One year ago, it’s doubtful that anyone could have accurately predicted the changes that would occur in healthcare in 2020. While facing the world’s greatest health crisis in living memory, we’ve seen amazing shifts in adapted care delivery and a surge in “telemedicine,” as well as implementation, regulation, coding, and payment adjustments established at great speed to facilitate use. We’ve seen unprecedented innovation in virus testing and treatment capability and protocols, and impressively rapid development of experimental vaccines— some using revolutionary mRNA technology. We’ve also seen unprecedented strain on healthcare supply chain, infrastructure, and staff.

While 2021 will surely hold its own surprises, there are some likely developments in healthcare on the horizon and many of them center on healthcare IT:

The need for a nationally and globally recognized record of COVID-19 immunization will produce a mini digital health record with critical and essential health information that may include blood type, medical conditions, critical medications, allergies, disabilities, and relevant demographic data.

Compiling, accessing, managing, and sharing these emergent mini digital health records may usher in greater use of new standardized authorizations such as biometrics (fingerprints, for example)—instead of relying on siloed government identification mechanisms, numbering, or documentation.

The increased need for the mini digital health records will raise concerns over what data can be shared, by whom, and whether any tracking or geo-location data can be provided to government and healthcare authorities globally. New policies and revisions to policies will be made at the country-level and debated, then hopefully agreed upon at the global level in the interest of public health.

Cloud computing will get significantly cheaper—on the order of 30-40%—due to increased automation, increased use of high-performing, low-power chips for average workloads, and the growth of compute competition at the edge and device level. Healthcare IT using cloud computing will see even greater market advantages that help drive growth in cloud adoption.

There will also be significant growth in the number of cloud-based healthcare apps and many current healthcare apps will fail as they fall by the wayside. Sadly, it’s also likely that a number of cloud-based healthcare app providers will experience a cybersecurity attack that results in a major service disruption and very likely a data breach.

Growing concern over the ethics of Artificial Intelligence (AI) overall, and particularly in healthcare, will spark greater interest in the “Safe” AI movement. There will be significant increases in public awareness of patient data privacy needs, especially where massive amounts of data are used without patient permission for AI development.

Concurrently, there will be at least one significant new breakthrough in AI for healthcare, most likely in the area of imaging diagnostics where AI will be seen as adding unique value to current capabilities.

Data analytics can you understand and mitigate risk

Devices for biometric identification of patients and healthcare professionals will advance significantly with the need for sharable mini health records and expansion of contactless identification solutions.

The growing cadre of Software as a Medical Device (SaMD) deployments will be deeply scrutinized by regulators, physicians, and patient groups for safety and efficacy. It’s likely that at least one SaMD will experience a safety incident that informs policy and regulation.

The number of healthcare Internet of Things (IoT) solutions will grow dramatically. Providers will pursue ways to find and consolidate IoT data related to Remote Patient Monitoring and integrate or translate it into Electronic Health Records (EHRs). Increased deployments will attract cybersecurity attacks that exploit new vulnerabilities in many healthcare IoT applications.

Patients will increasingly seek options to receive care and treatments at or near home and become extremely conscious about price as the economy struggles to rebound from pandemic upheavals.

Retail pharmacies with home delivery services will grow significantly. Low-cost procedure-based clinics and service providers will grow and compete for local patient populations, driving fees down.

Home health services will also grow significantly. There will be a shortage of home healthcare workers that drives the need for a more sophisticated solutions to match needs with skill sets available by location.

All of which will require streamlined healthcare IT infrastructure for support.

Physicians and healthcare professionals exhausted by both COVID-19 surges and impending floods of delayed non-urgent procedures expected in 2021 will produce a backlash. Strikes and subsequent negotiations for better working conditions, more paid time off, and mental/emotional health support services are probable.

There will be a higher than usual rate of healthcare professionals who retire or change professions in 2021 due to burn-out, and a greater than usual demand for innovation to help manage the disruption. Augmenting and managing the changing workforce along with workflow automation will be especially in demand.

Hopefully, employment and educational programs for healthcare professionals will be revamped around the remediation of workload fatigue, improved teamwork/interaction, expanded mental and emotional services — and the tools that help enable them.

Judy Barkal is a Managing Director at Health2047 and is a member of the IEEE working group on Clinical IOT Data and Device Interoperability. Her deep experience in strategy, innovation, and complex business and technology transformation includes stints as M2Gen’s Chief Technology and Medical Informatics Officer, Head of Information Strategy and Innovation at Oregon Health and Science University’s Knight Cancer Institute, and at IBM where she launched Systems Engineering Centers of Excellence and implemented transformations globally in healthcare, financial services, transportation, energy, retail, and consumer electronics industries.

Articles

Health IT Predictions for 2021: What awaits post-pandemic

Victor Bornstein, CEO and Founder of Justpoint, discusses how the company is using artificial intelligence to analyze medical malpractice claims and benefit both plaintiffs and defendants.

