Happy New Year!

                                                     May 2016 bring all the good things you hope for!

NurseValue’s blog has exceeded 3000 visits.  Whoop!  Whoop!  Thank you to our faithful followers.  We would like to meet your needs for good healthcare information for both our healthcare managers and healthcare consumers.  Please, feel free to let us know what you would like to see from us in the coming days.  Again, thank you!

How to Choose a Surgeon

When you have the opportunity to consider a surgical procedure, there are number of things to consider. First and foremost the best way to have the best surgical outcome is to avoid surgery entirely.  This option is not always possible, but it is important to explore all options before determining if surgery is the best option for your particular problem.  Obtaining a second opinion is something you may want to consider if you have the time.  Once that is determined that your surgery is necessary, the following suggestions may prove helpful in determining who you would like to be your surgeon.  Not all surgeons with wonderful personalities have the most skill in a particular surgery.  There is much more to consider!

·         Is the surgeon board certified and is his certification up to date?  This can be researched on http://www.abms.org

·         How often has your surgeon performed your type of surgery in the past year?  The purpose of this question is not to get the busiest surgeon in your area, but rather to choose a physician with experience in your type of surgery and not one who has never performed or rarely performed your particular surgery.

·         Not all surgeons will answer this question, but many of the good ones will—What is your success, failure or complication rates with this type of surgery?

·         Where does your surgeon plan on performing the surgery?   There are now a number of websites that provide infection rates for particular hospitals. You may access this information at

http://www.consumerreportshealth.org.  On the landing page put in Hospital and you will be taken to a page that will allow you to research hospital infection rates.  This web site provides a lot of different type of health ratings/evaluations that may prove helpful.

·         Is the surgeon and the hospital he is affiliated covered by your health plan? 

·         Does the hospital that you and your surgeon are considering follow best healthcare practices?  Luckily there are a number of hospital comparisons done by Medicare.  You can access this information at www.hospitalcompare.hhs.gov.   Put in the area code of the hospital you are considering and you will be provided with the hospitals within that zip code so you can compare the findings at each hospital. 

Prepare for the inevitable Health Emergency-Part III

We have identified several websites that will provide you additional information regarding future healthcare directives when you are unable to make decisions for yourself. 

             ·         https://www.nia.nih.gov/health/publication/advance-care-planning

 ·         http://www.americanbar.org/groups/real_property_trust_estate/resources/estate_

        planning/living_wills_health_care_proxies_advance_health_care_directives.html

·         http://mayoclinichealthsystem.org/locations/mankato/for-patients/advance-care-planning/create-your-advance-directive

     ·         https://www.justia.com/estate-planning/wills/living-wills-advanced-health-care-directives/

Prepare for the inevitable Health Emergency-Part II

 

When a major health issue arises there is often no time to prepare. It leaves us vulnerable to the decisions of others.  We can prepare for these times by discussing our wishes with at least two of our loved ones.  The reason I recommend two individuals be made aware of your wishes is that there is a possibility that you will be with one of these individuals who may also require emergency services and not be able to give directives for you. 

 

 

Below are some of the activities which will help to ensure your wishes are followed:

·         Think about your healthcare wishes carefully to determine exactly what you do and don’t want done if you are in a serious health situation

·         Choose your two representatives carefully and involve them in your plans; the person(s) you choose will be responsible for making decisions about your healthcare.  It is advisable that you choose one primary person and name a secondary person if the primary person is not available.

·         Discuss your wishes with your loved ones and your representatives

·         Obtain a “Healthcare Power of Attorney” form.  This form is often specific to the state in which you live in.  If you google healthcare power of attorney form for your state you will find a number of sites with this form.  Additionally, this form is often available at your Doctor’s office or your local hospital.  You just have to ask.  I suggest that you get 2 forms so you have one to plan on and the second to act as your final copy.

·         Fill out this form and remember that although each section has specific instructions, you may cross out a section you don’t agree with and write your precise desires.

·         Once the form is completed it is recommended that you sign it and date the form in front of a public notary.  Many banks have a notary and the services are often free or require a nominal fee.

·         Once the form is completed and notarized, keep a copy in a safe place in your home and/or in your bank box. Provide a copy to your attorney and a copy to your primary provider.  Also provide a copy of this form to both of your chosen representatives. 

