medical billing transcription supplier information

Medical billing industry has volumes of arcane terminology and payer- and time-dependent claim validity and pricing interpretation rules, facilitating massive payments of invalid or ineligible claims and denials of error-free claims. Process transparency provides its participants greater visibility of internal process activities. An increased level of access promotes teamwork, increases client satisfaction, and assists in process streamlining.

Billing process is the interaction between the participants (i.e., insurance company (payer), healthcare service provider (provider or doctor), patient, and billing service provider (biller)) designed to pay or deny a payment request (claim) submitted by the biller to the payer and to the patient on behalf of the provider. The amount and complexity of billing information make it very difficult for the doctor to maintain compliance and identify and resolve errors and underpayments.

Billing service transparency allows participants of the billing process to expedite error identification and resolution, resulting in reduced over- and under-payments and improved regulatory compliance.

Attributes of Billing Transparency

Billing transparency has four key attributes, including universality, continuity, ubiquity, and scalability.

• Universality: every participant in the billing process, including patient, provider, payer, and biller, has access to every aspect of the billing process.
• Continuity: process detail is available continuously on a 24 x 7 basis.
• Ubiquity: access to billing process is provided over secure standard Internet browser that requires no special hardware or software and is available everywhere.
• Scalability: both the big picture and minute detail are available for scrutiny universally and continuously. The big picture consists of total cash flow in a given time period, current submitted and failed claims, and billing quality metric. It must contain comprehensive summary of patient visits and unpaid balances. The minute detail pertains to individual claims making up the big picture, including complete history from the moment of creating the claim, testing its validity and eligibility, making corrections, performing submissions, reconciling payer messages and explanations of benefits (EOB) with original claims, until payment. Both perspectives must allow arbitrary aggregation of claims and drill in for detail to enable effective followup.

How to Build Transparency Into Your Billing Service?

A transparent billing service leverages technology to enable competent personnel to execute disciplined billing process. Therefore, to implement a transparent billing process, you must

[ ] Get access to adequate technology to support universality, continuity, ubiquity, and scalability.

[ ] Develop and thoroughly document claim processing procedures, including compliance and integration with practice workflow.

[ ] Train personnel in following the procedures and using the technology

[ ] Review personally and continuously billing quality, technology capabilities, adequacy of procedures, discipline, and training.

Note that Vericle-like technologies based on Straight Through Billing (STB) methodology implement billing transparency by design because billing transparency is an integral attribute of every component of STB process.

Over the course of the past two decades, federal and state enforcement agencies have investigated medical billing incidents and brought multiple enforcement actions against healthcare practices. The list of agencies tasked with billing compliance enforcement includes federal Department of Justice, the Office of Inspector General (OIG) at the Department of Health and Human Service, state Medicaid fraud control units, and others.

The number of medical billing fraud investigations and enforcement actions has been steadily growing. For instance, according to BillingWiki, thirteen articles and news items were published on the topic of medical billing fraud during May of 2006. In addition to growing frequency of incidents, the severity of penalties has also escalated from relatively non-adversarial audits and occasional return of payments to fines, suspension or loss of license, and imprisonment.

Six out of thirteen news items and articles about medical billing fraud published in May 2006 involve chiropractors (BillingWiki/Compliance). The remaining items are distributed more or less evenly across such specialties as psychiatry, gynecology, neurology, orthopedics, and aged care. The growing frequency of audits and increasing severity of penalties are symptomatic of inadequate attention to billing compliance at the chiropractic office.

An insurance company typically performs post-payment audit by soliciting medical notes for a random sample of paid claims during the previous year. Next, the proportion of inadequate medical notes defines the overpayment percentage. The total amount of overpayment is then calculated by applying the overpayment percentage to all payments over the past six years.

Billing compliance is doctor's responsibility and ignoring it often results in practice ruin. To avoid billing audit risks, some doctors have elected to work on cash-only basis, collecting cash payments directly from the patients instead of submitting medical claims to insurance agencies. However, such tactics does not help avoid the potential audit because patients submit requests to pay the claim to the healthcare insurance company on their own.

Since the top two reasons for post-payment audits are over utilization of certain CPT codes and hot line calls by patients and staff, the best strategy to manage post-payment audit risk has three prongs:

1. Formal compliance program,
2. Competent management of medical notes, and
3. Continuous monitoring of potential audit triggers.

First, the existence of a compliance program may determine whether the payer can routinely handle the matter as an innocent overpayment mistake or it must be investigated by the OIG as a potentially fraudulent act.

Next, careful management of medical notes is a basis for a successful audit defense, which often reduces the damages significantly and helps avoiding a repeat audit a few years later.

Finally, audit trigger monitoring ensures compliance of both cumulative service patterns across multiple patients and individual treatments. Real-time juxtaposition of histograms of CPT code frequencies between practice and national averages compares service patterns and alerts of potential compliance infringements.

Individual treatment compliance is ensured when no specific CPT code exceeds its monthly limits, such as billing a 9894X on each visit, or billing a 97140 manual therapy in place of a manipulation code because it pays more, or charging for 97149 together with 9894X, while both procedures linked to the same diagnosis. In the latter example, performing both an adjustment and a soft tissue manipulation in the same part of the body for the same complaint is illegal and a repeat submission of such a claim may trigger an audit.

An environment of high volume of patient encounters creates thousands of possibilities to deviate from normal distribution of services and trigger an audit. Therefore, real time analysis requires powerful technology infrastructure and competent legal coverage. Such infrastructure must handle all compliance aspects together, which necessitates modern Vericle-type integrative approach, combining billing, monitoring, and medical record management components in a single and comprehensive system.

One time, I saw a newspaper ad saying they are hiring work-at-home medical billers. I called the number (just to find out what it is!), I found out that for you to be able to work as a Medical Biller, you have to purchase their software at a range of $800-1,500 (I thought, it is actually a packaged-medical billing business). They will then train you how to use their software, after (I think) 10 days of training, you will have an access to their so-called doctors’ database. They promised you can get your 1st client through their database.

Due to my curiosity, I started reading and researching packaged homebased medical billing business. But take note: the training you will get is NOT actually a medical billing training. The bottom line here? – you simply purchase the business, pay for their software and start your business! But how realistic is this? I know some people who ended up with no clients at all after purchasing the software! And then later on, I’ve read that the Federal Trade Commission warned us about these companies offering homebased medical billing business with their false claims on how you make a lot of money on this business.

Medical Billing is a legitimate business (either home-based or office-based) and you can make good money as long as you know how to do it, the right way. But before that, consider the 10 Things You Need To Do:

1.Try to gain actual work experience. Work as a Medical Biller in a doctor’s office (or even as a volunteer at your nearest hospital). Do this for at least a year.

2.You should be highly knowledgeable on HIPAA (Health Insurance Portability and Accountability) and how does your current work/practice place complies/follows its rules and regulations. I always emphasize this because it is very important in any health provider businesses

3.Learn the actual “know-how” on claims submission (paper billing & electronic billing)

4.Learn how you can deal with insurances, can you handle collections? denied/rejected claims? Learn how to file appeals for denied claims

5.Learn how to analyze and optimize proper coding (procedure and diagnosis codes) to avoid rejection & denials

6.Learn how to review and analyze the reasons for unbilled and or aged medical claims

7.Beside learning the medical terminologies, you should also know many “medical billing” terms and its meaning: (PCP, copay, co-insurance, deductibles, allowed amounts, predetermination, medical necessity, progress notes, prognosis, treatment plan, preauthorization, appeals, referrals, scripts, benefits and eligibility, capitations, HMOs, PPOs, POS, EPO, HIPAA)

8.Learn how to properly post: – payments, deductibles, co-insurance, adjustments and write-offs (it is different when you are actually at work doing the postings than what you learned during your training)

9.Feel the medical billing scenario (how is the cash flow? what about the turn-around time of payments?)

10.And the last but not the least, feel the work--- do you like what you do? Do you have the ability and the managerial skill to run your business?

A growing number of professional, experienced health consultants and medical claim processors are needed in the country today. Healthcare is such a large and technologically driven industry that knowledge and procedures used today are likely to be seen as far outdated only a few years from now. To keep pace with all the various procedures, techniques, and technologies available and distinguish one from the other in a clear manner, definitions are made and coded for every kind of surgical procedure, diagnosis, and complaint. These definitions and codes help doctors ensure that they are compensated accurately for their services by the health insurance companies.