Videos

How Justpoint is using artificial intelligence to analyze medical malpractice claims 

Artificial intelligence can shake up malpractice claims

, 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, 

Two recent enforcement actions and answers to a common question of workplace privacy requirements in light of COVID-19.

"OCR created the Right of Access Initiative to address the many instances where patients have not been given timely access to their medical records. Health care providers, large and small, must ensure that individuals get timely access to their health records, and for a reasonable cost-based fee," said OCR Director Roger Severino.

Profit-sharing that works (and complies with the law)

In keeping with its Right of Access Initiative, the Office for Civil Rights (“OCR”) announced that 

), a primary care service provider in Georgia, paid $36,000 to settle a potential violation of the HIPAA Privacy Rule’s patient’s right to access his/her protected health information. In April 2019, a patient filed a complaint with OCR indicated that he had requested but was denied access to his medical records. In May 2019, OCR provided technical assistance to Elite. Still, in October 2019, the same patient filed a second complaint indicated that he still had not received his medical records. In May 2020, over a year after the initial request, the patient finally received a copy of his medical records. Seven months later, Elite paid OCR and entered into a corrective action plan, which includes two (2) years of monitoring.

Approximately, one month prior to the Elite settlement, OCR announced that the 

University of Cincinnati Medical Center, LLC (“UCMC”)

, which is an academic hospital providing a range of health care services, also settled a HIPAA Privacy Rule Right of Access potential violation for $65,000. Once again, in May 2019, OCR received a complaint that UCMC failed to respond to a patient’s request in February 2019 requesting an electronic copy of her medical records. The patient ultimately received her medical records in August 2019. In November 2020, UCMC paid OCR and entered into a corrective action plan, which includes two (2) years of monitoring.

Finally, the burning question, does disclosure of a COVID-19 diagnosis in the work place constitute a HIPAA violation or violation of another law, such as a state law or the Federal Trade Commission Breach Notification Rule? The answer is “it depends”. First, one must always turn to the facts and circumstances. For example, was a work force member being treated at its place of work and did another employee wrongfully access the records? This is a HIPAA violation under 45 CFR § 164.304

What about the scenario where an employee tests positive? What can an employer disclose and who may be notified?

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First, The Americans with Disabilities Act (“ADA”) requires that any mandatory medical test of employees be “job related and consistent with business necessity.” Applying this standard to the current circumstances of the COVID-19 pandemic, employers may take steps to determine if 

employees entering the workplace have COVID-19

an individual with the virus will pose a direct threat

 to the health of others. Therefore, a company may choose to administer COVID-19 testing to employees or require testing before they enter the workplace to determine if they have the virus.

Centers for Disease Control and Prevention (CDC)

 recommends that employers notify employees of their possible exposure to COVID-19 in the workplace when a fellow employee tests positive. Employers must not disclose the name of the employee testing positive, as that is confidential information under the ADA.

In light of this, here is a chart, which may be helpful:

In sum, HIPAA, as well as general notions of keeping medical records private and secure, continues to be an area of focus for OCR and other government agencies. This is a trend that is sure to continue in 2021.

, 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,

HIPAA Hot Topics: Enforcement actions and COVID disclosures in the work place

Over the last year, the American Medical Association (AMA) has offered guidance to reduce “unnecessary daily burdens for clinicians.” The 

AMA’s “Getting Rid of Stupid Stuff”

 (GROSS) initiative has more than just a great name; it also provides timely and appropriate advice for eliminating unnecessary tasks that add to heavy clinician workloads and contribute to burnout.

The AMA defines “stupid stuff” as everything from irrelevant training requirements, well-intentioned but not useful risk management processes, and overinterpretations of health information requirements, especially HIPAA. Not surprisingly, the AMA also calls out EHRs as a great source of “stupid stuff” that create significantly more work for clinicians. I would also throw in all the extraneous administrative, electronic, and managerial tasks that clinicians must perform that have nothing to do with practicing medicine.

If we made getting rid of the “stupid stuff” in EHRs a top priority, we could make a significant impact on physician well-being and satisfaction. Amidst the current health crisis, clinicians are under extreme duress and have little power to minimize the impact of rising case numbers, staff shortages, and high rates of infection. Healthcare leaders can provide some relief by addressing some of the stupid inefficiencies of EHRs that create clinician stress and frustration.

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EHR inefficiencies stem from three big issues:

Most EHRs were designed to meet coding and billing requirements, not to support clinical decision-making

EHRs lack interoperability, making it difficult for clinicians to share critical patient information between disparate clinical systems and between providers

Clinicians must enter an overabundance of data to satisfy quality reporting requirements for proper reimbursement

Ridding EHRs of “stupid stuff” starts with tackling these three big issues.

