Patient Portals and Direct Messaging, how do they affect me?

By Dr. Rod Snow,

The OOA has been receiving questions concerning “practice portals” of Electronic Medical Records versus “patient portals”, along with some confusion around direct messaging.  Is there a difference with these things and how do they affect me?  There may be some minor differences between each EMR, but here is some information on these terms that may be helpful:

There is a difference between the “practice portal” and the “patient portal”.

  1. The practice portal is the practice’s command center. It is where many of the essential functions of the EMR are set-up.  It is also where employees can message each other.  It has the “inbox” messages received from patients and from other doctor’s offices (called DIRECT messaging) because they are located on an encrypted server.
  2. The patient portal is a “subset” of the practice portal. This is where patients can log in and see some of their exam information. They will see the clinical summaries (CCD’s) that the doctor has created for that patient.  The patient can use this portal to send a message to the doctor and possibly schedule appointments through this portal.

“DIRECT” messaging is different than typical email.  Doctor to doctor communications via email should always be through “DIRECT”.  That is because DIRECT is associated with the doctor’s practice portal and will then be encrypted.

Important:  If a doctor uses private email to discuss health concerns, that is a HIPAA privacy violation as that information is not encrypted!

Doctors can exchange patient information through the DIRECT messaging account, which goes directly to the practice portal which is automatically encrypted for privacy.  Additionally, patients can email through the patient portal, which will connect to the practice portal where it will be viewed by the doctor.  It also is automatically encrypted.

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Blogs or Books? Guesses or Guidelines? It’s time to get serious about good medical records.

By: Charles B. Brownlow, OD  (drbrownlow@pmi-eyes.com)

Several years ago, I found myself jumping from one eye care chat room to another, trying in vain to correct bad information about patient care and record keeping that kept popping up there.  It seemed that my colleagues in eye care would rather ‘take a poll’ of other ODs and staff (who didn’t know the answer either) rather than go to the only true authorities.  After getting totally frustrated in that ‘Whack a Mole’ environment, I respectfully and quietly withdrew from the milieu, and I haven’t missed it one bit.

Over a decade ago, during the ramp up to HIPAA, the rules changed essentially clarifying that Current Procedural Terminology (©American Medical Association), ICD-9, and the Documentation Guidelines for the Evaluation and Management Services (99000 visit codes) were the sole acceptable references for codes and definitions for the vast majority of health care services.  That thought clarifies nearly everything in health care…All a health care provider needs to do to learn about the logic of health care delivery, good medical record keeping, and accurate choices of procedure, visit and diagnosis codes is purchase the current year’s CPT and a fresh ICD manual and download the 1997 Documentation Guidelines from CMS.gov.

Based on the questions that I get every day from ODs and staff from around the country, it’s pretty clear that a majority of those offices do not have those key references available in-house, or they are not current, or they just don’t refer to them when question arise.  That’s pretty sad, I think.  CPT is available through our AOA.org/marketplace at $100 a copy.  The Documentation Guidelines are a free download (.pdf or Word) at cms.gov.  ICD-9 and ICD-10 are available as complete manuals for around $100.  So, for between $200 and $250 per year, key staff and doctors could become ‘experts’ on the chat room scene real quickly.

I’ll provide a couple of examples to support my point.  One of the long-raging arguments among eye doctors; at least twenty years; has been whether the CPT definition of the comprehensive ophthalmological service (92004/92014) includes a dilated fundus examination as a requirement.  The definition has not changed since 1992 and it has never included that requirement!  The CPT definition clearly lists “…examination with cycloplegia or mydriasis” among the tests that the service “…often includes, as indicated”.  “Often includes” does not equate to “includes” or “is required.”

I think the confusion may come from the requirements for the ‘comprehensive physical examination’ for the evaluation and management services (99000 codes), but it was made very clear back when the 99000 codes were introduced nearly twenty years ago that the CPT definitions are unique and distinct for each set of visit codes and that there are no crosswalks or comparisons between the two.  In short, “external and ophthalmoscopic examinations” are required elements for 92004/92014…Dilation is not.

