The Primary Care Provider's Guide to Compensation and Quality: How to Get Paid and Not Get Sued

by Buppert, Carolyn, Crnp, Jd

• ISBN13: 9780834217447
• ISBN10: 0834217449
• Edition: Disk
• Format: Paperback
• Copyright: 2000-04-01
• Publisher: JONES & BARTLETT PUB

Summary

St. John's College, Annapolis, MD. Provides advice on growing patient enrollment in managed care health plans, performance evaluations by outside agencies, and dramatic increase in billing audits. CD-ROM includes customizable forms. Wire-spiral binding. System requirements: Windows 3.x, 95/98. DNLM: Quality Assurance, Health Care--methods.

Table of Contents

Preface	ix
Measuring Performance in Primary Care	1	(18)
Perspectives on Quality	1	(2)
Watchdogs Step in Where Professional Societies Held Back	3	(1)
Federal Government Efforts	3	(1)
The Court System as Enforcer	4	(1)
An Era of Attention to Consumer Needs	4	(1)
Who Will Measure and Report Quality?	4	(1)
How Are Health Plans Performing on Quality Evaluations?	5	(1)
The Measures	6	(7)
Future Measures	13	(2)
HEDIS Measures	15	(1)
Emerging Awareness	16	(3)
Systems for Meeting Benchmarks for Screening and Health Maintenance	19	(40)
Avoiding Poor Report Cards	19	(1)
The Problems with PPIP	20	(2)
Making Compliance a Sure Thing	22	(37)
Personal Health Guide from Put Prevention Into Practice	24	(9)
Child Health Guide from Put Prevention Into Practice	33	(10)
Personal Prevention Record	43	(1)
Adult Preventive Care Flowsheet	44	(1)
Child Preventive Care Flowsheet	45	(1)
Child Immunization Flowsheet	46	(2)
Performance Standards for PCPs	48	(1)
Health Care Maintenance Tracking Form-Adults	49	(1)
Diabetic Patient Follow-up Flowsheet	50	(1)
Asthmatic Patient Follow-up Flowsheet	51	(1)
Hospital Discharge Follow-up Flowsheet	52	(1)
Prenatal Care Tracking Form	53	(1)
Postcard for Adults from Put Prevention Into Practice	54	(1)
Postcard for Parents from Put Prevention Into Practice	55	(1)
Sources of Materials That Clinicians Can Use To Increase Preventive Services	56	(1)
Selected Codes Sought in HEDIS Audits	57	(1)
Questions PCP Staff Should Ask Patients at Each Visit	58	(1)
Measuring Outcomes in Primary Care	59	(6)
Advantages of Practice-Level Outcome Studies	60	(1)
Outcome Measures Distinguished from Performance Measures	61	(1)
Barriers to Measuring Outcomes	61	(1)
Arguments for Moving Past the Barriers	61	(1)
Public Reporting of Outcome Data	62	(1)
Principles of Outcomes Measurement	62	(1)
Process	63	(2)
Systems for Measuring Outcomes at the Practice Level	65	(10)
Steps for Measuring Practice-Level Outcomes	65	(5)
Balancing Time and Options	70	(5)
Example: Outcomes Measurement Process for Patients with Hypertension	71	(4)
Systems for Tracking Functional Status	75	(10)
The SF-12 Health Survey	79	(2)
Functional Status Tracking Form	81	(2)
Short Form for Tracking Seniors' Functional Status	83	(2)
Systems for Measuring and Tracking Patient Satisfaction	85	(36)
Tools	85	(1)
CAHPS Content	86	(1)
What Patients Want	86	(1)
Systems for Ensuring High Levels of Patient Satisfaction	87	(34)
CAHPS Adult Core Questionnaire	89	(9)
CAHPS Adult Supplemental Questions	98	(14)
CAHPS Sample Telephone Script	112	(9)
Malpractice: The Ultimate Failure in Quality	121	(12)
Incidence of Malpractice Lawsuits	122	(1)
Most Common Mistakes	122	(1)
Elements of Malpractice	123	(1)
Malpractice Scenarios	123	(2)
Summary of Legal Pitfalls in Primary Care	125	(1)
Deficiencies in Charting	126	(1)
The Process of a Lawsuit	126	(1)
Baseless Lawsuits	127	(1)
Patient Actions Short of a Successful Lawsuit	128	(1)
Conclusion	128	(5)
Four Cases against Primary Care Providers	129	(4)
Systems for Avoiding Malpractice	133	(22)
Systems To Avoid Diagnostic Errors	133	(2)
Systems for Tracking Follow-up	135	(1)
Systems for Optimizing Defense Efforts If a Lawsuit Is Filed	136	(1)
Avoiding Elements of Malpractice	137	(1)
Systems for Dealing with Mistakes, Angry Patients	138	(1)
Adopt the Principles of Risk Management from Hospital Practice	139	(1)
Special Advice for PCPs Who Perform Diagnostic Tests	140	(1)
Avoiding Malpractice Liability	140	(15)
Documentation: Dos and Don'ts	142	(2)