Medical billing is the process by which the needed data for completion of all the necessary forms (insurance cards, patient info, encounter forms, diagnosis, treatment, etc) is collected and processed for payment. This data is then entered into one of a variety of competing medical billing/patient accounting software programs. Medical billers are also responsible for following up using effective paperwork and time-management skills. Having been trained to understand an insurer’s EOB (explanation of benefits), the medical biller must review all claims for errors. If not all of a patient’s balance is covered by insurance, the medical biller has to decide if the balance will be written off or billed to the patient. The main job of the medical biller is to ensure that the physician or facility receives optimal reimbursement for services rendered. Weekly, bi-weekly, and monthly reports are often generated by the accounting software to show the client (physician, facility) whether they are losing or making money on various insurance contracts.

Besides the above main responsibilities, a medical biller must have or develop the following skills:
• Understand and be able to explain insurance terms and benefits to clients and patients
• Accurately read and complete claim forms
• Perform bookkeeping activities
• Bill insurance companies and patients promptly and accurately
• Handle everyday medical billing procedures
• Document all activities using the correct terminology
• Schedule appointments
• Follow-up with insurance companies and patients on unpaid bills

Medical billing is a growing opportunity to the ever-expanding health industry and many people are finding satisfying and well-paying careers working both at hospitals or small clinics and from home running their own medical billing small business.

Medical billing software, also referred to as electronic medical billing software, is now one of the most important components of a successful medical practice. Healthcare professionals from many different specialties can benefit from some level of medical billing software. Innovations in the field of medical billing software have created a new standard of digital precision. Many software packages in general can now fill all the needs of your practice; you can easily locate vendors who know about health care management solutions and will work with your practice to maintain your lead in the business.

When investigating possibilities for your billing software, ask questions such as how and for whom the system was designed, and whether the data will be safe and secure on backed-up, protected, HIPAA-compliant servers accessible only to authorized persons. (“HIPAA” is the acronym for the Health Insurance Portability and Accountability Act of 1996.) Then you can ask for the total price (including ongoing costs like software upgrades) of the entire software package. Some vendors will allow you to build your own medical billing software quote by providing you with a series of questions that will identify your essential needs. Moreover, look for companies who offer free updates to ensure continued efficiency and HIPAA compliance.

To figure out your software requirements, you can either assess them for yourself if you have excellent computer and software knowledge, or contact one of the many medical practice software providers who can assist you in comparing features, prices, and services. There are many companies that will do this free of charge.

One popular option that some electronic medical billing software experts will recommend is to use web-based software. These are companies that maintain practice management programs, electronic medical records, and various software programs on remote computers. All of your data is web-based and accessible through the Internet. These companies are commonly referred to as application service providers (ASPs). All you need to use an ASP is an ordinary computer and a broadband Internet connection. Most packages include software support, security, database management and training. This eliminates the burden of maintaining network servers, backup tapes, upgrades or modems. Additionally, search for software providers (web-based or otherwise) who will consistently upgrade their products in a timely manner, anticipate future developments, and translate those advances into system features.

Because dynamic, scalable software is now readily available to the modern medical establishment, even the most humble doctor’s office can install a fluid software system that everybody can use. Further, as the demand for electronic medical billing software has blossomed, so have the available choices. Medical billing software is just one of the many options now available that make operating a medical practice easier than ever before.

Importance of Using Proper Modifiers:

1. The physician performed multiple procedures

2. The procedure performed was bilateral

3. The E/M service was done on the same day of the procedure

4. The procedure was increased or decreased

5. The procedure has both professional and technical component

6. The procedure was performed by other provider (Anesthesiologist, Surgeon Physical Therapist, Speech Pathologists etc.)

7. Procedure on either one side of the body was performed

8. The E/M service was provided within the postoperative period

9. The E/M service resulted to Decision of Surgery

10. Unusual Circumstance

Maximize your reimbursement for bilateral procedures by using the correct modifier.

Bilateral Modifier (-50)

Depending upon the insurance payer, processing claims with bilateral procedure should be paid 150%

Medicare Part B requires one single line of bilateral procedure code with Modifier 50. They normally process the claim with 150% reimbursement. But again, you have to check on this in your state and in your region.

Some commercial insurance would prefer Two Lines of the same code, once with 50, second without 50. Then second modifier on the 1st line is RT or LT, modifier RT or LT on second line, with 1 unit of service each code. Must be reimbursed at 150%

Some commercial insurance would prefer two lines of the same code with modifier LT or RT on each line with 1 unit of service each code. Must be reimbursed at 150%

Always check on your Physician’s Fee Schedule if the procedure code is billable as bilateral .

Using LT & RT modifier is used to specify which side of the body the procedure was done by the physician. Medicare Part B based on my experience requires specific modifier, either LT or RT. Example you may report procedure 64626 done on the Right C4-C7 Facet Joint Nerve Ablation as 64626-RT.

Modifier -26. Professional Component.

Example: Report procedure code 76005 - Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid,, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint) including neurolytic agent destruction) with modifier -26 to indicate the physicians Professional Component only reimbursement and not technical component. If the provider’s office owns the fluoroscopic equipment, do not append -26 modifier.

Modifier -25. Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.

Example: Report E/M code 99213 (Office or other outpatient visit for the evaluation and management of an established patient) with Modifier -25 for procedure code 20610 Knee Joint Injection done on the same day of the procedure. Modifier -25 indicates significance and separate identifiable E/M service outside the procedure done on the patient. DO NOT use modifier -25 to report E/M service that resulted for initial decision for surgery.

Instead use modifier -57 for Decision for Surgery

Modifier -24. Unrelated Evaluation and Management Service by the Same Physician During Postoperative Period

Example: Report E/M code 99213 with Modifier -24 if the patient came back during the postoperative period. The physician must identify this service as completely unrelated with the recent procedure done on the patient. A detailed medical documentation is a good support for medical necessity.

Modifier -51 for Multiple Procedures.

Modifier -59 for Distinct Procedural Service

Modifier –KX Specific Required Documentation on File

Medicare requires Outpatient Physical Therapy & Speech Therapy provider affected by the Therapy cap to append a second Modifier –KX if the beneficiary is on exception and his diagnosis is considered under the list of automatic exemptions for automatic process or manual process.

Modifier-GP Services Rendered under Outpatient Physical Therapy plan of care

Modifier-GO Services Rendered under Outpatient Occupational Therapy plan of care

Modifier -GN Services Rendered under Outpatient Speech Pathology plan of care

Ms. Mcbanon is an experienced Medical Biller and Coder based in New York. A graduate of Bachelor Science in Computer Engineering. A Medical Practice Billing Consultant.

Medical insurance billing software, also called electronic claims software, is now one of the most important elements of a successful medical practice. Medical insurance billing is no longer as time consuming as it once was. Now you have the opportunity to electronically file insurance claims quickly and resolve issues easily. You can spend more time processing the claim and less time in follow-up. This will keep costs down, as insurance processing will now run more efficiently and administrative work will be reduced. You will receive payments more quickly and spend less time on accounts receivable follow-up calls.

Many medical offices utilize the power of the Internet to conduct everyday transactions more efficiently, more accurately, and less expensively than ever before. Some of the functions that can be performed via the Internet include checking eligibility and claims status, receiving referrals and authorizations, and acquiring pre-certifications.

A popular option that many experts recommend is web-based software. All you need is an average computer and a broadband Internet connection. Web-based companies offer many services, such as software support, security, database management and training. Some of the specific services offered for medical insurance billing are the fact that claim files are automatically generated at scheduled times and submitted to the carriers and clearinghouses without user intervention, and automatically downloaded responses that are interpreted and converted into word processing format and claims marked as submitted when the response file is received from the carrier instead of when the biller saves the claim. The web-based option eliminates the burden of maintaining network servers, backup tapes, upgrades or modems. Discover if the software package will fill all the medical insurance needs of your practice by finding providers who are experienced in health care management solutions and issues specific to medical insurance claims.

When searching for the appropriate medical insurance billing software, consider if the software makes the incomprehensible simple. Medical insurance software systems should include a comprehensive selection of features to ensure that you can manage your practice files, claims and billing with maximum ease and efficiency. Some important features to look for are access to the latest forms and guidelines, a step-by-step procedure that will prompt you through the claims process with relative ease, and features that will automatically print the proper forms, documents and bills when complete.