Few EHRs were designed to meet the needs of clinicians. Instead, they were created to help billers and coders get the details they need to do their jobs, and clinicians were tasked with feeding the computer all the data to support financial teams.

Instead of requiring clinicians to be data entry clerks–which is a “stupid stuff” task–we need smart computers that work behind the scenes to automatically interpret billing and coding details from within clinical documentation. We must empower clinicians with workflows that support how they practice medicine and deliver the information they need for clinical decision making at the point of care. This includes making it easy for them to find patient and problem specific information, without having to search through multiple screens. It requires technology that can sift through all the clinical noise in the chart and deliver the right information at the right time to inform clinical decisions.

We also need to get rid of disruptive EHR features that attempt to make medical decisions on a clinician’s behalf. The smartest computer in any exam room is between the clinician’s ears;any extra keystrokes that stand in the way of clinical decision making are a stupid waste of time.

COVID-19 has underscored the need for interoperable systems that facilitate the exchange of comprehensive and usable patient information, including details on preexisting conditions, medication histories, and test results; it has also revealed how much more work needs to be done to achieve true interoperability.

At a time when clinicians need ready access to patient information to accelerate treatment, we are still relying on faxes and PDFs to share COVID-19 test results and other critical patient details. We are dumping these records into EHRs and requiring clinicians to click and open multiple files to glean a complete view of a patient’s health.

Though the government has approved rules to enhance interoperability, enforcement has been delayed due to the many unforeseen challenges of COVID-19. However, without improved interoperability between EHRs and providers, clinicians will be forced to keep doing a lot of stupid stuff that takes away from quality patient care and creates stress and frustration. Rather than waiting on the government to push needed changes, healthcare leaders can alternatively embrace technologies that facilitate interoperability and give clinicians the key information they need to deliver care.

7 staff roles practices should consider adding

CMS and other payers continue to mandate quality initiatives designed to assure high quality healthcare. These programs require healthcare organizations to track and report various quality metrics that demonstrate quality healthcare processes, outcomes, patient satisfaction and other goals.

Despite the best of intentions, these initiatives have created more stupid tasks for clinicians, who are primarily the ones inputting all the required quality measures into the EHR so that financial analysts have data for reporting. Instead of focusing on the delivery of quality care, these programs often divert clinicians’ attention away from the patient and onto the computer screen. Rather than burdening clinicians with more data input, healthcare leaders should seek solutions that simplify the tracking of quality measurements by allowing clinicians to follow their usual clinical workflow and spend more time on patient care.

Get rid of stupid stuff in EHRs – without getting rid of the EHR

Reducing clinician burdens and getting rid of stupid stuff within EHRs doesn’t require that organizations get rid of their complete EHR platform. Healthcare systems can instead preserve their EHR investment and add technologies that make workflows more efficient for clinicians, improve interoperability, and give users more time to focus on the delivery of quality care. At a time that clinician burnout is reaching new highs, it’s time for healthcare leaders to embrace new solutions that make EHRs a little less stupid.

Jay Anders, M.D. is the chief medical officer of

, which provides physician-driven, point-of-care solutions that fix EHRs.

The AMA defines “stupid stuff” as everything from irrelevant training requirements, well-intentioned but not useful risk management processes, and overinterpretations of health information requirements. 

Reducing clinician burnout by getting rid of “stupid stuff” in EHRs

As a result of the COVID-19 pandemic, the American Hospital Association (AHA) estimates that 

hospitals and health systems have lost more than $202 billion

 from a drop in revenue, combined with COVID-19 expenses, during the four-month period from March to June 2020. 

Healthcare services expenditures also dropped 38%

 in April 2020, as compared to the previous year, and many practices are now contending more with patients who are unemployed or uninsured and unable to pay for doctor visits, specialty care and routine procedures. These numbers will undoubtedly rise, as 

nearly 27 million Americans could potentially become uninsured

Adjusting to new ways of operating during COVID-19 -- and maintaining the revenue cycle all the while – is critical as the industry continues to navigate uncertainties about reimbursement for virtual care and increasing numbers of patients losing their jobs.

Five Tips for Improving RCM in a Post-Pandemic World

With growing expenses and lower revenue, healthcare providers can no longer afford to wait weeks for payments to be processed or face extended reimbursement times because of denials and incorrect coding. Practices must put a stronger focus on revenue cycle management (RCM) in order to remain a viable business, reduce the risk of having to cut back on staff or practice hours, and continue delivering the services their patients expect.

, a leading health information technology and services provider, 

 serves as senior director, Greenway Revenue Services. With more than 13 years of experience in the ambulatory EHR and practice management market, he oversees the daily billing operations of revenue services for customers, ensuring compliance with divisional established policies and protocols, adherence to government and insurance payer policies and assurance of customer conflict resolution. In addition to his daily responsibilities, he also leads the Patient Call Center and Patient Accounts Receivable teams at Greenway.

