1 / 48

Informed Decision Making

Informed Decision Making. Options impacting your practice and your patients. Carmel L. Gold, LCSW BCD cgold@healthassets.com 845-334-3680 www.healthassets.com. Informed Decision Making. “Too often we enjoy the comfort of opinion without the discomfort of thought.”  John. F. Kennedy

bmckibben
Download Presentation

Informed Decision Making

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Informed Decision Making Options impacting your practice and your patients Carmel L. Gold, LCSW BCD cgold@healthassets.com 845-334-3680 www.healthassets.com

  2. Informed Decision Making “Too often we enjoy the comfort of opinion without the discomfort of thought.”  John. F. Kennedy “Everyone is entitled to their own opinion, but not to their own facts.”  Daniel Patrick Moynihan Health Assets Management, Inc. www.healthassets.com 845-334-3680

  3. Workshop Goals At the end of this workshop, participants should be able to: • Utilize informed decision making with issues impacting Social Work practice • Understand the impact of “in-network” and “out of network” status • Identify NYS Office of Professions’ role in Social Work practice’s “R” privilege • Recognize HIPAA influence on documentation Health Assets Management, Inc. www.healthassets.com 845-334-3680

  4. Informed Decision Making Informed decision making involves: • identifying issues, • gathering information • and weighing options. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  5. Informed Decision Making Steps • Identify the issue or problem Health Assets Management, Inc. www.healthassets.com 845-334-3680

  6. Informed Decision Making Steps • Identify the issue or problem • List the facts that have the most bearing on the decision Health Assets Management, Inc. www.healthassets.com 845-334-3680

  7. Informed Decision Making Steps • Identify the issue or problem • List the facts that have the most bearing on the decision • Identify who/what might be affected by your decision and how Health Assets Management, Inc. www.healthassets.com 845-334-3680

  8. Informed Decision Making Steps • Identify the issue or problem • List the facts that have the most bearing on the decision • Identify who/what might be affected by your decision and how • List 3 Alternative Actions and identify the best and worst case scenario for each alternative Health Assets Management, Inc. www.healthassets.com 845-334-3680

  9. List 3 Alternative Actions and identify the best and worst case scenario for each alternative • What would be difficult about this choice? • What would be compromised by making this choice? • What are the benefits of this choice? Health Assets Management, Inc. www.healthassets.com 845-334-3680

  10. Informed Decision Making Sheet Health Assets Management, Inc. www.healthassets.com 845-334-3680

  11. Historically Out-Of-Network Was Lucrative • Public resistance to the “closed” network of the HMO’s gave rise to OON – out-of-network benefits • OON benefits were created to satisfy the enrollee • OON benefits were, at one time, a virtual “right” • 80% of Usual &Customary rate was the common benefit level Health Assets Management, Inc. www.healthassets.com 845-334-3680

  12. Out-Of-Network • There is no obligation for practitioners to participate with a health plan • Those that do not are considered “out-of-network” • In the absence of a contract between a physician and a health plans the financial relationship is one ofself-payfor the patient. • This means……. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  13. What Was Happening • Out of Network (OON) costs grew dramatically, increasing premium costs to employers • Wide spread abuse of OON coverage by non-par practitioners. • WIP – whatever insurance pays • Waiving of Copays, coinsurance and deductibles Health Assets Management, Inc. www.healthassets.com 845-334-3680

  14. THE GREAT RECESSION & HEALTH EXCHANGES • Employers have become increasingly resistant to premium increases and increasingly willing to cut premium increases by cutting OON benefits • No New Yorker, outside of Western New York, has the option to purchase a policy on the individual Exchange market that includes out of network benefits.  Health Assets Management, Inc. www.healthassets.com 845-334-3680

  15. WIP Dangers • Danger in waiving co-pays • If you waive the co-pay is it an “inducement” to obtain services? • Danger in waiving the coinsurance • If you waive the coinsurance • File a false claim • Danger in “accepting only what the insurance pays” – in addition to filing a false claim. • What if the patient has a deductible? • You could end up with $0 Health Assets Management, Inc. www.healthassets.com 845-334-3680

  16. OON Payments to Patient • Health plans make payments to the patient, not the clinician • Non-par clinicians get to chase the patient • But the patient signed an assignment of benefits form? • Every health plan enrollee contract contains the following provision:. “Any assignment of benefits made by you (the enrollee) can be rendered void by us (the health plan)” Health Assets Management, Inc. www.healthassets.com 845-334-3680

