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In a report released by the CDC on 28 March 2014 (source here), the annual incidence rate of invasive cancers has dropped from 446 cases per 100,000 in year 2010 from 459 in year 2009. From the detailed analysis based on figures from the Cancer Statistics, several noteworthy conclusions were found:
"Cancer incidence rates were higher among men (503) than women (405), highest among blacks (455), and ranged by state from 380 to 511 per 100,000 persons. Many factors, including tobacco use, obesity, insufficient physical activity, and human papilloma virus (HPV) infection, contribute to the risk for developing cancer, and differences in cancer incidence indicate differences in the prevalence of these risk factors. These differences can be reduced through policy approaches such as the Affordable Care Act,* which could increase access for millions of persons to appropriate and timely cancer preventive services, including help with smoking cessation, cancer screening, and vaccination against HPV."
While the federal "Ethics in Patient Referrals Act" prevents referring patients to other organizations in which the physician has a financial stake, the ancillary services loophole may be expoited for radiology therapy, particularly for urology patients. In a recent article published in the New England Journal of Medicine, self-referring urologists were shown to be more likely to suggest expensive IMRT than alternatives shown to be just as effective. Read about it more here in Imaging Technology News.
Multiple Intensity-Modulated Radiation Therapy centers are now being reviewed by Recovery Audit Contractors (RACs); additional detail, including particular issues and the states being reviewed can be found in the following links:
Missing Documentation for Radiation Oncology and Brachytherapy Services
Craig McNabb, MBA, BSN
Radiation Coding Specialties, LLC
With increasing pressure on reimbursement from CMS and commercial payers it is important that documentation in the medical record for each patient and each encounter. Recent Comprehensive Error Rate Testing (CERT) contractor medical record requests for radiation oncology services, found that in some cases not all of the documentation is submitted to support the services billed. This can result in CERT error assessments or the need for additional follow-up contacts to obtain the necessary documentation. These additional requests cost time and money and tie up staff in gathering the needed documentation if it even exists.
Current Procedural Terminology (CPT®) listings for radiation oncology provide for teletherapy and brachytherapy to include initial consultations, clinical treatment planning, simulation, medical radiation physics, dosimetry, treatment devices, special services, and clinical treatment management procedures. They include normal follow-up care during course of treatment and for three months following its completion. Appropriate documentation of these services is paramount in order to establish the indications and limitations found in many of the existing Local Coverage Derterminations (LCD’s).
When responding to requests for documentation for these services, please review the documentation requirements in the applicable Local Coverage Determination (LCD) policy and make certain you provide all the needed information in order for the contractor to ascertain payment of the proper benefits. Remember, the billing provider has the ultimate responsibility to obtain and provide copies of medical record documentation, even if the records are housed elsewhere (i.e. radiology department).
What is Medical Necessity?
“Generally speaking, though, most definitions incorporate the principle of providing services which are "reasonable and necessary" or "appropriate" in light of clinical standards of practice.
The lack of objectivity inherent in these terms often leads to widely varying interpretations by physicians and payors, which, in turn, can result in the care provided not meeting the definition. And last, but not least, the decision as to whether the services were medically necessary is typically made by a payor reviewer who didn’t even see the patient.
“If it isn’t documented, it hasn’t been done” is an adage that is frequently heard in the health care setting.
Concise medical record documentation is critical to providing patients with quality care as well as to receiving accurate and timely reimbursement for furnished services.
Medical record documentation also assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring his or her health care over time.
Documentation that services are consistent with the insurance coverage provided assists in the validation of :
- The site of service;
- The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or
- That services furnished have been accurately reported.
- The Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
To ensure that medical record documentation is accurate, the following principles should be followed:
- The medical record should be complete and legible.
- The documentation of each patient encounter should include:
- Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results.
- Assessment, clinical impression, or diagnosis.
- Medical plan of care.
- Date and legible identity of the observer.
Protections Against Denial
“You should have known.” One of the most common reasons for denial of Medicare claims is that the physician didn’t know the services provided were not medically necessary.
