Wednesday, October 2, 2013

CMS Allows ’97 Extended HPI with ’95 Guidelines

Effective Sept. 10, the Centers for Medicare & Medicaid Services (CMS) has revised its Evaluation and Management (E/M) Documentation Guidelines (DG), to allow physicians to use the 1997 DG for an extended history of present illness (HPI) with the other elements of the 1995 DG to document an E/M service. As a result, “the status of three or more chronic conditions” qualifies as an Extended HPI for either set of DGs.
The revised guideline is presented as a Question and Answer on the CMS website:
FAQ on 1995 & 1997 Documentation Guidelines for Evaluation & Management Services.
Q. Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management HCPCS code?
A. For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.

ICD-10 Feature Story: Ticking Time Clock-or Bomb?

When it comes to ICD-10, Children's Hospital Colorado is about as well-positioned as any major health system can be in transitioning to the International Classification of Diseases and Related Health Problems - 10th revision, set to take effect by federal fiat on Oct.1, 2014.
Faced with a major challenge to both its clinical documentation and its revenue cycle, Children's Hospital's ICD-10 transition team-led by a group of four senior level executives at the top of the organization-has been hard at work for over two years. The Aurora-based pediatric hospital has hit important milestones such as completing its information systems impact assessment and establishing the remediation timeframe among key software vendors. It's now tackling clinical documentation improvements among physicians, implementing computer-assisted coding staff, training its coding staff, and discussing testing scenarios with some of its commercial payers, says Melinda Patten, director of health information management and one of the effort's executive sponsors. (The others include the CEO, CIO and CMO.)
That's why, come October of next year, Patten feels comfortable that the hospital will be where it should-at least internally. "We'll have our documentation in a good place and have the specificity we need," she says. "We will have our physicians and coders trained; we'll code in 10 and then drop the bill. But after that, we lose control. Payers say they'll be ready, but that is the unknown."
In an industry which has endured multiple delays of ICD-10 (after major industry resistance, the Centers for Medicare and Medicaid Services most recently postponed the go-live date from 2013 to 2014), Patten has plenty of company in pondering the many questions.
Many describe ICD-10 as the mother of all information systems and operational challenges. That's partly because the codes figure directly in reimbursement-a long and winding food chain linking providers, clearinghouses and payers. Get it wrong and the worst-case scenario is that revenue grinds to a halt. But there's more at stake than I.T. remediation and interfaces. Getting the codes right in the first place requires ever-more detailed documentation on the part of the medical staff, a group already beleaguered with meaningful use reporting requirements. Even if documentation is precise and notes, for example, such minutiae as which side of which finger was the subject of a skin biopsy, it will fall on the shoulders of coders to pick the best code. They can choose from among the tens of thousands of available new codes, (which are structured in very different way than predecessor ICD-9, the industry's longstanding coding and classification system).
Experts concur that because ICD-10 reaches virtually every nook and cranny of the modern health care organization, its implementation needs the sponsorship - and budget - that only top executives can deliver. Even with that, industry progress on the transition is mixed at best. Among group practices, which lack the resources of larger health systems, the transition is well behind schedule, according to multiple industry watchdogs and associations. Even for those organizations that had set out to meet the 2013 go-live date, there are far more questions than answers.
Here are some common concerns: Coder productivity, physician overload, insurers' payment plans, transition costs, cash flow impact, and perhaps biggest of all, trading partner testing.
Given the scope of an ICD-10 transition, the industry overall is struggling to stay on target with the many steps required to be prepared. Industry surveys, from such groups as WEDI and the Medical Group Management Association, reveal that large portions of the industry are behind schedule, at least when compared with widely recommended timeframes.
Bob Schywn, a principal at Aspen Advisors, a consulting group which is participating at several ICD-10 transition efforts on the hospital side of the industry, describes the effort needed as exhaustive and all-encompassing.
"It's surprising that we are still hearing from large health care organizations that they are just getting started to understand what ICD-10 is all about," he says. "That's concerning because there is a fair amount of work. If you are not knee deep in it by now and don't understand the risks, the last year will be fairly hairy for you."
Schwyn says the biggest challenge is getting organizations to understand ICD-10's vast impact. "It impacts health information management directly and there often is a coding focus," he says. "There are also implications downstream for finance and for claims. I.T. has a supporting role across the different work streams. But on the front end, clinical documentation is a huge driver."
All hands on deck
The consultant adds that a successful transition effort must be orchestrated by a multi-disciplinary group with stakeholders across I.T., finance and the compliance departments. "There will be a lot of scrambling to get this right," he predicts. A complicating factor is the large number of other industry initiatives underway at the same time. "At the same time you are doing ICD-10, you have a focus on meaningful use, value-based payments and health reform, all driving the need for additional data specificity. It is a perfect storm."