Why waste time on phone calls to insurance companies when medical insurance billing software can provide quick access to claims management. Let your medical insurance billing software interface directly with the carrier and your practice. Medical insurance billing software is just one of the many options now available that make operating a medical practice easier than ever before.

Billing medical software is used as a medical management system that can automate and track the process of submitting medical claims to insurance companies. It records the process from the first time a patient visits the doctor, through all the visits and diagnosis held from thereafter, till the end of the treatment. Plus it has several automatic processes and reports based on the information entered that can take much of the load experienced to run the medical process in a non-computerized environment.

Some of the features billing medical software has are:
1. appointment scheduling
2. electronic claims
3. flexible reporting
4. claim tracking
5. patient eligibility
6. ability to interact with other 3rd party software

Like other software applications, billing medical software needs to be easy to use and have the possibility to log the events that occur during the treatment. It needs to have a simple approach to the medical billing process as a whole, which normally, when done on paper, is a very time consuming process.

The advantages of billing medical software can be summarized as:
1. automatic billing computations for patients
2. auditable history of a treatment case at a glance
3. updated patient details availability
4. reduced time to process

Clients can benefit immensely from billing medical software. Some obvious benefits are:
1. confidentiality
2. eligibility verification
3. claims submission

Apart from offering the above advantages for both parties, billing medical software can automate the billing and collection process as well as offering simplified procedures for the main tasks needed as part of the medical and treatment process.

But who exactly can take advantage of billing medical software? This software is normally designed for doctors, dentists, medical billing centres and other healthcare professionals who intend to send electronic claims. A good quality billing medical software allows users to work on different modules simultaneously and have the ability to be used in a multi-user network environment. Entering patient details, diagnosis, issuing reports and scheduling appointments are all functions that can be done and are allowed to be done from different users at the same time.

Billing medical software is a must for highly geared medical centres nowadays. Many advantages can be taken from a well written and efficient software. The reduced time to process the work and paper involved, and the total organization of the medical process are just the highlights on which a billing medical software can focus and excel.

Online Medical Billing and Coding Specialist Schools teach courses that focus on the administration of Medical Billing and Coding for purposes of proper categorization of medical procedures and accurate billing processes. Students of Medical Billing and Coding will be prepared with those skills essential for Medical Billing and Coding processes and for Certified Medical Coding and Billing Specialist examinations for certification.

Online Medical Billing and Coding Specialist Schools train students specifically in the universal language that was developed for the purpose of streamlining medical insurance claims that ensure correct reimbursement from insurance companies for services rendered. Every symptom, diagnosis, procedure, and treatment has been assigned a numeric code that informs the insurance company which services were administered in a hospital, a doctor's office, a clinic, or other medical facility. This numeric language is used by Medical Billing and Coding Specialists to establish the exact services provided. The Medical Billing and Coding Specialist determines these codes and makes a selection based on information provided by the care provider, then processes the claim.

Online Medical Billing and Coding students can expect to study medical terminology, anatomy and physiology, reimbursement methods, law and ethics that apply to medicine, information management, and practices of various office environments.

Additionally, courses in Medical Billing and Coding will prepare students with professional skills that will allow for management of records, preparation of insurance forms, correct filing of claims, and for billing insurance companies for services rendered.

Responsibilities of a Medical Billing and Coding Specialist involve the accurate completion of billing and medical claim forms, appropriate billing, and good understanding of individual insurance company policies and procedures. Medical Billing and Coding Specialists can expect to work for hospitals, medical practitioners, medical clinics, and physical therapists, where efficient and well-prepared Medical Billing and Coding Specialists will manage billing and coding processes.

Medical billing software, also referred to as electronic medical billing software, is now one of the most important components of a successful medical practice. Healthcare professionals from many different specialties can benefit from some level of medical billing software. Innovations in the field of medical billing software have created a new standard of digital precision. Many software packages in general can now fill all the needs of your practice; you can easily locate vendors who know about health care management solutions and will work with your practice to maintain your lead in the business.

When investigating possibilities for your billing software, ask questions such as how and for whom the system was designed, and whether the data will be safe and secure on backed-up, protected, HIPAA-compliant servers accessible only to authorized persons. (“HIPAA” is the acronym for the Health Insurance Portability and Accountability Act of 1996.) Then you can ask for the total price (including ongoing costs like software upgrades) of the entire software package. Some vendors will allow you to build your own medical billing software quote by providing you with a series of questions that will identify your essential needs. Moreover, look for companies who offer free updates to ensure continued efficiency and HIPAA compliance.

To figure out your software requirements, you can either assess them for yourself if you have excellent computer and software knowledge, or contact one of the many medical practice software providers who can assist you in comparing features, prices, and services. There are many companies that will do this free of charge.

One popular option that some electronic medical billing software experts will recommend is to use web-based software. These are companies that maintain practice management programs, electronic medical records, and various software programs on remote computers. All of your data is web-based and accessible through the Internet. These companies are commonly referred to as application service providers (ASPs). All you need to use an ASP is an ordinary computer and a broadband Internet connection. Most packages include software support, security, database management and training. This eliminates the burden of maintaining network servers, backup tapes, upgrades or modems. Additionally, search for software providers (web-based or otherwise) who will consistently upgrade their products in a timely manner, anticipate future developments, and translate those advances into system features.

Because dynamic, scalable software is now readily available to the modern medical establishment, even the most humble doctor’s office can install a fluid software system that everybody can use. Further, as the demand for electronic medical billing software has blossomed, so have the available choices. Medical billing software is just one of the many options now available that make operating a medical practice easier than ever before.

Lockbox helps medical practices streamline HIPAA-compliant mail processing and same-day check deposits. Electronic access to scanned documents, including EOBs, simplifies key office and billing processes and achieves multiple benefits:

• Reliability Better revenue cycle reliability via elimination of dependency on staff or on billing service for handling checks

• Transparency Lockbox allows bi-directional verification of check deposit between the bank and billing service. Doctor can personally verify deposit 24 x7 via secure Internet connection. No lost checks.

• Billing Efficiency Faster and better controlled submission of secondary claims

• Patient Service Efficiency Simpler and faster resolution of patient account inquiries and disputes

• Added Interest Revenue Automated or semi-automated posting of insurance and patient payments. Check deposit upon arrival. Automated investment of deposit in a Money Market account earning interest (Automatic Sweep). The doctor's money is never idle.

Operation

1. Practice mail arrives directly to the lockbox service

2. Lockbox service
   1. Opens all mail and archives it in a document management system including scanning and indexing for future retrieval,
   2. Makes images available to practice or Billing Service via a secure, encrypted Web site;
   3. Deposits all checks received that day
3. Practice administrative staff has direct access to web-driven interfaces for mail and check queries and reports

Implementation

Lockbox service is typically offered by two kinds of providers:

• Large-scale Vericle-like billing service vendor as part of service
• Specialized financial institution, e.g., bank

Lockbox Selection

1. HIPAA Compliance - Can the service guarantee access only on the "need to know basis" and only to qualified staff? Are all required privacy and security measures in place? Is there a solid disaster recovery capability and process?
2. Quality Assurance Process - What measures are taken to ensure timely error identification, correction, and tracking? Is there sufficient QA process transparency to allow the practice owner complete control of mail and checks?
3. Intuitive User Interface - How many steps are required to find a letter, EOB, or a check? What are mail and check indexing parameters?
4. Batch Interfaces - Is there a convenient way to download all or partial content of the document management system for upload in other systems, such as a billing system, or in alternative lockbox provider facility?
5. Timeframes - How long does it take to open mail, scan it into a document management system, and deposit a check? What is the time horizon for archived image storage? What is the time period for storage of original paper before shredding?

Complexities

Lockbox

• Must be fully implemented - a partial implementation only increases management complexity.
• Adds headache with payers - all payers need to change mailing address, adding error likelihood during transition period.

Lockbox services lower administrative costs, increase staff productivity, and close collection cycles faster. A more efficiently run practice and happier staff mean more satisfied patients.

Remember when you were little and you played the game Truth or Dare. It seemed easy to decide between your choices then. Yet when considering the options of work at home medical billing, the choices can be a little more scary and your decisions a bit more daring. There are a number of companies out there looking to lure you in and take your money, but there is still the potential for a work at home medical billing business.