Five tips for improving RCM in a post-pandemic world

Recovering from COVID-19: How practices can maintain the revenue cycle in 2021

Finally, 2020 has come to end, and though there appears to be a light at the end of the tunnel, there is still plenty of work to be done.

Primary care physicians and specialists, along with their staff, have been on the front lines of everything from shut downs, to managing COVID-19 patients, to ensuring that patients with chronic conditions aren’t neglecting their health. It hasn’t been easy, and it hasn’t been lucrative either. There are important takeaways from 2020 though, and physicians should consider them in 2021 to improve their medical practices and patient relationships.

If a physician has a strong relationship with their patient, there is much that can be accomplished over the phone. The key is the development of a relationship based on trust. If the physician knows the patient, their typical health challenges and state of mind, many issues can be triaged virtually. 

This works in reverse as well. When a patient isn’t well and feeling vulnerable, they aren’t comfortable calling the 1-800 number on the back of their insurance card for an on-call nurse. They want the doctor who knows them, and who they trust.

Avoiding cognitive biases in decision-making

When office visits and elective procedures virtually dried up, it became apparent that doctors needed a way to generate revenue outside of these reimbursements. An alternate revenue stream can be a lifeline for a practice, helping them withstand a crisis like COVID-19. It can also help buffer the ever-increasing financial pressure smaller practices are facing every day, even outside of shutdowns.

Never before has the value of a personal relationship with one’s physician been more important. Seniors, often living far away from their adult children, need the security of knowing they have someone looking out for them. The idea of waiting on line at an urgent care clinic during a worldwide pandemic was unthinkable for some. A comfortable office visit, where they are ushered into a private room quickly and safely can make the difference between being seen and neglecting their health.

There were some medical practices that had these systems in place and had the tools to survive what 2020 threw at them. Physicians that offered concierge medicine, either in full or in part, had the ability to treat patients conveniently on the phone, continue to earn stable revenue, and provide comfort and peace of mind to anxious patients. 

“I never expected to have my established concierge practice benefit me as much as it has in the last six months of this pandemic,” said Glenn Soppe, MD, a primary care physician in Encinitas, California. “We had three months of very low patient visits and related billings. We are pretty much back to normal volume now and have been able to have an almost normally functioning, virus-safe office since July 1st.”

Dr. Elizabeth Halibuk, with a practice in Fairfax, VA agrees. “I have never been happier to be a concierge physician than I am right now,”she said.

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The current health crisis may slowly diminish in the coming months, but the need for convenient telemedicine and strong, stable medical practices that can put patients first will not end. The crisis has illuminated this need, and membership in concierge programs is growing and will continue to grow. The key in 2021 is finding the membership model that will complement your overall practice and support your patients.

Keith Elgart is the COO of Concierge Choice Physicians, the largest private provider of the full range of concierge programs available today. The company provides innovative, flexible and affordable models proven to work in medical practices of any size-from solo physicians to large medical practice corporations-both independent and affiliated with hospitals or health systems. Learn more about Concierge Choice Physicians at 

The current health crisis may slowly diminish in the coming months, but the need for convenient telemedicine and strong, stable medical practices that can put patients first will not. 

How membership medicine fits into a post-COVID medical practice

Victor Bornstein, Founder and CEO of Justpoint—an artificial intelligence startup—discusses the reasons behind the foundation of the company and why he feels it is important to revolutionize the medical malpractice claims space.

Victor Bornstein, Founder and CEO of Justpoint, discusses the reasons behind the foundation of the company 

A new startup tackling medical malpractice claims

Happy New Year! It’s good to start another year with Physicians Practice readers and to see a light at the end of the tunnel for America after one of the most challenging years in U.S. history. The country owes a profound debt to the healthcare community for its heroic service and courage in the face of not only overwhelming numbers, an unknown virus, and supply shortages, but also unprecedented levels of anti-science and anti-medicine hostility and disinformation.

The beginning of a vaccination program (which is already facing resistance, physical threats, and disinformation from anti-vaxxers) puts this country, its citizens, and our economy on track to recovery and a return to a new normalcy. If we can get most of the country vaccinated by the end of this year, the chances of some semblance of physical, social, political, and economic stability and normalcy by 2022 are 

. Here are some tips for practice owners and leaders to help make sure you make it until then.

The political violence that rocked the country last week potentially threatened every citizen and business in the area, including medical practices, and was not limited to Washington D.C. There were significant events of violence or threats at various state Capitols and protests across half a dozen or more states including Washington, Georgia, Michigan, and Oregon. The risk isn’t over and is considered high through and after the Presidential inauguration, as there are multiple reports of violent protests being planned both at the inauguration itself and at state Capitols around the United States.