Ignorance, however, is not a defense because a general notice to the medical community from CMS or a carrier (including a Medicare Report or Special Bulletin) that a service is not covered is considered sufficient notice.
If a physician was on Medicare’s mailing list as of a specific publication date, that may be sufficient to establish that the physician received the notice. Courts have concluded that it is reasonable to expect physicians to comply with the published policies or regulations they receive. Thus, no other evidence of knowledge may be necessary.
Per the Federal Register, November 2001 -
“Paragraph (d)(2)(i) would specify that the physician (or qualified nonphysician practitioner) who orders the service must maintain documentation of medical necessity for the service in the beneficiary’s medical record.”
“Presently, all entities that bill the Medicare program are held liable when they bill for services and are not able to produce documentation of the medical necessity of the service.”
Bottom line education of all persons charged with creating and providing services in your practice or department. Knowledge is power to coin a phrase, knowing what is required means less denials, increased reimbursement and more time staff can spend providing quality care to your patients.
7 Ways Accountable Care is Shaping Oncology
By Kate Canterbury and Kelley D. Simpson
Simply stated, the goal of the ACA is to expand access and control costs. Should the ACA remain intact as we move into a pivotal election cycle, oncology patients and their providers—physicians, hospitals and payers—will experience significant impact. The American health care delivery system is one of the best in the world. But, for many years, that care has gone to fewer and fewer people who can afford it with convincing evidence that variability in care exists depending upon a patient’s ability to pay. When exploring the impact of the ACA on oncology, there are key areas to which physicians and hospitals should pay close attention.
1. Growth with Efficiency: Under the ACA, cancer programs will be forced to intensify their focus on efficiency in concert with increased productivity/growth in patient population. While cancer programs may experience moderate financial relief due to coverage expansions, they will continue to face the challenges of caring for an aging, growing and multifaceted patient population, managing the rapid growth in the cost of cancer care, and achieving increasing regulatory and accreditation requirements … all in an environment of declining reimbursement. Maintaining a strong focus on building a care delivery system that is efficient and productive will be a necessity in order to maintain the profit margins required to continue delivering quality cancer care.
2. Expansion of Preventive Services: Most cancer screening modalities have been proven to prevent the spread of disease thereby improving quality of life and reducing the cost of care for that patient over
their lifetime. The ACA requires all health plans to cover preventive services that receive an “A” or “B” rating from the United States Preventive Services Task Force (USPSTF). Examples of oncology-related preventive services to which patients will have access and for which hospitals and physicians will be reimbursed include:
•Genetic counseling and evaluation for BRCA testing for at-risk women
•Chemoprevention for women at high-risk for breast cancer
•Mammograms every 1-2 years for women who are 40 years and older
•Cervical cancer screenings
•Colorectal cancer screenings via fecal occult blood test, sigmoidoscopy, or colonoscopy for patients 50 – 75 years
•Dietary counseling for diet-related chronic diseases by primary care physicians, nutritionists, or dieticians
•Tobacco use counseling and interventions
Although most oncology service lines offer some level of preventive care, cancer programs will be required to formalize and expand these services, while providing them in much greater collaboration with medical staff.
3. Capacity for More Covered Lives: The ACA expands Medicaid to individuals with incomes up to 133% of the federal poverty level, which will result in the addition of up to 20 million individuals, while standardizing Medicaid benefits by guaranteeing a minimum package of essential services. In addition, under the ACA, insurance companies will be required to accept all applicants and renew their coverage, despite the existence of pre-existing conditions. Furthermore, insurers cannot cancel coverage; the lifetime caps on insurance coverage for certain conditions have been eliminated; and, annual limits have been restricted. Cancer programs will need the clinical, facility and operational capacity to accept and deliver care to this expanded population.
4. Coverage for Clinical Trials: The ACA mandates coverage of routine costs for patients who participate in cancer clinical trials. Insurers are prohibited from dropping or limiting coverage for participants in cancer clinical trials. The most positive correlation of this mandate is the potential to increase minority participation in research. Additional benefits may include the establishment of the Patient Centered Outcomes Research Institute to compare the clinical effectiveness of treatments; grants to expedite translation of basic scientific discoveries into treatments; and, a substantial commitment to cancer prevention. Cancer programs will be faced with initiating or expanding access to clinical trials and building the infrastructure to actively maintain this element of quality cancer care.
