Practice Top 5

Top 5 Things to Know About Consults via Telephone/Internet/EHR

1. What is a non-face-to-face interprofessional consult (sometimes called an "eConsult")? An eConsult is essentially a documented virtual curbside between providers without the patient present. eConsults can be used to enhance access to neurology or other specialist expertise and to improve quality of in-person referrals seen by specialists.
2. Develop eConsult templates in partnership with your referral base. EConsults usually contain templates to request relevant information from referring providers to help specialists respond to the eConsult question. Templates may include guidance for referring providers and hyperlinks to relevant resources, such as guidelines, and should balance perceived burden by referring providers. One useful starting point is the AAN-developed Pertinent Data Sets for the American College of Physician High Value Care Coordination Toolkit, which addresses the most common neurology referral questions.
3. Responses to an eConsult require a written report back to the referring provider. When eConsult questions are too complex, responding that a formal in-person consultation is required is appropriate. Responses may include suggestions for additional history or diagnostic testing to be completed in order to improve the quality of the subsequent in-person consultation. It may be helpful to establish an expected timeframe in which specialists will respond to eConsults. One study demonstrated that 80% of reviewed eConsults were answered within one day.
4. You can get reimbursed for eConsults. The specialist can use time-based CPT codes 99446-99449 (interprofessional telephone/internet/EHR consultations) or the single interprofessional consultant code 99451. Read this guide for additional information including each code's requirements and case studies. The codes cannot be billed if the patient is seen by the specialist within 14 days of the eConsult, so submission after a 14-day hold is recommended. Since all codes require verbal consent, ensure that the patient’s consent to place the eConsult is documented.
5. Integrate eConsults with your telehealth and referral outreach strategy. As practices and health systems develop access, referral, and telehealth processes, integration of eConsults in the protocols can help address global issues such as obtaining consent for services, provision of standard eConsult templates, and determining billing and compensation strategy. Further, involvement of compliance/regulatory expertise is recommended to ensure that appropriate disclaimers are present given eConsults are documented without evaluating the patient in person.

Top 5 Ways to Improve Provider EHR Utilization

1. Improve efficiency and provider satisfaction. Increase provider use of documentation tools, “out-of-the-box” order sets, favorites features, and dictation to reduce overall time spent documenting. Utilize dashboard features to decrease navigating between screens. Find more resources from the AMA's Steps Forward website.
2. Improve readability. Use tools within your EHR to collapse, hide, or hyperlink information to reduce note length. Contact your EHR vendor to discuss options that integrate into your system.
3. Improve documentation accuracy. Train staff responsible for rooming patients to ensure accuracy when entering and updating patient’s past medical history, medications, allergies, family history, and social history. If possible, interface with local health systems and registries to improve the accuracy of patient’s history outside of your care.
4. Improve coding accuracy. EHR software that seamlessly integrates with medical billing allows multiple systems to function on a comprehensive platform, automating the process of EHR billing, coding, and submitting bills to patients and insurance companies. This significantly reduces the likelihood of coding errors by allowing the generation and submission of cleaner claims with improved first-pass claim rates. In addition, work processes are streamlined with enhanced productivity and there is improved ROI through increased billing, EHR accuracy, and more timely reimbursement. Learn more with AAN coding resources.
5. Improve communication. Utilize tools within your EHR to ensure notes are being sent to the patients’ other physicians. Learn more about sharing notes and avoiding information blocking practices.

Top 5 Things to Consider when Considering New Technology

1. Paint a Picture. Define how the new technology fits into the overall practice strategy. Identify overlapping and key integration points with current core (EHR) and ancillary (Patient Portal, Call Management, etc.) components. Use a simple systems/process mapto articulate the vision for and how key stakeholders will be impacted by the new technology.
2. Identify Specific Business Needs. List business requirements and use caseseven for solutions that are provided as part of existing technology. This will help prepare for implementation, including workflow planning, functionality testing, and user training, and demonstrate a return on investment (ROI) for the technology being considered.
3. Prioritize What is Most Important. Prioritize your requirements, such as EHR integration or best-of-breed functionality, to ensure your selection criteria aligns with those priorities. Defining specific selection criteria will help ensure an objective decision and measurable outcome.
4. Define Success. As an extension of the business requirements, document the desired results and metrics of success. Include potential mitigation strategies and alternative approaches if needed. Build go/no-go decision points in the selection process. 
5. Talk to Others Who Have Been There, Done That. Seek out references from businesses that are similar to your practice/business. Prepare a list of specific questions that pinpoint the priorities of your selection criteria. Be wary if the vendor insists on being on reference calls. Find connections by posting in the AAN’s Business Administration Section or emailing practice@aan.com. 

