April, 2009

There have not been many opportunities, lately, to provide an editorial or instructive message in most of the blog entries.  There is too much important data, too many important stories to pass along that I miss my chance to lecture for a minute.  Not today.

When a topic like swine flu takes over general news and discussion, you know it must dominate the pediatric gathering points.  That is certainly the case on PedTalk and SOAPM.  I'm painting a broad brushstroke, but most of the back-and-forth relates to how offices are managing the high volume of calls (99% of which are "unnecessary").  Even with minimal griping, the tone reflects a mild eye-rolling, an implication that these calls and communication represent just another chore tossed on the backs of pediatricians.

If you think this way, you're missing a giant opportunity. Every time a patient calls your office, you send them a letter, you change your on-hold message, etc., it is your chance to re-establish yourself as the trusted source of medical information for your patients.  It's also your chance to let your patients know about any changes to your practice.  And remind them that you, more than anyone, are looking out for their needs.

You work in a service industry.  Can you imagine if FedEx somehow had a crisis which meant that CNN would talk about them non-stop and tens of thousands of their customers would call FedEx just to make sure everything is OK?  You know that FedEx would take each and every one of those phone calls and turn them into a marketing opportunity.

You're not comfortable with that language?  I'm not talking about the money - I'm talking about improving your clinical care.  You just wrote out a protocol for your nurses to follow for everyone who calls in - add a single sentence about the importance of those well visits.  Did you add morning or evening office hours but many patients still don't know? Now's a good time to remind them, a few hundred are calling this week.  A new doctor in the practice?  Added or dropped an insurance company?  More details on the WWW site?  

What's happening to you right now is a marketing expert's dream.  Folks get nervous and they look to you for help and advice.  Stop thinking about it as a chore and start thinking about it as your chance to get them back in the fold.  Let them know that you are prepared to help them and that you care.

Anything less is a waste of time.

 

An important message from the AAP:

The Section on Telehealth Care (SOTC) distributes this special edition of Telephone Lines, our nurse triage educational newsletter, to assist practices in dealing with the Swine Flu situation.  It is our hope that this information will allow office-based and medical call center nurses to provide consistent information to patients.  Updates will be distributed if professional recommendations change.  This is just one example of the timely and useful resources from the SOTC.  If you are not yet a member of SOTC, please consider joining. Membership information can be found at http://www.aap.org/sections/telecare/membership.htm.

What's so special?  How about a good piece entitled, "Swine Flu for Telephone Triage Nurses"?  Enjoy, thanks to the AAP, SOTC, and Lynn Cramer.

Update: this CDC link comes from Dr. Bowman. A good addition.

 

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[Today's installment was ghost written by the obvious author.]

Q was alerted by the folks who publish the Pediatric Coder's Pink Sheet about the AAP's recent collaboration with American Academy of Child and Adolescent Psychiatry.  They've published a position paper calling for the "removal of financial barriers to children's mental health services." The paper addresses the "Insufficient payment by insurance purchasers, payers, and behavioral health organizations (that) impedes (primary care providers') ability to provide comprehensive treatment."  How's that for an appeal letter attachment?

Thanks, Q!

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The very first blog I ever wrote was about one client's fight with an HMO.  Now, more than two years later, I continue the battle.  Look at this funny message I received today, edited for brevity and privacy:

As promised, the outcome of my recent [HMO] "negotiations."  At the risk of hearing Chip's "I told you so's" ring in my ears, the following occurred today:  Nearly three months after accepting my termination, and with 5 days to go before the deadline, [HMO]
offered me a greatly improved contract...

The resultant offer improves E&M codes by 40-75% and preventive care by 90-140%, by virtue of and change from a defacto 50% of 2008 rates to 100% of 2009 Medicare...

The vaccines rates are interesting.  For many vaccines they pay essentially cost (100% of CDC), for some vaccines, especially the pricier ones, these amounts are enhanced by 5-11%.  But... they have set the Vaccine reimbursement rates at 120% of Medicare.   Thirty dollars for the first shot helps take the sting out of that a bit.  And they paid so little for the nasal admin fees that the new rates are almost a 400% increase.

The after hour codes are still under review.  It's apparent after a few negotiations that is it easier to get a custom fee schedule than to have a policy altered for an individual practice.  Perhaps you already knew that!