5. Care Coordination: The ACA will promote integration of health care on many levels. As cancer remains a major specialty cost driver for most payers, oncologists, referring physicians and hospitals will need to proactively “partner” to enhance cancer care delivery. Cancer remains a very complex diagnosis and treatment maze to navigate. Transitions inherent throughout the cancer care continuum can lead to duplication of services, increased anxiety and financial burdens for patients and their families. All providers—hospitals, oncologists, other medical specialists, emergency rooms, community services, etc.—will be tasked with more effectively communicating, providing access to high-quality services, managing tumor-specific disease along evidence-based guidelines, and tracking, measuring and supporting patients throughout their individual care paths.
6. Informatics Evolution: With care coordination, quality improvement and reduced cost as cornerstones of the ACA, providers are facing intense implementation of informatics to support care planning, decision making and outcomes measurement. Unfortunately, no single information system offers all facets of these informatics requirements, resulting in an amalgamation of systems that interface to provide an array of expertise to the cancer care network, ideally including:
•patient engagement software for proactive management of health and wellness;
•health information exchange among a range of providers/care delivery settings;
•rules/guideline/decision-making alerts, work flow re-design and operational process improvement;
•navigation and case management throughout care and survivorship;
•revenue cycle and contracts management; and,
•business analytics to measure episodes of care, tumor-specific care plans, outliers, and outcomes;
7. The Value Proposition: The ACA’s overarching purpose is creating greater value for every health care dollar spent, representing an opportunity for oncology providers to differentiate themselves on quality and cost. The shift from a volume, fee-for-service based care delivery model to one of value is inevitable for oncology, particularly considering the high cost of oncology-related treatments with the continued balancing act of what defines quality and outcomes. The delivery systems and payment reforms enacted by the ACA, including Medicare Shared Savings Program, Bundled Payments for Care Improvement, and Readmission Penalties, will continue to be rolled out by CMS over the next year.
Currently, CMS’ payment models have no components specifically targeting cancer care which has resulted in much of the progress in oncology being made by commercial payers, private practice physician groups and for-profit oncology organizations. Most likely, the earliest adopter of oncology pay-for-performance (P4P) plans was the Blue Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program’s Oncology Initiative which followed the 2006 establishment of the ASCO Quality Oncology Practice Initiative (QOPI) Health Plan Program. In 2008, BCBSM began providing financial incentives to oncology practices that participated in QOPI. The BCBSM was an interim step toward reimbursement systems based on evidence-based protocols and outcomes measures and certainly produced meaningful insights regarding methods to incentivize providers to furnish higher quality, less costly care. Since then, with industry movement from volume to value-based care reimbursement systems, more sophisticated models are being developed that provide greater inclusion of procedures for a payment per episode of care. In late 2011, the article “Bundled Payments Come to Oncology," ran in the publication Oncology Times (http://journals.lww.com/oncology-times/blog/onlinefirst/pages/post.aspx?PostID=318), outlining a couple of early payment schemas being introduced by providers and payers alike, including:
•Cancer Treatment Centers of America’s (CTCA) CareEdge® bundled-payment program for evaluation and treatment planning for breast, colorectal, lung and prostate cancers. The CTCA program bundles diagnostic services and a treatment plan that is delivered in a guaranteed timeframe for a flat fee. More information can be found on the CTCA website link: http://www.cancercenter.com/care-edge.cfm
•UnitedHealthcare’s Cancer Care Payment Program that focuses on best treatment practices and better health outcomes for patients with breast, colon and lung cancers. The program approaches physician reimbursement for cancer care based on overall treatment of the patient, reimbursing participating medical oncologists upfront for an entire cancer treatment program. At time of the Oncology Times publication, five oncology practices were in the second year of UnitedHealthcare’s pilot program. A description of the program may be found at: http://graphics8.nytimes.com/ref/business/UHCCancerCareProgram.pdf
Expertise on call
Annual outsourcing report shows providers of all sizes continue to pursue arrangements that offer savings for their revenue-strapped operations
By Beth Kutscher (Modern Health Care)
Whether it's called outsourcing, partnering or another term, hospitals and health systems continue to use that approach as they realize that much of the expertise and resources they need, especially in the new era of value-based care, aren't available in-house.
