Article about Emergency Room Experiences

All of us have been to the ER for either our own ailments or those of our families. I read an article here that details some of the unfortunate experiences of some people who seemed to have received the raw end of the stick. This is the article posted today, May 1st, 2018. It’s worth the read. Think about your own Emergency Room experiences. How do we get better over time? How frequent is this experience?


Are EHR vendors becoming Population Health corporations?

An interesting article surfaced in Healthcare IT News that suggested that executives at some healthcare software vendors want to transform themselves from generically being deemed as an EHR vendor and become a Population Health company like Cerner’s CEO Zane Burke told Healthcare IT News. 

Being able to access data relevant for patient care should be possible regardless of the format it is presently in or whether it is in an EHR,  national database or in pdf format. 
The constraints that “EHRs” are presently may not allow for this functionality  (yet). The article goes on to state that providers are also moving towards precision medicine, accountable care management, chronic care management and value based reimbursement. 
Movement for many on the ground is still in the initial stages and only those provider organizations with deep pockets and the ability to leverage collaborative working relationships with solution vendors can think about moving forward with all of the initiatives mentioned above in a meaningful way. 

Claim Denial! Definitely not a river in Egypt!

Revenue Cycle ManagementHaving worked with Revenue Cycle professionals over the last few years, gives me a finer appreciation of the work that provider organizations have to do to get paid. We’ve all received those bills we thought that the insurance company would have taken care of and wondered why are we receiving this? Why can’t I get through to the company that has sent me this? Did I really get disconnected after holding on this phone for 15 minutes? Frustration can certainly mount. I know it does for my family when trying to figure out next steps. According to an article from Healthcare Finance that I recently read, the top 5 medical claim denials that are the most common are:

1) Duplicate claims – When hospital administration resubmit claims when they have not heard back from the payer and end up restarting the clock for that claim and end up mostly with a denial due to re-submission

2) Lack of information on the claim – When a claim is processed but due to human errors, information such as a date of birth or the spelling of a name is incorrect, the claim gets denied.:

3) Expiration of Eligibility – When both the patient and the provider organization are unaware that the insurance eligibility of a patient has expired with that organization. This is a common mistake that can be avoided if the provider does an eligibility verification before and during when the patient comes in for their appointment.

4) Claim not covered by the payer – Providers can easily avoid this by leveraging the ability to use real time verification capabilities.

5) Time limit expiration –  Basically, the provider did not send the claim in on time as apparently many times, smaller providers don’t focus on smaller claims, but want to make sure larger claims are paid leaving a lot of smaller claim dollars on the table that eventually add up.

All in all, payer organizations also leverage the system to their benefit as any organization would. It is up to the patient to understand their eligibility options and the provider to recoup the money that they are owed. There are many opportunities for revenue cycle improvements that are more often than not, simple to deduce, but more difficult to achieve.


HIMSS16 – One week to go!

Las VegasI know many folks are eagerly looking forward to next week in Vegas and HIMSS16. I’m looking forward to meeting my “Conference Buddies” those folks we see once a year at the Big Show! I’ll be looking forward to the keynotes from  Sylvia Mathews Burwell, Secretary of Health & Human Services & Michael Dell, Founder of Dell, Inc next Monday the 29th at the Palazzo Ballroom at the Venetian Hotel.

I try and encourage a balanced approach; educational sessions in the morning, lunch and then exhibit hall and vendors in the afternoons. This gives me the opportunity to experience a full conference experience along with some of my friends from the CSO HIMSS chapter and other chapters I’m connected with. Areas focused on project management in the areas of interoperability solutions (of course focused on CCD’s) analytics and datawarehousing, tele- health (after my recent visit to Cisco in Bangalore), Clinically Integrated Networks and revenue cycle optimization post ICD-10 are at the top of my agenda of mandatory sessions to attend. The Interoperability Showcase is my favorite area of the exhibit hall area to visit after my HIMSS15 experience. Best part of the entire conference in my humble opinion. Don’t miss it. You’ll be glad you saw it when you did. I’ve been pushing for it to go on the road to each state. I’m rarely a petition type of guy, but I’ll sign a petition for an “Interoperability Road Show” if I have to. It’s basically the essence of this blog entirely so “hell ya!” I’ll sign it.

