans and benefit levels, combined with unmet deductibles, is confusing for practice staff, which makes it difficult for them to explain to patients. Rather than have each front-desk staff member be responsible for answering patient questions, consider training one resource to serve as a coverage advisor. Giving patients the opportunity to ask questions in a private, one-on-one setting can help reduce confusion and frustration. 

How to improve your practice’s online presence post-pandemic

While many physician practices have built robust marketing programs and campaigns, others operate in a somewhat old-fashioned mindset that views promotional activities as inappropriate or suspect. But that attitude must change. Your current and future patients are searching for you online, so make sure your website and your social media channels (yes, you should be on social media) are attractive and contain up-to-date information. 

Understandably, you may be wondering where to find the staffing to meet these resource-intensive requirements. One of the first things you should do is evaluate your front and back-office processes and determine if there are opportunities to streamline manual processes. There are many tools on the market today that can help with referrals and billing, which would allow you to reallocate resources to higher-value activities. 

Price transparency is a good thing for the healthcare industry, and providers that embrace the changes brought on by consumerism will rise to the top.

Lillian Phelps is a senior director of product management at

Price transparency and consumerism are here to stay. Ensure your practice is as well.

Differentiate your practice with a unique patient-centric approach

Colin Carr, CEO of CARR Realty, discusses how the pandemic has affected commercial real estate in the healthcare realm.

How the pandemic has affected commercial real estate in the healthcare realm. 

How the pandemic has effected healthcare real estate

Physicians in these five states made the highest, on average, compared to their peers in other states in 2020.

If your income is one of your primary concerns, you might want to check out these 5 states.

Best states for physicians in 2021: 5 states with the highest physician salaries

Physicians in these five states made the highest, on average, compared to their peers.

Hackers are always working on new ways to infiltrate a network. As they continue to get more and more sophisticated, 

 can’t always detect them. IT security teams need to consider new frameworks to protect their networks.

The healthcare industry is a notorious target for cyberattacks, and traditional cybersecurity measures simply aren’t effective anymore. Zero Trust Security for email may well be the answer.

Zero Trust is a security framework that assumes that every person or device requesting access to a network is a potential threat. It is an emergent security strategy requiring a user validate their identity multiple times before gaining access, and even then, the user doesn’t get full access to the network.

, COVID-19 is accelerating the adoption of the model since users are more likely to access sensitive information remotely.

No single technology is associated with Zero Trust. Instead, it’s a comprehensive framework that incorporates several different principles and technologies.

Here are the guiding principles behind Zero Trust Security:

Nothing and no one is automatically trusted.

 Attackers could come from either inside or outside of a network.

 Users only get as much access as they need, thereby limiting exposure to sensitive data.

 Security perimeters are broken up into small zones to maintain separate access for separate parts of the network.

 A core value of Zero Trust Security, MFA means more than one piece of evidence is required to authenticate a user.

 Zero Trust Security systems monitor how many different devices are trying to access a network and ensure every device is authorized.

 It is critical to spot abnormalities in behavior in real time in order to shut down a possible hacking attempt immediately.

Telehealth fraud and abuse enforcement efforts unlikely to taper

 overtook remote desk protocol (RDP) compromises as the dominant attack vector last year. 

 also finds that 91% of all cyberattacks begin with a phishing email. Even the recent massive 

 attack was most likely caused by an employee falling for a phishing email.

 to send malicious emails, such as Amazon SES, Sendinblue, and Mailgun. This puts 

 out of reach of the early warning system run by the 

 (NSA) because it is prohibited by law from conducting surveillance inside the United States.

In other words, we can no longer trust email sent from American hosting and infrastructure companies.

Nation state threat actors are sending sophisticated email phishing campaigns that pass the following security checks:

 This frontline defense system checks whether a sending IP address is on a blacklist of IP addresses reputed to send malicious email.

 An email authentication method that indicates that a mail server is authorized to send email for your domain.

 Another email authentication system that uses digital signatures to allow the receiver to check that an email was indeed authorized by the owner of that domain.

Domain-based Message Authentication, Reporting and Conformance

 Yet another authentication protocol that leverages SPF and DKIM to determine the authenticity of an email message.

 Newly registered domain names sending email are a red flag and quarantined.

Malicious emails pass these checks because the bad actors registered new email domains, sat on them for years so they did not raise any red flags, took the time to configure and maintain their accounts correctly, and then hid behind American companies inaccessible to the NSA.

Therefore, in order to keep up in the cybersecurity arms race, what’s needed is a Zero Trust Security framework for email.

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As part of a Zero Trust framework for email, MFA can be reimagined as an authentication method not for a user, but for a machine.

Let’s say a mail server is attempting to send you an email. During the SMTP conversation between mail servers, the sender claims it is a part of Amazon’s SES platform, and your MX record host verifies that this is true because it passes the security checks outlined above.

However, with a Zero Trust for email paradigm, those checks aren’t good enough. One more piece of evidence is required to authenticate that the email is truly legitimate and not a phishing attack cloaked under the guise of Amazon’s email platform.

I believe this new piece of evidence should be unique to each customer and be updated based on usage over time. In other words, it must be very difficult for bad actors to impersonate.

This new approach will yield a unique form of MFA, an additional piece of evidence required to authenticate an email. It would be especially useful for healthcare providers that not only need extra security to send 

, but also must block incoming cyberattacks.

Traditional cybersecurity measures aren’t effective anymore. 