HIPAA Compliance: Yet Again

     Once upon a time, there was a law enacted that protected personal health information. While setting out to ensure individual privacy, HIPAA has morphed into a reporting headache that continues to repeat.

Because of the law’s complexity, it has been implemented in stages. The latest stage to appear on the horizon – compliance with Version 5010 – adoption of an electronic transaction standard  for, among other things, Medicaid pharmacy subrogation. Also, the rule adopted two standards for billing retail pharmacy supplies and professional services.

By all accounts, 5010 is a more complicated version of the current 4010A1 standards. Changes include codes designating principal diagnosis, admitting diagnosis, external cause of injury, and reason for visit. That means new codes. Therein lies the latest challenge.

Adoption of the new ICD-10 codes, effective October 1, 2014, will require changes across the entirety of the healthcare industry. If you deal with HIPAA – even non-Medicare/Medicaid HIPAA – the changes will affect you. What companies should be doing now:

Early adoption. In its tenth revision, the ICD-10 codes, set forth by World Health Organization, are now expected to be in place by the 2014 date. All “HIPAA covered entities” must use the codes. The sooner companies adopt the structure, the more time there is to learn a more complex code set.

Test and implement. The law has warned that “if you are not ready, your claims will not be paid. Preparing now can help you avoid potential reimbursement issues.” Despite the deadline moving (the previous deadline for implementation was October 1, 2013), companies adopting the standard sooner can avoid denial of claim issues when the new law finally takes effect.

Train staff. Transitions can be tough, especially when using new coding structures. Set up training sessions and provide printouts of the new processes and codes to all employees. The ICD-10 codes amass over 14,000 codes – much more than typical coding structures. Thus, the learning curve could be steep.

Plan a side-by-side, gradual implementation. Probably the best way to transition is by building a plan that allows for partial transitions of the business over to the new coding system. The goal is to maintain claims and work flow while the transition is occurring.

Enlist help. It’s daunting to run a business while learning an entirely new electronic structure. Look for HIPAA specialists who can help train and transition your company faster. 

While HIPAA, like other regulations, is an ever-changing environment, companies can stay compliant with a bit of planning. When in doubt, get help. Compliance means fewer denials, which results in a smoother workflow.

Prevention through Job Analysis

Sometimes you just don’t know what will hurt you until it actually does. In the case of a worker performing a job, there are processes by which employers can measure each job function and determine an injury probability.

This helps in a few ways:
Identifies job hazards. You can’t avoid what you don’t see. If your workers are suffering repeated back, shoulder, or joint injuries, a job analysis could determine exactly why that is.

Allows for modification. Suppose your workers are filing workers’ compensation claims for back injuries rather frequently. An analysis of the job uncovers some improper lifting techniques. You are then able to put training in place that helps modify those habits, thus reducing the number of workers’ compensation claims.

Helps with establishing modified duties. If you know exactly what physical requirements each job entails, you can build a modified return-to-work plan that more effectively protects the worker’s recovery while returning him or her to work sooner.

Can help determine if the injury is work-related. Not all workers’ compensation claims are a result of an actual work injury. When adjudicating a claim, a workers’ compensation adjuster can use a job analysis to determine what job functions may have caused the injury, and what may not seem likely given the physical demands of the position.

Allows for better training. Not only can you train your current employees more effectively, but you can further reduce the instance of improper work habits by training new employees on the modifications needed to bring down those workers’ comp claims.

Reveals need for protective/different equipment. For example, your data entry department has an unusually high number of carpal tunnel claims. A job analysis reveals that the desks you’ve provided do not have adjustable keyboard trays, thus creating a strain risk.

Helps with establishing safety guidelines. Probably the primary benefit of a comprehensive job analysis is gaining the knowledge needed to build a stronger safety program. By knowing how much and how often your employees are lifting, carrying, pushing/pulling, or how they’re sitting and moving, you can then create workflow processes that reduce the repetitive movements, lower the maximum weight lifted, and give employees breaks in order to relieve the stress on the joints.

Some state workers’ compensation boards offer job analysis templates to help you get started with your job analyses. Still, for a more comprehensive study of the physical demands and strain present in each position, a vocational management team trained in job analysis can uncover those hidden areas of concern and offer solutions and modifications that can significantly reduce your company’s workers’ comp risks.