Novant Health is one organization trying to stay ahead of the ICD-10 curve. Based in Winston-Salem, N.C., the 13-hospital health system spans a three-state service area and has a payer mix which varies widely by region. Novant began its ICD-10 work in earnest in early 2010, establishing an executive sponsorship group with the CEO, CMO, CFO and CIO among the members. Laura Pait, senior director, HIM and revenue cycle services, represents the hospital as co-chair of an enterprise project management group. Her physician counterpart represents the ambulatory side of Novant. The government's decision to postpone its 2013 deadline was a mixed blessing for Novant, which had set out to meet it. "We had to re-engage the team," Pait said.
Novant's four main workgroups report up to Pait and her co-chair. These include: 1) an education and training group that oversees work not only for the coding crew, but multiple other business owners also affected by ICD-10; 2) a financial impact group, which is analyzing likely service line reimbursement shortfalls; 3) clinical services, which focuses on documentation by physicians, both employed and community-based; and 4) technology, whose task is to "ensure all systems and apps are cued up," Pait says.
The I.T. effort alone is so big it sports its own project management office to keep things on track. To complicate matters, Novant will be standardizing on a common EHR from Epic during the next three years, Pait says. Novant began the Epic project with its ambulatory practices first and those will be complete this year, meaning all physicians will be on a common platform. "That's the good news," she says. "We had 10 different physician EHRs before. But the hospitals face a major, complex web."
The hospital transition to Epic will commence October 2013 and by the time the 2014 deadline rolls around, about half of them will be live on Epic, with the remainder still operating on three different legacy systems. Beyond these core hospital information systems, Novant has identified approximately 60 other bolt-on applications that will also require ICD-10 upgrades. "We have a confidence level of 80 percent that all our system vendors will be ready," she says.
Run silent, run deep
Despite the many moving parts, Pait thinks that Novant will "be as ready as we can be" by October 2014. "We have the senior leadership's support," she emphasizes. But even so, there are aspects of internal preparation that concern her. "My biggest concern is the 'silent pockets,' areas where business owners have not realized that ICD-10 touches them. It's easy to talk about coders and physicians. But we may have bolt-on applications to help with such things as strategic planning and I'm not sure these owners are aware. Even with all the distractions of the Epic go-live, we are trying to make ICD-10 an equal conversation."
Children's Hospital Colorado also faces a large number of silent pockets. According to Patten, the health system inventoried about 4,000 systems, applications and stand-alone databases when it launched its ICD-10 transition in 2010. Although it will wind up remediating about 100 of these through its enterprise corporate governance effort, the health system must still educate the business owners of the remaining systems about the need to analyze their longevity under ICD-10.
At its affiliated school of medicine, for example, many physicians maintain independent databases as part of research projects. Novant's Pait points out that independent analytics databases housing ICD-9 data will somehow need to be cross-walked to ICD-10 when they begin accepting data from the new code set. "That is why education and training are so huge."
The scope of the ICD-10 transition accounts for many organizations' delays in preparing, no doubt. But the mixed progress in moving to the new code set extends far and wide. For their part, payers must be ready to accept ICD-10 claims as well. That leaves claims clearinghouses stuck in the middle between providers and payers. And some clearinghouses wondering what will happen on October 1, 2014.
"We are seeing delays on the payer side and we are not getting a lot of feedback from them on their testing plans," says Jackie Griffin, director of client services at Gateway EDI, a clearinghouse which processes some 25 million claims a month, facilitating data exchange between some 200,000 providers and 3,000 payers. While larger payers have been reaching out to Gateway - which began conducting readiness surveys earlier this year - the plans of many payers, frets Griffin, "are very vague."
She paints an even more checkered portrait of group practices' preparations. "Small practices are not thinking about ICD-10 yet. Many of them expect another federal delay, even though CMS has said repeatedly there will be none."
Griffin's contention about small group practice procrastination is upheld by survey data from the Medical Group Management Association. Its 23,000 group practice manager members span some 13,000 practices with 280,000 physicians, "from the very small to the largest multi-specialty groups in the nation" says Robert Tennant, senior policy advisor. MGMA released a survey in June showing widespread delays in moving to ICD-10. Just over half have not even started the work, Tennant says, with "significant progress" being reported by under 5%. About one-third report they are "somewhat done."
Practices facing ICD-10 must contend with an expensive transition, Tennant says. "About 30 percent will have their upgrades covered with their maintenance agreements," Tennant says. "Among the others, the cost will be about $10,000 per physician for both the practice management system and EHR." Thus, a 10-physician practice is looking at a potential outlay of $200,000 to remediate the two systems, he adds. "That is a heavy lift for the practices," he says.
Even among group practices in transition mode, doubts remain about trading partner readiness. Among those surveyed, 60 percent say they have heard nothing from their clearinghouses about ICD-10 and 70 percent are in the dark with their payers. "These are the critical trading partners that need to be aggressively communicating their transition plans," he says.