Lastly the bad news:  We took a huge hit on a few procedures. 30-40% Fortunately most if not all of these codes are low volume...

The bottom line.  If the current fee schedule had been in effect for 1/1/07 to date, our revenue would have been enhanced by a 31%, which I would project as the enhanced value of the new contract.

31% increase.  By asking, dropping, and negotiating.  And he's not done.  Anyone else want to tell me it can't be done?

Meanwhile, I posted a substantial update to our Pediatric RVU Calculator.  Check out the new version - flash-based, produces CSVs, etc.  Very nice.  

OK, I think I have written about the 96110 more than any other specific subject!

First, big thanks go out to Igor for getting this data for me. Sure, he deserves a raise...we all do.

The list below should not be considered a 100% accurate report of which payers, by state, cover the 96110 (or 96111, for that matter) for two reasons:

• First, as noted yesterday, these only reflect charges for which payments were made.  They could, conceivably, reflect payments made from patients on waivers, etc.  We can get the super-accurate data, but this is what we have on-hand today and it's pretty accurate, I suspect.  For example, how many Medicaid patients are on waivers?  Exactly.
• Second, it's quite conceivable that I counted a state when I shouldn't have because I am not aware of all the differences among "Blue Cross" vs. "Blue Shield" that exist in different parts of the country.  Most often, the follow each other identically.  But in places like PA, you can't just trust that the word "Blue" in the name means "BCBS."  I did my best.

 

Thanks again to Igor, we know that the states where BCBS appears to cover 96110 include: AL, AZ, CA, CO, CT, DE, FL, GA, IL, KS, MA, MD, MI, NC, NH, NJ, NY, OH, OK, PA, RI, TN, TX, UT, VA, VT, WV, WY. 28 states - not bad, considering the relatively low usage of this code and the fact that we don't have any clients in places like Alaska, Hawaii, North Dakota, etc.  Sure, we have clients in Maine, but I think it's more likely that they aren't billing and not that it isn't being paid.

As for Medicaid, the list is similar, though not identical: AL, AR, AZ, CO, CT, GA, KS, MA, MI, NC, NH, NJ, NY, OH, OK, PA, TN, TX, VA, VT, WA, OR, WV, MT, WY.  25, I believe. That means at least 1/2 of them (and quite likely many more).  

I have had a number of off-line and on-line requests for details about who, exactly, is paying for the deveopmental testing (96110 and 96111) and non-face-to-face codes (or the "telephone codes"), so Igor was kind enough to look it up for me.

As an aside, PCC allows our customers a great deal of flexibility when it comes to configuring their systems.  Thus, our clients use all kinds of names/spellings/etc. for recording work done with individual payers.  This is in contrast to the way that, say, Athenahealth does it, which is to hand you a list of payers and say, "Choose one."  Though our method is friendlier, theirs is better for the amalgamation of data, so please forgive me if I somehow mis-categorize one or more of these plans.  I have no fewer than 66 versions of "Aetna," for example, so it's easy to miss one.  I also have only a partial listing of the Medicaids and BCBSs, as I didn't track down all the states yet.  If your state info is missing, ask me.

Enough whining from me.  Below, please find a list of payers whose patients have recorded payments on the 96110 in 2009 for our clients.  Note: this does not mean that the payer covers the charge, but that it also may allow the patient to be billed for it.  I thought that this was an important addition.

I'll look into updating this again in a few months.  Tomorrow, a shorter list of the telephone codes.

 

1st MN/MR/GA 1st Aetna Affinity MA Affordable AHCCCS Alliance AL Medicaid Alta Bates Americaid AmeriChoice AmeriGroup AmeriHealth Anthem ASR Atlantic Health System BCBS Alabama BCBS CO BCBS Federal Employees BCBS Georgia BCBS MA BCBS NJ BCBS NY BCBS RI BCBS TX BCBS UT Beech Street Berkshire Health Plan Best Choice Plus Best Health Blue Card BlueCare Bluechip Blue Choice Blue Shield CO Blue Shield NH Blue Shield PA Boston Medical Center HealthNet Plan Buckeye Community Health Capital Blue Cross Carefirst 345 Caresource CBA CCHMO St. Francis CCHMO St. John (ValuMed) CCN Champus Children's Mercy CHIPS ChoiceCare ChoiceCare CHPW Healthy Options Cigna CMSP Cofinity Community Blue Community Care Community Care Network Community Health Network Comy Connecticare Consultec

