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Strategies for success with value-based reimbursement
by Michael Merrill, M.D., Medical Director, Clinical Performance Management

Success Strategy #5 – Work at the top of your license. Delegate data collection (review of systems, standard questions on diabetes management, etc.) to staff, to the patient via questionnaires or the portal. Delegate gap closure and patient education.

As a physician, be jealous of every 30 seconds of your time. 
It may not seem like much at first, but thirty seconds per patient plus 25 patients each day equals 50 hours per year. The time adds up. Do you need 50 hours for anything? 
So, how can you remove 30 seconds of unnecessary physician work with every patient?


One way to look at this is "practicing at the top of your license."  This means, as a doctor, you should delegate care appropriately to nursing, medical assistant or other staff.  Doing so allows them to practice at the top of their license, too.  This leads to better, more efficient care and greater satisfaction among staff throughout your practice.


Let's look at what is perhaps the core work of a physician - the history and physical. It's the first thing we learn to do as a medical student and we go through the steps automatically.  Re-examining those steps might feel inappropriate but could save a few minutes with each patient.

What to do. 

The chief complaint may be recorded by whoever rooms the patient. But what about the HPI? For follow-ups of chronic disease patients, there are several questions I know, as a physician, that need to be asked. For example, with diabetes: 

1.    What have your morning sugars been running? 
2.    Are you getting any hypoglycemia? 
3.    Any problems with your feet? 
4.    Any loss of feeling? 
5.    Are you taking your medications regularly?

Then I want to look at the last few A1Cs and the most recent LDL.  I also want to know that a retinal exam is being done. I don't need to gather all this information myself, even if I have to ask one or two questions of this individual patient.  A medical assistant or other staff member can collect the preliminary information to save time with each diabetic patient.  The same process can be used for other chronic diseases. Now before you enter the room, part of the data collection is already done. 
What about a new complaint?  If the patient is complaining of dizziness, for example, there are at least a few questions that need to be asked. If I write these questions down and share them with the staff, they will be available for them to use every time a patient arrives with dizziness. Why not let the medical assistant get these questions started? 

1.    Do you mean a spinning sensation, or is it more like you stood up too fast? 
2.    Have you passed out? 
3.    Have you had a cold or an ear infection? 
4.    Etc. 
Some providers ask their own review of systems questions.  Perhaps this isn't necessary.  The answers could be collected through a patient a checklist completed when they first arrive.  More questions can always be asked when you enter the room.

Let's look at one more daily task: reviewing a patient’s ophthalmology consult.  From a physician point-of-view, I want to know if there are any new diagnoses.  If the patient is a diabetic, I want the retinal exam recorded in the appropriate place in the EMR.  Again, I don't personally need to do any of this.  A nurse can let me know of any new diagnoses. 

For the U.S. healthcare system to work well, we need primary care. For primary care to work, we need to debulk the work that primary care doctors and advance practice providers do. There is no other reasonable way forward. It starts with looking at 30-second intervals and delegating aggressively.
Additional references

1)    Here's a great comment from a blog posted on Sinsky Healthcare Innovations, promoting patient and physician well-being through practice redesign: 

In no other industry is the highest trained professional spending most of her time on work that others could perform. …  For example: prescriptions. A physician can make the decision with the patient to add a blood pressure medication. Communicating that decision to an assistant, such as an RN, takes only a few seconds. Putting that order into the computer and sending to the pharmacy make take one minute. Multiplied over thousands of prescriptions/renewals per year and that is a lot of waste. 

More here.
2)    Here's another great blog entry on the topic posted on 

The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.” Often, you’ll hear people advocate that every health care worker should “practice at the top of their license.” What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively.

More here.