Inquiring minds
Tennant's questions are being raised across the industry. For Pait at Novant Health, payer preparation and payment policy lurk as large unknowns. The health system is adding a fifth workgroup to its enterprise effort, dedicated to denials management. "We are expecting an increase in both physician and hospital denials," she says. Expecting to gear up about three months prior to the October 2014 ICD-10 go live, the group will monitor both pre-billing edits before claims go out the door and then later denials as they hit the payer. "We will have to distinguish between technology issues and coding accuracy issues," Pait says, meaning that some claims may be held up as the result of improper interfaces and data transactions, while others may make it through the clearinghouse to the payer, only to be kicked back during adjudication as the result of improper coding or inadequate documentation. "We will have to break it down fast, so our recovery efforts can be shared and we are not taking corrective action six months after the claim comes back."
The claims edit piece is a bit of a Catch-22 for Novant. Before it can tweak its own software to accommodate payer edits around medical necessity, Novant needs to know payer policies. "We have not gotten that far and payers have not gotten that far," she says. Meanwhile, Novant's payer contracts management staff are beginning outreach to its trading partners to set the stage to receive payment policies and related efforts. Those conversations will accelerate in the first quarter of 2014, according to Novant's timetable.
Denials management is also front and center at New York's Mount Sinai Health System, which maintains about 1,200 beds across two hospitals and is set to expand later this year when it merges with Continuum Health Partners. Mount Sinai began its ICD-10 work in 2011 then, a year later, established a cluster of six workgroups devoted to managing different aspects of the effort. Mount Sinai will upgrade nearly 50 information systems, says Julio Arniella, senior director of patient financial systems. "Anything that touches, looks at, or moves an ICD code has to be upgraded." Arniella serves on the denial management team with some 20 other staff.
The denials management group has assisted in determining which service lines are most likely to be at risk under ICD-10. It is beginning with an analysis of denials under the current ICD-9 set-up to identify which types of claims will call for increased attention under ICD-10. A contract management group which negotiates with payers is examining forthcoming changes in payer DRG set-ups and corresponding policy changes.
In New York, three DRG groupers are in play among the various payers, one of which, AP-DRGs (all payer), is not compatible with ICD-10 and is being sunsetted. "We are working with the payers to see if they are willing to do claims testing and neutrality testing."
"Claims testing" is submitting claims to the payer to see if they clear technical hurdles. "Neutrality testing" involves actually remediating an ICD-10 claim to compare its reimbursement with an ICD-9 counterpart. Mount Sinai has not yet begun either type of payer testing, but like most health systems, it works with a large diverse payer mix. "We are about 20 percent Medicare, 20 percent Medicaid, with the rest going to commercial plans and some self-pay patients," Arniella says.
Coder conundrum
A short-term concern around ICD-10 is coder productivity. For Meg McGill at Memphis-based Methodist Hospital, the impact will be enormous, reverberating all the way to AR. "We have been using ICD-9 for a long time," says McGill, corporate administrative director of HIM at the eight-hospital, 1,600-bed health system. She's a member of Methodist's ICD-10 steering committee, which includes representation from allied health, home health, ambulatory surgery centers, physicians, I.T., coding and patient financial services. Asked where ICD-10 delivers the biggest impact, McGill doesn't hesitate: "There will be a big impact on coders. It will be a huge learning curve and it will affect physician documentation. If the information is not in the chart to code, we will query the physicians for additional specificity. Coders will not be as productive. And the slower I am in coding, the slower the bills go out."
To soften the blow, Methodist is partnering with a software vendor, IOD, to develop a coding training tool. For its part, Methodist has provided some 1,000 de-identified charts to use in the training tool. "It will be a coding training tool with actual medical records instead of case studies," she says. "Trainees will code a chart in ICD-10 and the system will them if they got it right. If they got it wrong, the tool takes you directly to the chart and if you need more information, it will take you to the training tool where the idea is discussed."
Rather than take a scattered approach to the vast universe of ICD-10 codes, Methodist is focusing on its top DRG payment groups and high-volume procedures, McGill says. A separate clinical documentation group is analyzing physician documentation to identify likely gaps. But even if Methodist knows which areas of ICD-10 to focus on, the load on coders will be big, perhaps too big, McGill says.
"I am worried about the amount of change our coding staff can take," she says. "Several have already retired, rather than go through ICD-10. These are not clinically trained people." That's why, in addition to offering coding training, the health system is providing training to coders in anatomy and physiology, medical terminology and pharmacology, content areas which often remain outside the skill set of coding staff.
At its core, ICD-10 is little more than a regulatory mandate-one among many in play in the health care industry. Groups like the American Health Information Management Association have long championed the system for the increased specificity it offers in describing healthcare events. Not only that, ICD-10 includes a multitude of newer procedures and better reflects the complexity of diagnostic analysis, champions say.