  17. Direct payment as a non-par • Getting paid directly may mean that the payer sees you as par. Problematic if you are in the process or trying to terminate from a payer • You should be getting paid out-of-network directly by the patient. • If you cash the check it may be “acceptance is considered payment in full” No balance bill. • In case of a problem, you took the payer’s money; they are coming after you • Don’t send it to the patient – return it, let the patient get paid by the plan. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  18. NYS Surprise Bill On March 31, 2015, the so called “Surprise Bill Law” is scheduled to go into effect. Practitioners must disclose the plans in which they participate – “most insurances accepted” is not adequate, without clearly indicating out of network status. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  19. NASW Code of Ethics Political and Social Action • Social workers should act to: • Expand choice and opportunity for all people, with special regard for vulnerable, disadvantaged, oppressed, and exploited people and groups. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  20. Can I serve Medicaid beneficiaries? • NY LCSWs cannot be paid directly by Medicaid except in specific circumstances. • QMB modifier indicates the Medicaid beneficiary is entitled to have Social Worker services paid by Medicaid. • NY LCSWs can have Medicaid identification numbers • Many NY health plans with Managed Medicaid products require practitioners to have Medicaid identification numbers. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  21. Can I bill a Medicaid beneficiary? • A provider may charge a Medicaid beneficiary, including a Medicaid or FHPlus beneficiary enrolled in a managed care plan, only when both parties have agreed prior to the rendering of the service that the beneficiary is being seen as a private pay patient. • This agreement must be mutual and voluntary. It is suggested that providers keep the beneficiary’s signed consent to be seen as a private pay patient on file. http://www.health.ny.gov/health_care/medicaid/program/update/2014/feb14_mu.pdf Health Assets Management, Inc. www.healthassets.com 845-334-3680

  22. How do I opt out of Insurances? • You are not automatically on any insurance panel. If you have not enrolled, you are not in-network • If you are eligible to provide services to Medicare beneficiaries, you must opt-out of Medicare if you don’t want to be in network. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  23. Opting out of Medicare If you see any Medicare beneficiaries, you must do one of two things: • be enrolled as a Medicare provider or • opt out of Medicare through your Medicare Administrative Contractor (NGS in NYS) and privately contract with any Medicare patients. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  24. Opting out of Medicare The primary difference between enrolled Medicare providers and those who furnish services through private contracts lies in how fees are collected. • Medicare providers receive payment directly from Medicare, • while those who opt out and privately contract collect payment directly from the patient.  Health Assets Management, Inc. www.healthassets.com 845-334-3680

  25. Opting out of Medicare • To enter into private contracts with Medicare beneficiaries, the health care professional must file an affidavit with the MAC for their state in which they agree to not file any Medicare claims for a period of two years and to meet certain other criteria. This affidavit must be refiled every two years in order for the health care professional to retain their opt-out status.  Health Assets Management, Inc. www.healthassets.com 845-334-3680

  26. Terminating Commercial Contracts • Send resignation request, in writing, to the provider relations department. • The request can take 60 days or more to become “in effect” • You may not be able to re-enroll in the health plan for a designated number of years. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  27. Is Cash Only a viable choice? • 51% of American are not prepared to pay for out-of-pocket expenses beyond insurance coverage (Aflac study 6-11) • 33% have less than $500 in savings for medical emergencies and unexpected medical costs • High Deductible accounts may make choosing OON vs. In-Network providers less important to consumers. • Understand your community’s demographics Health Assets Management, Inc. www.healthassets.com 845-334-3680

  28. Pros/Cons, Weigh the Evidence • Review the Facts • What might happen if you choose each option? • What are the disadvantages, costs, and consequences? • What are the advantages and benefits? • How much do you care about the things that might be gained or lost by each possible alternative? Health Assets Management, Inc. www.healthassets.com 845-334-3680

  29. Choose the one that seems best! • Prioritize your options • Identify plan B in case the one you choose doesn’t work out for you. • Take Action! • Do what is necessary to create the solution you choose for your practice. • Review your decision and consequences. If your choice was not best for you, revisit the steps you took and make a new decision. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  30. Exercise in Decision Making • Identify the Issue • Gather the Facts • Identify 3 Alternatives • Review the Facts • Weigh the Options • Make a Decision • What is the Action Plan? Health Assets Management, Inc. www.healthassets.com 845-334-3680

  31. Identified Issues • Out of Network vs. In-Network, what is right for my practice • “R” designation – is it important to my practice? • What documentation is necessary to maintain? Must I comply with HIPAA? • What should I name my practice? Health Assets Management, Inc. www.healthassets.com 845-334-3680