·         Advise your representatives to keep this form in a safe place as they may need to provide it to the hospital or facility that you are admitted to.  This form is then kept in your medical file for the duration of your hospital or facility (i.e.:  nursing home or rehabilitation facility) stay.

It is important to note the difference between the Healthcare Power of Attorney and a Living Will.  The Living Will is limited to your deathbed concerns only.  It is used to declare your desire to or not to have life prolonging measures when there is no hope of recovery.  The Durable Power of Attorney for Healthcare covers all health care decisions and is active only when you are incapable of making decisions for yourself.  You can, however direct your healthcare power of attorney designee(s) how you would like them to act in regards to your deathbed issues within the scope of your Healthcare Power of Attorney. You may want both forms as the Living Will generally covers the do not resuscitate directives but does not deal with important medical concerns you may have leading up to this point in time.  Some facilities and hospitals may accept the forms you have written, but may also require their own specific forms during an inpatient stay. 

This is the second article concerning Healthcare delegation.  The first one was very general identifying the actions you may want to consider.  The next post will lay out some links on the internet that may provide you with additional resources and ideas regarding you plans for your future healthcare management.

Coding for Imaging Services

In most cases imaging services are split into technical and professional components.  A modifier for the technical component is added to the 5 digit CPT code (copyright per AMA).  The abbreviation for the technical component is TC and the abbreviation for the professional component is PC. 

The PC of an imaging service is for the physician’s work interpreting a diagnostic test or performing a procedure.  The modifier for PC is 26.  Depending upon the provider pricing guidelines the PC or the 26 may be added to the 5 digit CPT code to communicate that the pricing is for the physician’s portion of the imaging. (I.e. 71010-26 or 71010-TC)

The TC of an imaging service is for the non-physician work.  This portion of the imaging includes the administrative, personnel, equipment and equipment cost related to the testing.  Depending upon the provider guidelines the TC or 27 is added to the 5 digit CPT code.

Generally speaking the charge for the technical component is higher than the charge for the professional component.  However, the cost of the professional plus the cost for the technical component is not larger than the charge for the global service.  The global code is the 5 digit CPT code without modifiers.  Without modifiers appended to the CPT code it describes an imaging service in which the same billing entity provided both the professional and technical component of the service.  An example of this would be a chest x-ray that was done in the MD office and the MD in that office read the x-ray. 

Now, if this is not enough to think about, it should be noted that not all imaging services can be distinctly split into a professional and technical component.  Examples of these types of services would be the interventional radiology services (CPT codes 77401-77416).  These codes are billed as global services.

When reviewing the charges for imaging services it is important to determine if the charges are for the TC, the PC or are global. This ensures the appropriate assessment of the billing for the imaging service(s) provided.  This is not always a straight forward process.  Often there are two separate providers with two separate bills that are issued without the modifier to identify the partial service provided.  The appropriate billing price must be assessed relying on the place of service and the type of provider entity.

Prepare for the inevitable Health Emergency-Part I

The first thing that most of us think about when estate planning is a will.  There are other decisions and forms to think about.  In the upcoming posts we will discuss the living will and the Healthcare Power of Attorney. These two forms provide you with a voice for your healthcare should you not be able to speak for yourself.

Celebration of Veterans everywhere--Every day is Veterans day

I

Source: Acuity-Insurance-flagpole; source Wikipedia

Thank you for all the men and women who have served, are serving and will serve.  NurseValue recognizes your commitment, service and sacrifices.  Thank you for allowing us to be free and live in a country of opportunity.

NurseValue is proud to announce our newest certified case manager,  Cortney Hubbard, RN, CCM.  Cortney joined us in 2010.  She has been a very busy since that time.  Cortney became a certified professional coder (CPM) and then went on to complete nursing school and obtained her RN licensure.  She has done so much in the last 5 years while continuing to be an asset not only to NurseValue but to every client she works with.  Please join us in celebrating Cortney's long list of accomplishments!

I am excited to be part of the new second edition of the Path to Legal Nurse Consulting. I provided one of the chapters.

Wherever you are on the path to legal nurse consulting career, you will benefit from these inspiring stories from successful LNCs. In this new second edition, Patricia Iyer tapped the expertise of her colleagues to bring you wit, wisdom, and lessons learned. The 42 chapters include updated chapters as well as 16 brand new chapters written by legal nurse consultants who are independents, expert witnesses and in-house consultants. The book is chock full of advice, encouragement, and humor.