But others in the industry - notably physician organizations like the American Medical Association and MGMA - have a more jaundiced view. "The government has not made a compelling argument for the return on investment of ICD-10," asserts MGMA's Tennant. "It will be extremely costly for practices."
Tennant notes that groups like his and the American Medical Association have not resisted ICD-10 because of any inherent problems in the code set. "It's a superior code set," he says. The resistance, he argues, stems from the implementation challenges. ICD-10 proponents cite the fact that the United States is the last major nation to move to the classification system.
But Tenant dismisses that idea as a "complete falsehood," noting that other countries adopting ICD-10 did so with a far more limited version of the coding system and that national governments helped defray the cost. "Here it is all on the backs of providers," says Tennant.
For Tennant, however, the bottom line is indeed the bottom line. "The most worrisome aspect is reimbursement," he says.
That's one reason Tennant reserves his strongest criticism of CMS for its decision to side-step any transactions testing. (CMS declined to comment for this story.) The agency announced the policy decision earlier this year. "What message does CMS send by saying we will flip the switch on October 1, 2014 and hope everything goes well?" he asks. "That is highly unlikely," particularly given the industry's transition to 5010, the technical claims format predecessor to ICD-10, which went into in effect in 2012.
Asked his opinion of the CMS testing announcement, Schwyn, the consultant, says "CMS is a little short-sighted. Most organizations are thoroughly engaged in preparing their own environments. But the challenge is full end-to-end testing with payers."
Arniella, at Mount Sinai, is even more blunt. "For us to feel comfortable next year, I want to submit my claims to Medicare. Until you test with specific payers - and Medicare is 20 percent of our business - you don't know what will pop up."
Providers Plan Dual Coding
Melinda Patten is keenly aware of the ICD-10 deadline, quickly citing the exact number of days to the October 1, 2014 deadline from CMS. Patten is director of Health Information Management at Children's Hospital Colorado, a 536-bed facility with 2000 medical staff. She serves on the hospital's ICD-10 project management team with a focus on coding. The hospital is currently implementing computer-assisted coding software from Optum that will use natural language processing to help coders analyze charts and make suggestions about appropriate diagnoses and procedures based on physician documentation. The software currently directs coders to ICD-9 codes, but will support ICD-10, she says.
Patten is leaning on an outside firm, the Haugen Group, to assist in training the coders. And the hospital is looking to get ahead of the curve by doing "dual coding," a strategy that some hospitals are beginning to adopt as they stare down the code proliferation of ICD-10. Children's, Haugen explains, will begin the dual coding in October 2013 with a select group of coders. They will also code charts in ICD-9, which will appear on claims generated from those charts, and add corresponding ICD-10 codes, creating databases of services against which the hospital can analyze coding quality.
Novant Health, a 13-hospital delivery system based in Winston-Salem, N.C., is taking a similar approach, says Laura Pait, senior director, Health Information Management. Beginning in January, 2014, Novant will begin a dual coding effort across its hospitals-which will be mid-way through through an enterprise deployment of a new EHR from Epic. Novant uses coding software from 3M, and the system can retain two sets of codes, Pait says.
While bills will go out in ICD-9, the dual coding effort will facilate efforts to audit coder progress in learning the new system. In addition, the retained database of ICD-10 coded charts can serve as fodder for future tests with payers, Pait adds. Novant is talking with one of its big payers, Aetna, which would like to run transaction tests in the future. "When they're ready to test, they can pull straight from the retained data," she says.
Insights from 5010
Beginning Jan. 1, 2012, the 5010 claims format presumably went into effect in the industry. The ANSI transaction standard enhanced certain claims-related transactions, such as eligibility inquiries and remittance advice. It also set the stage for ICD-10 by expanding the data fields for ICD-10. But well past one year after the deadline, useage of the 5010 format is still lurching forward, causing many to wonder about the long-term success of ICD-10. The reasoning is simple: 4010 can't accommodate an ICD-10 data field; thus no payer can accept it.
Gateway EDI, a claims clearinghouse which processes some 25 million claims a month, still receives 4010 files, says Jackie Griffin, director of client services. Many of them come as a print image file, which the clearinghouse can scan and map to an appropriate 5010 data field. Part of the issue is that practice management system vendors, whose software inaugurates the claims transaction, have not yet updated their systems. "A lot of vendors still in 4010 are upgrading to 5010 as part of their ICD-10 effort," she says.
Gateway dispatches claims to nearly 3,000 payers, the vast majority of which accept 5010 transactions, she adds. But a number of low-volume payers-perhaps some 300, she estimates-are still on 4010. Gateway played a big role in helping its provider trading partners transition to 5010. "It was 80 percent technical and 20% provider," she says. "ICD-10 is the opposite. It's 80 percent provider." Clearinghouses are electronic data exchange facilitators, and it would fall on the providers' shoulders to submit the correct claim in the correct format in the first place.