Driven by the near-desperate need to reduce operating costs to cope with lower reimbursement rates, they're increasingly turning to outside contractors for services such as construction, medical staffing, food services and information technology to bridge the gap in a more cost-effective manner. In turn, the companies providing the services are reporting double-digit growth in their clients.
Modern Healthcare's annual Outsourcing Survey found that the top 20 outsourcing firms, based on the number of national healthcare clients, reported 13.1% growth between 2010 and 2011. As a group, the top 20 contractors served a total of 16,463 healthcare clients in 2011, up from 14,556 the previous year. This year's survey includes responses from 34 vendors.
Stephen Mooney, president of Conifer Health Solutions, Frisco, Texas, which provides revenue-cycle management services, notes that independent and smaller hospitals used to be the primary clients for outsourcing firms. But its customers are now getting larger. Hospitals big and small are “having trouble keeping up with curve,” he says.
For the first time, this year's survey results were also supplemented by data from a random sample of 75 not-for-profit hospitals and health systems in 37 states. The supplemental healthcare provider data was culled from not-for-profit financial database Guidestar, and represents information that was reported to the Internal Revenue Service on Form 990s for tax year 2009, which was often the most recent year available.
The hospitals and systems included in the supplemental data had median annual revenue of $528 million and median total annual expenses of $518.6 million. The median amount spent on contracted services—based on the five highest-compensated independent contractors cited by each provider—was $16.9 million, or roughly 3.3% of annual expenses.
Looking for partners
However, some hospitals and health systems relied on outsourcing more heavily than others. At the top of the list, Tri-County Memorial Hospital, Whitehall, Wis., reported that 23% of its 2009 expenses went toward its top five independent contractors. Those payments represented about $3.5 million of its roughly $14.9 million in expenses.
Its top two independent contractors, according to its Form 990, were Gundersen Lutheran Administrative Services, La Crosse, Wis., and Computerized Medical Imaging, Eau Claire, Wis., which provides diagnostic imaging services. Tri-County is part of Gundersen Lutheran Health System.
“I prefer to look at it as partnering,” says Brian Theiler, CEO at Tri-County Memorial. “The outsourcing is really more technology and expertise. We have not lost jobs; we have actually expanded jobs.”
Outside technology firms, for instance, have helped the facility implement an electronic health-record system from vendor Epic Systems, Verona, Wis. “We would never be able to put Epic in our system without partnering,” he says, adding that its partnership needs are “consistently growing.”
Just as many independent hospitals have turned to mergers and clinical affiliations with larger systems to expand their services, others have called in vendors to provide that additional expertise.
“With small facilities, you're not going to be in existence if you don't find a partner,” Theiler says.
Yet small medical facilities are not alone. Eight of the top 10 largest spenders on outsourcing services, in terms of percentage of total expenses, had at least 395 beds.
Stanford Hospital and Clinics, Palo Alto, Calif., ranked second on the overall list, spending 22%, or $432.6 million, of its $1.95 billion in expenses on independent contractors. Yet its largest contract—at $288 million—was with its parent, Stanford University, according to its 990 tax form.
“Those payments are compensation for clinical services provided by Stanford School of Medicine faculty,” a spokeswoman wrote in an e-mail. “Because most nonacademic medical centers don't report physician payments as contractor expenses, it is difficult to make a direct comparison (to other hospitals.)”
The other four largest contractors hired by the medical center included Blue Cross of California, Thousand Oaks; DPR Construction, Redwood City, Calif.; Perot Systems, Plano, Texas; and Accenture, Chicago. (Perot Systems became part of Dell in 2009.)
Continuing to build
Despite the challenging economic environment, hospitals continued to invest in facility upgrades, with the 75 hospitals and health systems included in the analysis spending a total of $458.3 million on independent construction firms in 2009, again based on aggregate spending from each organization's top five contractors.