The Federal Trade Commission has sent out stern warnings to people when it comes to the advertisements they see to start their own work at home medical billing business. There are a number of advertisements out there for pre-packaged work at home medical billing businesses. These advertisements will tell you that there is a shortage of medical billers, and doctors are clamoring to outsource the work to trained work at home medical billing experts.

Many of these companies promoting these pre-packaged businesses for a work at home medical billing business make big promises like providing you with a list of clients along with training and software. The truth is, most doctors will hire larger companies to handle their medical billing, and the list of clients given are just doctors names that you need to contact and to whom you need to promote your work at home medical billing services. The false claims by these companies that you can make significant money from a work at home medical billing business by using their packages has prompted the FTC to file suit against those companies.

If you are considering a work at home medical billing package, you will want to asks some questions from the promoter. You will need to ask for names of previous purchasers of the work at home medical billing program so that you can contact them for references. You can also discuss the work at home medical billing field with doctors and other medical billing professionals to learn about the potential of the business in your area. Also, the Attorney General’s Office and other consumer agencies like the Better Business Bureau can give you insight into the promoter.

Still, there is an opportunity out there for you to start your own work at home medical billing business if you have the experience, contacts, and wiliness to market and network. If you have worked as a medical biller for years and have a number of medical contacts, starting your own work at home medical billing business could be a viable option if you are looking to work from home. You will need to be prepared at first to do battle with larger firms as you build up your work at home medical billing business.

When you start your own work at home medical billing business, make sure that you examine whether or not you really have what it takes to run your own work at home medical billing business. It may sound like heaven to work at home, but you will need to learn to discipline yourself to get work done and manage your time effectively. You will also have to make sure you do not get so caught up in your work at home medical billing business that you forget to have your own personal life.

If handling your practice's medical billing seems like pulling teeth, you probably need a solution that will simplify things around the office. Many medical professionals are turning to the automated way of processing medical invoices and claims. They are discovering the amazing advantages of using advanced medical billing software to do the work. Here are five key benefits of using medical billing software.

1. Automation for Medical Billing

Every business owner understands the necessity to automate some things around the office. For an MD or other health professional, running the office is no different. Automating the invoicing and claims process in your office through medical billing software is what differentiates yesterday's doctors and today's advanced MD!

You can use the medical billing software to pull up patient or insurance company information any time you need it. A click of the mouse tells who, when, where and how much is due.

2. Reduce Paperwork

In any medical practice, paperwork builds in a hurry. Whether you use medical billing services or your own software, you will reduce paperwork dramatically. Even medical billing services provide and use software to keep up with all patient records, bills, claims, etc. So, filing and organizing paperwork is reduced, thus, saving much space in your office.

3. Reduce Office Expenses

Doing everything by hand takes time and plenty of employees to handle the paperwork during busy times. The medical billing software prices may seem high, but not when compared with the cost of hiring additional employees, paying a portion of their social security and insurance costs, space and time used in the office, etc. You can even save money on your software by comparing medical billing software prices and discounts. Sometimes, you can find the software at very affordable prices. It's considered a tax deduction as well.

Even if you choose to use medical billing services, you can sometimes find very affordable rates. The key is to compare apples with apples. Consider every aspect of the service or software as compared with your current operational costs before making a commitment.

4. Easy Access to Patient Information

Another advantage of medical billing software is you can access your patients' information from anywhere. Most software can be integrated with a program as simple and common as Microsoft Office and with the Internet. This makes it possible to open several practices and have all information in one central location on the Web. You and your employees will be able to update billing information from either office location.

5. Reduce Error Margin

There will always be some human error when entering a lot of information into a computer system. Medical billing software helps to reduce this error by "catching" common mistakes. You can personalize the software for your billing needs and reduce entry errors by pre-programming the software. This will save time and money for the long haul.

Whether you choose to buy medical billing software for your office or use a medical billing service, you can work like the pros. You can become an advanced MD or other health professional that stays ahead of the competitors.

Owning a busy medical practice demands organization, tight schedules, and don't forget - plenty of time to care for every patient. In all the hustle and bustle, the very backbone of your financial well-being, medical billing, can get put on the back burner if you're not careful. But, don't let it get out of hand. Use the tips below to develop a steady stream of capital for your practice and keep your medical billing in check.

Organize your Medical Office

The first step to saving time and overhead costs is to get organized in the office. The office is where all patient information and billing is processed. You can't afford to lose patient or billing information. To organize your office, be sure every paper, form and bill has a designated area or file. Be sure the employees are trained properly so they'll know exactly where all paperwork belongs. This helps prevent lost paperwork, and benefits both your practice and the patient. A lost bill every now and then could result in hundreds or thousands of lost dollars each year!

Use Medical Billing Software

Another time-saver is sophisticated web-based medical billing software. This software is designed to make your medical billing easier and keep it organized. You can quickly retrieve records or past-due bills and claims when needed. You can enter information for insurance companies for quick access to process claims. Medical bills and records are stored at a secure online server instead of on your computer's hard drive. You can access the records from anywhere twenty-four hours a day, seven days a week.

EMR (Electronic Medical Records)

Some web-based medical billing software includes an EMR, or electronic medical records, feature that enables you to file medical histories on each patient, scan related images for each medical record, and even dictate information for a transcriber to access from another computer. The EMR feature works through online technology, making it easy to outsource jobs such as medical transcription, medical billing, etc.

Use a Medical Billing Service

You may choose to outsource your billing needs by using professional medical billing services. Companies that offer medical billing services usually will provide the necessary medical billing software, training and staff to get the job done - saving you many future headaches! Once you have the software in place, it's just a matter of entering information into a computer, and the medical billing company handles the rest. They keep your medical billing and claims organized, so you don't have to worry with it. You are able to concentrate on treating patients and keeping other pertinent office functions in operation.

Most medical billing companies today will provide medical billing software and training on how to work with the software to help make the process easy for you and your employees. For example, if the medical billing software is designed to be integrated with Microsoft Office, you might receive a video or materials for yourself and employees with the necessary Microsoft Office training.

Whether you choose to do your own billing with web-based medical billing software or use medical billing services, follow the tips above to create a smooth-running office and watch your profits soar!

Medical billing is a fast growing industry, attributed to by the rapidly evolving field of medical insurance. Because many working adults are not willing to forfeit current employment to attend a traditional college, many schools are now offering courses in medical billing over the Internet. If you are looking to become a Medical Billing Specialist, an online course can put you in your new career in a matter of weeks!

Physicians need medical billing and coding specialists who fully understand the complex insurance billing processes. Students attending Online Medical Billing Schools are instructed on the responsibilities that require accuracy in completing insurance claim forms, prompt billing, and adherence to individual insurance company policies and procedures. Hospitals, private medical practices, and medical clinics require the services of efficient medical billing specialists that can manage daily medical billing responsibilities.

Online Medical billing schools focus on medical terminology, medical coding and billing practices, human anatomy and physiology, medical law and ethics, administrative techniques, and the Universal Medical Coding Language. Online colleges and universities offer programs that can be completed by the dedicated student in just a few weeks.

Online Medical billing courses are designed for easy to understand, easy to learn methods of study. Students will gain all the necessary skills to be fully prepared for entry-level medical office positions through Online Medical Billing university and college programs.

The Certified Medical Billing Specialist Certification (CMBS) is a nationally recognized certificate in the medical billing field. Skills, knowledge, and techniques learned through Online Medical Billing Schools will prepare students for the CMBS examination.

The average practice submits half of its codes wrong, while some practices rarely exceed more than one code right out of every five codes. Inexact and inconsistent coding increases the risks of undercharging, overcharging, and post-payment audit. This article outlines evolution of coding from individualistic art towards disciplined and systematic process.

It is convenient to review the role of coding in the context of the entire claim processing cycle, which consists of patient appointment scheduling, preauthorization, patient encounter note creation, charge generation, claim scrubbing, claim submission to payer, and followup, which in turn includes denial or underpayment identification, payment reconciliation, and appeal management. The importance of thorough knowledge and correct application of coding rules at the charge generation stage of claim processing cycle are well known and have been frequently discussed. Less obvious but no less important is the ability to make correct interpretations of the same rules at the claim followup stage during denial or underpayment analysis and upon receiving payment and explanation of benefits.