If you haven’t already, register for the CSO HIMSS Luncheon on Tuesday March 1st. I’ll be there as well as many of our CSO HIMSS Board and our esteemed Chapter President, Scott Mash.

We can’t end without obviously the perfunctory “Viva Las Vegas!”

See you on the flip side folks!

Ajay Sharma - Professional Photo-10-25-14

ICD-10 – How far we’ve come!

It’s still a surprise to me that we are actually here. It’s coming up to the end of July 2015 and we are closer to ICD-10 Go Live than anytime before. I’ve heard of one organization regionally that is still surprised we got here and are scrambling to get their work done. Others have been working on this for a few years and have put in more efforts over the last 7-8 months to prepare for this event. Many physicians can’t believe that we have come this far and are now concerned that they don’t have the tools and training to be ready for ICD-10 go live. What will the world look like on October 1st, 2015?

There are some vendors that are keeping their customers guessing about remediation of the systems and have their remediation requests in a long queue. Have you increased the real estate on those reports and extracts that you publish? Have you tested your main EMR and have you established your plans for command center for the go live? Are your organizational priorities focused on ICD-10 and maybe one other initiative? These are the questions that operationally and in IT, that leaders are dealing with right now. If they are not, then they have to do some soul searching as to how did they get to this status.

Healthcare IT News reported recently that the Centers for Medicare & Medicaid Services announced that it would work with the AMA on steps to ease the move to ICD-10 and that CMS will adopt suggestions made by the AMA with regard to the code set conversion. Those changes cover i) Claim Denials  ii) Quality Reporting and other penalties iii) Payment disruptions and iv) Navigating transition problems where CMS will create a communication or command center as well as a Tsar of ICD-10 to assist and triage provider related issues or concerns and be able to resolve issues caused by the new code sets.

Below are the points directly from Healthcare IT News:

1. Claims denials. “While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family,” CMS officials wrote in a guidance document.

2. Quality reporting and other penalties. “For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes,” CMS explained. “Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes.”

3. Payment disruptions. “If Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to physicians,” AMA president Steven Stack, MD, noted in a viewpoint piece on the group’s website.

4. Navigating transition problems. CMS intends to create a communication center of sorts, including an ICD-10 Ombudsman, “to help receive and triage physician and provider issues.” The center will also “identify and initiate”resolution of issues caused by the new code sets, officials added.

Interview with a CAC PM – ICD-10 Beware!

It’s been some time since I shared my thoughts as we are well into 2015. ICD-10 for many organizations is well under way and I thought that it might be good to hear from folks other than myself once in a while. So I connected with my good friend and colleague whom I worked with last year, Paul Arel.  I had the chance to sit down with Paul and talk about our recently completed engagement working together at a provider organization last year. We discussed his experience with a Computer Assisted Coding (CAC) product that is getting a lot of attention due to the ICD-10 Transition.

Ajay:  Thanks for sharing your thoughts on CAC. You’ve been working in other verticals before you got into healthcare IT recently. Tell me the origin of how you started on your recent CAC project?

Paul: My pleasure Ajay. As you’re aware, I have been in the healthcare IT sector for a number of years. When our provider client started its enterprise-wide implementation of a vendor’s CDIS and CAC products to get ready for ICD-10 implementation, they planned on a 3-year project. With about 3 months planned project schedule left, they were having misgivings about the project’s true status and hired me to come in as the new Project Manager. My first task was to get familiar with the project and its players, then ascertain the project’s true delivery status. In so doing, we ended up adding another year onto the project’s delivery schedule.

Ajay: Who were your primary stakeholders and what was their involvement?