Acute Injury Management: Reducing Indemnity Costs

When Carl slipped and fell in the coffee room Friday afternoon, his employer Gary insisted he see the company’s workers’ compensation provider. Carl balked, saying it was just a slip and he was fine. Gary allowed him to return to work.

However, over the weekend Carl was experiencing headaches and nausea. An emergency room visit later, he was diagnosed with a concussion. Gary, thinking it was minor, didn’t follow up. A week later, Carl was released from the hospital. Having had no word from Gary or the company, Carl began to feel unappreciated. Three weeks later, he filed suit against his company for negligence.

Despite our best efforts at safety and wellness, employees have injuries. Whenever an employee is injured, the goal of your health care and cost containment plan shifts from injury prevention to reduction in lost time. That begs the question – how do we get the injured worker treated properly and back to work in a reasonable amount of time?

By managing the injury throughout the injury lifecycle. We’ve found that medical case management is the most effective method of reducing indemnity costs. By getting the injured worker into treatment quickly and by managing treatments and appointments, employers can greatly reduce their indemnity costs and get workers back on the job sooner.

At SRS Group, we employ early treatment methodologies to get the injured worker into therapy immediately after an injury:
- Care coordination: by managing treatments, appointments, and all necessary communication, a care coordinator can ensure that injured workers are receiving all prescribed therapies and treatments.
- Clear communication with the injured worker, provider, and employer: this in turn assures a worker who feels cared for, which can reduce the potential for legal action.
- Priority appointment scheduling: by using a preferred provider network, employers can be assured that workers are seeing a physician early in the injury phase, which can lower any instance of an exacerbated condition.
- Status updates: employers should receive regular updates after each physician visit. This can help employers make informed decisions on how to assist in getting the injured worker back on the job, or what interim arrangements need to be made to accommodate the absence.
- Immediate, 24/7 access and easy reporting: A key component of SRS Group’s Acute Injury Management Program is the availability of a RN case manager 24/7, the immediate access of Medical Provider panel along with the 1-800 number to report an injury 24/7. Employers direct their injured employees to call the 800 number to report ALL injuries and receive medical direction. Triage services are available with immediate reporting to the employers designated contact personnel. If additional services are needed to coordinate treatment then telephonic management of the case ensues until the injured worker returns to work – 95% of the time within 2-4 weeks.

The goal of any acute management program is to apply proactive, aggressive cost containment solutions that aid in the management of injured workers. By managing the injury from the outset through to recovery, employers can contain medical, legal, and operational costs and help restore good health to the employee while ensuring a healthy employer/employee relationship.

Six Ways to Speed Bill Review (and Save Money)

What’s the average bill review cost to your operations? If you’re looking for that measurable so you can understand how bill review costs affect you, good luck. While each vendor has its own idea of what bill review costs, there is no hard evidence, no independent study to say just how much this part of your claim management process should cost.
It’s a time-consuming process, and that comes at a price. So how to save money? By speeding up the process. Here are six ways to do that:

1. Establish minimum turnaround time for bill review. Make this part of your overall agreement negotiations with your bill review vendor. How many business days from receipt of the bill to return to the carrier do you expect? Also, negotiate a tracking and compliance reporting process from your bill reviewer, and require either real-time or weekly reporting.

2. Establish an electronic process to combine information. Make it easy for staff to transfer claim information and bill review results between the client claim system and the medical bill review application. By combining both claim information and bill review results into one file, adjusters can then quickly review and approve medical bill payments, plus populate their own claim system with all the data. After the adjuster vetting process, the Bill ID and approved payment amount can then be sent back to the originator, who will then issue the check and EOB. This greatly reduces data entry redundancy costs and drives faster payments.

3. Scan bills in the mail room. The less time your staff spends touching the same piece of paper, the less it will cost. Establish the process in the mail room by which all bills are indexed and scanned and shared over an Internet/Intranet platform.

4. Automate an interface between any pre-certification of treatment and medical bill review.  This assures that payment for non-approved treatment is not made.

5. Automate sending different classes of medical bills to different decision pathways. For example, out of network bills with an allowed amount of greater than $10,000 go to the payment negotiation process; trauma bills automatically are routed to an RN to determine whether they are valid Trauma bills under state rules; all other business can be directed via customized routing rules to meet the carriers’ requirements.