I recently covered some basic election violence risk management 

 that you should review if you haven’t already seen it. Protecting your patients, staff and business continuity requires 

 and may range from dealing with simple curfews and road closures to more direct, physical threats, like 

Be legally prepared to separate partners and employees from your practice

If you’ve seen the news in the last 72 hours, you have likely seen footage from all over the country of people who live streamed, tweeted, or otherwise shared their political activities on social media being exposed, arrested, and terminated from their employment. Healthcare workers including physicians, nurses, and paramedics have not been immune to this and have been identified on social media 

 ranging from unsafe pandemic behavior that exposes themselves and their patients to COVID19, to making false statements and reciting ‘Q-Anon’ conspiracy theories, encouraging violence and allegedly even being part of the attack on the capitol building itself, and 

We’ve previously discussed the importance of formal 

 that control what happens when a partner leaves a medical practice due to issues including disability, departure, and 

. Having this crisis management tool in place may become vital to the reputation and solvency of your practice. Similarly, termination of an employee for disqualifying conduct that threatens the reputation, safety, or operation of a medical practice 

 and needs to follow both the law and the internal process outlined in your office 

, a vital business asset protection tool we have covered in detail.

Whether you’re a power user #SoMeDoc or don’t know a Tweet from a TikTok, social media is faster, more necessary and more powerful and more potentially dangerous to your practice than ever before. Make sure you have (and actually review with all staff and partners, the rules apply to 

 that, in conjunction with your employment manual, outlines your policies and the penalties for violating them. The risks you face range from personal and professional reputation damage to significant financial and legal loss. 

Given recent events, make it unquestionably clear that any content attributable to their employment at your practice including images of them in your uniforms, your logo, their ID badges, or that identify your practice should be treated with the highest level of caution.

 They should know that while they have a right to free speech, that right may have consequences that affect their employment.

Stay safe, we continue the discussion in our next installment.

, JD, has practiced law exclusively in the areas of asset protection, risk management and wealth preservation for the last 16 years. He helps protect a national client base with more than $5 billion in personal assets, including several thousand physicians. He is a contributing author to multiple books for physicians and a frequent medical conference speaker and CME presenter. Learn more at

As 2021 begins, it presents both familiar risks and new challenges never experienced in the lifetimes of most Americans. We start the year by reviewing key measures to help you to manage and survive both. 

Physicians 2021 Asset Protection Checklist – Part 1 

As part of its goal to reduce administrative burdens on physicians, the Centers for Medicare and Medicaid Services (CMS) has introduced a final rule for Evaluation and Management (E&M) coding changes that go into effect in January 2021. Extensive revisions to the guidelines aim to minimize the amount of time physicians spend on documenting visits—prioritizing the documentation of information pertinent to patient care, creating resource-based reimbursement, and achieving less need for audits.

The move reflects a positive step forward in terms of patient care and administrative burden, yet documentation readiness hinges on a clear understanding of how the changes impact current practices. Rather than focusing on a checklist of conditions for reimbursement, documentation must prioritize a holistic view of patient care to align with the framework supporting E&M codes going forward.

The best strategies for ensuring compliance make use of ongoing monitoring and use of prospective and retrospective auditing. Coupled with the right technology-enabled workflow, these tactics can go along way toward helping the average resource-strapped provider organization avoid pitfalls and maximize reimbursement. 

New year resolutions for private practice

While the American Medical Association (AMA) provides a 

, key highlights that coding teams need to be aware of include:

Eliminating history & physical (H&P) exam as element for code selection

While H&Ps can still be calculated as part of the total time of a visit, they no longer serve as the basis for what level of service a clinician should choose for that visit.

Medical decision making (MDM) or total time as basis for documentation and code selection

With the changes, MDM or “total time” is now the basis for coding, with the goal of better recognizing the work involved in services that are not performed face-to-face, such as care coordination. “Total time” is now defined as the time spent with a patient that is greater than 15 minutes and includes such activities as reviewing tests, obtaining and reviewing histories, performing exams, ordering medications, tests or procedures, and counseling patients and caregivers. MDM is now based on the number and complexity of the problems addressed in an encounter, the amount of complexity associated with patient data that are analyzed, and the risk of complications.

Changing MDM criteria to focus on tasks that affect the management of a patient’s condition

As part of the changes to MDM criteria, ambiguous terms such as “mild” were removed, and terms such as “acute” or “chronic illness with systemic symptoms” are now more clearly defined.

CPT code 99201 is being eliminated since 99201 and 99202 are both straightforward and differentiated by only history and exam elements.

Creation of shorter prolonged service codes

Since time is the primary basis for code selection, when the visit exceeds 75 minutes there is an additional code to capture time in 15-minute increments when time exceeds the levels in 99205 and 99215. It can only be used with those codes and when time is the basis for code selection.

A New Perspective for Coders and Auditors

The 2021 E&M coding changes will usher in a new way of thinking in terms of auditing practices. The focus now shifts to a holistic view of the patient, the problem, and the risks.