Paul: This implementation grew out of the Revenue Cycle side of the hospital. CDIS (Clinical Documentation Improvement System) is utilized by the case reviewers during the patient’s hospital stay. The software helps reviewers make sure that treatment for ailments/injuries follows a path of documented diagnoses. CAC is utilized by the coders to generate billing codes for all care that is given to each patient during their visit or stay. The two work hand in hand to correlate patient care with diagnoses and billing codes, maximizing the revenue stream for the hospital system and driving compliance with the Affordable Care Act. Because of the over-reaching nature of the software and its implementation being enterprise-wide, the stakeholders were numerous and diverse. I would say that the primary stakeholders were the software end users themselves. End user management and the IT support staff were intimately involved in the planning, testing, implementation and monitoring (problem resolution) at every turn during the project. At any one point in time, there were roughly 60 stakeholders intimately involved in the project’s implementation.

Ajay: What was your main challenge especially with the vendor?

Paul: Our main challenge arose as the organization began to realize the gap in knowledge for implementation of the CAC/CDIS products on the scale that the hospital system needed. The chosen software appeared to not be mature at the project’s inception and the disparate EHR systems that the organization used in different markets created a troubling scenario for implementing this software as a standard throughout the organization. At the time, the CAC vendor appeared to have no prior implementation experience on this large and complex an installation, so much of  the implementation was learn as you go for everyone involved, including our CAC vendor and the various other vendors.

Ajay:  Besides the change in ICD -10 dates by the government, what were the main risks associated with your project go live?

Paul: Risks certainly evolve during a project’s life, but, hands down, the biggest over-riding risk was indeed the interoperability of the  software systems involved. While the HL7 standard has been a giant stride forward in interoperability, there still exists much work to be done as the need for pieces of software to communicate as part of a larger whole are constantly expanding. At some point in time, healthcare will require its software vendors to blend their software into a homogeneous system that should appear to the end users to be a single, common interface on the EHR level. At the same time, it needs to allow Operations and Revenue Cycle to pull relevant data from any of the subsystems effortlessly.

Ajay: What issues did you face? Any consistent ones throughout the project?

Paul: Personnel availability was probably the single biggest issue on numerous fronts. Starting with the CAC/CDIS vendor and including most all of the other vendors involved and even within the hospital system itself, personnel availability was the biggest ongoing obstacle to implementation. Most organizations had their personnel “all hands on deck” with the myriad of work needed to test and become ICD-10 compliant in all aspects, as well as performing their regular duties. Congress postponing the ICD-10 implementation date confused and compounded the problem for everybody. And the additional postponement only makes the situation much more problematic for planning in 2015. It is a nightmare right now for all healthcare organizations trying to plan personnel needs for 2015. Nobody knows exactly which personnel will be needed, how many of them will be required, who will be available and, ultimately, if Congress will pull another bonehead move to delay ICD-10 implementation yet again.

Ajay: Bonehead indeed! Healthcare Provider organizations have spent billions to date and hopefully the ecosystem realizes that. Ultimately it’s you and I and the patient population of the United States that pays for all of that.

Ajay: Did you have any outside training organizations train the coders?

Paul: End user training was conducted by the CAC/CDIS vendor, as part of their contract with the organization for implementing their software. Additional training was conducted by Revenue Cycle staff and additional training is also available as part of the vendor’s ongoing usage contract.

Ajay: How was the implementation of the software left, in the wake of the ICD-10 delay?

Paul: The software is designed, like many of its kind, to be compliant for both ICD-9 and ICD-10 usage. When the project ended, the provider organization was utilizing the software in ICD-9 mode only. Provisions were underway to continue with ICD-10 training and the roll-out of dual coding (ICD-9 and ICD-10 coding simultaneously) to help familiarize end users with ICD-10 coding before the nation transitions.