One of the national speakers in the medical record area continued to state that dilation was a requirement. Every year I would hear that, refer to my then current CPT book for confirmation that I was still right, and shoot off an email to suggest that the speaker ‘change his tune’.  Months later, I’d hear that the message had not changed.  Finally, early one year, with the ink barely dry on my current copy of CPT, I heard again that dilation was required.  Instead of emailing again, I picked up the phone and called. “Hey, how are you doing?  Keeping out of trouble?  Family doing fine”, etc.  After about 30 seconds of small talk I dropped my challenge.  “It’s right there in the definition”, the speaker replied. Then it hit me and I responded, “Which CPT book says that?”  “Why, the (Brand X) CPT, of course”, he parried.  FLASH!  The lights snapped on.  He wasn’t using the only official CPT book, the AMA CPT, he was using a cheap imitation, the book that continues to confuse the issues, the (Brand X) CPT!

As with so many things, we must accept no substitutes.  If I’m ever in court, I’ll want an attorney who knows the laws and, when pressed, is able to refer to the current, official statutes that pertain to the case.  I’m not going to be very comfortable if the attorney attempts to reassure me by saying that she got the information off a blog or chat room, or that he called a couple of friends or read it in a novel.  The same is true with medical records.  The care you provide had better be consistent with accepted modes of practice; the standards of care; and the medical records you keep must demonstrate clear connections between the needs of the patient and what was done, and your choices of procedure and visit codes must have been chosen by comparing the content of the chart and the definitions in AMA CPT and the current ICD listings.

Relying upon trusted resources and references can help us avoid hassles and sometimes disasters.  I know you’ve been putting this off for a long time.  Just do it today.  Get your 2015 copies of CPT and ICD-9 (and ICD-10).  Read the introductions at the front of the CPT book and the front of the 1997 Documentation Guidelines.  And then refer to those key references when questions pop up.  You’ll sleep better…You’ll find yourself chuckling quietly when you ‘listen’ in on a discussion in a chat room or read somebody’s blog…Then, without typing a response, you’ll go to the references, double check your understanding of the question, and live happily ever after.  You’re welcome.

Medicare Update for 2015

Medicare Update for 2015

Dr Brownlow

10 and 90 day global periods will be eliminated for minor surgical procedures in 2017 and for major surgical procedures in 2018.  Current 0, 10, and 90 day post op periods are still in effect for 2015!  Lots of ODs and staff have been asking me about the potential impact of all global periods going to 0 days.  Actually, I think it will be an advantage, as doctors providing post op care will no longer be limited by the meager CMS payments for post op periods, and will be submit claims for whatever visits and procedures are necessary during the post op period, just as they are during any other time they are caring for the patient.  Another interesting thing I’ve noticed about this issue…I’ve been getting more questions regarding these changes; though they won’t go into effect for two or three years; than I get on issues that should be of concern to doctors and staff currently and/or should have been of concern to docs and staff for years…Go figure!

Medicare Fee Schedule

The 2015 Medicare Fee Schedule has been published and it does include some changes, resulting in small net increases across the board for services ODs provide most commonly. Medicare’s fees are calculated based on relative values assigned for each service and the Conversion Factor, set by Congress each year.  The formula for calculating the fee for each services is Relative Value x Conversion Factor = Fee.  The conversion factor will be slightly lower at the beginning of 2015, though some of the relative values have increased, so the net impact will be very small.  However, a very large decrease in the conversion factor is slated to go into effect April 1, 2015, unless Congress acts prior to that date.  For those of you who have watched this strange scenario play out in previous years, this is no surprise.  My prediction?  Congress will act in the 11th hour to avoid the big cuts and leave the fee schedule pretty much as it is in 2014.

Act Now to Avoid PQRS Penalties in the Future

AOA has been successful in convincing CMS that small group practices (1-9 doctors) should not be penalized for PQRS issues, but should be eligible for the PQRS bonus payments.  2017 PQRS bonuses will be earned by PQRS participation in 2015, so gear up now to be sure you qualify.  You can continue to report PQRS measures on your Medicare claims, although AOA will be providing members with an easier way to accomplish that reporting, referred to as ‘registry reporting’, early in 2015.  Watch for more PQRS information from AOA in December.  If you decide to begin (or continue) to use the traditional method of reporting PQRS measures on each Medicare claim, you may do that as well.  There are lots of PQRS changes for 2015, so please refer to all of the information that has been created by the AOA Third Party Center. It’s all available to AOA members at aoa.org/pqrs.  The major change for this year is that you must now report nine measures 50% of the time the related diagnoses appear on a claim.  Prior to his year you could have qualified by reporting only three PQRS measures 50% of the time the related diagnoses appear on a claim.  My advice at this point is to wait for AOA’s ‘Registry’ for PQRS reporting, which will make the process much more workable.