Get your copy of this book at a special prepublication price of $20. Order at this link to get this price: www.legalnursebusiness.com/Path.

Vaccination Schedule 7-18 years

http://www.cdc.gov/vaccines/who/teens/downloads/parent-version-schedule-7-18yrs.pdf

Vaccination Schedule for birth to 6 years of age

https://www.healthychildren.org/Documents/tips-tools/Immunization%20Schedules/IZSchedule_Childhood.pdf

Osgood-Schlatter Disease

Providing taxi rides to and from practice for every sport offered to an adolescent, eating endless dinners in the car on the way to the practice field or a game, rearranging meetings at work to make sure I could make my taxi pick up at 4:00 pm and wiping the tears from my children after they lost a “game of a lifetime” were nothing compared to the day I had to explain Osgood-Schlatter Disease to my oldest son.

This young man didn’t know the definition of moderation.  Everything he did was higher, faster, longer, or it wasn’t worth doing.  He excelled in athletics from a very young age and loved every minute of practice, but competition was his real “high”.  This child took many hits and falls, but never acknowledged pain.  At age twelve he began to complain that his knees ached and that he was having difficulty sleeping because of the pain.  Having a nurse as a mother is not always the best thing for a boy.  I assumed he had just overdone it and encouraged him to take a hot bath and go to sleep. 

His complaints continued day after day.  He denied having had any high impact injury or having twisted his knees.  I have to admit that I was concerned when the achy feeling in one knee soon became an achy feeling in both knees.  I scheduled an appointment with his pediatrician just to make sure that everything was ok and that he just needed to rest.

X-rays of both knees were taken.  Blood tests were completed and Dr. Brown asked us to return to her office for a follow up visit.    Dr. Brown showed us the x-ray and told my son that he had Osgood-Schlatter Disease.

Osgood-Schlatter Disease is a condition causing pain and swelling at the tibial tuberosity.  The tibia is the large of the two lower leg bones.  The tibial tuberosity is the bump on the front of the tibia, just below the kneecap (patella).   The patellar tendon attaches the quadriceps to this bump or tuberosity.  In the adolescent the tuberosity does not yet have bony attachment to the rest of the tibia.  The mechanical attachment of the patellar tendon to the tuberosity is weak and occasionally causes separation of fragments of bone.  This separation causes pain and swelling in the teenager’s knee or knees.  Usually, this occurs in one knee, but research reveals that 25 % of the time both knee are affected.

My son’s daily athletic endeavors were just too much for his maturing knees.  Activities such as climbing stairs, running and deep knee bends increased his pain. 

The goal of treatment is to decrease the stress and inflammation at the tubercles.  My son was instructed to sit out of practice and games for the next two weeks.  He was given an anti-inflammatory medication to take three times a day and we were then to return to the doctor’s office for a recheck. 

All the way home, my son tried to convince me that the pain wasn’t that bad.  I listened and tried to calm his anger about being taken out of his beloved athletics.  Somehow my family made it through the next two weeks and we return for the follow up visit.  My son told the doctor that the pain was much better in both knees and pleaded to be able to return to his normal activity.  Dr. Brown recommended the anti-inflammatory medication be continued.  He was given permission to return to his regular activities, but was to take it easy for a while and not push his body “to its limits”.  Following any athletic work out he was to immediately ice both knees for twenty minutes.  He anxiously agreed to the treatment plan—anything to get back out on the field! 

My son’s pain slowly dissipated over a period of about three months.  He remained active and was able to do what he loved most-PLAY!  To this day I count my blessings.  Keeping this boy down was almost impossible and miserable for everyone in his life!  Osgood-Schlatter Disease may last over a period of months or years.  It may reoccur intermittently up until about age eighteen at which time the tuberosity fuses to the tibia.

If conservative treatment does not end the pain and swelling, it may be necessary to completely rest the knee or knees with a knee immobilizer or cast.  Luckily, this type treatment is rarely necessary.  The very best news is that Osgood-Schlatter Disease rarely causes any permanent injury except for an enlarged tuberosity (a larger protrusion on the lower portion of the knee).

