Quality medical practice management is equally as significant as quality patient care in establishing healthcare organization Practices that are efficient and effective in providing quality patient care.
Successful medical practice management ensures that All staff members, providers, medical billing staff and clerical support staff, are aware of all medical regulations and laws (e.g., HIPAA, Federal Deficit Reduction Act of 2005, DOH Waived Testing Regulations) that pertain to their job function, are trained to implement and adhere to them properly, and are notified when any updates take place.
A prospective medical record review includes claims/encounters reviewed prior to claim submission.
This type of audit allows for adjustments in coding to be corrected prior to claim submission.
A retrospective medical record review includes claims/encounters that have been submitted to and paid/denied by carriers. Retrospective audits are occasionally focused audits based on specific procedures or billing concerns. They are performed on data from claims that have been submitted for payment to carrier.
Generally, a random sampling of 10-15 encounters/dates of service are selected for review. The sample may be selected by client or RRHS.
A focused audit concentrates on a particular element, type of service, place of service or provider of service to determine the appropriateness of documentation and associated coding/billing.
RRHS provides a detailed report summarizing key audit findings and associated recommendations.
The audit process can typically take 2-3 weeks for completion. The time frame varies based on the size of the audit.
RRHS utilizes a secure File Transfer Protocol (FTP) website which assists in transferring files between two remote locations.
A Patient Centered Medical Home (PCMH) is a model for primary care practices in which the patient is the center of all processes and decisions. This model describes an approach to the delivery of primary care that is patient centered, comprehensive, coordinated, accessible and committed to both quality and safety.
In order to be recognized as a PCMH, the practice will need to align their policies, procedures and processes with the 2014 PCMH Standards and Guidelines from NCQA. Once implementation of the standards and guidelines is complete, the practice will compile documentation demonstrating how each requirement is met. The last phase requires that the practice purchases a survey tool and online application from NCQA in order to upload the documentation to NCQA’s platform for review. The documentation required varies from screen shots of examples to reports run by the practice.
The National Committee for Quality Assurance (NCQA) is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the health care system, helping to elevate the issue of health care quality to the top of the national agenda.
Benefits include improvements in Quality of care, Patient experience and access, enhanced work environment, and reimbursement from key payers, including Medicaid. PCMH recognized practices also see a reduction in cost related to preventable, duplicative and unnecessary care. As a results of medical homes, hospitals are experiencing a reduction in ER visits and Inpatient admissions.
The initial recognition timeline varies based on practice and RRHS level of support. Historically, practices attain recognition within 12 months.
Recognition under the 2014 standards lasts for 3 years, you may renew your recognition before expiration and will only have to submit documentation for a selected number of sections rather than every element.
PCMH recognition is granted in one of three levels. Level three is the highest down to Level one which is the lowest. NCQA uses a point system to determine which level of recognition a practice will receive.
|Recognition Levels||Points||Must Elements (50% or higher)|
|Level 3||85 - 100||6 of 6|
|Level 2||60 - 84||6 of 6|
|Level 1||35 - 59||6 of 6|
|Not Recognitized||0 - 34||< 6|
Yes, PCMH recognition also aligns with Meaningful Use (MU), Delivery System Reform Incentive Payment (DSRIP), Medicare Access & CHIP Reauthorization Act (MACRA), Merit-Based Incentive Payment System (MIPS), Healthcare Effectiveness Data Information Set (HEDIS), Physician Quality Reporting System (PQRS), Physician Quality Reporting Initiative (PQRI).1
Yes, the amount of reimbursement depends on the level you reached.
|NCQA Level 22011/2014 Standards||NCQA Level 32011/2014 Standards|
|MMC - PMPM||$2.00 / $6.00||$4.00 / $8.00|
|FFS Institutional - per visit||$7.75 / $23.25||$12.50 / $25.25|
|FFS Professional - per visit||$6.75 / $20.50||$14.50 / $29.00|
PCMH is not a one-time process, the practice must continue performance improvement initiatives and providing care in a patient-centered fashion.
At RR Health Strategies, we have the tools and knowledge to make the PCMH transformation process as simple as possible. First, we visit your site and complete a baseline assessment to see where your practice sits according to the NCQA PCMH 2014 Standards and Guidelines. From there, we create a work plan to follow during the transformation process. We set up weekly webinars to cover both implementation and documentation for each Standard. We also discuss examples from previous submissions and explain templates that the practice could use.
Research have shown that practices are more successful obtaining PCMH recognition when they use a PCMH Consultant. Working with a consultant will streamline the recognition process and alleviate any guesswork in the PCMH submission process.