Medicare’s Impact on Optometry

CMS estimates that ODs provided services and were reimbursed over $1 billion in 2014 and predicts the total payments will rise in again for ODs in 2015.

Pretty amazing! And clear testimony of the value of your membership in the state association and AOA.  Without the hard work of organized optometry during the past thirty years and currently, we would not have been prepared to provide medical care to anyone, and we certainly would not have been granted full parity in Medicare, nor would we be providing full scope eye care services and being reimbursed by Medicare and other medical insurers today!

Charles B. Brownlow, OD, OS, OU

Meaningful Use and ICD-10 Update

Dr Jay HenryBy Jay W. Henry, OD, MS – It is important for all of us to know that in order to get an incentive payment for the CMS EHR Incentive Programs, you must use an EHR that is certified specifically for the EHR Incentive Programs. To meet meaningful use in 2014, you must be using software that is certified to the new 2014 standards. The 2014 certified software can be used to meet either stage 1 or stage 2 of meaningful use. Remember, that software is always certified by version number and you will want to be sure that your software is updated to the new 2014 standards and that you are using the version that was certified for 2014 before beginning your reporting period to meet meaningful use this year. If you want to see what version of your software is certified, visit http://oncchpl.force.com/ehrcert and click on the 2014 edition.

Most of the software vendors that specialize in optometry are either already certified to the 2014 standards or are finalizing their 2014 certification currently. Don’t panic if your software hasn’t been updated just yet to the new standards. Everyone (stage 1 or stage 2) only needs to have a reporting period of three months in 2014. If you are under the Medicare EHR incentive program, that three months must align with a calendar quarter (Jan – March, April – June, July – Sept, Oct – Dec). If you are under the Medicaid EHR incentive program in Ohio you are not tied to a calendar quarte­r but may choose any three-month reporting period. If 2014 is your very first year of Meaningful Use you may choose any continuous 90 days as your reporting period, but to avoid penalties that start in 2015 you must begin your 90 days of Stage 1 of meaningful use no later than July 1, 2014,and submit attestation by October 1, 2014!

The OOA has obtained a list of vendors that state they have met the 2014 standards as of writing this article. Those include: Compulink, Crystal PM, Diversified Practice Maximus Elite, FoxFire EHR, MaximEyes SQL, MyVision Express, RevolutionEHR, and VisionWeb Uprise.

ICD-10

Now that ICD-10 has officially been delayed until at least Oct. 1, 2015, we have a little more time to prepare our offices for the change. It is important to know that most EHR vendors are nearly ready to implement and utilize ICD-10 code sets. Many of them have already implemented a system that has the ability to do either ICD-9, ICD-10, or show both code sets at the same time. Oftentimes, in your software you will be presented with both ICD-9 and ICD-10 codes allowing you to pick which code set to use when billing. This concept of seeing both will allow you to learn what ICD-10 codes looks like and with the new delay it gives you plenty of time to prepare.

Don’t put off the change until late in 2015 but keep working toward transition with all of your software and billing vendors. It will be an added bonus when you are ready before the change is mandated by law.

Coordination of Benefits – Why Make the Effort?

Miller 968Jason R. Miller, OD, MBA, FAAO – Please note: The following column is based on my experience and not an official opinion of the OOA. Every optometrist must decide how to handle this issue.

Are you confused about how to bill your diabetic patients? Especially your diabetic patients who also have VSP? Many health care payers have sent notices to many eye care providers asking for the claim when their member is diabetic. It’s kind of a blessing and a curse when two different carriers are asking for the claim with these specific patients. For example, this letter recently arrived in my office from Medical Mutual:

MedMut Form

 

 

 

These letters are correct when determining who to send the claims to, but need some clarification when it comes to actually submitting the claims and the order in which they are processed. There can be some confusion, as most vision insurances will not accept Refraction Only claims.

Determining who gets the bill starts with the reason for the visit. The patient’s reason for the visit should determine who gets the bill. If it is a refractive complaint (Myopia, Presbyopia, etc.), the vision plan should receive the bill for the encounter. If is a medical complaint (Diabetes, Dry eyes, Allergic Conjunctivitis, etc.), the medical insurance should get the bill for the encounter. That reason for the visit can be either a patient complaint or an order from the doctor at their previous visit (for example: Order Procedure: Glaucoma Work-Up in three months). That order from their previous encounter becomes the reason for the visit when they come in for that testing.