 

Adhesive Capsulitis

I have had the pleasure of caring for a number of individual   following shoulder surgery over this past year so I am sharing one of the complications that may occur following this type of surgery.  Adhesive capsulitis is the medical term used to describe a substantial range of motion loss in the shoulder.  Sometimes this is referred to as a “frozen shoulder”.  This condition is painful as the shoulder capsule becomes contracted and thickened.  Pain will increase as a person or their physician tries moves the shoulder or tries to passively put the shoulder through the range of motion.

Many of my patient’s hear me say, “I hate shoulders” or after shoulder surgery, “No pain, no gain”.  My experience is that I see “frozen shoulders” after shoulder surgery.  The exact cause of this condition is not well described in the literature and it is not found to be the result of a rotator cuff tear. 

There are however, risk factors associated with this phenomenon.  Individuals with diabetes are more prone to adhesive capsulitis as are women between the ages of 30 and 50.  There may be other underlying diseases such as thyroid disease, Parkinson’s disease or cardiac disease.  This condition is often noted following shoulder surgery following a period of immobilization.

The patient will note a dull, achy pain that increases with motion and/or activity.  The pain is often located in the shoulder itself, but sometimes can occur in the upper arm below the shoulder.  The shoulder’s motion is restricted due to stiffness.

The initial treatment is pain control and physical therapy to restore the shoulder’s motion.  Literature notes that about 95% of those affected with note some improvement or resolution within 2 years.  Aggressive physical therapy is utilized over the first year.  Local nerve blocks may be used to decrease the pain while physical therapy is being utilized. 

If conservative therapy fails, the physician may recommend manipulation under anesthesia or shoulder arthroscopy.  During manipulation under anesthesia, the patient is put to sleep and the surgeon manipulates the shoulder to move forcing the capsule to tear and/or stretch.  The shoulder arthroscopy usually involves a release of the shoulder with small incisions to free the capsule allowing for movement in the area.  Both procedures are followed by intense (usually daily) physical therapy with emphasis on range of motion within the joint.

In summary, physical therapy is sometimes painful, especially when involving the shoulder joint.  I encourage my patient’s to give therapy their very best effort to ensure decreased pain and a return to normal function and range of motion.  It is helpful to take your prescribed pain medication prior to the therapy sessions (at least initially).  Icing of the shoulder joint following therapy also helps to control the pain.  Ask your therapist for instructions on a home exercise program that can be done at home to increase.  Most of all, stay strong as most people regain functional range of motion over time.

 

Youth Athletic concern--Quadriceps Contusion

When our youth participate in sports there are many opportunities for injury.  One injury that is often overlooked or underestimated with regard to the seriousness is the Quadriceps contusion.  The contusion may be mild, moderate or severe in nature.  The severity of the injury is determined by the amount of motion of the knee following the injury.

Signs and symptoms

·         History of a blow to the front part of the thigh (the quadriceps area)

·         Pain and/or weakness in the quadriceps muscle group.

·         Tightness and welling in the anterior thigh

·         Inability to actively bend the knee

·         A knot noted in the thigh that is palpable and most likely discolored (hematoma)

                                                          Treatment...

Usually the athlete complains of immediate pain and is attended to by either a parent or a coach.  The first line of treatment is to apply ice to the injured area to the leg that is extended to about 90 degrees.  The ice should remain in place for about 20 minutes.  This procedure is then repeated about every 1 to 2 hours minutes (ice on 20 minutes and ice off about 1-2 hours).  This should continue over the next 48 to 72 hours to decrease the pain and swelling.

Compression with an elastic bandage may also help the injury sight and the athlete should utilize crutches for mobility if he/she is not able to walk without pain or a limp.  Complete rest from all lower extremity activity should be maintained for approximately three days following the injury.

It is not helpful to use heat, head rubs, thigh message, or to stretch the tight thigh muscles aggressively.  At any time if there is a suspicion of a fracture or pain is not manageable a follow up visit with your physician is advisable. 

Following three to seven days of rest the athlete may begin mild quadriceps stretching two to three times per day.  Light activity like jogging, swimming or stationary cycling can be utilized to rehabilitate the quadriceps contusion.  Activity may be increased daily if no pain is present.  If at any time the pain is not diminishing or is increasing enlist the care of your physician.  It is helpful to ice following periods of activity for about 15 to 20 minutes.  This will aid in decreasing the pain and swelling in the area.