In addition, three of the top 10 contractors, based on total payments received, in the supplemental analysis were construction firms: DE Harvey Builders, Houston, which earned $66.8 million in payments from the organizations; Hensel Phelps Construction, Greeley, Colo., with $65.6 million; and Turner Construction Co., New York, with $57.6 million.
At 909-bed Methodist Hospital System in Houston, all five of its largest independent contractors were related to construction. The system spent $173.8 million, representing 14% of its total expenses, on four construction companies and an architecture firm.
“Houston's still a growing market and still a strong economy,” says Mick Cantu, the system's executive vice president, who notes that its expansion projects have included a large outpatient facility, research labs and a 200-bed replacement hospital on the west side of the city.
Still, he says that the system does only limited outsourcing of other functions, with one exception being installing new technology and teaching staff how to use it. “I don't really see us doing very much from an outsourcing perspective,” he says. “Our preference is to do it ourselves versus having someone else do it.”
Local presence, national model
Outsourcing firms have taken note of hospitals' reluctance to use contractors and have tried to build offerings that pair local talent with outside experts.
Radisphere, a Beachwood, Ohio-based radiology outsourcing firm, says its niche is having local radiologists work alongside a network of offsite subspecialists who can offer around-the-clock consultations. Dr. Frank Seidelmann, the company's chief medical officer, notes that radiology has become increasingly subspecialized, posing a challenge to smaller hospitals.
“Hospitals are looking for the full array of subspecialty care,” he says. “Our people are onsite, we're local, but being supported by a model that has national expertise.”
Hank Schlissberg, the company's chief strategy and business development officer, notes that about 98% of hospitals outsource radiology services—significantly more than any other field—but most rely only on local practice groups.
Outsourcing firms in Modern Healthcare's survey reported a 12% decline in the number of contracts they had last year for radiology services, the largest among medical specialties. Observers say reimbursement concerns as well as acquisitions and consolidation in the industry often drive growth or contraction of services in each specialty.
Yet Charlie Rhoades, assistant administrator of general services at El Centro (Calif.) Regional Medical Center, notes that by using an outside radiology firm, scans that used to take up to 24 hours to read can now be done in an average of 25 minutes. “One of the big benefits that we've seen for our system is turnaround time,” he says.
The 165-bed hospital also works with a number of other medical services companies including TeamHealth for emergency medicine staffing, Quantum for hospitalists and Specialists on Call for neurology telemedicine.
Medical services as a whole represented the second-largest category for outsourcing expenditures, following closely behind construction. The 75 hospitals and systems included in the analysis spent a total of $456.8 million to hire companies that provide medical staffing services and other clinical functions.
Yet providers differed in which medical services they outsourced. Contractors that provide medical services reported in Modern Healthcare's survey that requests for nursing staff saw the largest fall-off, with a 22% decline in hospital clients using that service.
Psychiatric services similarly saw a decline of 4.3%, but contracts for anesthesiology and emergency department services increased 21.4% and 10.1%, respectively, among the outsourcing firms that responded to the survey.
EmCare, Dallas, which provides outsourced physician management services in five specialties and witnessed a 16.1% increase in healthcare clients between 2010 and 2011, reports that it has seen the greatest amount of growth in its integrated service lines, such as staffing hospitals with both emergency medical specialists and hospitalists.
“Traditionally there's been a bit of friction between those service lines,” says Todd Zimmerman, EmCare's president. “What it allows us to do is provide more coordinated care.”
Its services, he notes, can improve patient flow and reduce the number of emergency room patients who leave without treatment—both of which can have an impact on revenue as well as patient satisfaction in an age of value-based purchasing and patient-centered medicine.
“The focus on the patient experience is heightened right now,” Zimmerman says.
According to the survey, food service contractors saw the largest percentage increase, 55%, in the number of facilities served. Healthcare providers included in the supplemental data spent a total of $52 million in 2009 on food service contractors, making it the eighth-largest category for expenditures.