Typical Scenario:

If the patient is diabetic, they may be in for new glasses or contact lenses and their annual diabetic exam as prescribed by their primary care physician or endocrinologist. One possibility is to provide their vision exam (submit to vision) and have them back for any diabetic testing (submit to medical). That is typically not very patient-centric, as we can usually provide this service at the same time and will save the patient a trip to our office. This article details steps to take in order to coordinate the patient’s visit between both their Medical and VSP when appropriate.

  1. To coordinate this claim to VSP, there must be a refraction done on the same date as well.
  2. The exam can be either a 99xxx or 92xxx CPT, whichever you deem appropriate. The medical exam needs to be pointed to the medical diagnosis (choose a Diabetic code in this scenario – 250.xx) listed in position 1 on the HCFA form.
  3. The refraction (92015) must be pointed toward a refractive diagnosis.
  4. The claim, in its entirety with the exam, refraction and any special testing if applicable (92250 Fundus photos if medically necessary), will be filed to the health insurance carrier for consideration.

Note: You do not have to collect any co-pays at this visit.

The health insurance is going to process the claim as primary and they are going to pay based on the patient’s coverage for that service. Once the health insurance processes the claim, you will receive the explanation of payment (EOP). After the health insurance company processes the claim as primary, the claim can then be filed to VSP under their coordination policy.

Keep in mind that this secondary claim to VSP must mirror the primary claim exactly. This is not just sending the refraction code to VSP. The CPT codes and diagnosis order cannot be altered.

Once VSP gets the secondary claim, they will pay up to $66 on Signature or Choice plans, less the copay amount per the patient’s plan. VSP will not pay on any testing overages the primary does not cover. They will only pay on the exam and refraction overages that the health insurance carrier does not pay.

COB Max COB Payment for all states as of 04/01/13:

VSP COB

 

 

 

 

Let’s say they have a $30 copay from the medical insurance and the $XX refraction is non-covered. Per the health plan, the patient’s total out of pocket should be $30 + $XX for the refraction.

Next steps – this is taken directly from the VSP Coordination Policy (click on the link for the policy):

For Paper Claims:

  • When you receive payment from the health plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

For Electronic Claims:

  • When you receive payment from the health plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

After the claim is submitted to VSP as secondary and when VSP considers the claim, they are willing to pay up to $66 ($66 less the $XX VSP copay) as secondary. Of the $30 + $XX balance that is outstanding from primary, VSP will cover their portion and the patient responsibility will be what is left, if anything.

Please Note: There is no VSP write-off when VSP is acting as secondary. The primary health insurance allowable will be honored, but VSP requires no additional write-off on a medical coordination; it is a flat benefit amount as secondary.

Explaining this to the patient can also be a challenging situation, but Dr. Neil Gailmard just had a very good practice management explanation of this situation along with a handout to use with patients. I have copied and pasted this explanation from his post, but you can also access this online at:

http://www.optometricmanagement.com/om_mtotw.aspx

Optometric Management Tip # 561 – Wednesday, December 05, 2012

A Patient Handout for Vision vs. Medical. In last week’s article, I provided an overview of the differences between vision plans and medical insurance. If your practice routinely bills all eye exams to vision plans, you may want to consider differentiating medical eye exams from routine vision exams and billing the former to medical insurance plans. 

The difficult part of this process is educating patients about the differences. That requires significant staff training, but a patient handout like the one below can be a big help. Feel free to modify the form below to describe your office policies. The handout can be given to patients at check-in or check-out and it serves as a guide for staff members as they speak to patients over the phone. I find it is best to keep educational handouts short and simple. Many patients simply will not read a form if it is long and wordy.

***Sample Handout***

About Your Insurance. There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts both: 
Vision care plans (such as VSP and EyeMed)
Medical insurance (such as Blue Cross/Blue Shield and Medicare).

Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.

Medical insurance must be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history.

If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.

We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract.

I have read and agree with these policies.

________________________            __________

Patient signature (parent if child)                Date

Please provide your insurance cards to our staff member.

Best wishes for continued success,

Dr. xxx, O.D.