CMS issues policy memorandum encouraging automatic assignment of Medicare agreement following change of ownership

On September 6, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a policy memorandum to State Survey Agency (SA) Directors regarding the change of ownership (CHOW) process and the assignment of Medicare provider agreements to new owners.  The memorandum emphasizes policies meant to encourage automatic assignment of the prior Medicare agreement. In particular, the memorandum discusses CMS’ concerns that SAs and accreditation organizations (AOs) are not following proper procedure for the timing of the required survey that arises when a new owner rejects automatic assignment of the seller’s provider agreement.
Typically, when a Medicare provider is acquired, the Medicare provider agreement is automatically assigned to the new owner.  However, new owners have the option to reject automatic assignment, resulting in the termination of the prior Medicare provider agreement.  If the new owner rejects assignment, the new provider is treated as an initial applicant and will experience a period of time without Medicare payments.  Generally, rejecting assignment precludes the new owner from having successor liability for Medicare overpayments or underpayments. 
CMS stated in its September 6 policy memorandum that automatic assignment is an important tool in protecting Medicare Trust Funds because it allows CMS to recover outstanding overpayments to the provider.  However, the effectiveness of this tool can be undermined if the incentives to accept automatic assignment are weakened by SA or AO practices that do not abide by CMS’ policies. 
CMS focused on survey timing in particular, stating that if an initial survey of an applicant that rejected assignment is conducted shortly after the CHOW date, it raises significant doubts that the survey was unannounced.  CMS stated, “At a minimum, the appearance is created that the SA or AO collaborated with the new owner on the timing of the survey.”  CMS can therefore refuse to accept a survey for certification purposes if the survey timing creates reasonable doubt that the survey was unannounced. 
CMS also stated that SAs must not conduct initial surveys until they are able to complete their higher priority workload.  Also, CMS clarified that the last day of an initial Medicare survey conducted by the SA or AO will not necessarily be the effective date of the new Medicare provider agreement.  Since CMS Regional Offices determine the effective date of each Medicare provider agreement, SAs and AOs should not speculate to prospective providers about what the likely effective date will be.
In short, CMS’ memorandum is intended to make it more time consuming and burdensome for Medicare providers contemplating rejection of automatic assignment of the seller’s provider agreement.  Prospective buyers should be aware of this guidance when determining whether to accept automatic assignment.