“The demand for the services has always been strong,” says Theodore Wahl, president and chief operating officer at Healthcare Services Group, Bensalem, Pa., which specializes in housekeeping, laundry, environmental services, and dining and nutrition.
The publicly traded company grew its healthcare client list 26.8% between 2010 and 2011 to 3,733, according to the survey. Its food services business grew 62%. It also reported in an earnings release that revenue increased 15% to $889 million and net income increased 11% to $38 million.
Wahl attributes the growth to a maturing middle management team that has been able to take on new clients.
Yet he notes that cost pressures have created new opportunities for all outsourcing firms—adding that his company has a diverse list of clients that range from large national chains to small independent hospitals.
Focus on the revenue cycle
A tighter reimbursement environment has also spurred interest in technology that helps providers extract the most money for the care they deliver.
Richard Close, senior research analyst at Avondale Partners who covers healthcare technology, says he's seeing outsourcing growth primarily in revenue-cycle management, particularly as providers seek help in getting paid on managed-care contracts and containing bad debt.
That sector also has been boosted by high-profile account wins and partnerships. In May, Conifer, a subsidiary of for-profit hospital chain Tenet Healthcare Corp., Dallas, announced that it forged a 10-year deal to provide revenue-cycle services to 56 hospitals that are part of Catholic Health Initiatives, Englewood, Colo. As part of the deal, CHI took a minority stake in Conifer.
Revenue-cycle management represents the largest piece of Conifer's business, and also contributed to the company's 41.4% growth in clients between 2010 and 2011, according to Mooney. At the end of last year, it counted 270 national healthcare clients and expects this year's number to be even larger owing to deals such as the one with CHI. “You're seeing an uptick in the level of service,” he says.
But Mooney notes that going forward it expects its capitation management business—which focuses on accountable care organizations and other risk-based payment models—to be an increasingly important part of its bottom line.
“There's a lot of discussion about population management,” Mooney says, adding that some providers are taking baby steps and others are going full-steam ahead toward implementing the new risk-based payment models.
Other contractors similarly expect to see the most growth in areas that relate to healthcare reform, such as setting up ACOs.
“The key is very accurately being able to measure performance,” says Tom Vorpahl, COO at TriMedx, which specializes in healthcare technology management.
The company, which saw a 32% jump in healthcare clients from 2010 to 2011, helps to “bridge the gap between the CIO and COO,” he says. “What we end up doing is becoming chief technology officer to take care of their supply chain.”
Information technology as a whole ranked seventh in terms of the amount of money spent by the 75 hospitals and systems represented in the supplemental data. Those providers spent a total of $63.2 million on information technology services, based on their 2009 tax forms.
Vorpahl notes that TriMedx brings in the tools and infrastructure but still works with the hospital's employees. “Our model is not an outsource model; it's an in-source model,” he says. “They can literally take care of all their (needs) with in-house talent. Our role going forward is more of a consulting role.”
Outsourcing, according to Avondale's Close, generally has been seen as a taboo for healthcare providers. “A lot of these hospitals might be the largest employers in town,” he says. “They're viewed as one of the stable cornerstones of the community. Sometimes there's a negative connotation.”
But financial considerations have made it the new reality. “They need to cut significant costs out of their operations,” Close says.
TAKEAWAY: Noting some providers' reluctance to use outsourcing, vendors are touting partnership roles to help hospitals and health systems cope in tough economic times.
Electronic Medical Records, Health, Medical Oncology, Medicare & Private Insurance, Radiation Oncology
CareCore Launches National Radiation Therapy Management Program on Behalf of Cigna Customers PR Web
Bluffton, SC (PRWEB) September 04, 2012
CareCore National, LLC has launched an evidence-based radiation therapy quality management program on behalf of Cigna customers. Cigna is a global health service company that administers health plan benefits for more than 12 million people in the United States. CareCore’s radiation therapy management program is designed to help radiation oncologists improve healthcare quality by matching a patient’s treatment plan with radiation therapy treatment plans demonstrated to be most effective for each patient’s specific conditions.