A special thanks to my business partner, Dr. Tamara Kuhlmann, OD, MS, FAAO, and Branda Barton of Optometric Billing Solutions for their assistance with this article.

Managing Mandatory Children’s Eye Exams

Dr Jeff MyersBy Jeffrey Myers, OD – I love kids. Spending time with my two grandchildren always brings joy and is a highlight of my day or week. At reunions of my wife’s family, I rarely am talking to the adults. More interesting to me is connecting with the folks under 18. Many of my volunteer activities over the years have been focused on young people. I find that connecting with the young folks at church when volunteering with the youth group is energizing. Generally, young folks enjoy the attention of an adult who is truly interested in talking to them, and who treats them as an equal.

In practice, you might share the experience with me that certain types of patients are energizing, interesting, and intellectually stimulating. For me, removing foreign bodies, relieving the pain of iritis, and protecting patients from the loss of vision associated with glaucoma all fall into this category. I confess that examining patients under age 10 does not fall into this category. While I love kids, my passion is not in examining them. And examining more than one child a day is draining for me. So, what do you do if you share this challenge of examining young children with the implementation of the pediatric Essential Health Benefit under the Affordable Care Act (ACA) which has mandated eye exams for children?

Fortunately, I observed this about myself more than a decade ago. As I was looking to add a second doctor to our practice, I specifically looked for a doctor who brought a passion for pediatrics to the practice as well as an interest in cultivating a vision therapy practice. Dr. Amy Keller fit that profile and joined my practice in 2005. Her lack of interest in managing glaucoma patients made our skill sets complementary. In addition her special interest in the challenging contact lens fit and dry eye round out a valuable doctor.

In 2011, we were finding our schedule busier and needed additional doctor coverage. Dr. Kari Cardiff joined our practice and shares Dr. Keller’s passion for the young folks. She had experience in performing vision therapy and brought an additional passion for vision rehabilitation. Her addition has allowed the expansion of specialty services in the practice, adding greater value for our patients.

Today, patients who come to our practice are matched with a doctor passionate about meeting their vision care needs. Young folks see Dr. Keller or Dr. Cardiff, glaucoma patients usually see me, and patients in need of special services are connected with the doctor best suited for them. Other professionals build practices centered around the strengths and interests of the individual doctors. We can learn from that model.

If seeing young patients is not your interest yet you anticipate an increase in pediatric patients, consider the addition of a colleague who has a passion for the young patients. Your patients deserve someone who is excited about caring for them.

AOA Provides ICD-10 Resources

The AOA has provided a list of resources for ICD-10 available to members. You can read the summary here: AOA ICD10 Resource Summary.

The summary reflects what is available today – resources are continuously being updated.

The Medical Records and Coding Service for AOA members is provided by the Third Party Center (TPC) Coding Experts, Doug Morrow, O.D., Rebecca Wartman, O.D., and Harvey Richman, O.D. All medical records and coding questions can be sent to the email address: askthecodingexperts@aoa.org or questions may be submitted online at www.aoa.org/coding.

For questions pertaining to “Ask the Coding Experts” webinars, please email tpc@aoa.org.

Some Good News for Our Members and All Providers

Dr Jay HenryBy Dr. Jay Henry – CMS is extending the deadline for Eligible Professionals (EPs) to attest to Meaningful Use (MU) for the Medicare EHR Incentive Program 2013 reporting year from 11:59 p.m. ET on February 28, 2014, to 11:59 p.m. ET March 31, 2014. This extension does not impact the deadlines for the Medicaid Electronic Health Record (EHR) Incentive Program.

Additionally, 2014 is a special reporting year. All EPs regardless of stage will be required to meet and report on MU for a quarter for 2014. It is locked to a calendar quarter for Medicare but not for Medicaid.

CMS announced its intent to change the Meaningful Use Stage 3 timeline, as well as extend Stage 2 through 2016. However, please note:

  • This does not delay the start of Stage 2 Meaningful Use that began Jan. 1, 2014.
  • This does not affect the current reporting periods and deadlines for 2014 participation.

What This Means for Providers

If you begin with your first year of Stage 1 for the Medicare EHR Incentive Program in 2014:

  • You must begin your 90 days of Meaningful Use Stage 1 no later than July 1, 2014, and submit attestation by Oct. 1, 2014, to avoid the 2015 payment adjustment. Consequently, providers who start their 90-day Stage 1 reporting in 2014 will have to attest before October 2014 to avoid 2015 and 2016 penalties.
  • 2014 is the last year a Medicare provider can start the program.