Four-year-old calls 911 to help his mother who was unconscious.

Now this is one fine young man!  I couldn't help but share!

http://911.viraltales.com/4-year-old-called-911-knew-help-2/http://911.viraltales.com/4-year-old-called-911-knew-help-2/

Happy 4th of July! Be safe and have fun!

Misdiagnosis---why does it occur?

 

When we go to our doctor’s office we all hope that we get a diagnosis for our symptoms.  We further anticipate the doctor to recommend a plan of treatment that will solve our problem or at the very least improve how we feel.  There are many times that we have to see the doctor more than once to obtain any relief for our problems.

It could be a misdiagnosis.  There are many individuals involved with special skills sets that contribute information to make a diagnosis.

We as the patient are the first point of contact.  With the world-wide-web at our finger tips it is very tempting and convenient to “google” our symptoms and attempt to treat ourselves.  This can lead to a misdiagnosis, inappropriate treatment and perhaps (if the condition is serous) a bad outcome.   If there are symptoms that concern us we seek medical care from our family physician or personal care provider.  At the first appointment with this provider, it is up to us to give him/her a history of our illness/concerns. It is often helpful to bring a list of your problems with as much detail as possible.  It is also helpful to bring a list of the questions to address with the doctor. Many times the doctor is busy and we are nervous.  It is easy to forget to ask something important. Before leaving the office, ask the doctor to wait a minute while you check your list to make sure something important wasn’t missed.  

Many times the next area necessary for the doctor to make an accurate diagnosis is diagnostic testing (blood work, x-rays or imaging).  Often the doctor’s staff will schedule these tests for you.  Again it is up to you, the patient to make sure that the tests requested by the doctor are actually the tests you are receiving.  Leave the doctor’s office with a list of the testing the doctor has recommended.  When it comes time for testing ask the name of the tests you are getting, compare them to your list of recommendations and make sure they are the same.  If not, ask the testing facility staff to call the MD or call yourself to clarify the testing required. 

The test results are sent to the doctor that ordered the testing. If you had x-rays or imaging studies, ask if the doctor will also receive a disc of the test results.  If not ask when the test results will be completed and make plans to pick up a copy of the testing on a disc so that you can go over the actual films with your doctor at the follow-up visit.  Keep a copy of the disc so that you will also have it to take to a second doctor should that become necessary.

 In summary:  three areas in which a patient may contribute to poor outcome or misdiagnosis are: self-diagnosis; not reporting symptoms; failure to complete ordered testing

The next area where medical diagnoses can run afoul is in the area of diagnostics.  They are useful tools, but are not perfect as they involve human error and have innate error margins which create false negatives as well as false positives.  We, as patients must be vigilant in following through on the preparation instructions provided for the testing.  If the test results carry a serious diagnosis it may be prudent to have a second test or a second reading of the test results (remember you have your disc of your films) by a second opinion doctor to make sure that the treatment plan you are about to embark on is appropriate and warranted.

 Laboratory and pathology tests are useful, but not perfect; all diagnostic testing may be altered by human error and all diagnostic testing has a certain innate margin of error.

The next person that is essential in making an accurate diagnosis is your physician.  Often the first physician you visit is your private physician who is usually a family practice physician or an internal medicine specialist.  The evaluation and management examination should include a history of your present illness/concerns, a physical examination and a discussion of the diagnosis and the treatment plan.  Medicine has become very specialized.  In many ways this is a good thing, but can also lead to a misdiagnosis.  Many doctors know only the most common diseases, illnesses and injuries.  After all, these are what they see day in and day out.  If you have an unusual problem or a serious diagnosis involving a particular body part it may be prudent to ask for a referral to a specialist in that area of medicine.  There are many other reasons that your primary care physician may not be the best treating doctor.  Primary care doctors are familiar with the patients and may have a bias with regard to diagnosing particular disease.  The may try to save you money and not order all testing that may be necessary.  Unfortunately, many family doctors are extremely busy and due to their hectic schedule may not have or take the time for an accurate diagnosis.  Added to this time constraint, behavior or mental symptoms are hard to analyze and take the doctor’s time and attention.  There are other physician diagnoses problems that involve the physician him/herself as we all have specific areas of knowledge and biases which lead us to certain decisions.  Medical providers are human, most care and try to do the best they can to enable a full recovery for their patient’s.  As the patient, we must provide them with accurate; concise information; ask questions when we are unsure or don’t understand; follow their instructions; and know when it is time to ask for a second opinion. 