“Cigna's goal is to ensure that each of our customers receives the highest quality care through the application of evidence-based medical guidelines,” said Nicholas J. Gettas, M.D., national medical officer for Cigna. “The consistent practice of evidence-based medicine will result in safer treatments and better outcomes for our customers, and the right care at the right time will help restore their health so they can lead productive, satisfying lives.”
Each year, over 900,000 cancer patients undergo some form of radiation therapy in the U.S.at a cost of more than $55 billion. CareCore National’s radiation therapy program promotes adherence to appropriate evidence-based treatment guidelines through information sharing and dialogue with treating physicians to ensure that healthcare dollars are spent on those treatments proven to have the best outcomes. CareCore will also review new technologies and treatments under the guidance of a national advisory board of prominent radiation oncology specialists.
“We look forward to working closely with Cigna to implement our innovative approach to radiation treatment management in order to improve patient outcomes, quality of care, and cost efficiency,” said Richard Weininger, M.D, EVP, corporate strategies, and Chairman of CareCore National. “Individuals, healthcare professionals and health plans all benefit from the application of evidence-based clinical guidelines.”
CareCore’s radiation therapy management program is the first radiation therapy management program to address a patient‘s specific disease state, stage and treatment goals, and currently manages more than 9 million insured lives.
To learn more about CareCore National’s radiation therapy management program please visit http://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-radcare.aspx.
About CareCore National
CareCore National, LLC (http://www.carecorenational.com) provides innovative healthcare solutions that improve quality of care. Our products address a wide array of healthcare services including radiology, cardiology, medical oncology, radiation oncology, sleep apnea, musculoskeletal care and lab services that touch the lives of over 45 million insured across more than 35 Commercial, Medicare Advantage, Managed Medicaid health plans, ACO’s and Self-insured entities. CareCore solutions utilize the most innovative technologies in healthcare underpinned by partnerships with Cisco, VMWare, EMC2 and GemFire combined with clinical expertise from academic and community physicians from across the country. The company is headquartered in Bluffton, SC, and has more than 1400 employees.
Healthcare Revenue Management Firm Automates Billing Processes With Westbrook Technologies FortisBlue
Oncology Convergence, Inc. Uses Westbrook's Content Management Platform to Digitize Records and Streamline Workflow, Simplifying Compliance With Medicare, HIPAA, and Insurance Industry Regulations
BRANFORD, CT--(Marketwire - Apr 24, 2012) - Westbrook Technologies, developer of Fortis™ and FortisBlue™ enterprise content management (ECM) software, today announced that Oncology Convergence, Inc. has implemented FortisBlue to increase the efficiency of billing processes for clients and ensure compliance with federal and insurance industry regulations.
Oncology Convergence, Inc. (OCI) based in Tempe, Arizona, focuses on oncology reimbursement, management, and technology. "Our clients turn to us because we have one of the best teams of resources in the country," said Peder Thygesen, manager, information technology services at OCI. "Every medical coder is cross-trained in all aspects of oncology billing, so that gives us tremendous flexibility."
OCI uses FortisBlue to digitize documents, automate workflow and deploy online forms. FortisBlue enables medical coders to enter the proper diagnostic and billing codes electronically after reviewing doctors' notes, index them using an OCR template and route the information into a charge entry work queue. "This automation lets us use very accurate and detail-oriented people to interpret and enter the information, while automating the process. By using medical coders' input at the front-end of the process, we eliminate the possibility of having someone with less knowledge, not understanding the finer points, sending out a bill in error," Thygesen explained.
OCI's FortisBlue implementation is designed to prevent errors and reinforce processes that support compliance with Medicare, HIPAA and insurance industry regulations. A configurable Audit Log confirms who has accessed a document and made changes to it, providing further evidence of compliance. FortisBlue also meets the needs of OCI's telecommuting workforce and helps the organization contain costs. "Our employees love the money they save on gas. They can maintain a better work/life balance because they don't waste time commuting. OCI benefits because we don't need to expand our office space to accommodate staff or storage of paper documents."