If you have completed Year 1 of Stage 1 Meaningful Use:

  • You will demonstrate a second year of Stage 1 Meaningful Use in 2014 for a three-month reporting period fixed to the quarter for Medicare or any 90 days for Medicaid.
  • You will demonstrate Stage 2 Meaningful Use for two years – 2015 and 2016.
  • You will begin Stage 3 Meaningful Use in 2017.

If you have completed two or more years of Stage 1 Meaningful Use:

  • You will still demonstrate Stage 2 Meaningful Use in 2014 for a three-month reporting period fixed to the quarter for Medicare or any 90 days for Medicaid.
  • You will demonstrate Stage 2 Meaningful Use for three years – 2014, 2015, and 2016.
  • You will begin Stage 3 Meaningful Use in 2017.

Some Statistics

  • More than 93 percent of all eligible hospitals have registered to participate in the EHR Incentive Programs.
  • Approximately 82 percent of all EPs have registered to participate in the EHR Incentive Programs.
  • More than 61 percent of all Medicare EPs who have received an EHR incentive payment are non-primary care.

PQRS has changed for 2014

Most PQRS reporting options require an EP or group practice to report nine or more measures covering at least three National Quality Strategy (NQS) domains for incentive purposes.

The domains associated with the measures are as follows:

  • Patient Safety
  • Person and Caregiver-Centered Experience and Outcomes
  • Communication and Care Coordination
  • Effective Clinical Care
  • Community/Population Health
  • Efficiency and Cost Reduction

To be a successful PQRS provider during 2014 and receive the incentive payment, you must submit nine PQRS measures half the time that they apply based on diagnosis code and procedure code.  You can avoid the 2016 payment penalty (but you will not get an incentive payment nor be considered successful in terms of PQRS) by successfully submitting at least three measures 50 percent of the time that they apply.

Visit the PQRS link at http://www.ehrguru.net/ for up-to-date information and the PQRS codes that apply for ICD-9 and ICD-10 diagnosis for 2014.

New Rules Regarding Termination of Doctor-Patient Relationships and Proper Notice to Patients upon Physician Termination

By Daniel Zinsmaster, Esq. – Ohio law has undergone a number of developments concerning the appropriate means of notifying patients when a physician leaves a practice, as well as the proper steps for terminating a patient from a medical practice. Effective March 22, 2013, health care entities were required to advise patients when an employed physician left the entity or medical practice, regardless of whether the physician’s departure was a result of the employer’s or the practitioner’s decision (Ohio Revised Code Section 4731.228). Now, administrative rules recently amended or adopted by the State Medical Board of Ohio (“Board”) attempt to provide further clarity to this requirement, as well as outline the necessary steps for discharging or terminating an individual patient from a medical practice.

Effective December 31, 2013, any physician leaving, selling or retiring from a practice must comply with Ohio Administrative Code Rule 4731-27-03. Within 30 days of learning of a physician’s termination or resignation, a medical practice must send notice by mail or by HIPAA-compliant electronic means to all patients treated by the departing physician within the past two years. A medical practice may transfer this notification mandate to the departing physician by providing a list of patients treated along with patient contact information to the physician.

The notice to patients must contain all of the following:

  • A statement that the physician will no longer be practicing at the health care entity,
  • The date the physician ceased or will cease providing services at the health care entity,
  • If the physician will be practicing at another location, the contact information for the physician’s new location,
  • Contact information for alternative physicians at the health care entity who can provide care to the patient, and
  • Contact information so the patient may acquire their medical records.

 The notification requirements do not apply to physicians who have provided treatment on an episodic basis, in an emergency department setting, or at an urgent care center. Notice is not required to patients treated by medical residents, interns and fellows. Furthermore, a health care entity is not required to provide contact information for the physician’s subsequent location when a good faith concern exists regarding patient safety.

In terms of the discharge or termination of a patient from a medical practice, the physician must send notice by certified mail, return receipt request, or by HIPAA-complaint electronic means to the patient. If the electronic communication is not viewed within ten days by the patient, notice by certified mail must be provided. The notice must state that the physician-patient relationship has been terminated, that the physician will provide emergency care and access to services for up to 30 days, and that the patient’s medical records will be available to transfer to another provider. The physician is not obligated to aid or assist the patient in acquisition of a new provider.