Tenet Closes on $4.3B Vanguard Acquisition

TenetlogoTenet paid $1.8 billion in cash, or $21 per share of Vanguard stock, and agreed to assume $2.5 billion of Vanguard's debt, giving the transaction a total value of $4.3 billion.
"Through this acquisition, we have significantly increased our scale and expanded the services we offer," Trevor Fetter, president and CEO of Tenet, said in a news release. "We intend to be a leader in addressing the opportunities in our healthcare system, and we are strongly positioned to drive improvements in quality and value for the millions of people to whom we provide care."
Tenet, which will maintain headquarters in Dallas, now owns and operates 77 acute-care hospitals, 173 ambulatory surgery centers and outpatient facilities and five health plans. It also could add several more hospitals into its system, as Vanguard has been working on a few hospital acquisitions in Connecticut, such as Eastern Connecticut Health Network in Manchester. Tenet, which now has more than 100,000 employees, also oversees six accountable care organizations.
Tenet currently stands as second-largest for-profit hospital chain in terms of revenue and the third-largest in number of hospitals owned. Further, Tenet gained market share in areas it previously had no footprint, such as Chicago, Detroit, San Antonio, Phoenix and New England — giving it the number one or two position in 19 major markets.
Tenet announced plans to acquire Vanguard in June. Vanguard, which has ceased trading on the New York Stock Exchange as of today, produced a large payday for its largest shareholder, New York City-based private equity firm Blackstone Group. According to a Bloomberg Businessweek report from earlier this summer, Blackstone should receive $617 million from the sale.
Since the merger was announced, Vanguard also had to settle two lawsuits that claimed the transaction was approved through "an unfair process and at an unfair price."

Medicare Advantage plans available in Central Florida today

Central Florida seniors curious about what Medicare has in store for them next year can now get a sneak peek, two weeks before enrollment begins.
Today, the website posted details about the Medicare Advantage plans and stand-alone prescription plans that will be available next year to Americans 65 and older. Seniors — a group not eligible for coverage on the new health-insurance exchange — can find Medicare plans by county and compare deductibles, premiums and drug coverage for 2014.
In Central Florida's five counties, the number of Medicare Advantage plans offered will increase by nearly 10 percent, and one more insurer will provide coverage.
By contrast, residents will see a slight reduction in the number of stand-alone prescription-coverage plans, also called Part D plans, which have uniform benefits statewide. The number of plans will decrease by more than 10 percent and be offered by two fewer insurance providers.
The new crop of drug plans will bring some cost relief. For instance, deductibles will be lower. 
The particulars of the "doughnut hole," the point where seniors must pay medication costs out-of-pocket until they spend a certain amount, also will change. That coverage gap will be slightly smaller. While in it, seniors will pay slightly less for generic drugs. Although they will fall into the doughnut hole sooner, seniors will exit it faster next year.
Enrollment begins Oct. 15 and continues through Dec. 7.
Though much new information is now available, the Medicare website won't post each plan's ranking under the five-star rating system for at least another week, said officials from the Centers for Medicare and Medicaid.
Plan checkup
"It's important for beneficiaries to look at the new information and evaluate the Medicare coverage they have now," said Gretchen Jacobson, associate director with the Kaiser Family Foundation's program on Medicare policy.
That's particularly true in Florida's retiree-dense metropolitan areas, she said, where seniors have far more choices than almost anywhere else in the country.
Most will find about the same variety and benefits as last year, and the majority of plans will continue to charge no additional premium beyond what seniors already pay for traditional Medicare B.
That 2013 premium was $99.90 to $319.70. The 2014 amount will be announced next week, said CMS officials.
Seniors who don't make any changes to their current health plan will automatically continue on the same plan if it's available, said Sarah Lightell, chief operating officer for the Senior Resource Alliance in Orlando.
Not to be confused
Consumer advocates are concerned that seniors will confuse the new Medicare Advantage plans with health plans also coming out this month on the health-insurance exchange as a result of Obamacare.
The two are not related.
"We have the perfect storm for confusion," Lightell said. "It's important seniors know that the Affordable Care Act will not affect them. Medicare is still their health insurance."
A recent nationwide study of 1,101 adults age 65 and older commissioned by the Express Scripts pharmacy-benefit-management company found that 29 percent of respondents thought the health-care law raised Medicare eligibility age to 68, and 17 percent thought the act replaced Medicare.
To answer questions and help sort out their options, seniors can call trained counselors at Florida's Serving Health Insurance Needs of Elders beginning this month, Lightell said.