"FortisBlue helps healthcare organizations streamline administrative processes that involve patient information securely over the Web," said Einar Haukeland, CEO of Westbrook. "FortisBlue's online forms make it more efficient to capture, share and archive documents and data while complying with industry regulations such as HIPAA. The Web-accessed software also supports the needs of geographically distributed and telecommuting employees."
About Oncology Convergence, Inc.
With more than 50 employees focused on oncology reimbursement, management, and technology, Oncology Convergence, Inc. (OCI) has one of the most specialized teams in the industry. OCI combines clinical and financial experience to assist and guide oncology practices to maximize profits without sacrificing patient care, time or compliance. Their managers and staff have expertise in Radiation Oncology, Medical Oncology, Gynecologic Oncology, Pediatric Oncology, Clinical Research and Diagnostic Imaging. OCI manages revenue for more than 120 physicians nationwide. For more information call 877-754-7799 or visit oncologyconvergence.com.
About Westbrook Technologies
Founded in 1991 and headquartered in Branford, CT, Westbrook Technologies helps organizations of all sizes manage their documents and data to make people's work lives easier. The company is the developer of Fortis content management software in use at thousands of customer sites worldwide to capture, index, store and retrieve critical information -- instantly and securely. Fortis has received the federal government's "meaningful use" stamp of approval by earning Modular EHR Certification under the Drummond Group's Electronic Health Records Office of the National Coordinator Authorized Testing and Certification Body (ONC-ATCB) program. Its FortisBlue product line, accessed from the Internet, has an intuitive interface to make daily document management tasks effortless. For more information, call (203) 483-6666 or visit westbrooktech.com.
Are you planning on attending ASTRO and/or SROA conferences in San Diego from October 30th - November 3rd? Come by Booth # 816 and visit with Oncology Convergence. Hear about how Oncology Convergence can assist your organziation with its Revenue Management challenges. Also attending the Elekta Users Conference on October 30th.
Amednews.com posted an article on Monday to discuss planned RAC audit expansions by the end of this year. The Patient Protection and Affordable Care Act requires CMS to include in the audit umbrella Medicare Advantage, the Medicare drug benefit and Medicaid in addition to the current Medicare design. The article notes that, “Earlier this year, President Obama called for expanding payment recapture audits throughout the federal government to improve payment accountability.”
The president and CEO of HealthDataInsights, the Medicare RAC for audit region D, also mentioned expansion into the Veterans Health Administration and Tricare. “To the extent that we can accelerate the national RAC program…speedy returns to the Medicare trust fund will be achieved,” she noted.
This expansion would certainly be a huge benefit to the government, but issues persist. Despite the looming Medicaid inclusion deadline, the director and CFO of CMS’ Office of Financial Management, Deborah Taylor, explained the difficulties they face in meeting that target. Indeed, she noted, “We are still in the planning stages,” due to the fact that there are 50 state programs in Medicaid with which CMS needs to coordinate efforts.
Still, with the Medicare overbill recapture dollars growing from $54 million in the first year to $247 million in the second, plus the promise to help fund the recent healthcare bill overhaul with such RAC audit programs, pressure on CMS will be intense to meet the required deadline. CMS has met some of the bill’s targets and are close to others. For example, the requirement to expand the Medicare RACs to all 50 states has been met, and Taylor asserted they are far along with implementing the prescription drug benefit into the program.
In response to physician complaints which arose during the demonstration phase of the RAC audits, CMS has added many changes to the Permanent RAC program. Amednews added a chart to the article that demonstrates those changes. I’ve copied it below:
RAC medical director
Reviewers' credentials upon request
Maximum claims look-back date
Oct. 1, 2007
Limits on medical records requested
General RAC website
Operational since January
RAC claim status website
Operational since January
Source: Centers for Medicare & Medicaid Services Office of Financial Management
The bottom line is that the RACs are here to stay. In addition to seeking and charging with crimes the overtly fraudulent Medicare schemes, they are also going after the unintended overbills arising from simple coding errors and rule misunderstandings. Few specialties can surely be impacted by such audits as oncology, particularly with regard to Medicare. With the volume of Medicare patients oncologists see and the complicated coding rules, it would be wise to be prepared for such an eventuality.