Coventry CT Care Definity Health Devon Health Services Diamond State Partner Direct Access EBMS Educators Mutual EHP Empire Employee Health Plans Evergreen Fallon Famis Federal Select First Carolina Care First Health Network First Priority Life Geisinger Health Plans GHI GIC Great West Greatwest PPO Guardian Harvard Pilgrim Harvard Pilgrim HCVM Health America Health Assurance Health First Child Hlth+ Health First MA Healthmate HealthNet Health Net Health New England Health Plan of Michigan Healthsmart Highmark Blue Shield Hip Hip MA Horizon Humana Interplan Kaiser Permanente Keystone Magnacare Mailhandlers Mail Handlers Mass Health Medallion Medcost Medicaid MA Medicaid MT Medicaid OR Medicaid WY Medical Mutual Medical Network MediChoice Mercy

Metlife Network Metrahealth Molina Multiplan Multiplan NCAS Capital Blue Cross NC Healthchoice Neighborhood Health Plan Nethealth Network Health New Mexico POS North American Preferred NovaNet OH DPA OHIO HEALTH CHOICE OK Soonercare One Health Plan Optima OSMA/PLICO Oxford PABS BLUECARD Pacificare Peachstate PHC PHCS PHS Physician's Care Physicians Health Services PPOM Preferred Community Choice Premera (Non-Regence Blues) Primary Care Plus Principal Life Priority Priority Health Private Healthcare Systems QualCare Rocky Mountain Health Plan Select Health SouthCare Summa Teamsters TennCare TPA TriCare Tufts TX True Choice Unicare Unison UnitedHealthCare UOVDPW UOVHP UPMC UPMC Tristate US Healthcare Valley Preferred Vermont Managed Care WellCare Well Choice WV DPW

 

 

It's official - go sign up.  Space is limited.  Similar to our previous endeavors but two days, a lot of content, and the largest collection of pediatric practices in one place all year long.  The best part -it's at Disney, you bring your family! 

It's also substantially cheaper than other events held at the same location (or elsewhere) around the same time...

---

PCC is pleased to announce that this summer's Pediatric Coding & Practice Management Conference will take place at Walt Disney World® Resort, Florida from July 23-24 2009.

We are planning an exciting conference packed with pediatric practice
management education in a fun-filled learning environment. Mark your
calendars or begin to plan your trip to Walt Disney World® Resort now.

New! Register Now!

---

I'd also like to call attention to these archived teleconferences about the Medical Home model that everyone with interest in this issue should listen to:

 

Medical Home Implementation Teleconference Series

The American Academy of Pediatrics is hosting a free
teleconference series to provide child health professionals with
practical strategies for implementing medical home in practice. These
informative calls will be led by nationally recognized experts with the
goal of educating participants about the value of the family-centered
primary care medical home for all children and youth, the availability
of practical tools and resources, and will provide strategies for
improving care and increasing patient/family satisfaction. Note: Calls 3,4, and 5 will be held in a Webinar format to accommodate the demand for additional participation. 

 

Presentations and podcasts are now available online for the first call (held on March 3^rd) at http://www.medicalhomeinfo.org/training/archivescall1.html and the second call (held on March 25th) at http://www.medicalhomeinfo.org/training/archivescall2.html. Descriptions of the calls are listed below:

 

Call #1: Implementing Medical Home for all Children and Youth
Featured Speakers:  
Vera Fan Tait, MD, FAAP; Associate Executive Director, American Academy of Pediatrics

Jeanne McAllister, BSN, MS, MHA; Director, Center for Medical Home Improvement (CMHI); Crotched Mountain Foundation, New Hampshire; AAP Medical Home Implementation Toolkit, Lead Consultant

 

By the end of this event, participants will be able to:

- Learn about essential tools to have in your practice that provide successful Medical Home for all children and youth;

-  Understand how those tools can help your practice pass Level 1 of the National Committee on Quality Assurance (NCQA) standards