 

CNN's World's Untold Stories: Dementia Village

I cried throughout this video realizing that there is another option for the care of our elderly dementia people, but for the lack of public finance and I think public caring for each other, this option (and others) are not available to our loved ones. 

We hit over 2000 views!

A special thank you goes out to those of you who are following us and viewing our posts.  We appreciate your time and look forward to many more conversations!

Story from the trenches—is utilization review a good thing for healthcare?

 

There is renewed interest in utilization review in workers compensation claims management .  The purpose of utilization review is to provide oversight of professional healthcare decision making.  Utilization review can be viewed as providing reinforcement of the professional decisions rather than to undermine these decisions.  This author does not feel that the goal of utilization review should be to save claims’ cost.  This may be a byproduct of the process, but should never overshadow the ultimate goal of appropriate patient care.

 

UR—negative perspective

Many in the healthcare industry would view utilization review as undermining the autonomy of the healthcare providers as it imposes an external control that may mitigate the individual provider’s healthcare decisions.  The second major objection to utilization review is the amount of time it takes to provide the documentation for medical necessity which increases the cost of the provider’s business.  Those that find this a problem also point to the fact that it takes the clinician away from actual patient care.  Another negative often reported when the discussion centers around utilization review is that the standards and clinical guidelines imposed by the utilization review process fail to take into account those individuals who fall outside the standards either with comorbidities or with special needs.  Most important to this author is the risk of delaying access to care by long delays of the utilization review process.

 

UR—redeeming qualities

If one is to set aside the concerns voiced above, it is possible that the utilization review process may bolster the legitimacy of the medical profession by clinical guidelines and standards of care.

One area that may be influenced positively is that an external review may hold all practitioners accountable for their decision making and thus weed out the incompetent providers (or at least limit the questionable practices).  This oversight may in turn bolster the public’s confidence in medical care. 

 

It’s all what you make it...

The determination of utilization review as a “bad” process or a “good” is dependent upon the utilization review agencies policies and procedures.  There are many aspects of the process that either encourage or discourage appropriate care and positive outcomes.  There are several areas in which a payer can determine what utilization review process is most appropriate for their population and needs.  

·         How much documentation and paper work must a clinician submit for the UR process?

·         What is the willingness of the utilization review entity to adapt review protocols in response to changes in medicine and/or complaints of the treating providers?

·         To what extent does the UR process take into consideration demographic treatment norms?

·         Are non-physicians allowed to deny authorization for medical treatment?

·         To what extent are physician reviews allowed to deviate from the formal protocols or clinical guidelines of the utilization review vendor?

The reader may want to address the questions above (and others) when choosing a utilization review company.  Much of the angst for utilization review can be overcome by a clinically driven, but patient centered utilization review process.

Story From the Case Management Trenches

Ms. Brown was in a skilled nursing facility for rehabilitation of a work-related injury.  She was receiving physical therapy at the facility, but needed transportation to and from her MD appointments.  The account was advised of the client’s needs and provided the case manager with the name and number of their preferred transportation vendor.  A precursory search for transportation was made by the case manager prior to being advised to use the carrier's preferred vender.  When the pricing was obtained from the preferred vendor it was questioned by the nurse case manager--it was significantly higher than the transportation company utilized by the nursing facility.  Not all venders improve the bottom-line cost of the claim! 

Story From the Case Management Trenches

As workers compensation field case managers we must work within the guidelines of our accounts while looking out for the safety and health of our injured worker. These two goals do not always mesh.

A call was received from the extended care facility that Ms. Brown was ready for discharge in two days—a Thursday.  The consultant asked if she would be able to take the walker she was using in the facility home with her.  The facility said no and this consultant then advised the account that the client would need to have a walker delivered to the extended care facility so that it could be modified to fit the patient prior to her discharge.  Unfortunately the MD was in surgery on this day and could not provide the script for the walker until Wednesday, the day prior to discharge.  The account kindly advised that they would contact their preferred provider to supply the client with the walker.