For example, consider how age may have impacted care planning in the past. Going forward, no two patients should have the same treatment plan based on age. Providers will need to document a clear understanding of the problem— for example what kind of acuity exists and/or whether there any chronic conditions or a differential diagnosis. In terms of risk, documentation should answer questions such as: “What are the risks of having a treatment plan versus not having one?” and “What social conditions exist that impact outcomes?”

With these shifts in focus, providers face revenue integrity challenges and should prepare for these in a proactive manner. Morbidity and mortality levels will still drive MDM, and accurate diagnosis coding and level compatibility are critical. Consequently, providers should avoid non-specific codes and include comorbidities.

Documentation must support the time spent with a patient to maximize reimbursement. Insights into the patient risks, complex conditions and acuity will be paramount to support optimal revenue capture. In addition, complexity and “leveling” driven by MDM will help providers support the “why” for poor outcomes when they occur.

The financial impact of over/under coding cannot be overstated. E&M codes 99211-99205 represent 40% of total revenue on average. Thus, auditing and denial monitoring will be critical to ensure no revenue is being left behind.

 (see image at right) to help practices prepare. Working in tandem with these tactics, the best strategies draw on the power of advanced analytics, automation, and artificial intelligence tools to improve collaboration between coding, billing, and compliance teams. Solutions exist now that can extract insights from claims in near real-time and detect anomalies, fueling new and expanded insights to advance process improvement initiatives around E&M changes. And, not surprisingly, the value proposition of these tools is growing rapidly as healthcare organizations try to maximize reimbursements against current revenue shortfalls associated with the COVID-19 pandemic and rapidly changing regulations.

Healthcare stakeholders stand to benefit in significant ways with current movements aimed at achieving patient-centered care. Changes to E&M coding reflect this progress by reducing administrative burden for providers and helping them focus on their primary priority: care delivery. Providers who embrace this shift and prepare for it with the right technology-enabled workflows will be best positioned for success.

Extensive revisions aim to prioritize patient care information, resource-based reimbursement, and lessening the need for audits.

2021 E&M Changes: Avoiding pitfalls with the right technology-enabled strategy

Eliminating staff gossip at your practice

Creating a winning team culture in an office is a key to success that cannot be overlooked. Most team builders come in with a lot of buzzwords, flashing lights, and games in order to engage staff members; often times their solutions dwindle and fade as fast as they arrived. There are simple solutions that create a unified team environment that can become permanent. One of the easiest ways to build team unity is a no gossip policy.

The policy is simple- gossip once and you will be warned, gossip again and you will be released. You could implement a few different versions, and with a problematic and bickering staff, you may have to add a few additional steps prior to releasing an employee.

Gossip is dishonest, contagious, and breeds disloyalty for your medical practice and within your team. All of the standard bullet points about building a great culture within your company are affected by gossip. Typically, team members that gossip about each other, gossip about everybody: staff, physicians, patients, and business. It is not “healthy” for your office to allow gossip and having an office full of gossip is a quick way to experience legal and professional ramifications.

When you bring a policy like this into an existing office dynamic, it is imperative that you don’t hand this out in a memo or e-mail. It is imperative to hold a team meeting, with a detailed explanation, and an opportunity for your team to ask questions.

This policy may not be well-received by all of your staff or team members at first. Your biggest culprits will be the most vocal and try to win over the others. Quality people do not gossip, and after the initial implementation phase of this policy, you will be left with quality people, who monitor and remind each other to remain gossip free. 

Here are some tips to make your office a gossip-free zone.


 Last year, The American Medical Association released results of their prior authorization survey, which found that physicians were completing an average of 33 prior authorizations per week, waiting an average of two whole business days for approval. The entire approval process had become so burdensome that some respondents reported increasing their staff specifically to deal with the increased burdens of prior authorizations.

We spoke with Paul Joiner, chief operating officer of Availity, to flesh out some of the results from the survey and find out how primary care practices can improve their prior authorization processes.

In case you are new to the concept of prior authorizations, here is a brief explanation from Paul.

 So prior authorization is a process in which providers have to go through on behalf of their patients to get approval from the health plan to provide a service and get paid for it. This process is often reserved for procedures and diagnostics. It's probably the biggest burden in the diagnostic process, just because you're anxious to get to a diagnosis. You'll also hear it referred to as pre certification. And then sometimes there's other confusing topics, like notice of admission sometimes gets called a ‘preauth’, with people technically, because of a common transaction name, but by and large, in general, pre authorization and pre certification is an approval prior to service from the health insurance plan to perform a procedure and get paid for it.

 Paul mentions radiology, but he also said other treatments that typically require prior authorizations are those that require some medical guidelines before administering or performing, including many preventative diagnostic type tests.

Furthermore, they are intertwined with electronic health records, which may present additional hurdles.