More information
Plan information is available in the annual "Medicare & You" handbook that Central Floridians have started receiving by mail. Seniors also can contact Medicare at 800-633-4227.
Counselors with Florida's Serving Health Insurance Needs of Elders will be available to answer questions and help seniors sort through plan choices beginning this month. 
To find enrollment events or a SHINE location, go to or call 800-963-5337.

Tuomey Healthcare System, Inc. to pay more than $276 million

A federal judge has ordered Tuomey Healthcare System, Inc. to pay more than $276 million in fines, costs and reimbursements after a jury found the Sumter County healthcare provider guilty of filing false Medicare claims earlier this year.


  • Tuomey's CEO and VP resign from hospital

    Tuomey Healthcare System President and CEO Jay Cox and Executive VicePresident/COO Gregg Martin have negotiated an exit from the hospital's administrative staff, according to a news release from the company.
    The release says the pair and the hospital mutually agreed to a separation agreement.
    Continue reading >>
  • The order, signed Monday by Senior United States District Judge Margaret B. Seymour, states Tuomey must repay $39,313,065, plus post judgment interest at the rate of .1 percent, along with costs, as well as $237,454,195 in penalties.
    In May, a jury in Columbia found the healthcare provider had violated two federal statutes: the so-called Stark Law and the False Claims Act.
    The charges were linked to multiple allegations of Medicare fraud after the hospital signed doctors to exclusive contracts designed to funnel patients to them and away from other physicians who had set up their own outpatient surgery center.
    Seymour also rejected Tuomey's request for a new trial.

    For patients, it’s all about the white coat

    SAN DIEGO – The next time you enter an exam room without first donning your white coat or name tag, you might consider backtracking to retrieve them.

    According to a survey of patients presenting to a family medicine clinic, 51% hold some opinion about your attire. "Even if they don’t admit that they care about those things, patients are picking the options of having physicians wear a white coat and having a traditional look," study author Dr. Seema Tayal said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians. "Traditional looks still matter."

    ©Lars Lindblad/

    "Even if they don’t admit that they care about those things, patients are picking the options of having physicians wear a white coat and having a traditional look," said Dr. Seema Tayal.

    For the study, Dr. Tayal, a third-year resident in the family medicine department at the Brooklyn (N.Y.) Hospital Center, and her associates set out to determine what effects exist between the patient’s perception of a physician’s physical appearance and the patient’s compliance with medical recommendations.

    They distributed anonymous questionnaires to 200 patients who presented to the practice.

    More than half of respondents (59%) were between the ages of 18 and 50 years, while the remaining 41% were over age 51. The majority (69%) were female.

    When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her gender?" 91% responded yes and 9% responded no.

    When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her appearance?" 83% responded yes and 17% responded no.

    Dr. Seema Tayal
    When asked, "Do you feel your decision to follow a physician’s advice is influenced by his/her age?" 85% responded yes and 15% responded no.
    When asked about the preference of a physician’s attire, 49% had no preference and 51% did. Among those who did have a preference, the appearance accessory rated as most desirable was a white coat (52%), followed by a name tag (41%), stethoscope (25%), a "clean" look (33%), scrubs (15%), dress pants (14%), a tie and dress shirt (12%), dress shoes (10%), cologne/perfume (8%), short hair (6%), and jewelry (4%).
    In another part of the questionnaire, respondents were asked to choose the most professional-looking image from a set of six photographs depicting medical personnel, including one of Dr. Gregory House, the fictional physician played by actor Hugh Laurie on the "House" television series. The "winning" image depicted a clean-looking young female with short hair who wore a white coat and a stethoscope.
    The researchers stated that they had no relevant financial conflicts to disclose.