This is one of ten strategies your practice can adopt to succeed in a value-based reimbursement model outlined in our Checklist for Success.  Throughout 2018, we will continue to share steps your practice can take to achieve these strategie
Independent Health now accepts electronic claims adjustments
Independent Health is pleased to announce we now accept electronic claim adjustments with a frequency code of 7 or 8 for both professional and institutional claims.  This capability will ease practices’ administrative work with Independent Health. 
If your practice would like to submit claims and adjustments electronically, please contact our eCommerce call center at 716-635-3911.
Please review the following guidelines and steps in order to maximize the usefulness of the claims submission process:
Timeframe of Filing Electronic Claims Adjustments
  • Submit all electronic claim adjustments within applicable timely filing guidelines to prevent unnecessary denials.
  • The provider inquiry process is still available for provider use but using the electronic claim adjustment functionality within the timely filing period will increase adjustment processing time and accuracy.
  • Claims adjustments after the timely filing period (but still within the defined reconsideration period), must follow the provider inquiry process.  
Submission of Electronic Claims
Providers must submit all electronic claim adjustments with the applicable 14-digit Independent Health Claim number in the appropriate REF segment. (Contact your software vendor or our E-commerce department if you have questions on how to submit these.) 
Claims with frequency code of 7 or 8 without a valid claim number will be sent back to the submitting provider on the 277CA.  Failure to include the correct claim number could delay or inhibit the completion of the adjustment.
Frequency Code 7 Claims
A frequency code of 7 represents a complete replacement of the original claim. The following claims scenarios are eligible for electronic claims submission using a frequency code of 7.
The electronic claim adjustment should be submitted in its entirety:
  • Additional services added to claim or removal of originally submitted lines
  • Changes to the number of units
  • Changes to the date of service(s) on the claim (if the DOS remains within the appropriate timely filing guidelines)
  • Addition or removal of a modifier
  • Changes to coding claims (i.e. diagnosis codes, value codes, occurrence codes)
  • Addition of primary payor EOB information (requests for secondary payment)
  • Requests to reprocess claims previously denied for no authorization after an approved authorization has been added to the system
  • Reprocessing of claims after a member’s PCP has been successfully updated
  • Addition of valid NDC codes on claims previously denied for invalid NDC
Frequency Code 8 Claims:
A Frequency Code of 8 indicates the claim is a voided/canceled claim.
The following scenarios can be submitted electronically using a frequency code of 8:
  • Requests to retract claims or deny claims “Services Never Rendered”
  • Member Changes:  please submit a void and submit a new claim with the appropriate member ID.
  • Rendering Provider/ Billing Provider / Taxonomy Changes:  please submit a void and submit a new claim with the appropriate provider information.
  • Requests to change the level of care on a claim (Institutional Claims changing from inpatient to outpatient, submit a void and submit a new claim with the appropriate level of care)
  • Changes to the claim form type (i.e. CMS1500 to UB04)
  • Requests to combine multiple claims previously processed: please submit a void for one claim and a replacement for the other claim with all services represented.
The following scenarios should continue to be submitted via Provider Inquiry Form (accompanied by a complete corrected claim):
  • All adjustment requests submitted after timely filing guidelines (but within reconsideration.)
  • Payment errors or requests to review reimbursement (unless otherwise directed by a member of the IH provider relations team.)
  • Inquiries related to member liability on claims
  • Claims with office notes or invoices attached
Please note, we will not accept electronic claim adjustments on claims that you previously submitted with invalid or missing information (i.e. claims denied for invalid member information (CARC 31) or invalid diagnosis codes (CARC 146.) 
An attempt to send an electronic claims adjustment will result in an error returned on your 277CA.  In the event a previous claim submission was denied for invalid information, you will need to submit a new claim (frequency 1). 
Provider Servicing at or (716) 631-3282, Mon. to Fri., 8 a.m. to 6 p.m.
How can a Health Home help your patients?

The New York State Health Home program is available for your Medicaid patients at no cost to help ensure they receive the health care and other services they may need.

To be eligible for Health Home services, the individual must be enrolled in Medicaid and must have:
  • Two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes*) OR
  • One single qualifying chronic condition: HIV/AIDS or
  • Serious Mental Illness (SMI) (Adults) or
  • Serious Emotional Disturbance (SED) or Complex Trauma (Children)
Once a patient is enrolled in Health Home, they are assigned a care manager who will create a care plan to determine services they need and help to schedule appointments, including for mental health, substance abuse, social services, housing and other community programs.

Additional information you may share with your patients is available in this brochure or by calling the New York State Department of Health’s Health Home program at (518) 473-5569.  A list of Health Homes by county across New York State and  overview of the Health Home benefit is available online here
Formulary update about Viagra®

Effective June 11, 2018, the generic equivalent of Viagra, called sildenafil citrate, will be added to Tier 1 of Independent Health’s Drug Formulary, as well as to the formulary of our subsidiary, Pharmacy Benefit Dimensions. 