Coding is difficult because of a four-dimensional complexity. First, the sheer volume and intricacy of coding rules make it difficult to select the right procedure code, correct modifier, and necessary diagnosis code for the given medical note. For instance, a claim will get denied if you charged for two CPT codes but provided an ICD-9 code that shows medical necessity for one CPT code only. Next, the payer-specific modifications exacerbate the complexity of coding, creating the need to code or process differently the same procedures depending on the payer. For example, some payers require medical notes attached to some CPT codes in addition to standard ICD-9 codes. Third, the codes and regulations change over time, necessitating continuous coding education and re-education. Finally, charge generation and claim followup are disconnected in space and time and often performed by different people, adding to confusion and costs of the claim processing cycle.

Only experienced coders can handle such complexity but experience too often turns into handicap as, in the absence of a reliable self-correcting process, the coder or the followup person may repeat the same mistake over and over. Hence ad hoc coding is error-prone and expensive. Paper superbill-driven coding improves upon traditional coding because it allows fewer errors and eliminates some of the costs. Computer aided coding with integrated superbill completes the transformation of coding from individualistic art towards disciplined and systematic process and is the most reliable and least expensive solution.

Traditional Coding

Since the practice owner is ultimately responsible for coding quality, it behooves the physician to manage personally the coding process. But traditionally, in the absence of systematic practice management, the physician looked for a coding approach to avoid the burden of coding. Such an approach to coding is error-prone and expensive. According to the Healthcare Financial Management Association's "Tip Sheet: Medical Claims Denial Management," the average error rate for CPT coding is 45%-55%. Some specialties (e.g., interventional radiologists) have trouble exceeding even 18% of correct coding, according to the March 2003 issue of "Healthcare Biller: The Communication Network for America's Health Care Billers," a monthly newsletter from Aspen Publishing.

Traditional coding involves the doctor, data entry personnel, and certified coder. The doctor dictates, types, or handwrites descriptions of diagnosis and procedures, without listing actual codes. The data entry personnel enter codes based on reading doctor's descriptions, and the certified coder supervises and audits the quality of coding by the data entry personnel.

Traditional coding process is error-prone because the certified coder does not audit 100% of entered codes and because such process does not have a vehicle for context maintenance between the charge creation and claim followup stages. The errors may become especially expensive upon post payment audit of the charges by the insurance company. This process is also expensive because multiple people are involved in the coding process and because the errors, if discovered at all, will be discovered only downstream, rising the costs of error correction.

Paper Superbill-driven Coding

Pre-compiled superbill-driven coding process places the doctor in control of coding, ties together claim creation and followup stages, and avoids many shortcomings of traditional coding. Such a process delivers two-fold advantage of lower cost and improved communication. First, the doctor codes at the end of patient encounter without involving data entry personnel in the middle. Second, the paper superbill serves the role of a formal vehicle for coding information communication between charge creation and claim followup stages. Additionally, a pre-compiled superbill improves coding consistency across the doctors within the same practice.

Superbill creation process has four stages:
1. List the codes used most often first. Use CPT frequency report.
2. List the diagnosis codes
3. Leave room for ancillary services
4. Include patient's information

Along with the advantages over the traditional coding process, the paper-based superbill still has four shortcomings. First, the data must be re-entered into the system from the paper superbill, introducing potential for errors. Next, the superbill must be reviewed periodically to adjust for changes in practice operations. Worse, it is difficult to keep up with changes in coding regulations, necessary modifiers, and bundling decisions that differ across various payers. Finally, the paper superbill contributes nothing to upfront coding error identification and correction, delaying potential error identification and resolution to post-submission, or worse, post-payment phases. Obviously, the later in the process the error is identified, the more expensive is its correction.

Computer Aided Coding with Integrated Superbill

Computerization and integration overcome most of the problems of paper superbills, eliminating duplicate data entry, automating code review and adjustment for frequency, practice operations, and payer idiosyncrasies, and shifting much of the error identification and correction from post-payment stage to claim pre-submission stage.

Computer aided coding with integrated superbill offers multiple advantages:
1. Dynamic - Adjusts for changes in practice operations and payer specifics. For instance, adds automated alert to satisfy unique payer demands, such as requests for paid drug invoices in addition to injection CPT code and J code for supplies.
2. Precise - Matches codes to EMR and alerts in real time about potential coding errors, such as confusing modifiers 59, 76, 77, and 91 for repeat procedure or test, or not coding the ICD-9 code to the highest level of possible digits in spite of specific diagnostic available in EMR.
3. Defensive - Allows for real-time profiling of coding patterns to alert about potential audit flag.
4. Reliable - Facilitates end-of-day juxtaposition of visits with charges, avoiding unpaid visits.
5. Inexpensive - The doctor can use it directly, eliminating extra data entry step and associated costs.

In summary, coding is a mission-critical responsibility of practice owner. Computer aided coding with integrated superbill places the doctor in control and enables dynamic, precise, reliable, consistent, defensive, and inexpensive coding process. Superbill digitization and integration overcome the four-dimensional coding complexity, tie it to EMR, patient scheduling, and billing (i.e., to the entire spectrum of practice management functions), and require powerful Vericle-like computing platforms.

HIPAA compliance requires special focus and effort as failure to comply carries significant risk of damage and penalties. A practice with multiple separate systems for patient scheduling, electronic medical records, and billing, requires multiple separate HIPAA management efforts. This article presents an integrated approach to HIPAA compliance and outlines key HIPAA terminology, principles, and requirements to help the practice owner to ensure HIPAA compliance by medical billing service and software vendors.

The last decade of the previous century witnessed accelerating proliferation of digital technology in health care, which, along with reduced costs and greater service quality, introduced new and greater risks for accidental disclosure of personal health information.

The Health insurance Portability and Accountability Act (HIPAA) was passed in 1996 by Congress to establish national standards for privacy and security of personal health data. The Privacy Rule, written by the US Department of Health and Human Services took effect on April 14, 2003.

Failure to comply with HIPAA risks accreditation and reputation damage, lawsuits by federal government, financial penalties, ranging from $100 to $250,000, and imprisonment, ranging from one year to ten years.

Protected Health Information (PHI)

The key term of HIPAA is Protected Health Information (PHI), which includes anything that can be used to identify an individual and any information shared with other health care providers or clearinghouses in any media (digital, verbal, recorded voice, faxed, printed, or written). Information that can be used to identify an individual includes:

1. Name
2. Dates (except year)
3. Zip code of more than 3 digits, telephone and fax numbers, email
4. Social security numbers
5. Medical record numbers
6. Health plan numbers
7. License numbers
8. Photographs

Information shared with other healthcare providers or clearinghouses

1. Nursing and physician notes
2. Billing and other treatment records

Principles of HIPAA

HIPAA intends to allow smooth flow of PHI for healthcare operations subject to patient's consent but prohibit any flow of unauthorized PHI for any other purposes. Healthcare operations include treatment, payment, care quality assessment, competence review training, accreditation, insurance rating, auditing, and legal procedures.

HIPAA promotes fair information practices and requires those with access to PHI to safeguard it. Fair information practices means that a subject must be allowed

1. Access to PHI,
2. Correction for errors and completeness, and
3. Knowledge of others who use PHI

Safeguarding of PHI means that the persons that hold PHI must

1. Be accountable for own use and disclosure
2. Have a legal recourse to combat violations

HIPAA Implementation Process

HIPAA implementation begins upon making assumptions about PHI disclosure threat model. The implementation includes both pre-emptive and retroactive controls and involves process, technology, and personnel aspects.

A threat model helps understanding the purpose of HIPAA implementation process. It includes assumptions about

1. Threat nature (Accidental disclosure by insiders? Access for profit? ),
2. Source of threat (outsider or insider?),
3. Means of potential threat (break in, physical intrusion, computer hack, virus?),
4. Specific kind of data at risk (patient identification, financials, medical?), and
5. Scale (how many patient records threatened?).

HIPAA process must include clearly stated policy, educational materials and events, clear enforcement means, a schedule for testing of HIPAA compliance, and means for continued transparency about HIPAA compliance. Stated policy typically includes a statement of least privilege data access to complete the job, definition of PHI and incident monitoring and reporting procedures. Educational materials may include case studies, control questions, and a schedule of review seminars for personnel.

Technology Requirements for HIPAA Compliance

Technology implementation of HIPAA proceeds in stages from logical data definition to physical data center to network.