Through another project, we tested ICD-10 functionality, but, as with most hospital systems, a thorough end-to end, integrated test of ICD-10 is still necessary. Hospital systems not only need to be certain that ICD-10 codes pass through their software systems, but that the reimbursements they receive are truly being maximized under the new ICD-10 system. There needs to be validation on two fronts: 1) that the care each patient receives benefits their well-being in the most efficient manner, and 2) that the patient stay generates the maximum return on the dollar for the hospital system. Combined together, these two aspects will drive the hospital system towards providing the best possible care for all patients today and in the future. Despite the politics behind the Affordable Care Act and how/when it is implemented, I feel that this is the underlying goal of both healthcare providers and the government.

Ajay: Thanks for your time Paul. All the best for 2015 and beyond.

Paul: Thanks Ajay. Same to you.

About Paul Arel:


About Paul:

Paul Arel, PMP, MCSE, is a Senior Information Technology Project Manager with over 10 years of experience in project management, having spent much of his career providing services in the healthcare sector. Paul graduated from Miami University (Oxford, Ohio), started his professional career as a Practice Administrator for Art of Smiles Dentistry for more than ten  years. During his tenure there, he became a certified EHR trainer for Dentrix, and the practice became a test site for the vendor, providing continual feedback for enhancements and software improvements. Paul guided the practice towards the cutting edge of technological innovations in the field, being one of the first practices nationwide to implement digital x-rays, voice-activated charting & integrated intra-oral photography. He then moved into IT full-time, and earned his Microsoft Certified Systems Engineer (MCSE) certification. He continued to refine his path in IT and healthcare, becoming a Project Manager. Though his projects took him into many fields, including construction, IT infrastructure and automotive support, he continues to be passionate for healthcare. As he was assisting ever-larger healthcare organizations with their project management initiatives, he also earned his Project Management Professional (PMP) certification. His experience led to managing projects for Cincinnati Children’s Hospital and numerous physician practices. Most recently, his healthcare IT expertise was brought to bear when he was hired to manage an enterprise-wide installation of 3M’s CAC/CDIS products for Mercy Health (formerly Catholic Health Partners).

Revenue Cycle Management – Discovering the New World…. of Value Based Care

Much like Christopher Columbus during his voyages of discovery in the 15th century, revenue cycle departments are discovering that their world may indeed be round and sense that the new world of value based healthcare services is where they will soon land, if not already there. Both the regulatory environment and the newly engaged patient community are more educated than ever before as to what is available to them as consumers of health. Education coming from their payers as well as organizations such as Healthgrades and with apps on each person’s smart devices, these capabilities are literally at their fingertips.

Much of the provider ecosystem has completed their EHR implementations over the last 4 years and  some of these organizations are looking to update their financials or ERP/RCM applications which have been postponed over the years. Now  that there is more pressure from systems to focus on concepts such as “pay for performance”, the movement to new methodologies of care are being assessed.  Solution vendors are seeing an uptick in their sales cycles to provider systems, leveraging the recent merger between two of the large healthcare vendors last year. I’ve heard the phrase “2 wrongs don’t make a right” mentioned in this context.

The HFMA provides the MAP award for revenue cycle and the process as to how to win that award. On the HFMA site, it states that the “MAP Award for High Performance in Revenue Cycle recognizes hospitals, health systems, and physician practices whose innovative and effective strategies have enabled them to achieve excellence in revenue cycle performance”. How many days outstanding Net AR do they have and if you are in the low 30s (days), its understood that you are doing exceptionally well. Reporting is becoming an all important focus in this regard and expect to see that area of analytics to come more into focus in the coming months and years as payment reform occurs.

The “For Profit” healthcare organizations are acquiring healthcare providers that are currently “not for profit organizations and now have had layoffs in the healthcare ecosystem, that was previously unheard of due to the need for those individuals and their years of domain experience and knowledge.


The driver for the future will be around analytics and data that will help in the decision making to drive patient care and outcomes as well as the effect of physician engagement and it’s relationship with these positive outcomes with the hopes of increasing quality and reducing the cost of care.  The hope is to effectively create a model and hopefully, the foundation for better patient care through process, people and technology.