The Primary Care Provider's Guide to Compensation and Quality: How to Get Paid and Not Get Sued (Book with CD-ROM)

by Buppert, Carolyn

• ISBN13: 9780763729585
• ISBN10: 0763729582
• Edition: 1st
• Format: Spiral Bound
• Copyright: 2005-02-01
• Publisher: Jones & Bartlett

Summary

This book has been updated to provide practical advice for primary care providers (PCPs) about major trends that have emerged over the past five years, such as growing patient enrollment in managed care health plans, performance evaluation of PCPs by outside agencies, and the dramatic increase in billing being audited. This book links quality and reimbursement issues, using a systems approach that clinicians may incorporate into their practice. The included CD-ROM contains customizable forms, with checklist progress note forms for the 20 most common primary care diagnoses and checklists of 20 primary care tasks for HEDIS measurements.

Table of Contents

About the Author	vii
Preface	ix
Measuring Performance in Primary Care	1	(20)
Measures	1	(7)
The NCQA's Hedis Measures	8	(1)
How Are Health Plans Performing on Quality Evaluations?	9	(4)
The Measures	13	(3)
Reporting Schedule	16	(1)
Hedis Measures	17	(2)
NCQA's Plan to Measure Performance at the Physician Level	19	(1)
Pay for Performance	19	(1)
Emerging Awareness	19	(2)
Systems for Meeting Benchmarks for Screening and Health Maintenance	21	(102)
Avoiding Poor Report Cards	21	(1)
The Problems with PPIP	22	(2)
Making Compliance a Sure Thing	24	(99)
The Pocket Guide to Good Health for Adults	26	(27)
Prevention Charts	53	(3)
Child Health Guide	56	(15)
Immunization Record	71	(5)
The Pocket Guide to Staying Healthy at 50+	76	(25)
Prevention Charts	101	(3)
Adult Preventive Care Flow Sheet	104	(2)
Child and Adolescent Preventive Care Flow Sheet	106	(4)
Adult Health Risk Profile	110	(3)
Child and Adolescent Health Risk Profile	113	(2)
Performance Standards for PCPs	115	(1)
Diabetic Patient Follow-up Flow Sheet	116	(1)
Asthmatic Patient Follow-up Flow Sheet	117	(1)
Hospital Discharge Follow-up Flow Sheet	118	(1)
Prenatal Care Tracking Form	119	(1)
Postcard for Adult from Put Prevention into Practice	120	(1)
Postcard for Parents from Put Prevention into Practice	121	(1)
Questions PCP Staff Should Ask Patients at Each Visit	122	(1)
Measuring Outcomes in Primary Care	123	(6)
Advantages of Practice-Level Outcome Studies	124	(1)
Outcome Measures Distinguished from Performance Measures	125	(1)
Barriers to Measuring Outcomes	125	(1)
Arguments for Moving Past the Barriers	125	(1)
Public Reporting of Outcome Data	126	(1)
Principles of Outcomes Measurement	126	(1)
Process	127	(2)
Systems for Measuring Outcomes at the Practice Level	129	(10)
Steps for Measuring Practice-Level Outcomes	129	(5)
Balancing Time and Options	134	(5)
Example: Outcomes Measurement Process for Patients with Hypertension	135	(4)
Systems for Tracking Functional Status	139	(10)
The SF-12 Health Survey	143	(2)
Functional Status Tracking Form	145	(2)
Short Form for Tracking Seniors' Functional Status	147	(2)
Systems for Measuring and Tracking Patient Satisfaction	149	(62)
Tools	149	(1)
CAHPS Content	149	(1)
What Patients Want	150	(1)
Systems for Ensuring High Levels of Patient Satisfaction	151	(60)
CAHPS Adult Core Questionnaire	153	(9)
CAHPS Adult Supplemental Questions	162	(14)
CAHPS 2.0 Child Core Questionnaire	176	(10)
CAHPS 2.0 Child Supplemental Questions	186	(15)
CAHPS Sample Telephone Script	201	(10)
Malpractice: The Ultimate Failure in Quality	211	(12)
Most Common Mistakes	212	(1)
Elements of Malpractice	212	(1)
Malpractice Scenarios	213	(2)
Summary of Legal Pitfalls in Primary Care	215	(1)
Deficiencies in Charting	216	(1)
The Process of a Lawsuit	216	(1)
Baseless Lawsuits	217	(1)
Patient Actions Short of a Successful Lawsuit	217	(1)
Conclusion	218	(5)
Four Cases against Primary Care Providers	219	(4)
Systems for Avoiding Malpractice	223	(22)
Systems to Avoid Diagnostic Errors	223	(2)
Systems for Tracking Follow-up	225	(1)
Systems for Optimizing Defense Efforts if a Lawsuit is Filed	226	(1)
Avoiding Elements of Malpractice	227	(1)