 

Thursday morning arrives and the injured worker is contacted and states that she has not received her walker, but did receive a call from the vendor asking if they could deliver her walker at home rather than at the nursing facility as “it was more convenient for them”.  Luckily, this injured worker knew the importance of obtaining a walker for safe mobility from the nursing facility to her home.  She told the vendor that she needed the walker to be fitted before she went home.  She contacted her nurse case manager and told her what transpired this afternoon and was assured that she did the right thing to ensure her safety.  This is just one example of preferred vendors not realizing that the safety of the injured worker takes precedence over the convenience of the vendor. 

Wishing all of you a very happy Mother's day!

Communication counts!

When giving instructions to a patient or caregiver communication is important.  The verbal queues and spoken words are often not interpreted as we intend them to be. 

I am reminded of one such instance in a pediatrician’s office. 

A fussy child came to the doctor’s appointment with a fever of 102 and was observed pulling at his ears.  Following a thorough examination the doctor determined that the child had an ear infection (otitis media).  A prescription of an oral antibiotic was given.  The mother was instructed to fill the prescription at the local pharmacy.  She was told that the medication bottle would have a dropper that she could use to give the child the medication.  The mother stated she would stop by the pharmacy on the way home and start the medication as soon as she arrived home.  Luckily she was further advised that if after 24 hours there was no change in her child that she should call the doctor’s office again.  She verbalized understanding and agreed. 

On the morning of the second day following the initial doctor’s office visit, the mother called the doctor and stated that her child was crying, not sleeping and continued to have a high temperature.  She was instructed to bring the child back to the doctor’s office for another examination.  When the mother and child arrived at the office the child was noted to be unchanged from the initial examination except one very important observation—there was drainage in both ears.  The mother was asked how she had given the medicine to her child and stated that she had done just as the doctor had instructed.  She put 3 ml of the medicine in each ear every six hours. 

Bill review companies –solution to high cost workers’ compensation?

Recently there has been much discussion regarding the failings of the workers’ compensation system.  What is the cost of the system on a worker’s life and on the employers who pay the high cost of workers unable to perform their jobs?   Claims claim administrators are tasked with saving money on each claim file.  Many “cost saving methods” add to the both time and expense cost to the claim.  This post is devoted to bill review companies that re-price medical bills with the goal of “discounting medical bills”-- a retroactive review.

 

Bill review companies orate that they are specialty bill review organizations and often tout their network affiliations.  The goal of all of these “parts” is to discount the workers’ compensation medical bills.  Most workers’ compensation networks do not demonstrate better medical care by their physicians.  They don’t advertise better medical outcomes. 

The business of medical bill review is to “slash” the medical bills retrospectively.  Each medical bill review vendor has its own business model and advertising strategy. Each may take a slightly different approach to the common goal of medical bill reduction.  Bill review does have a purpose in workers’ compensation, but one size does not fit all. 

For many years bill review has been a commodity.  (I anticipate every bill review company will object to this terminology.)  Each company tries to differentiate them self from their competitors, but most of their clients are looking only at the cost of the service.  Thus, there is increased automation, auto-adjudication, streamlining and off-shoring of at least a portion of the bill review process.  None of these processes are “bad” and all will decrease the cost of the bill review, but do nothing for the quality of medical care and often delay the payment of the medical bill due to the lengthy grievance process and the slow turn-around of many vendors.  This is the reason that “balance billing” of the injured worker is often banned by workers’ compensation statutes as it stays the injured worker from being referred for collection.

Many bill review companies will emphasize their goal of ensuring their clients pay the appropriate amount and no more.  This goal has been somewhat lost in the shuffle.  Automation, speed and strong competition have not always ensured an equitable solution of fair payment of appropriate medical bills.  An overzealous bill review company will deeply discount bills only to find that the review does not stand up to appeal and/or scrutiny and their client will often have to pay additional money to the provider of the medical care.

Most medical bill review companies have a per bill charge, usually called a “header charge”.  This is a small amount charged per bill which covers the data entry required for each bill.  It is common in the industry then to charge a percentage of savings.  This type of savings is realized by the bill review in several different ways and varies within the industry.