Problem List	144	(1)
Tracking Form for Abnormal Findings	145	(1)
Forms for Tracking Follow-up of Diagnostic Tests	146	(3)
Form for Tracking Referrals	149	(1)
Referral Form	150	(1)
Refill Tracking Form	151	(1)
Documentation of Telephone Advice to Patients	152	(1)
Self-audit of Medical Records	153	(2)
Reimbursement for Primary Care	155	(10)
Medicare	155	(1)
Medicaid	156	(1)
Indemnity Insurers	157	(1)
Managed Care Organizations	157	(2)
Billing	159	(1)
Direct Contracts for Health Services	160	(1)
Self-paying Patients	160	(1)
Conclusion	160	(5)
Glossary	162	(3)
What Is Fraud and Abuse in Billing?	165	(14)
Definitions	165	(1)
Billing Medicare	166	(2)
Health Care Fraud	168	(1)
Focus on Documentation	169	(1)
Good Faith Errors	169	(1)
More Examples of Charges	170	(1)
The Possibility of Getting Caught	171	(1)
Audits	171	(3)
Appeals	174	(1)
Defenses	175	(1)
Possible Administrative Actions	176	(1)
Risky Billing Practices	176	(1)
The Stark Laws	176	(1)
Rumor Control	177	(2)
Systems for Complying with Requirements of Medicare and Other Payers	179	(138)
Why Do Medical Practices Need New Systems?	179	(1)
How To Avoid Investigation	179	(2)
Compliance Programs	181	(4)
Legal Reviews of Contracts and Operating Procedures	185	(1)
Know the Rules	185	(3)
Choose a Code: HCFA Guidelines	188	(4)
How To Write a Medical Record Note That Passes Audit: HCFA Guidelines	192	(8)
Frequently Asked Questions about Billing	200	(1)
Common Billing Errors	201	(1)
Additional Dos and Don'ts when Choosing Codes	202	(1)
Tools for Helping Clinicians Bill Correctly	203	(1)
New Providers: The Medicare Provider Application	203	(1)
Avoiding Fraudulent Billing of Commercial Insurance	204	(1)
Special Billing Rules for Nurse Practitioners and Physician Assistants	204	(113)
Documentation Guidelines for Evaluation and Management Services: Health Care Financing Administration, 1997	211	(36)
Documentation Guidelines for Evaluation and Management Services: Health Care Financing Administration, 1995	247	(10)
Documentation Guidelines for Evaluation and Management Services: American Medical Association, 1999	257	(40)
History Taking: HCFA and AMA Documentation Guidelines Compared	297	(4)
Examination: HCFA and AMA Documentation Guidelines Compared	301	(2)
Medical Decision Making: HCFA and AMA Documentation Guidelines Compared	303	(3)
Criteria for Documenting Evaluation and Management Codes for Established Patients, Office Visits	306	(4)
Documentation of a Face-to-Face Counseling Visit	310	(3)
Documentation Guidelines from HCFA	313	(4)
How To Contract with Managed Care Organizations	317	(14)
Capitated Contracts	317	(1)
Some Basics about Capitation	318	(1)
Steps for Negotiating a Managed Care Contract	319	(1)
Gather Information	319	(2)
Do an Analysis of Risk	321	(2)
Prepare Lists of Included and Excluded Services	323	(1)
Evaluate the Company's Fee Schedule	323	(1)
Evaluate the Company's Non-monetary Contract Provisions	324	(1)
Prepare a List of Must-haves, Would-likes, and Do-not-needs	324	(1)
Negotiate the Contract	324	(1)
Important Contract Language	325	(2)
Issues To Guide Contract Review	327	(2)
Fulfilling the Contract	329	(2)
How To Maximize Reimbursement	331	(8)
See More Patients	332	(1)
Maximize Billings	332	(1)
Ensure That Payers Pay	333	(1)
Negotiate Better Fee Agreements	333	(3)
Physician Assistants and Nurse Practitioners	336	(1)
Give Employees Incentives To Bill Wisely	336	(3)
Appendix A---Checklist Documentation Forms	339	(66)
Cardiovascular Evaluation/Plan	340	(4)
Diabetic Evaluation/Plan	344	(4)
Gastrointestinal Evaluation/Plan	348	(4)
Gynecologic Evaluation/Plan	352	(4)
Multi-System Evaluation/Plan	356	(5)
Multi-System Evaluation/Plan---Adolescent	361	(6)
Multi-System Evaluation/Plan---School-age Child	367	(6)
Multi-System Evaluation/Plan---Infant	373	(5)
Musculoskeletal Evaluation/Plan---Adult	378	(5)
Musculoskeletal Evaluation/Plan---Adolescent	383	(5)
Musculoskeletal Evaluation/Plan---School-age Child	388	(4)
Psychiatric Evaluation/Plan	392	(3)
Upper Respiratory Complaint	395	(2)
Upper Respiratory Complaint---Child	397	(2)
General Evaluation/Plan	399	(6)
Index	405