6. Establish medical bill automatic adjudication process. For example, if the claim has been accepted as compensable, and the loss is less than 90 days old, then the rule would allow for automatic payment of bills of less than $500 from Chiropractors and Physical Therapy without requiring adjuster approval. The rule should allow for notifying the adjuster so that the claims records will reflect payment.

What time-saving processes have you put in place that have saved money?

RIMS Conference 2012 - April 15-18 Philadelphia Pa

If you own a company or have employees heed this excerpt from the RIMS Risk Insurance Management Society Conference Website:

If your organization is like most, risk is not confined to just one department. Everyone has risk management responsibilities. At RIMS 2012 Annual Conference & Exhibition, there are no limits to the information and resources available to help you and your organization innovatively minimize risks. You’ll find a wide array of educational sessions offering practical strategies, no matter what your business area. Sessions are offered at all experience levels—from beginner to advanced—so you can design an educational experience that fits your needs. And, the Exhibit Hall is jam-packed with solutions–everything you’ll need for the upcoming year.

RIMS '12 will be held at the Pennsylvania Convention Center located on 1101 Arch Street, Philadelphia, PA 19107.

Join The SRS Group, LLC and hundreds of other exhibitors as we share concepts, ideas, and solutions to managing the risk of our companies.

Cost Containment - Top priority For Employers

Companies are always looking for ways to control costs and this year the focus is on Controlling Workers' Compensation costs.

In an article we posted in December of 2011 we noticed a new trend to do so by laying off workers to cut workers' comp costs . Cutting staff lessens the number of employees at risk and the amount of the premiums companies pay to insure them. Now cutting workers' comp is not an after thought but it has become a strategic weapon in the race to keep companies competitive.

In an interesting article in Insurance Journal posted yesterday, surveys of employers indicate this will be the trend in 2012.

Here is an excerpt from that article;

Controlling workers’ compensation costs is a top priority for employers.

During the next 12 months, employers say cost containment is their number one workers’ compensation insurance concern, a new study shows. Some 59 percent of employers say they are very or somewhat concerned about cost containment in 2012. Employers also expressed concerns about increasing exposures, renewals and rising fraud behaviors.

Almost half of all respondents to the survey – 48 percent – reported a workers’ compensation premium increase in the past year, while 28 percent reported a decrease and 24 percent said their premiums stayed the same.

While The SRS Group, LLC has long understood the benefit of cost containment of workers' comp as a key component of managing both risk and claims, in 2012 it has become recognized as a necessity.

To read the complete article in Insurance Journal click here

Heart Disease in Women

Ladies do you, your spouse, or your employer know the signs of a heart attack.

Yes it does happen to women, in fact Heart Disease is the #1 Killer in Women.

According to the American Heart Association more women die of heart disease than all forms of cancer combined.

Warning signs as posted by the American Heart Association:

• · Discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back
• · Shortness of breath
• · Nausea
• · Breaking into a cold sweat
• · Pain or discomfort in one or both arms, the back, neck, jaw or stomach.

Narcotics in Workers' Compensation

How much do narcotics cost workers compensation?

In research completed by NCCI Holdings reports the following:

Narcotics account for nearly one quarter of all workers compensation prescription drug costs. Few members of the medical community would object to the use of narcotics to treat severe, chronic, cancer-related pain. However, the medical community seems divided over the suitability of narcotics to treat other forms of pain, such as those resulting from the majority of workers compensation injuries. Currently, the FDA is in the process of establishing a federal program to ensure the safe, appropriate use of narcotics. The New York Times discussed this future FDA program designed to control “the prescribing, dispensing and distribution of extended-release [narcotics].” One aim of the future program would be to ensure that only physicians who are properly trained in the safe use of narcotics can prescribe them. Several recent articles and studies also point to increased scrutiny of narcotics use. One article notes that, in at least one state, diagnoses of “chronic pain” or “failed back syndrome,” “virtually guarantee that the claim involves over prescription [of narcotics] because these are the diagnoses used to justify the use of narcotics.” Another states that overuse of narcotics has “shown adverse effects on the overall well-being and treatment of injured parties.” This NCCI study examines the use and prescribing patterns of this controversial category of drugs in workers compensation. Click here for the complete article and research findings