Network “savings” is billed as a percentage of the discounted amount.  The network savings is incurred most often by retroactive re-pricing of the billing without upfront steerage to the “network” providers.   As an onlooker of this process, I find this an area of conflict between medical providers and their payers--the providers are often not aware that they are a member of these networks.  For more information look at the many articles on “Silent PPOs” written over the last decade. 

Some states do have preferred networks for Workers’ compensation and the injured worker is required to a certain degree to access these network providers.  In this case the networks often do not discuss the quality of the care over the price of the care.  Many excellent providers are not in these networks and may prove critical to a good outcome for a particular injured worker.

 Savings is also calculated by the amount of billed charges that are reduced down from the state fee schedule.  Bill review clients beware:  this may be over stated and the full discounted price of the billed charges may be taken rather than the difference of the reduction below the state fee schedule. 

Another way that bill review companies realize savings on a medical bill is to analyze the medical records and compare them to the billing statement to determine if the billing is based on the actual services rendered.  This is often done by a nurse who is not a certified coder, or a certified coder that has no billing experience or auditing experience. 

The conversation so far has pointed out many areas of concern with regard to the success or failure of medical bill review companies on the evaluating the medical care as it relates to appropriate billing.  This is not entirely the bill review vendors' fault. Their client’s bear much of the responsibility as they engage the vendors in competitive bidding wars to find the lowest cost for the bill review services. 

Bill review as a commodity comes with a cost that neither saves money nor ensures appropriate medical care.  Some of my thoughts and observations are listed below to delineate some of the short-comings I have seen in the current bill review system.

·         For some procedures, the amount reimbursed is dependent on modifier codes.  The modifiers must be entered and are often overlooked as the data entry quotas become unattainable.

·         A nurse audit may be separately charged at a higher rate than other types of bill savings typically charged to the client.  The payer would be well served to see that a nurse review was completed and the impact on the bill documented. 

·         More often than not the payer pays the bill review vender for all bills big and small.  A 100 dollar bill and a 5000 bill without “savings” found are both charged the same header fee.  Is it necessary to review every bill?  Would a Vendor review of the bills and a selection of bills referred for bill review be prudent?  This may especially be true in fee schedule states when the bill is from a provider that has been paid many times in the past.

·         It is now becoming more prevalent that the bill review client must now approve the vendors recommended payment to the provider.  This author feels that process may be in place to decrease the conflict between payer and provider.  Is this cost necessary if the bill review company is making sure the payers pay what they owe?

·         A question every bill review client should consider asking is:  does bill review vendor depend only upon their system to reduce the bills or if they employ certified coders for data entry so the data is being input correctly?

·         Off shoring part or all of the process may be of interest to some bill review clients.  This practice is not always advertised by bill review venders, but at least some of the venders employ this at some point in the process.

·       Payers need and want national solutions bill analysis.  It is important for the file handlers and/or the employers take the time to understand some of the state-specific as some of the state-specific billing can dramatically influence costs. The bill review vendor’s automated system may or may not be able to pick up on the state differences.

·        Preferred provider networks are important not only in cost control, but in appropriate medical services.  An example of this is an MRI provider.  Preferred provider networks do not always save the payer money as they do not always provide high resolution films that enable appropriate diagnoses.  The image quality of an MRI depends on signal and field strength.  Many networks include MRI vendors who have low signal and/or field strength resulting in poor films.  The need for a second MRI due to poor film quality not only delays medical treatment and increases the claim cost. 

·        Network providers may extend a discounted rate by offering a different level of care. Do the injured workers see physical therapy assistants rather than certified physical therapists?  Do the injured workers see a physician or a nurse practitioner?

·      Preferred provider networks are not created equally.  The providers in the network are credentialed with regard to current unimpeded licensure.  The question is are the network providers known for their expertise and positive medical outcomes?

In conclusion, insurance companies/TPAs have been able to cut their medical bill costs, but the question is whether or not the price they are paying is greater than or less than the reduction in their in-house administrative expenses.

My thought on the current trend:  Carriers, TPAs and self-insured employers rely on accessing networks for cost reduction.  Bill review is a necessary way to get bills re-priced to network rates, and a source of data for state reporting.  This may lead to the bill review venders charging a flat rate per line or per bill.  This in turn moves the bill through an automated system and removes the incentive for bill review venders to find billing discrepancies and the original purpose of bill review is no longer realized.