 

Call #2: Improving Communication and Co-management Between Specialty Providers and the Medical Home

Featured Speakers:  
Chris Stille, MD, MPH, FAAP;
Co-Principal Investigator with the American Academy of Pediatrics and
the Shriners Hospitals for Children Project; Assoc Professor, UMass
Medical School, Worcester, MA
Jennifer Lail, MD, FAAP; Chapel Hill Pediatrics and Adolescents, PA, Chapel Hill, NC
Donald Lighter, MD, MBA, FAAP, FACHE; Vice President for Quality at WellCare, Inc

 

By the end of this event, participants will be able to:

-
Discuss the importance of primary and specialty care collaboration in
the provision of comprehensive, family-centered care provided in the
medical home.
- Describe the benefits of enhancing communication in the continuity between health systems.
-
Identify 3 practical approaches to enhance communication and
co-management and their potential applications for improved chronic
condition management in their practice.

 
For additional information about the teleconference series, please visit: http://www.medicalhomeinfo.org/training/archives.html

Thanks, Siouxsie, for that info.

I've written extensively about 96110 usage among practicing pediatricians in the past and wanted to provide an update for 2008/9.

96110 Charge Reimbursement Data

(Paid-off Charges, 2008/9)

	Average Charge	Average Ins. Payment	Average Pers. Payment	Average Total Payment
2008	$40.26	$11.01	$1.41	$12.42
2009	$38.40	$12.50	$.98	$13.48

The declining personal charges combined with the increasing insurance payments (increasing at a faster rate) imply that, indeed, more and more payers are picking up this code.

More telling?  That the number of PCC clients using this code increased by more than 50% (Q1 2008 vs. Q1 2009) and now nearly 1/2 of our clients are using this code regularly.  Why aren't you?

 

 

I've mentioned the use of telephone codes in pediatric offices a few times previously, but it looks like I may have never actually provided any usage data!  It just so happens that the a good friend asked me, "Are most insurance companies paying for the 96110?" which made me wonder about any changes to the phone codes.  [More about the 96110 tomorrow.]

Although the numbers show an improvement, they are still depressing.  First, the codes I'm talking about: 99441, 99442, 99443 and the new telephone codes 98966, 98967, and 98968.  If you don't know what these codes are, they are easily Googled and learned about.  I will just assume you know.

First, fewer than 20% of  PCC clients even use these codes.  Fewer than 10% of PCC clients have used these codes more than 20 times.  And only one used the codes more than 100 times.  That's right - even though these CPT codes have RVU values, descriptions, and are recognized by law (thanks to HIPAA), pediatricians still aren't using them.  

How are they being used?  Well, the 99441 - the lowly "Phone e/m by phys 5-10 min" - makes up nealy 75% of all the usage.  Maybe that's normal, but we have only one client (and you know who you are!) who has billed the 98966 (same call, but only by a non-doc).  And they have billed only 9 since 1/1/09.

Insert my deep sigh here.

However, here's the good news.  We have some new payers who are covering these procedures.  They include PHC, Health Assurance, Health New England, Americaid, Alta Bates, Tufts, Aetna, DSHS, CHPW, and others.  

Here's what I can tell you:

Avg Charge/Payment By Code 

	Average Charge	Average Payment
99441	$29	$17
99442	$40	$4
99443	$60	$7

So, we have some odd behavior related to the average reimbursement dropping as the value of the code rises, but it's easily explained: payers understand the 99441 and are working their way up the ladder.  Although most payers are in the $3-$10 range for these codes, some are paying $14, $27, and even $35 a pop!  Amazing.

Tell me, again, why you aren't using these codes?

More detail about the 96110 tomorrow.

About a year ago, I shared a piece from softwareadvice.com about CCHIT (on whose Child Health Certification committee I serve).  I found their original response pretty well balanced, so I now pass along their followup to the piece.  I won't go through it like I did last time, as my points haven't changed much, but it's a decent review of the pros and I cons of the CCHIT impact.

I also wanted to point out that another expert has weighed in on the consequences of the Obama HIT stimulus and feels quite similar to how I feel.  Read Jeff Daigrepont's blog entry here (their other blog pieces are good reading, too).