1. To assure physical data center security, the manager must
   1. Lock data center
   2. Manage access list
   3. Track data center access with closed circuit TV cameras to monitor both internal and external building activities
   4. Protect access to data center with 24 x 7 onsite security
   5. Protect backup data
   6. Test recovery procedure
2. For network security, the data center must have special facilities for
   1. Secure networking - firewall protection, encrypted data transfer only
   2. Network access monitoring and report auditing
3. For data security, the manager must have
   1. Individual authentication - individual logins and passwords
   2. Role Based Access Control (see below)
   3. Audit trails - all access to all data fields tracked and recorded
   4. Data discipline - Limited ability to download data

Role Based Access Control (RBAC)

RBAC improves convenience and flexibility of systems management. Greater convenience helps reducing the errors of commission and omission in granting access privileges to users. Greater flexibility helps implement the policy of least privilege, where the users are granted only as much privileges as required for completing their job.

RBAC promotes economies of scale, because the frequency of changes of role definition for a single user is higher than the frequency of changes of role definitions across entire organization. Thus, to make a massive change of privileges for a large number of users with same set of privileges, the administrator only makes changes to the role definition.

Hierarchical RBAC further promotes economies of scale and reduces the likelihood of errors. It allows redefining roles by inheriting privileges assigned to roles in the higher hierarchical level.

RBAC is based on establishing a set of user profiles or roles according to responsibilities. Each role has a predefined set of privileges. The user acquires privileges by receiving membership in the role or assignment of a profile by the administrator.

Every time when the definition of the role changes along with the set of privileges that is required to complete the job associated with the role, the administrator needs only to redefine the privileges of the role. The privileges of all of the users that have this role get redefined automatically.

Similarly, if the role of a single user is changed, the only operation that needs to be performed is the reassignment of the user profile, which will redefine user's access privileges automatically according to the new profile.

Summary

HIPAA compliance requires special practice management attention. A practice with multiple separate systems for scheduling, electronic medical records, and billing, requires multiple separate HIPAA management efforts. An integrated system reduces the complexity of HIPAA implementation. By outsourcing technology to a HIPAA-compliant vendor of vericle-like technology solution on an ASP or SaaS basis, HIPAA management overhead can be eliminated (see companion papers on ASP and SaaS for medical billing).

Complex billing makes reducing receivables difficult Hospital's average days revenue in receivables (the standard industry measure of accounts receivable management effectiveness) has increased by 18 percent or 11.3 days during the past eight years--a present-day negative cash flow effect of more than $8 billion dollars.

What has caused the hospital industry's current cash flow crisis? Why have hospital accounts receivables increased to such an extent that financial viability is threatened for many hospitals?

The answers to these questions are simple; the solutions to these problems are complex.

Two of the primary causes of the current cash flow difficulty are cost containment initiatives generated by the zealous efforts of Congress to meet Gramm-Rudman-Hollings Federal deficit reduction targets and the ever-increasing complexity of third-party billing requirements.

MEDICARE. Recent American Hospital Association statistics show that Medicare accounts for nearly 49 percent of an average hospital's gross patient revenue. With this in mind, it is easy to understand why any change in Medicare payment rules has such a dramatic effect on the financial health of hospitals.

During the past several years, Medicare has implemented a series of Medicare Secondary Payer (MSP) provisions that require hospitals to bill other third-party payers (rather than Medicare), under certain circumstances, for primary payment of the hospital's bill.

Determining whether Medicare patients have other insurance coverage is not an easy task, and other payers are not always prompt or cooperative in recognizing their primary payment responsibility.

The Health Care Financing Administration has established a $1.4 billion MSP savings goal for the Medicare program for FY 1989 from these secondary payer requirements. This equates to a $1.4 billion reduction in Medicare payments to hospitals.

Two other significant changes to Medicare payment policy occurred on July 1, 1987, and July 1, 1988. Provisions of the Omnibus Budget Reconciliation Act of 1986 eliminated Medicare's periodic interim payment (PIP) program for most hospitals effective July 1, 1987.

HFMA's Survey of Medicare Accounts Receivable Trends (SMART) indicated that on average hospital receivables increased 5.3 percent because of the elimination of PIP, while hospitals in New York and Illinois experienced an average 33 percent and 29 percent receivables increase, respectively.

Additionally, Congress legislated a 10 day payment "floor" for Medicare intermediary claims processing beginning July 1, 1988. The payment floor increased to 14 days on Oct. 1, 1988.

The intended savings to the Medicare program as a result of the 10 day floor was $521 million--simply by delaying payments to hospitals. HFMA's SMART survey reported that the 10 day floor legislation caused an 8 percent increase (4.8 days) in hospital Medicare days revenue in receivables with a comparable increase expected from the further delay to 14 days.

Many other Medicare claims processing and prepayment requirements have been implemented in the past five years, including Medicare Code Editor requirements, the "clean" claim criteria, and most importantly, Medicare's prospective price setting (PPS) system.

These changes have added to an already complex set of Medicare billing instructions and have resulted in increased Medicare receivables and diminished cash flow.

MEDICAID. On average, 7 percent of a hospital's revenue is generated from services provided to Medicaid recipients. Medicaid receivables represent a growing concern for healthcare financial managers. Many state Medicaid programs do not meet the Federal 60 day prompt payment requirement. Hospital groups in several states, including Illinois, Washington, Texas, and Louisiana, have filed lawsuits against state Medicaid programs for slow payments.

Ten states have implemented Medicaid payment systems based on diagnosis related groups (DRGs); 10 percent of all Medicaid enrollees are now covered through capitated health maintenance organization (HMO) plans; and 34 state Medicaid programs currently are experimenting with payment methods other than the traditional cost-based method.

As Medicaid programs continue to implement new payment systems, hospitals will continue to feel the pressure of slow aggregate Medicaid payment levels.

CHAMPUS. Revenue generated from services provided to beneficiaries of the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) is significant for a few hospitals.

Hospitals located near large military installations serve a disproportionate share of CHAMPUS patients and are keenly sensitive to the recent drastic changes in the CHAMPUS payment method, including the CHAMPUS DRG-based payment system, implementation of mental health per diem payments, and the creation of a children's hospital differential payment method.

With the advent of these recent CHAMPUS program changes and experimentation with a triple option coverage plan for CHAMPUS beneficiaries, hospitals have been uncertain about the regularity and dependability of CHAMPUS payment levels.

For more than two decades, the federal government has been concerned with rising health care costs. In 1983, the Health Care Financing Administration sought to control hospital costs by making diagnostic and procedural data the primary determinant of hospital reimbursement through the prospective payment system. Recently, the US Congress has implemented a similar approach to control physician costs in the ambulatory care setting for the Medicare program. Through the Omnibus Budget and Reconciliation Act of 1989, any office procedure provided to Medicare patients and the reason (ie. diagnosis) must be reported in a standard format. From these data, Medicare authorities determine medical necessity and "appropriated" level of reimbursement; payment may be denied or reduced for diagnostic and office procedural services that do not fall within the defined limits for the given diagnosis.

The hospital discharge database and its ambulatory care analogue, the patient encounter database, are the sources of diagnostic and procedural information for patient and third-party billing. These databases also are used for health services research, such as the assessment of quality of care.(1-7) Consequently, the reliability and validity of the data are essential for appropriate reimbursement and valid research.

The reliability and validity of hospital discharge data have been investigated since the 1970s. Reports consistently demonstrate that inpatient data are inaccurate, particularly for diagnoses.(1-6) Some researchers believe sufficient error exists in the diagnostic information to render hospital discharge data inadequate for "detailed research and evaluation."(3(p1003)

Few similar evaluations of the reliability and validity of the ambulatory care database have been conducted, and the results vary.(8-12) Level of agreement between diagnoses listed in the office medical record and the observed events of the visit range from 20% to 90%.(8-10) Studies of the quality of computerized medical files, including patient billing files, show that between 30% and 50% of visits contain errors in the recorded data.(11-12) Underreporting of diagnoses in the major type of error; coding errors are a minor problem.(10-12) These reports are based on relatively few visits, however, ie, 26 to 150 visits; hence, they may not reflect the actual degree of validity and reliability of billing files.

This study presents the results of an investigation into the accuracy of billing information in a family practice, and is based on a large number of visits. The recording behavior of physicians on the faculty, physicians in training, family nurse practitioners (FNPs), and registered nurses was examined.