 Well, they are because the source of information for supporting the need for the diagnostic test or for that procedure lives within the medical records. So proper documentation and understanding what is needed to attain the authorization is very, very important. It's important from a training perspective. And it's important that this team working on the authorization process is giving that feedback to the physicians, the physician extenders, so the medical assistants, the nurses and the physician assistants, if you will.

 Regarding the report mentioned earlier, Paul says that the average two-day wait time for prior authorization decisions is due to the fact that every health plan handles various authorization types differently.

 Sure, well, every health plan handles various authorization types differently. It takes two days, because one, the sheer volume, and then two, it requires a lot of these requires some type of clinical review and some type of clinical back and forth. And those are limited, expensive, highly skilled, specific resources. And then the back and forth part is, is that many times, there's a level of clinical information that needs to be supplied. And sometimes there's a back and forth conversation that needs to occur before the final disposition of the pre-authorization or the approval or the denial of the authorization can be can be given. And so many times, providers get very frustrated because they're a little confused about the status of the prior authorization, and how plans sometimes struggle to convey that status back to the providers. Obviously the patient's anxious to move on, so it creates a lot of anxiety, but it's a function of resources, the function of the complexity of the process, and in the back and forth conversation sometimes has to occur.

 Also mentioned in the report from the American Medical Association is a reported increase in a sense of burden among respondents. When asked whether or not this burden was perceptual—that it was an incorrect assessment from the physicians—or whether their sense of burden was actually due to requirement changes and increases in complexity, Paul says that it is certainly the latter.

 Requirements are truly been being increased. The level of which, the types of procedures, the variety of procedures, and diagnostic tests that requiring prior authorization is increasing. And then the nature in which these procedures and services are being scrutinized has been ratcheted up.

To the health plans’ credit though, many health plans are trying their best to innovate and improve the process and exchange of clinical information and make it clear to providers on when a prior authorization is required, and information that they need in order to give the prior approval.

You know any recommendation I would give to any provider or any physician especially if they're new to practice or long established, take a second and spend a couple extra moments with your staff and to make sure the process is worked out. And you as a physician know how you can help and how you can provide the proper documentation to facilitate the process or make sure the process is moving. smoothly.

And then the other thing is, is a lot of this misconception going back this 86% of burden increase. There's a lot of misunderstanding between the providers and health plans. And so, if something doesn't make sense, I encourage the providers to reach out to the health plans and have a conversation about it. Because a lot of times, it's a process or a structural issue in terms of how the information is being sent to the health plan, or the way that information is being interpreted creates a lot of confusion, a lot of problem between the providers and health plans, which increases the burden.

I've seen examples where providers have sat down with health plans and worked out and improve the process. And there's always going to be a little friction to the process. But it definitely can be reduced if you just take the time to kind of learn the process, both internally and also engage the health plans.

 Requirements from health plans are not the only way in which requirements, and subsequent physician burden, are increasing. Paul says that there are some legal and regulatory changes that can affect the prior authorization process as well.

 Well, there are in there are different mandates out there trying to improve the process. In fact, I just participated in and testified to Washington organization in relation to the improvement of the process and different operating rules. Core is putting for roles, the AMA is obviously involved. There are other technological advances that will could probably change the authorization process there since the Da Vinci project, which is a clinical information interoperability initiative that's underway. So, there's a lot of pressure from the federal and state governments to improve interoperability to improve the process. Really, where a lot of the technical legal stuff happens is that if you perform a procedure, and the payer denies it, because they don't think proper authorization was in place, that does trigger a formal legal process that does vary from state to state.

 Though some practices said in the American Medical Association report that they were increasing staffing levels to deal with the prior authorization process, Paul says that improvements do not stop at the hiring process.

 Well, yes, staffing. I'm familiar with one practice. You know, a dozen years ago, they had two people working prior authorizations, and now they have eight, it's a practice I'm familiar with. And so, number one thing around when you're increasing staffing is training. So, make sure that you're working hard to evolve your training with the times and staying current corporate policies, and that you're just not perpetuating common myths and workflows that you're constantly improving as you're training your employees.

Number two, invest. Invest in these in these resources that you have in the authorization problem and make sure that are of a high caliber, because there is a valuable payback in terms of them being a sophisticated resource and capable to navigate the system and capital is also capable to, you know, interpret how this process is changing and how the payers are changing.

Next on the process side, you can subdivide the authorization work by payer type, by procedure type, so you can subdivide the work. And that typically helps because then your resources can get more and more specialized and more and more focused in terms of information they're collecting, and who they're communicating with. Because many health plans outsource certain segments of the authorization process to vendors. Radiology benefit managers is a common one, you'll hear where there's an actual health I know speaking with, they're actually speaking a company, who providers provides the UN services or the authorization process to the provider to the health plan. And then providers have to engage the UN vendor. So, from a process perspective, it's about how can you subdivide the work and make sure the work is prioritized and bucket in terms of the most complex the least and make sure the right people working on the right task.