The more expensive brand-name version of Viagra will no longer be covered by Independent Health or Pharmacy Benefit Dimensions as of June 11, 2018. 

Sildenafil citrate is identical to brand-name Viagra in terms of active ingredients, dosage, safety and effectiveness. It will also be a lower cost-option than its brand-name counterpart. 

Since sildenafil citrate will appear on Tier 1 of our formulary, your patients’ copayments will remain the same as it is today. 

New prescription needed for your patients

We will notify all Independent Health and Pharmacy Benefit Dimensions members currently prescribed Viagra about this change within the next week. This notification will inform them that they will need to obtain a new prescription for sildenafil citrate to ensure their pharmacy dispenses the generic equivalent of Viagra when filling their prescription on or after June 11 and not the non-covered brand name version. 

Please note: Do not include Dispense as Written (DAW) when writing the new prescription for you patients.

If you have questions, please call our Provider Relations Department at (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.
New York State Department of Health Medicaid Update

2018-2019 Enacted Budget Initiative: Patient Centered Medical Home Statewide Incentive Payment Program -  revised incentive payments and updated billing guidance

Effective May 1, 2018, in accordance with the 2018-2019 Enacted State Budget, New York State (NYS) Medicaid is changing the reimbursement amounts for providers working at practices that are recognized as a Patient Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA). The revised policy applies to both Medicaid Managed Care (MMC) and Medicaid Fee-For-Service (FFS). This policy replaces the policy outlined in the January 2018 issue of the Medicaid Update.

The full current issue of The NYS Department of Health special edition of the April 2018 Medicaid Update focusing on 2018-19 Enacted Budget Initiatives, which includes the Patient Centered Medical Home Statewide Incentive Payment Program: Revised Incentive Payments and Updated Billing Guidance, is accessible here
CMS Summary: Billing and anti-discrimination rules applicable to dual eligible enrollees
CMS has identified an issue which causes concern regarding discrimination and billing practices for QMB (fully dual) Medicare and Medicaid eligible members. CMS has increased communication and focus by setting clear expectations for plans to reeducate and communicate to providers the importance to adhere to these regulations based on the vulnerability of these members. 
Based on CMS guidance, Independent Health is notifying participating physicians and providers about billing rules applicable to dual eligible beneficiaries as required under 42 C.F.R. §422.504(g)(1)(iii). Federal law prohibits Medicare providers from collecting Medicare Part A and Medicare Part B deductibles, coinsurance, or copayments from those enrolled in the Qualified Medicare Beneficiaries (QMB) program, a dual eligible program which exempts individuals from Medicare cost-sharing liability.
Balance billing prohibitions may also apply to other dual eligible beneficiaries in MA plans if the State Medicaid Program holds these individuals harmless for Part A and Part B cost sharing.  Note that the prohibition on collecting Medicare cost-sharing is limited to services covered under Parts A and B.  Low Income Subsidy copayments still apply for Part D benefits.
Also, it is important to note that health providers may not refuse to serve enrollees because they receive assistance with Medicare cost-sharing from a State Medicaid program.  
Statement regarding incentives

Independent Health is required on an annual basis to affirm the following:

While Independent Health rewards physicians for providing high levels of quality care to patients, it does not use incentives to encourage barriers to care and service. Independent Health is prohibited from and does not make decisions regarding hiring, promoting or terminating its practitioners or other individuals based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits. Independent Health encourages appropriate utilization and discourages underutilization.

As always, if you have any questions, please contact Independent Health Provider Servicing at (preferred method) or call (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.
June 2018 policy updates

View our June 2018 Policies and Clinical Practice Guidelines Updates on the Independent Health website to find out which policies are new, revised, discontinued or reviewed (You will need to log in as a provider to access.  Then click on the "Policies & Guidelines" button).

Make sure to check our policy pages frequently as they are constantly being updated with the most current versions.
Run. Walk. Bike. Eat. And more!

Bringing you healthy and fun events all summer long

Independent Health and the Independent Health Foundation are proud to participate in and support a number of community events throughout the year – from area races and family fun programs to healthy cooking classes and more! Our calendar of events makes it easy to see what’s coming up next.

View our calendar of events for the summer to learn more about what's happening, and be sure to check back often as programs and events are added daily and dates, times and locations are subject to change.
Contact Independent Health's Provider Services Department
(716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.
Copyright © 2019 Independent Health, All rights reserved.

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