Similar to an individual physician’s departure from a health care entity, a physician is not required nor expected to provide notice of formal termination if the physician treated the patient in an emergency setting or on an episodic basis. Moreover, notice of termination is not necessary if the patient’s care has been formally transferred to another physician who is not within the same medical practice, or when the patient is the person responsible for terminating the physician-patient relationship. Nonetheless, such events should be documented in the patient’s chart.

Ohio physicians must also be cognizant that ethical mandates published by the American Medical Association and the American Osteopathic Association similarly prohibit patient abandonment, and set forth appropriate steps for ending physician-patient relationships. Breach of statute, administrative rule or ethical code may expose a physician to professional licensure sanction by the Board and other entities. In light of this evolving area of health care regulation, medical practices and individual physicians must be mindful of the specific notification mandates when an established physician-patient relationship is concluded.

Daniel Zinsmaster is an associate with the Columbus office of Dinsmore & Shohl, LLP.

The ACA and Practical Applications

By Dr. DavDr. David Andersonid Anderson –  So, the Affordable Care Act is here – now what? I know we have all seen some impact from the changes brought by the ACA. Some were with our own insurance plans and unexpected. Some were with insurance that our patients have. Some changes will be from new patients who previously didn’t have health coverage. With all of this change, a few questions came to mind.

  • Where do I go to evaluate the exchange plans to find out whether I am a provider for these plans?
  • How do I find out the fee schedule for these new plans?
  • How do I know if I am a provider for the “new” plans that are subject to ACA minimum requirements to be a privately sold plan?
  • I understand there will be a new network with the potential for providers being left off plans (e.g. UHC and other skinny networks). How do I find out if I am included, or have been dropped from the network?
  • How do I find the fee schedules for these plans?
  • In my area, there are some newly developed Accountable Care Organizations (ACO’s) that are self-insured by a hospital group. How do I find out about these plans?
  • How do I know which medical plans cover children’s vision benefits, and which plans have subcontracted the services/materials to a vision plan?

The best place to find answers is with the specific carrier of these plans and their provider portal information. Health care providers should have been notified by mail of any changes at the end of last year. In most cases, if you are already a provider for Medical Mutual, Humana, Buckeye, CareSource, Molina or Paramount, then you are already a provider for those on the exchange as well, and the new ACA minimum-required plans.

Speak with your carrier representatives, and email them your questions. This gives you a permanent record. The reps can give you more specifics for their plans. Each company is free to provide these plans, within certain guidelines as laid out by the ACA, as they find most appropriate. The insurance companies will use existing fee schedules unless they have new signed agreements or amendments with you. In many cases, this means Medicaid levels of reimbursement. Additionally, each insurance company has a website that you can access for information. You can find out if you are a provider by searching for your own name on their “find a doctor” feature on each website.

The exchange plans sold in Ohio can be found on www.healthcare.gov. This website allows a search by county to find out about the new exchange plans and provider panels. Generally, you will have to request fee schedules by providing specific CPT codes. Admittedly, the website is set up for those people looking to purchase an insurance plan, but there is still information about the plans that our patients will be gaining access to.

Some information is not readily available at this time, such as how certain ACOs affect you and your patients. This is a new and rapidly changing area of health care. At this point, discussion with your patients and perhaps administrators at your local hospital group may be the best way to gather information about these plans.

When we review vision benefits, the ACA law requires each plan to provide a comprehensive examination and materials to children age 18 and under. Each insurance company has its own way of interpreting how this benefit is to be implemented. In some cases, the eye care product will be subcontracted to a vendor like VSP or EyeMed. In other cases, the plan will be managing the vision portion themselves. The websites are a good source for ACA-related product information. Continue watching this OOA Blog for further updates on this topic.

In summary, through all the confusion there is information available. Certainly, much more change will come. The best advice is to know the plans you are on, and contact those plans to ask about how they intend to comply with the children’s benefits.

Ask them if vision benefits will be subcontracted to another company. Ask them if there are new networks and if you are still on them. Decide which of these plans are most suited to your practice and your patients. Finally, be ready for a shift in both patient demand as well patient coverage for optical goods for some plans.

One final question: Is the ACA here to stay? Whether it is or not obviously will play out in the next year or two. We must work hard from all facets of healthcare reform to assure that primary eye care is a core component of every individual’s health care.