Partnership Puts Integrated Evidence-Based Point of Care Content Directly Into Electronic Medical Record to Improve Quality and Consistency of Decision-Making

ST. LOUIS, Missouri, September 29 /PRNewswire-FirstCall/ -- Elsevier, a world-leading medical publisher, today announced it has partnered with SOAPware, a leader in providing electronic medical records software for over 10 years with over 30,000 users and with more medical clinic installs than any other EHR in the U.S. . The partnership will allow Elsevier's iCONSULT clinical decision support content to be offered as a Clinical Knowledge Module to its SOAPware v5 (liger) EHR users.

"Elsevier's iCONSULT information will enable us to deliver a fantastic value-added offering. This Clinical Knowledge Module will enable our customers to have evidence-based, clinical information and medical reference information at their fingertips from our SOAPware electronic health record. This will enable the physician to provide better health care by promoting best clinical practices, improving consistency and quality of decision-making; and ultimately increasing the quality of care," say David Powell, chief executive, SOAPware.

For the physician, the Clinical Knowledge Module will include two components, the first, integrated evidence-based point of care content, powered by FIRST Consult, is continuously updated to offer information on evaluation, diagnosis, and treatment of a variety of disease categories to generate specific clinical decision support with the physician's workflow. The integrated medical referential content, powered by MD Consult, allows users to seamlessly search and access clinical information and included respected reference books, full-text articles from professional journals, practice guidelines and much more.

Background: Essential hypertension and symptoms of depression such as unexplained fatigue and tiredness are frequently encountered in primary, medical care clinics. Although, exhaustive evaluation rarely detects unsuspected underlying disorders, obstructive sleep apnea (OSA) is commonly associated with each of these conditions. We tested the hypothesis that therapy with antihypertensive and antidepressant medications predicts the increased likelihood of OSA.

Methods: We analyzed the computer archive of 212,972 patients for prescriptions for antihypertensive medications, antidepressant medications, and International Classification of Diseases, Ninth Revision codes for OSA. Prevalence, prevalence odds ratio (POR), and confidence intervals (CIs) were calculated correcting for gender and age group.

Results: The prevalence rates of OSA were 0.8%, 2.8%, and 3.2% for men and 0.4%, 1.4%, and 1.8% for women aged 20 to 39 years, 40 to 59 years, and [greater than or equal to] 60 years, respectively. Compared to groups of corresponding age and gender who had not received prescriptions for either hypertension or depression,

Conclusions: We found that the likelihood of having a diagnosis of OSA increases when either antihypertensive or antidepressant medications have been prescribed. The probability is highest in the young and middle-age groups receiving prescriptions for both medications. The possibility of OSA should be considered in any patient with hypertension and depression or unexplained fatigue who is receiving antihypertensive and antidepressant medications.

Study objective: To evaluate the practice of using nasopharyngoscopy without routine fiberoptic bronchoscopy for children presenting to a pediatric pulmonary practice with nonspecific noisy breathing.

Design: Retrospective chart review. Records of patients who underwent nasopharyngoscopy between January 1, 1990, and December 31, 1999, were reviewed. Follow-up was obtained by office records and direct contact with the patient's family and/or primary care physician.

Setting: Academic, tertiary care facility.

Results: Eighty-one children who underwent upper airway endoscopy to evaluate noisy breathing consistent with extrathoracic lesions were identified. One child had two evaluations separated by years for differing complaints, making a total of 82 procedures. Strider was the chief complaint in three fourths of the children. Half of the children with strider were found to have laryngomalacia. Long-term follow-up was available for 75 of 81 children, with median follow-up of 6 years (range, 1 to 13 years). No medical problems related to missed airway lesions developed in any infants initially evaluated using nasopharyngoscopy.

Conclusions: Nasopharyngoscopy without lower airway endoscopy can be used safely for the initial evaluation of noisy breathing in infants and children provided excellent follow-up is available.

Infants and children who present to primary care physicians with the nonspecific complaint of noisy breathing often are referred to pediatric pulmonologists or otolaryngologists. Some have argued that the lower airway should be visualized in all children with hoarseness, stridor, and other upper airway sounds due to the possibility of finding a concomitant sublaryngeal lesion. (1-5) Since it is not obvious from the published material that clinically significant lesions would be missed, the practice at our institution has been to use procedures less invasive than full endoscopic visualization of the lower airways for the initial evaluation of children when the history and physical examination are highly suggestive of a sole upper airway problem. We reviewed the outcomes of our patients over a 10-year period to determine if our practice pattern was appropriate.

Education of rehabilitation professionals traditionally has occurred in acute care hospitals, rehabilitation centres, and other publicly funded institutions, but increasing numbers of rehabilitation professionals are now working in the community in private agencies and clinics. These privately owned clinics and community agencies represent underutilized resources for the clinical training of students. Historically, private practitioners have been less likely to participate in clinical education because of concerns over patient satisfaction and quality of care, workload, costs, and liability. Through a program funded by the Ministry of Health of Ontario, we conducted a series of interviews and focus groups with private practitioners, which identified that several incentives could potentially increase the numbers of clinical placements in private practices, including participation in the development of student learning objectives related to private practice, professional recognition, and improved relationships with the university departments. Placement in private practices can afford students skills in administration, business management, marketing and promotion, resource development, research, consulting, networking, and medical-legal assessments and processes. This paper presents a discussion of clinical education issues from the perspective of private practitioners, based on the findings of a clinical education project undertaken at Queen's University, Kingston, Ontario, and previous literature. J Allied Health. 2004; 33:47-50.

THE RECRUITMENT AND RETENTION of clinical education placements for rehabilitation science students, particularly in rural and remote communitiese, is of major concern worldwide.1-5 In Canada, changing health care structures have affected significantly clinical education practical training resources. Although most physical therapists and occupational therapists traditionally have worked in publicly funded institutions, increasing numbers now are working in the community, employed by private agencies and clinics.2,4-6 Evidence suggests that private practices represent underused resources for clinical training of rehabilitation professionals.

Rehabilitation professional education has been geared to practice in acute care hospitals, rehabilitation centers, and related institutions; students have tended to choose clinical education placements that reflect this training.7,8 Although the literature describes innovative curriculum models and strategies focused on educating students for community practice and increasing student interest in working in smaller and more remote areas, learning objectives have tended to relate to culture, role definition, health determinants, health promotion, and community resources and advocacy.5,8 There has been little reference to the inclusion of education and skill training in the area of private practice specifically.

Confounding this issue is the fact that private practitioners are less likely to participate in clinical education than therapists working in traditional institutions.2,6,7,9 Although the literature is scarce in this area, MacPhee and Kotlarenko2 reported many concerns about having students, including patient satisfaction and quality of care, reduced patient load, decreased revenues, liability issues, and student selection. Similarly, a study by Bridle and Hawkes9 found that private practitioners avoided clinical supervision roles because of workload, liability, cost, or scheduling issues. This article discusses clinical education issues from the perspective of private practitioners, based on the findings of a clinical education project undertaken at Queen's University, Kingston, Ontario, and previous literature.

Nation's Largest Private Provider of Medical Transportation

Leverages Acorde to Streamline and Consolidate Processes

Optika Inc. (Nasdaq:OPTK), a leading provider of imaging, workflow and collaborative commerce software, Wednesday announced that American Medical Response (AMR) has purchased Acorde enterprise solutions.

AMR is the largest provider of emergency and non-emergency medical transportation in the United States. The company, founded in 1992, operates in 35 states and employs over 20,000 persons at 265 operating sites. The company transports more than 4 million patients per year in a fleet of more than 4,000 vehicles.

AMR will deploy the Acorde solution to reduce cost and increase efficiency in the Patient Billing Services (PBS) processing of Patient Care Records (PCRS) and payment processing in its accounts payable and voucher entry applications.

"We are very confident that implementing Acorde enterprise solutions will reduce our billing cycles and significantly lower Days Sales Outstanding (DSOs)," said Bill Nicolai, national director of technical services at AMR. "This solution will help to eliminate most hard-copy documents generated by the EMTs and paramedics in the field so that they can focus all their attention on quality patient care.

"We believe that the product will increase the speed with which payments are received from payers such as HMOs, private insurance companies, Medicaid and Medicare carriers."

Within the Patient Care Records (PCR) area, Acorde will fundamentally change and improve the speed with which these records are processed and billed while decreasing processing costs by automating the Quality Assurance (QA), activation, coding & data entry, billing, and re-billing processes.

The result will be an on-time filing of claims and a faster, more consistent receipt of payment.