Things Administrators Need Their Physicians to Know

1. HIPAA Compliance is still a thing and your phone may be putting you and the practice at risk. Texting PHI information has been and will remain a non-HIPAA compliant action. Making verbal phone calls or faxing this information is much more HIPAA compliant and will not leave the practice exposed to liabilities. There are HIPAA compliant texting apps that can be installed on PCs and smartphones that make this process much safer. Here are additional things to know about HIPAA.
2. Proper E/M Coding can help profitability, is important, and yet not always easy for physicians to know all the nuances of the coding guidelines. Ensure that the services provided are correctly documented to support the billable code that reimburses at the appropriate level for that work and to avoid under coding, which can impact profitability. The AAN has templates to help calculate E/M points, identify where billing and codes can be escalated and why, and guide documentation to maximize reimbursement. Additionally, review the AAN's preparedness checklist to ensure maximization of the 2021 Outpatient E/M Changes
3. Harness the power of promotion. Promoting yourself and harnessing the power of patients promoting your work can be a key differentiator for your business. If someone is extremely happy with you or your office's services, ask them to leave a review online. Prospective patients do read these, and while they are not the ultimate factor of why patients choose your practice, good ratings certainly do help. Learn more about boosting your online reviews.
4. Stay in-tune with your MIPS quality measures. It is critical to understand how measure selection and calculation impacts overall MIPS scoring that drives the reimbursement calculation. And timing matters! MIPS quality measures now require 1 year of continuous calculations and getting behind on them can mean the difference between a positive or negative payment adjustment. Physicians should work with their admin and IT teams and give them the support to review numbers and adjust workflows to maximize scoring. Stay up to date on changes to the Quality Payment Program here.
5. Consider adding more auxiliary staff to the practice. If the physician’s day-to-day activities are becoming more administrative or clinical task-oriented, consider adding auxiliary staff such as medical assistants, social workers, pharmacists, APPs, etc. to the team. Adding auxiliary staff can not only improve efficiencies and expand service lines, but it can also improve the quality of life for the physicians. Learn more from the AAN’s Advanced Practice Provider resources.

Top 5: Things to Know about Working with Medicare Administrative Contractors (MAC)

1. Understand the functions of a MAC and how they impact contractor priced codes.

2. Locate your MAC assigned by jurisdiction and understand how to navigate your MAC's coverage site.

3. Find a local coverage determination (LCD) for a specific procedure

4. Review an LCD or National Coverage Determination (NCD) following these steps:

   1. Locate LCD or NCD

   2. If an NCD does not specifically exclude/ limit an indication, or the service is not mentioned in the NCD or Medicare manual, it is up to the MAC to make the coverage decision.

   3. An LCD may be created in the absence of an NCD or further define an NCD. (LCDs will no longer include CPT or ICD-10-CM codes, rather will be placed in billing & coding articles that are linked to the LCD)

5. Access AAN resources on MACs

Top 5: Consulting Appropriate Use Criteria Program Rescinded

In a significant win for AAN advocacy, the Centers for Medicare and Medicaid Services (CMS) is rescinding the Appropriate Use Criteria (AUC) program and all implementing regulations to allow for reevaluation. As outlined in the 2024 Medicare Physician Fee Schedule (PFS) final rule, CMS states that the goals of appropriate, evidence-based, coordinated care can be achieved more effectively, efficiently, and comprehensively through other CMS quality initiatives. Effective January 1, 2024, providers and suppliers should no longer include AUC consultation information on Medicare FFS claims.” Read the AAN’s full summary of the 2024 PFS final rule here.