Systems for Dealing with Mistakes and Angry Patients	228	(1)
Adapt the Principles of Risk Management from Hospital Practice	229	(1)
Avoiding Malpractice Liability	230	(15)
Documentation: Dos and Don'ts	232	(2)
Problem List	234	(1)
Tracking Form for Abnormal Findings	235	(1)
Forms for Tracking Follow-up of Diagnostic Tests	236	(3)
Form for Tracking Referrals	239	(1)
Referral Form	240	(1)
Refill Tracking Form	241	(1)
Documentation of Telephone Advice to Patients	242	(1)
Self-Audit of Medical Records	243	(2)
Reimbursement for Primary Care	245	(10)
Medicare	245	(2)
Medicaid	247	(1)
Indemnity Insurers	247	(1)
Managed Care Organizations	247	(2)
Billing	249	(1)
Direct Contracts for Health Services	250	(1)
Self-Paying Patients	250	(1)
Conclusion	250	(1)
Suggested Readings	251	(4)
Glossary	252	(3)
What Is Fraud and Abuse in Billing?	255	(14)
Definitions	255	(1)
Billing Medicare	255	(3)
Health Care Fraud	258	(1)
Focus on Documentation	259	(1)
Good Faith Errors	259	(1)
More Examples of Charges	260	(1)
The Possibility of Getting Caught	260	(1)
Audits	261	(3)
Appeals	264	(1)
Defenses	265	(1)
Possible Administrative Actions	265	(1)
Risky Billing Practices	266	(1)
The Stark Laws	266	(1)
Rumor Control	267	(2)
Systems for Complying with Requirements of Medicare and Other Payers	269	(88)
Why Do Medical Practices Need New Systems?	269	(1)
How to Avoid Investigation	269	(2)
Compliance Programs	271	(4)
Legal Reviews of Contracts and Operating Procedures	275	(1)
Know the Rules	275	(3)
Choose a Code: CMS Guidelines	278	(6)
How to Write a Medical Record Note That Passes Audit: CMS Guidelines	284	(2)
Frequently Asked Questions About Billing	286	(1)
Common Billing Errors	287	(1)
Additional Dos and Don'ts When Choosing Codes	288	(2)
Tools for Helping Clinicians Bill Correctly	290	(1)
New Providers: The Medicare Provider Application	290	(1)
Avoiding Fraudulent Billing of Commercial Insurance	291	(1)
Special Billing Rules for Nurse Practitioners and Physician Assistants	291	(66)
Documentation Guidelines for Evaluation and Management Services: Center for Medicaid & Medicare Services, 1997	298	(36)
Documentation Guidelines for Evaluation and Management Services: Center for Medicare & Medicaid Services, 1995	334	(11)
Side-By-Side Comparison E/M Documentation Guidelines	345	(1)
Criteria for Documenting Evaluation and Management Codes for Established Patients, Office Visits	346	(4)
Documentation of a Face-to-Face Counseling Visit	350	(3)
Documentation Guidelines from CMS	353	(4)
How to Contract with Managed Care Organizations	357	(14)
Capitated Contracts	358	(1)
Some Basics About Capitation	358	(1)
Steps for Negotiating a Managed Care Contract	359	(1)
Gather Information	359	(2)
Do An Analysis of Risk	361	(2)
Prepare Lists of Included and Excluded Services	363	(1)
Evaluate the Company's Fee Schedule	364	(1)
Evaluate the Company's Nonmonetary Contract Provisions	364	(1)
Prepare a List of Must-Haves, Would-Likes, and Do-Not-Needs	364	(1)
Negotiate the Contract	364	(1)
Important Contract Language	365	(2)
Issues to Guide Contract Review	367	(2)
Fulfilling the Contract	369	(2)
How to Maximize Reimbursement	371	(6)
See More Patients	372	(1)
Maximize Billings	372	(1)
Ensure that Payers Pay	373	(1)
Negotiate Better Fee Agreements	373	(3)
Physician Assistants and Nurse Practitioners	376	(1)
Encourage Employees to Learn Coding	376	(1)
Appendix A---Checklist Documentation Forms	377	(66)
Cardiovascular Evaluation/Plan	378	(4)
Diabetic Evaluation/Plan	382	(4)
Gastrointestinal Evaluation/Plan	386	(4)
Gynecologic Evaluation/Plan	390	(4)
Multi-System Evaluation/Plan	394	(5)
Multi-System Evaluation/Plan---Adolescent	399	(6)
Multi-System Evaluation/Plan---School-Age Child	405	(6)
Multi-System Evaluation/Plan---Infant	411	(5)
Musculoskeletal Evaluation/Plan---Adult	416	(5)
Musculoskeletal Evaluation/Plan---Adolescent	421	(5)
Musculoskeletal Evaluation/Plan---School-Age Child	426	(4)
Psychiatric Evaluation/Plan	430	(3)
Upper Respiratory Complaint	433	(2)
Upper Respiratory Complaint---Child	435	(2)
General Evaluation Plan	437	(6)
Index	443