  32. Facts about the “R” designation An LCSW who fulfills the requirements of the insurance law for supervised experience providing psychotherapy, is recognized in New York State as a reimbursable psychotherapist. The "R" privilege requires insurance carriers to provide reimbursement for psychotherapy services whenever a health insurance contract includes reimbursement of qualified psychologists and psychiatrists. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  33. Facts about the “R” designation This privilege requires the LCSW license and three years of supervised experience in psychotherapy obtained after receiving the LCSW. A separate application and fee are required for this privilege. • A total of 36 months and 2,400 hours of direct client contact after you are licensed as an LCSW is required. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  34. Facts about the “R” designation • Insurance panels may reject your application if you do not have an “R” designation. • Some companies will deny you access to certain policies if you do not have an “R” • You can still enroll with Medicare without an “R” Health Assets Management, Inc. www.healthassets.com 845-334-3680

  35. Facts about Documentation • You can keep separate psychotherapy notes – not reviewed in an audit. • If it isn’t documented, you have no proof that it happened! • HIPAA has changed public awareness of protected information – but Mental Hygiene Law has been with us long before HIPAA Health Assets Management, Inc. www.healthassets.com 845-334-3680

  36. Patient Consents • Consent for Psychotherapy Treatment • Consent to Release Information • Client Agreement – to be responsible for the payment of your fees, including Medicare language “If I am covered by Medicare I request that payment of authorized benefits be made on my behalf to my Therapist for services furnished to me by the Therapist. I authorize any holder of medical information about me to release to National Government Services and/or other health plans any information needed to determine these benefits or the benefits payable for related services.” Health Assets Management, Inc. www.healthassets.com 845-334-3680

  37. Clinical Forms • Initial Evaluation • Clinical Summary Forms – notes from subsequent sessions • Treatment Plans • Treatment plan updates/changes • Discharge Summary Health Assets Management, Inc. www.healthassets.com 845-334-3680

  38. Paper or EHR? • EHR is easy to access – able to write notes at home or in the office, no need for files. • Paper is comfortable – no technology involved • Paper can be scanned into EHR with patient signatures. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  39. Transmitting information • HIPAA Set a federal floor for protecting individually identifiable health information across all mediums (electronic, paper, & oral) • Storing patient information must be HIPAA compliant. • Locked file cabinets • Password protected files on computers • Sending patient information via electronic devices must be HIPAA compliant Health Assets Management, Inc. www.healthassets.com 845-334-3680

  40. HIPAA/HITECH compliance • All practices must have up-to-date Business Associates Agreements (BAA) with anyone who handles their patient protected health information • Includes Date of Birth, Social Security Number • Includes Health Insurance Information • Includes Diagnoses, Services provided Health Assets Management, Inc. www.healthassets.com 845-334-3680

  41. No Skype Sessions • Skype is not HIPAA compliant • Claims must indicate where the service was delivered – your office, patient’s home, other location • Do not indicate you had an office session, if it was actually via phone or internet • Your credentialing documentation must be accurate – all locations where you see patients must be listed. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  42. HIPAA/HITECH Compliance • Most email is not HIPAA compliant • Use a billing service that subscribes to encrypted HIPAA compliant systems to protect yourself and your patients. • Healthplans that allow you to submit claims online must be HIPAA compliant. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  43. What’s in a Name? • Your name, NPI, and Social Security Number can be associated with your claims – no need for a practice name • Practitioners who want to keep their Social Security Numbers out of their claims can get an EIN (Employer Identification Number)– which can be a variation on your name, or another name. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  44. A Rose by any other name… • Inconsistent names can remove you from the Medicare panel • Inconsistent names can deny payment – if you change you practice name, you must inform payers • Any other name under which you practice must have an NPI (type 2) Health Assets Management, Inc. www.healthassets.com 845-334-3680

  45. Can I Choose Any Name? • Some terms are regulated in NY, for example: • Center • Clinic • If you choose to incorporate in NYS, you must form a professional corporation. • Check with NYS Office of the Profession before deciding on a name. They are the authority on professional practice names. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  46. My Accountant Set Up an Inc. • You will need to change it to a professional corporation – PC or PLLC • Ask your legal or accounting advisor about which one is best for you. • Get the facts! • Check with NYS Office of Professions • A corporate name like Jane Smith LCSW PC, or Happy Children Counseling LCSW PC might be accepted. Health Assets Management, Inc. www.healthassets.com 845-334-3680

  47. Informed Decision Making “A public opinion poll is no substitute for thought.”   Warren Buffet “The majority have no other reason for their opinions other than that they are in fashion.”  Samuel Johnson Health Assets Management, Inc. www.healthassets.com 845-334-3680

  48. Questions? Health Assets Management, Inc. www.healthassets.com 845-334-3680

More Related