Top 5: HIPAA

1. Protected patient health information (PHI) should only be texted through a HIPAA compliant, encrypted platform. It is a HIPAA violation to text patient identifiers without the minimum necessary standard or compliance with technical safeguards as outlined in the HIPPA Security Rule.
2. While HIPAA doesn’t explicitly prohibit the use of email to communicate with patients, it does require that safeguards, such as passwords and encryption, are in place to protect patient information.
3. Remember to not discuss patients’ PHI in open areas where others are present. This includes elevators, stairwells, nurses’ stations, and waiting areas.
4. Don’t leave detailed messages on a home answering machine without the patient’s written permission. In the absence of a signed consent form, leave only your name, number, and a request to be called back. Ask patients how they prefer information to be shared.
5. Sharing a patient’s PHI with another health care provider for treatment purposes, for billing, or for administrative purposes like quality improvement is permitted under HIPAA.

Top 5: Key Facts about Interoperability

1. Interoperability is the ability of your electronic health record (EHR) to exchange data with other data systems such as other EHRs or registries, and view the data within your EHR. Interoperability is needed for providers to view all the care delivered to a patient across sites and settings. Interoperability decreases duplicate testing, and provides a longitudinal view of the patient’s care, saving money and time for both providers and patients and potentially increasing safety and quality of care. Manually scanning documents into your EHR that are faxed from another site is not true interoperability!
2. Changes to programs are coming. The Federal Government is revising the purpose of the Meaningful Use program to focus on Promoting Interoperability. More details available from CMS.
3. There are technical barriers to interoperability. Considerable work or configuration may be required at both the transmitting EHR and the receiving EHR. In addition, because the United States does not use a national patient identifier, matching patient records across data systems depends on matching demographic fields (i.e., name, date of birth) that may not always be accurate.
4. The AAN supports the free exchange of data between vendors. Some EHRs charge fees for exchanging data and require additional licenses or modifications to your EHR contract. Please check with your EHR vendor for additional information.
5. Connect your data. While a connection can be built from your site to another specific site, it can also be done between your site and national/state/regional health information exchanges (HIEs) or data frameworks (such as Carequality and CommonWell), enabling access to much more information. A number of third party vendors also offer products and services to enhance EHRs interoperability features.

Top 5: Tips to Improve Patient Access

1. Make your EHR work for you. Refer to your EHR vendor's manual or support services to automate processes such as flagging open slots and cancellations.
2. Consider an advanced access/open-scheduling model to allow for a certain amount of same-day or next-day appointments. Test the model with a single provider as a trial.
3. Match patient demand. Tailor any increase in dedicated visit slots to match a specific demand. For example, increase the number of reserved new-patient appointment slots.
4. Manage no-shows. Consider strategic overbooking for patients with past "no-show" visits, use technology to remind patients of appointments, or reduce lead time by scheduling appointments no more than six months in advance.
5. Ensure continuity of care. Implement scheduling policies that make efforts to maintain provider-patient continuity of care in group practices.

Top 5: Things to Know about Promoting Interoperability (PI)

Promoting Interoperability accounts for 25% of the overall Traditional MIPS score in 2023. This weight may change if you participate in the Quality Payment Program in a different way, such as through MIPS Value Pathways (MVPs) or have a special status. Learn more about ways to participate in the Quality Payment Program.

1. Report using 2015 Cures Update Edition Certified EHR Technology (CEHRT). The Cures Update requires vendors to include interoperability standards, security criteria, and exporting functionality. Look up and report your EHR's CMS Identification Code from the Certified Health IT Product List.
2. Submit your data to meet the e-prescribing, provider-to-patient exchange, and public health and clinical data exchange objectives.  To meet these three objectives, you will submit data for 4 objectives (p. 28). New for 2023, participants are now required to query a prescription drug monitoring program (PDMP) to meet the e-prescribing objective. There are no major changes for 2023 in the data exchange objectives.
3. Choose from three options to fulfill the health information exchange objective. The first option includes sending, receiving, and reconciling electronic referral information. To help in establishing these electronic communications, review these AAN-created pertinent data sets to ensure the high-value communication is exchanged.
4. Submit attestations. Attest that a security risk analysis was performed or reviewed. Annually, conduct and attest that a review has been completed using the SAFER Guides.
5. Review exceptions for the PI category or individual measures. Small practices (15 or fewer clinicians reporting under the same TIN) automatically qualify to have the PI category reweighted to 0% of their MIPS score. Clinicians experiencing extreme and uncontrollable circumstances or facing hardships meeting the requirements due to EHR or internet challenges may apply for an exception. Additionally, individual measure exceptions (p. 28) may apply when the clinician doesn’t meet a minimum threshold, doesn’t treat a specific condition associated with a public registry, or is unable to report health data.