Then from the technology perspective, there's all sorts of opportunity to think through the person trying to attain the authorization and the approval making sure they have all the proper clinical documentation. And then try to understand and engage with that your largest health plans on what tools they have available to you to submit for an authorization or check the status of it. Besides picking up the phone and calling. One thing I want to share that is a common issue that a lot of providers think that they'll go through a solution like you know like Availity has or other vendors have in relation to electronic submission or authorization. I've heard numerous for physician practices say well I also call even if I get an electronic because I want the name and phone number and I want documentation that got called to double check or for an extra level of verification that the authorization is in place because I do not want to denial after treatment. So, despite so what that means is despite electronic channels and technology channels, and integration channels, they're still calling the health plans and trying to write down the name of a call center and the name or name of the time and a reference number for that phone call. So that they have that additional evidence that they did obtain authorization in the event that their claim was denied for that service because prior auth wasn't on file.

Train, hire well, process, constantly review the process, and make sure you're subdividing the work and the technology. Look for all the opportunities you can to pull the practice correct information forward to the process. And that that you're using all the proper available channels to the end of your largest health plans.

 Before we parted, Paul offered some final advice to practices looking to streamline their prior authorization process.

 Well, I hope that they are who are curious, and they go down and try to find the team and staff and they invest a little extra trying time trying to understand how their practice or their facility is managing authorization process and what role they play in that process.

The other thing is that, despite I know, many, many physicians are very frustrated with the authorization process and get upset. And I understand—put those emotions aside and look at it as it is a process it's out there, it's not going away. So with the most open and innovative mine, you can go to the process and see how you can help improve it, or how you can give additional resources or technical resources or integration resources or additional training to make sure your staff is only calling when they have to call and they're using all the best possible tools out there, available to them.

And another thing is, you know, if it is an increasing burden for your organization, keep the Google search up around, you know, authorization tools, because there are some small, innovative companies out there. We're partnering with some and then there are some that we're keeping an eye on that I think are working on trying to come up with little neat little widgets and modules to improve the gathering of the clinical information and the submission of it. And so keep your eyes and ears open because I do think it's a big enough problem that solutions will continue and innovation will continue to evolve the process probably at a more accelerated rate.

Podcasts

Physician's Practice spoke with Paul Joiner, chief operating officer of Availity, to discuss the implications of an American Medical Association survey and find out how you can improve your prior authorization processes.

Improving the prior authorization process

The outcome of a decade-long debate over value-based care is clear: either adapt or a clinician’s practice will suffer. Moreover, adapting to a value-based care model now will allow independent physicians the chance to shape and impact future care models and how success is defined and measured.

For independent physicians, the debate has been whether value-based care or the fee-for-service model is better. Value-based care is a simple concept that links reimbursement for healthcare services, not just to the volume of work performed, but also the quality of the work performed. Providers receive a premium for making thoughtful care decisions that improve the total care experience for the patient. This could mean getting patients back to work sooner, treating patients with conservative therapy vs. higher acuity procedures where possible or managing the total cost of care for certain diseases, illnesses, or ailments. This contrasts with a traditional fee-for-service model in which providers are not incentivized to improve care over time across their patient populations.

As annual healthcare spending eclipses $3.5 trillion in the United States, value-based care initiatives are an opportunity to slow rising healthcare costs while also narrowing the gap between cost and quality. This new model helps shift some of the spend toward providers who are good stewards of our healthcare system. Despite the industry heading toward value-based care, some physicians are hesitant to switch their model, and by delaying, could negatively impact their business.

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There’s a common misconception among providers that value-based care and its goals to lower cost ultimately mean that they will make less money. However, in the value-based world and under the proper models, physicians are incentivized to take on more responsibility for the outcomes of care while commercial payors are willing to pay more for higher levels of care if it can be measured and reported on.

Through the right tools and infrastructure, physicians are better able to understand, analyze and leverage key performance indicators and outcomes data. A deep dive into data can tell an important story. It can highlight best practices, identify opportunities for improvement and potentially uncover cost-saving measures. It is an opportunity to gain knowledge that can spark improvement in the practice and chart a path forward.

Physicians have a small window of opportunity to transition to a value-based care model—just two to three years—before they fall behind their peers. We are seeing tremendous aggregation in the orthopedic and neuromusculoskeletal spaces for example, which is making it harder for independent physicians to compete against larger healthcare infrastructures.

Over the next two to three years, independent physicians should focus on three areas of opportunity. First, they should incorporate a standard for enhancing data collection and reporting within the practice. This allows data to be parsed and sorted in a variety of ways and allows the practice to track changes in outcomes based on adjustments in treatment. Another important consideration is to define key performance indicators within the practice that lead to improved outcomes and lower costs. Finally, assign an outcomes officer within the practice to work with the collected data points and incorporate a constant improvement process into the group’s regular cadence.

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Waiting to change could negatively affect business