Acorde's ability to scan and index AMR's paper-based trip tickets and supporting documentation upon arrival at various field locations and regional operation centers will virtually eliminate PCR loss, duplication and storage.

In addition, the Acorde system will provide enterprise-wide digital access from the desktop to all trip-related information from a single integrated interface. This will dramatically improve processing time by eliminating the need for employees to repeatedly leave their work areas to research, retrieve, fax and copy documents.

"We are pleased that American Medical Response is realizing the considerable value in leveraging its existing business applications to gain process efficiencies while further streamlining strategic areas of its business," said Mark K. Ruport, president, chief executive officer and chairman of Optika.

"By enabling AMR and others to take advantage of the process automation, storage and retrieval, and collaboration capabilities of Acorde, we expect to continue seeing dramatic reduction in costs and increased efficiencies for businesses worldwide."

This uncontrolled observational study examined the injury and medical discharge outcomes in 318 female and 1,634 male recruits as a result of changes to the Australian Army recruit physical training program. Changes included cessation of road runs, introduction of 400- to 800-m interval training, reduction in test run distance from 5 to 2.4 km, standardization of route marches, and the introduction of deep-water running. There was a 46.6% reduction in the rate of total injury presentation (chi^sup 2^ = 14.31, p = 0.0002) after the change. The annual rate of male medical discharges decreased 40.8% from 81.1/ 1,000 recruits in 1994/1995 to 47.0/1,000 recruits in 1995/ 1996 (chi^sup 2^ = 26.33, p = 0.0001). Female rates increased 58.3% from 104/1,000 recruits to 164.2/1,000 recruits (chi^sup 2^ = 6.09, p = 0.014). The decrease in the male medical discharge rate resulted in an estimated saving of $1,267,805 Australian. Bone scans were reduced by 50%, resulting in an estimated annual saving of $61,539 Australian. The disparity between male and female injury rates is a concern. The merits of mixed-gender physical training should be reviewed in the light of these observations, and the establishment of initial entry fitness standards for recruit training may need to be considered.

Introduction

High rates of injury have been reported in recruits from a number of different western armies. Reported injury rates were 27.4% in male and 44.6% in female U.S. Army recruits,1 31% in male South African recruits,2 33.5% in male British Marines,3 and 47.2% and 37.9% in two groups of male Australian recruits.4 Most of these injuries were ascribed to physical training.

Women have been noted to have higher morbidity during U.S. Army recruit training. The incidence of stress fracture is higher,5 and the rate of sick call visits for injury in female recruits was found to be twice that of male recruits.6 Limited duty rates for injury were 16 days/100 recruits/month in males and 77 days/100 recruits/month in females. However, several well-- designed studies of injury in civilian runners have shown no differences in the rates of injury between men and women.7-9 There would appear to be a disproportionate rate and impact of injury in female U.S. Army recruits.

Most researchers have sought to identify risk factors for injury. Jones et al.1 identified a number of risk factors, including low levels of past activity, low levels of physical fitness, previous history of injury, high running mileage, smoking, and age. Most of these risk factors are intrinsic in nature and could be controlled only by a process of exclusion at the enlistment stage. This would be difficult to justify without high relative risk values and would also reduce the available pool of potential recruits. Running distance has been consistently identified as a major risk for injury in civilian runners8,10 and recently in military recruits.1,4

As a result of previous research findings,1,4 the Commandant of the 1st Recruit Training Battalion (IRTB) directed that the physical training program be completely revised in the belief that reduced injury rates would result. These changes were developed and implemented within 8 weeks. This paper presents a retrospective review of the outcomes of these changes, specifically, the effect on male and female injury and medical discharge rates.

Methods

Study Design

This was a retrospective, uncontrolled observational study comparing the rates of injury and medical discharge before the change in the standard Australian Army physical training (PT) program with the rates after the change.

Platoons that entered the 1st Recruit Training Battalion during financial year 1995/1996 were divided into three groups. The platoons that arrived during the 3-month period from July to September 1995 (N = 708) represented group 1, or the prechange sample. Group 2 (October 1, 1995, to January 17, 1996 [N = 667]) entered training when the two physical training programs were in concurrent use. Group 3 (January 24, 1996, to May 6, 1996 [N = 579]) commenced training when the new program was universal. It was assumed that the 3-month period before the change was representative of the preexisting training cycle.

This analytical approach was adopted because of a perceived staff need to adapt to the new physical training regimen. Because of the concurrent physical training systems in place, it was felt that there may have been some "lapses" into old ways during the group 2 training.

Calculation of Injury Rates and Data

Presentations to the physiotherapy department were used to calculate injury rates. All recruits were initially assessed by a single medical officer, and any injury requiring sick leave, hospitalization, or 3 days of restricted duty was automatically referred for physiotherapy. The only exception to this was recruits with undisclosed preexisting injuries, who were rapidly discharged for failure to disclose.

All physiotherapy attendance records were reviewed, and individuals were identified by their date of arrival (or group). Although the true incidence of injury was likely to have been higher, the use of physiotherapy attendance was considered representative of more severe injury, because any injury requiring only 3 days of restriction is likely to have been minor.

TWENTY YEARS AGO, WHEN a hospital established a medical director position, the goal was to place a physician on the senior management team who would be the liaison between the administrative and medical staff, keeping all parties informed and assuring that decisions included a clinical perspective. The medical director or vice president of medical affairs assumed differing levels of responsibility and management duties depending on the support of the hospital's CEO and the board and medical staffs commitment to the concept of a physician in a leadership role.

Managed care organizations had a place for medical directors from the beginning as a liaison between the plan and the physicians in the community. Self-governed group practices tended to use one of their own physicians to serve as intermediary, as well as to improve communications. All of these physician executives were also responsible for the utilization review and quality of care functions, and these positions increased in levels of responsibility as the organizations grew and the marketplace became more complex.

The Physician Executive Management Center conducted a study in 1998/99 of 1,500 physicians serving in senior medical management positions to learn about their perceived value to their organizations. They were asked to identify the top two services they provide. More than 350 chief medical officers in systems, hospitals, group practice, and managed care organizations responded. providing an excellent view of the physician executive in full-time leadership positions.

Greatest value

Senior physician executives believe that the greatest value they provide to their organizations is their accumulated knowledge and experience--both in medicine and management. This medical management expertise is considered the key advantage of serving on the senior management team in helping to shape the organization's decisions and direction, and in planning and managing clinical affairs. Respondents also cited their leadership role and serving as a liaison for the medical staff or the physician practitioners in the community as a critical aspect of their position.

The survey results reinforce the importance of a solid clinical background for physician executives. The time spent as a practitioner and the necessary clinical training is a prerequisite for being accepted as a leader among other physicians and being seen as a credible member of the management team. Even with the trend of pursuing advanced management degrees, physicians also need the grounding of clinical experience to be successful in a senior management position in a health care delivery organization.

Functions related to managing the organization and day-to-day operational decisions were cited most often as valued services by physician executives in managed care organizations and group practices and only rarely by those in health care systems. Managed care organizations and groups typically have smaller management teams and the medical director must serve in an operational role more often than in a hospital or system environment. Also, since groups and managed care organizations are on the forefront of primary care delivery, the medical director would be the logical manager to oversee the operations of medical delivery and to provide direction to the physicians.

Personal values and characteristics were also considered important. About 10 percent of respondents cited characteristics such as judgment, loyalty, rational thinking, common sense, ethics, and integrity as the most valued services they provide. Here, we see an example of the value of the profession based on the physician and his or her reputation, rather than on the work that they do on a daily basis.

The medical director's role in quality management was rarely cited in the value equation. This represents a change in the nature of the position-the responsibility for overall quality of patient care likely continues to fall under the purview of the chief medical officer but is delegated. In group practices, no CMO said that quality management is one of their top two valued services.

Most enjoyed

We also asked chief medical officers what parts of their jobs they enjoyed the most. The number one response was working with the physicians on the medical staff and in the community. This includes the day-to-day involvement as a leader, as a mentor and educator, and overall as a liaison to the organization's practitioners. A closely ranked activity that respondents cited was management duties, such as daily operations and problem-solving, implementing new programs, negotiating, and meeting the challenges of managing in a complex environment.

If these physicians are correct about what is valued in their organizations, they are the right people in the right jobs. The activities respondents most enjoyed were the same as the functions they believe are of highest value to their organizations. So, they are doing what they like to do, and what they do is good for their organizations.