Top 5: Ways to Be Successful in the Cost Category of MIPS

1. Learn more about MIPS Cost measures. Explore the global and condition-specific cost measures including how measures are attributed in this component. 
2. Review your Field Test Report (or mock report, if not available) by logging into your EIDM Portal.
3. Verify coding practices. Make sure you are coding specifically to improve Hierarchical Condition Category/Risk Adjustment Factor.
4. Ensure that your specialty designation is accurate by looking at Physician Compare.
5. Check whether your patients have Primary Care Physicians. Costs attributed to neurologists or PCPs may provide insight into cost scores.

Top 5: Reasons You Should Complete the Neurology Compensation and Productivity Survey

1. Participants receive free data. It's easy to participate, and Business Administrators are eligible to participate on behalf of their practice or department. Participate before the survey closes to receive free access to the entire data set, a $500 value.
2. Benchmark your value. Determine if you are being compensated fairly for your clinical, administrative, and on-call services relative to your peers based on your subspecialty, region, practice type, and more.
3. Review practice benchmarks. Is your wait time longer than your peers? How does your practice revenue compare to others? Is your payer mix diverse enough to support your practice? Find answers to these questions in this valuable data set.
4. Find new revenue streams. Review ancillary service benchmarks to see if you are missing opportunities for your practice.
5. Make the data work for you. The customizable dashboard makes it easy to filter data based on subspecialty, region, practice setting, and more to ensure you get getting the most meaningful data for you and your practice.

Top 5: Critical Monthly EHR Reports for Neurology Administrators

1. Total charges. Review your total charges monthly and be able to explain both positive and negative fluctuations.
2. Collection ratio. Monitor your adjusted collection ratio (collections + adjustments + write-offs) as a percent of charges, which should hover in the 95% range for efficient practices.
3. Accounts receivable. Track how many days in A/R that you carry; efficient practices should keep this number to around 30 days. Also, monitor what percent of your A/R is 90 days or older.
4. Patient volume. Scrutinize your total patient volume in your clinic and ancillary services provided by your practice.
5. Third next available appointment. Track your third available date for the next new-patient visit slot. If it is more than three weeks, you may be losing referrals and your no-show rate will rise accordingly.

Top 5: Strategies to Develop and Maintain Relationships with Payers

1. Create and maintain a template that allows you to collect and organize key contact information for the payers with whom you contract.
2. Develop a template letter to serve as an introduction to the payer before a specific issue arises.
3. Meet annually and in person with each payer. Conference calls with the medical director or other decision-maker are an acceptable way to communicate and nurture an established relationship, but never underestimate the power of an in-person meeting as an opportunity for personal connection to build credibility and develop mutual trust.
4. Communicate effectively by being preparing information ahead of time, speaking in a professional manner, avoiding inflammatory rhetoric, and listening. Review payer-specific policies and get to know the "buzzwords" used by the payer and their meanings to the payer (e.g., some payers automatically deny a claim when certain terminology is used).
5. Work with your state neurological or medical society to understand and address regional payer policies.

Top 5: Ways to Improve and Maintain Your Referral Network

1. Visit key referral practices. Personally visiting key practices that serve as a referral source for you can help establish an identity for your practice. This identity can be sustained and strengthened by setting up a strong referral management program with a dedicated program liaison, if possible. 
2. Communicate. Referring providers want to hear how their patients are doing. Commit to providing a note back to the referring provider within 48 hours of seeing the patient, and promote that commitment during site visits.
3. Deliver an exceptional patient experience. Ensure your practice is running well and that patients receive an exceptional experience at your office and under your care. This can be a key differentiator for your practice.  Develop analytics to identify key performance indicators and track progress.
4. Review your online presence. Know what information referring providers and patients are seeing about you and your practice when they are searching online for qualified neurologists in your area. Develop a webpage for the practice to proactively tell your story and show referring providers and patients what they can expect. Harness the power of promotion by encouraging happy patients to leave reviews.
5. Watch your ratings. Review how payers are rating you in their designation programs (e.g., stars). These programs use quality and cost designations to financially incentivize primary care physicians' referrals to offer lower co-pays to patients who choose to see designated physicians.

