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Editor watches staggering changes in medical office management

By Susan Crawford

Founding Editor

Dear Readers:

Medical Office Manager’s first issue came out in November 1987. And now after 26 years as your editor, I have retired.

This is a good time to look at the issues and conundrums you as manager have faced during all that time and to congratulate you on a job well done.

The changes have been staggering. You have kept up with them all.

It began 30 years ago with DRGs

The gargantuan health care system you deal with today was essentially born 30 years ago when Medicare realized it had to cut back on what it was paying out. And because commercial payers always follow Medicare’s lead, the resulting changes have been universal.

It started with hospitals. In 1983 Medicare stopped paying for each individual service a hospital provided for a patient and paid instead a single amount for the patient’s diagnosis related group, or DRG, which was determined mostly by the diagnosis that necessitated the admission.

At that point, the ICD-9-CM codes moved into the limelight, because it was the codes that determined the DRG and the DRG that determined the payment.

From the hospitals to the offices

At the beginning of the 1990s, Medicare took a similar focus on medical offices, and doctors’ pay became based on relative value units, or RVUs, which were values assigned to individual services. Doctors’ payments then became determined by the CPT codes and the ICD-9-CM codes supporting them.

Until that point, most offices had paid little attention to coding. In fact, many were using code books several years old just to avoid the expense of buying new books each year.

But within a short while, it was the codes that determined an office’s success, particularly the new evaluation and management codes, which covered the different types of patient encounters and thus became the basis for most of an office’s revenue.

On to HIPAA, PQRI, EHRs, ACOs, and ICD-10

From there, the regulatory complexity of office management blossomed.

One of the most significant and far-reaching elements was the Health Insurance Portability and Accountability Act, or HIPAA.

Its basis was general patient privacy, but as technology has expanded, so has HIPAA grown until now a manager has to know everything from how to set up privacy guards to what the business associate agreement has to cover to when data breaches have to be reported on down to whether a divorced parent can see a child’s record.

And nothing is laid out in easy format. Some parts of HIPAA, such as the recent requirement to update the Notice of Privacy Practices, have come with so little fanfare that any office could easily overlook them. Other provisions, such as the risk analysis requirement, have come to light only because of new HIPAA enforcement by the Office for Civil Rights

It’s never ending.

Past HIPAA, you have dealt with the Physician Quality Reporting Initiative, or PQRI, which allows Medicare (and commercial payers) to pay more for quality and less for individual services.

You have set up electronic prescribing systems.

You are moving to a system of total electronic health records.

You are dealing with the new Accountable Care Organizations, or ACOs.

And you are completing the changeover to ICD-10-CM, by itself a major undertaking yet particularly significant because if it’s not done right, there will be no money from any payer.

Plus legal issues along the way

Along with all that have been the employment law issues you have to follow, especially important because employees have become increasingly litigious.

The number of employment law elements you handle will surprise you.

There are the minutia of overtime – when comp time has to be taken, how to handle unauthorized overtime, the overtime requirements for employee travel, and which employees are exempt.

There are the Equal Employment Opportunity Commission rules on discrimination: race, disability, equal compensation, genetic information, harassment, national origin, pregnancy, race, religion, retaliation, sexual discrimination, and sexual harassment. Today there’s even discrimination protection for cross dressing, piercings, and tattoos.

There is the Americans with Disabilities Act, which in addition to its standards for office design has set out rules that raise constant questions for offices – when is an accommodation required? what is and isn’t considered a disability? how do mental illness, alcoholism, and drug use fit into the law? when are drug tests and personality profiles not allowed?

And for managers of larger offices, the Family and Medical Leave Act has created not only the question of when to grant leave but when it can include unused paid time off and what supporting documentation an employee has to provide.

On to health care reform

Now the health care reform law is taking center stage. And while managers have already passed many of its hurdles, the questions are ongoing: how much the payers within the exchanges will pay and how to determine the participation the office can afford and how to bill the exchanges.

But still at the top: managing the people

And then there is staff management.

Despite the intense difficulty of handling the money, the regulations, and the laws, MOM’s readers have always cited staff management as their most difficult duty.

“So-and-So just said this about me and I don’t like it” sounds like the most trivial of all trivia. Yet it is the ability to settle those small human issues that determine a manager’s success. And managers are always developing new ideas to deal with them – so many that we have carried at least one in every issue.

It’s time to take a bow

All that is what you, the manager, have accomplished. You should be proud. And I am proud to have served as your editor through it all.









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