    5 ways Cleveland Clinic improved its patient engagement strategies

    Some healthcare initiatives underway these days are easier to explain in succinct terms than others. Take ICD-10 and meaningful use, for example. One can be summed up as an updated coding system; the other is an effort to encourage healthcare providers to switch from paper to electronic health records.
    Now take a term like "patient engagement." Yes, it's safe to call it an effort to get patients to take more responsibility for their health information. But when you try to think in more specific terms it becomes clear that those specifics vary significantly from provider to provider.
    On an operational level, what this means is that providers who want to improve their "patient engagement" need to determine both what that looks like presently within their own practices, and what steps they need to take to move forward.
    According to David Levin, MD, chief medical information officer at the Cleveland Clinic, a few years ago the organization's leadership took a comprehensive look at how patients engaged the its services, focusing primarily on the impacts the overall patient experience had on care outcomes.
    "The result," he said, "was a series of initiatives that helped define what we wanted to do (with patient experience), as well as how to measure the impact of the changes."
    Together with Lori Posk, MD, Cleveland Clinic's medical director for its MyChart personal health record, Levin recently pointed to five key changes in how patients interact with the organization, changes which, he said, have led to dramatic improvements in the patients' experience.
    • Open access scheduling. According to Levin, one of the earliest and biggest changes came when the decision was made to make it easier for patients to get in and see their doctors. Now, at all of Cleveland Clinic's family health centers, patients can log on through the patient portal, view their provider's entire schedule and make their own appointments.
    • Patient education. A key part of ensuring both patient satisfaction and ongoing engagement, Levin said, is "being sure that patients understand what's going on with them, as well as what's supposed to happen next." To that end, Cleveland Clinic creates appropriate patient educational materials, which can also be accessed online, that runs the gamut from follow-up information following individual visits to continuing care information for chronic conditions.
    • Open medical records policy. According to Posk, Cleveland Clinic has had an open records policy for years, but now everything is getting put online in personal health records. Moreover, since October of 2012 the organization has been rolling out increasing access to electronic patient information, beginning first with lab results,. From January to September of this year, Posk noted, 3.5 million lab results and images had been made available to patients electronically. Soon, she said, patients will also be able to review their physicians' notes online after a visit, in addition to being able to schedule follow-up appointments.
    • Two--way messaging via patient portal. The telephone has long been the indispensable tool for communications between doctors and patients, but now communication has been significantly expanded, as well as made considerably more convenient, with email and other electronic formats made available on the Clinic's patient portal. Levin pointed to the ease with which a variety of information can be shared in this manner, noting also that "in a world defined by healthcare reform, we see a big role for this kind of communication in coaching patients and eliminating unnecessary office visits."
    • Patient reported outcomes. Taking patient engagement up yet another notch, Levin said the organization has begun a series of pilot projects in which patients can enter data into their own records. This information, he said, then becomes part of the clinical workflow, enabling doctors to track their patients' progress, and potentially modify their care, between visits.
    Of course, Levin and Posk noted that none of these changes would have taken place without an overall plan.
    "Some of the initiatives began as experiments," Levin said, "but they're all part of a very deliberate strategy. It seems very clear to us that part of how we're going to get to better outcomes is through this kind of collaboration with patients."

    United Healthcare Medicare Advantage drops several providers in SW Florida

    LEE COUNTY, Fla.- WINK News has learned United Healthcare's Medicare Advantage plan has dropped several major Southwest Florida doctor groups for 2014.
    Some of them include Orthopedic Specialists of Southwest Florida, Ear, Nose and Throat Specialists of Florida, Florida Heart Associates and Associates in Dermatology.
    United Healthcare released a statement that says, "With the many changes happening in health care, we are building a network of health care providers we can work with more closely to have the most positive impact on the health of our members. Current plan members are being informed in writing about changes before they need to make decisions about their 2014 coverage."
    At Orthopedic Spedicalists, director of business services Tiffany Drake says they found out about the change on July 31 in a letter from United, and began sending letters to the 1500 patients impacted in September. "Currently their co-pay is $30 which is going to $50 in January, it would be $70 for out of network."

    She adds, "patients who continue to have United Medicare (Advantage) may change providers so we would lose some patients, we're hoping not too many, but that is one of the possibilities that may happen. Many of them are elderly, many of them are chronically ill and have multiple physicians that are affected by this decision so now they're in the middle of treatment for something and having to find a different doctor or change plans or pay more."
    Drake says, "we have submitted an appeal to United Healthcare. This is something we weren't anticipating and wish we had some control over but we really don't."
    Dr. Phillip Andrews at Ear, Nose and Throat Specialists of Florida says, "I was blown away, we've been taking care of those people forever." He says the patient-doctor relationship is very important, and he's worried about what will happen to his patients when his office is dropped. "I don't have any idea who's going to take care of them if we can't, it's a total mystery."
    He wonders whether pressure from the federal government is forceing United to make the changes. "It's all about the dollar. It's not about taking care of people."
    Both his practice and Orthopedic Specialists have not heard back about their appeals to United. Several patients have also filed grievences with the healthcare company.
    Open enrollment for Medicare Advantage begins October 15. Healthcare providers are encouraging all patients to review their plans and what coverage is important to them.