Top 5: Ways Small and Solo Practices can Remain Financially Sustainable without Losing Their Identity

1. Find local allies. Look for opportunities in your community or state to join forces with other practices in non-financially dependent entities.
2. Join an independent physician association (IPA)to align with other practices. These often include primary care, though specialty-specific IPAs are developing.
3. Join a management services organization (MSO) for greater support and more alignment. An MSO can help you with managed care contracting, quality reporting, and administrative support.
4. Expand your referral base by joining additional health system physician networks.
5. Consider a concierge practice. If independence is of primary importance and the current revenue system is untenable, then evaluate the concierge practice model.

Top 5: Tops to Ensure Your First Value-Based Contract is a Success

1. Consider your market and outliers. Identify any areas for improvement and start there!
2. Choose a payer with whom you have an established, positive relationship. Involve leaders-including both providers and administration-in the contract negotiations and understand the payer's policies.
3. Review evidence-based resources. See if the neurology-specific quality measures developed by the AAN can be incorporated into the contract.
4. Communicate expectations. Consider what type of feedback reports you will need from the payer and articulate your preferred timeline for receiving the data.
5. Spend to succeed. Invest in technology and other resources that help you to know your data and costs.

Top 5: Ways to Get into the Value Mindset

1. Familiarize yourself with the changing landscape. In contrast to traditional fee-for-service payment systems, recognize that using services creates expense-rather than revenue-in-risk arrangements. The Centers for Medicare & Medicaid Services (CMS) and commercial payers are driving the shift from volume to value. 
2. Accept the need for change. Different incentives and new reporting structures are necessary in order to set providers up for success in improving patient outcomes and reducing health care costs.
3. Make care delivery a team sport. Learn how to integrate advanced practice providers (e.g., NPs, PAs) into your neurology practice and how neurologists can function as part of the Medical Neighborhood.
4. Seek out evidence-based resources. The AAN has guidelines, quality measures, shared decision-making tools that provide evidence-based services to all patients, regardless of payer agreements.
5. Explore new payment and care delivery models. The AAN is building resources on value-based care and how it relates to neurology. 

Top 5: Mistakes to Avoid When Joining an Accountable Care Organization (ACO)

1. Don't skip the fine print. Never sign a contract without reading it or getting your own legal review. Explore AMA's guide for evaluating ACO agreements. Understand physician employment agreements under ACO.
2. Understand the expectations for financial obligations and reimbursements. Review AMA's resources on joining an ACO.
3. Don't underestimate the demand for clinical information exchange. Familiarize yourself with best practices for using technology to support success in an ACO.
4. Don't rely on non-neurologists to serve on the leadership and quality committees. Participate to ensure the specialist perspective is considered.
5. Don't join without considering an exit strategy.

Top 5: Member Resources for Business Administrators

1. Build your network. The Business Administration Section on Synapse enables networking among your counterparts and sharing practical tools in the Resource Library.
2. Benchmark your data. The data from the Neurology Compensation and Productivity Survey and Report is vital for negotiating and comparing practice benchmarks.
3. Reach experts. Email practice@aan.com to quickly access staff and member experts to answer your practice, MIPS, coding, and other practice-related questions.
4. Expand your knowledge. Neurology-focused practice management education from business administrators to business administrators via webinars and conferences.   
5. Get involved. Develop professionally and join leadership of the AAN through committee participation.

Top 5: Things to Consider When Closing a Practice

1. Create a Timeline and Checklist. Outline your plan to create a timeline with which you are comfortable.  Review this AAN-created Checklist for When a Physician Retires or Leaves a Practice or the American Academy of Family Practice's resource to help build your own checklist.
2. Be Aware of State-Specific Regulations. In many cases, state laws and regulations will guide your closing processes. Connect with your state medical society to ensure compliance with local requirements.
3. Assemble your Closing Team. Your closing team will include your legal and financial teams to ensure you are compliant with local laws and processes are in place to manage any issues that may arise after your practice is closed. This team may include your practice and personal attorneys, accountant, and malpractice carrier to purchase tail coverage. It may also include your practice HR Team to help develop a communication and severance plan for employees and manage employee records.
4. Identify Stakeholders and Develop a Communication Plan for Sharing Closure Plans. Remember to connect with various stakeholders including your referral base, hospitals at which you have privileges or are connected to via EHR, insurance providers, your suppliers, etc. so they can update their systems.
5. Inform Patients of your decision to close your practice, how they can access records and refill medications, and how they can find alternate providers. There are many examples of letters such as this one from the American College of Physicians. Be sure to include information about how patients can obtain their records in accordance with local requirements.

Top 5: Things to Know about Restricting Surprise Billing

1. Regulations protecting patients from surprise, or balance billing went into effect January 1, 2022. The rules restrict surprising billing for patients who get care from out-of-network providers at in-network facilities. The act regulates private insurance (fully-insured patients) and does not apply to federal payers or services provided to Medicare/Medicaid patients. Patients may waive surprise billing protections for non-emergency out-of-network care provided that certain key criteria are met.
2. If you provide services in a hospital or ASC, post information to alert patients. The rules require some providers to post information publicly, including on your website, about surprise billing restrictions, state laws, and ways to resolve a dispute. View the specific requirements and a disclosure example here.
3. Providers are also required to provide a good faith estimate (GFE) of the cost of services to patients who are uninsured or self-pay. Provider must publicly post the availability of GFEs for patients. Starting in 2023, providers will be required to also obtain GFEs from co-providers and co-facilities participating in patient care. Requirements relating to providing GFEs to insured patients are pending additional regulations.
4. CMS has created this example GFE for providers to use. The GFE must be provided within one business day if the services are scheduled at least three days in advance, and three business days if the services have been scheduled more than ten days in advance. The patient's bill should be no more than $400 above the GFE. If it is, the patient may qualify to proceed with the dispute resolution process, during which the provider must discontinue all collection attempts. The AMA’s No Surprises Act Toolkit provides additional information.
5. In addition to patient-provider disputes, there is also a process for independent dispute resolution (IDR) regarding provider-payer disputes. This process requires patients be commercially insured and does not apply for patients that are uninsured or covered under government health programs. The AMA has created a toolkit providers can use to navigate the IDR process.

Top 5: Things to Know About 2023 E/M Documentation Guideline Updates

1. Familiarize yourself with all CPT^® Evaluation and Management (E/M) Code and Guidelines Changes effective January 1, 2023. Changes impact inpatient and other facility-based E/M services and align with changes made to the outpatient code set in 2021.
2. Understand changes to the Medical Decision-Making (MDM) Table, including the addition of criterion for low complexity in the “Number and Complexity of Problems Addressed” column of the table and revised examples of high risk in the “Risk of Complications and/or Morbidity” column of the table.
3. Determine if medical decision-making (MDM) or time is more appropriate for the majority of your workflow by comparing the level of service achieved based on MDM vs. total time. Update your coding templates and documentation patterns (e.g., is a review of systems still part of your documentation?) accordingly to fully benefit from the administrative simplification of the new code language.
4. Review your coverage policies and/or institutional mandates to clarify your payer’s policy of prolonged services. If the total time of an encounter exceeds the time allowed for 99205 and 99215: an additional prolonged service code can be reported to capture that time. CMS has implemented G-codes G2212 and G0316, respectively, for prolonged services, as the agency did not agree with the time threshold to report 99417 (prolonged outpatient services) or 99418 (prolonged inpatient services).
5. Familiarize yourself with the billing provider’s activities that count towards the total time for E/M services performed on the date of the encounter, both face-to-face, and non-face-to-face:
   1. preparing to see the patient
   2. obtaining and/or reviewing the separately obtained history
   3. performing a medically appropriate examination
   4. counseling and educating the patient/caregiver
   5. ordering medications, tests, or procedures
   6. documenting clinical information in the EHR
   7. care coordination