As the physician readers of this blog and many of the non-physician readers are aware, a new wave of government-mandated regulations is about to wash over medical practices. Protocols for communication of medical information and claims data are now being revised. This page is a simplified explanation of how PDA understands the acronyms.
The Accredited Standards Committee Version 4010/4010A
Simple Explanation: Sets the protocol for electronic transmission of claims as used today.
New version for claims protocols scheduled to take effect 1/1/2012
Extensive software updates are required for claims filing.
Principal modification: allows 7-digit diagnosis code.
NCPDP Version D.0 and 3.0
National Council for Prescription Drug Programs
This acronym is frequently discussed along with Version 5010, but applies to pharmacists.
Being Replaced: International Classification of Diseases, 9th Revision, Clinical Modification
Adopted 8/17/2000 to describe a diagnosis for purposes of a medical claim
Involves a 5-digit code, i.e. 123.45, to describe a specific diagnosis
Scheduled to replace ICD-9 on 10/1/2013
Principle change:A 7-digit code will give more specificity in describing a diagnosis.
To be used for both inpatient and outpatient situations
Procedure Coding System
To replace ICD-9-CM volume 3
Affects Medicare Part A claims (Form UB-92 for hospital claims)
These changes will affect all physicians, hospitals, health care plans, and billing offices. Unfortunately, physicians and their office managers must be prepared to devote a significantly larger portion of their day to poring over code books. This is a profound example of the regulations and processes being piled on top of American small business.
Medicare Learning Network
CMS ICD-10 Website
The persistent economic slump enveloping the United States and Europe is a growing universal anxiety. Business leaders are facing falling revenues, increased regulations and uncertain unionization rules. They are, like PDA, working hard to keep bottom lines from descending into red ink. That impacts jobs, hiring and benefits. Most employers have been able to offer traditional health insurance in the past. Now, they are slashing all costs including insurance programs in an effort to hold down costs.
A new term is emerging that applies to PDA and its constituents. The term is “narrow network”. These networks offer fewer choices of medical providers, are often focused on self-insured direct contracts for service, and are based on a foundation of focused community care. With the onset of the 2008 recession, the trend toward “narrow network” has been gaining momentum. They incentivize patients to shift from their regular physician to a “network physician and community hospital”. This model also may be accompanied by creative benefit plans. This process has reportedly saved as much as 25% on healthcare premiums. Three of the largest national providers of health insurance coverage have begun offering these “narrow network” programs. WellPoint, Inc., Aetna Inc. and United Health Group, Inc. are all offering this niche product in an effort to capture new customers. And, the Flagship Physician Network in collaboration with PDA is also offering such a product under the Flagship banner in three major markets!
The Flagship Physician Network is focused on providing care to the Dallas/Fort Worth geographical area (17 counties). Specifically, the initial roll-out of the Flagship product will encompass approximately two million individuals. This is a concentric network concentrating on great patient care and competitive pricing. The PDA practitioners will be at the core of this offering. PDA will care for community patients and internally refer them within the physician organization. Another group of physicians and facilities will be available for tertiary referral of patients who require specialized care not available at the client facilities or because the patient is significantly geographically distant.
Motivated Flagship physicians will provide the high quality care with affordable charges. That always happens when the practitioners find out they can control the benefit plan costs and patient service. Good things are coming from these community based networks. You will soon be called on by a Flagship representative or a PDA physician to catch the vision in more detail.
August 26, 2011
Physician Direct Access (PDA) is pleased to welcome Timothy J. Paquette to the position of Chief of Finance and Administration. Tim has an impressive physician service background. Mr. Paquette has both professional accounting and finance skills which are complimented by operating experience. He was a founder and Chief Financial Officer of the JVE, Inc. As the precursor to Genesis Physician Group, the Joint Venture was a nationally recognized physician-hospital organization (PHO). JVE began with an idea to represent managed care and direct self funded ERISA contracting for quality providers. It grew to 1,000 physicians and multiple Presbyterian Healthcare facilities.
This experience led to his decade of performance as Chief Operating Officer of the Jefferson Physicians Group, a premier PCP network. Among many duty sites, Tim has assisted physicians at UT Southwestern, Children’s Medical Center of Dallas, and the Carrell Memorial Clinic. His experience includes insurance companies and managed care distribution. He also has experience in audit compliance, data analysis, and finance.
Wayne A. Bertsch CPA, CFO of the Miers Group, LLC states, “His experience with operating systems, data bases, and financial applications will be a major asset for PDA as the IPA grows within the era of healthcare reform.”
Tim holds a B.A. and M.A. plus the Executive Healthcare Finance Certificate from the Ohio State University executive program. Importantly, he is a licensed insurance agent with the State of Texas. He is also a certified medical coder.
Tim’s decision to join the PDA team has been received with great anticipation. Many of PDA’s physician membership know him and his long service to independent physicians. PDA leadership as represented by Dwight A. Lee M.D., Chief Medical Officer and Chairman of PDA joins with Daniel S. Karin M.D., PDA Medical Director, to speak with one voice and express a warm welcome for Mr. Paquette.
Primary care physicians will relate to Tim’s major contributions to the Jefferson primary care interests and the JVE physicians. “We are building a venture that is uniquely competent and experienced in physician advocacy,” added Mark A. Heaver D.O., a Primary Care Practice Leader. “We look forward to Mr. Paquette’s coming on board ASAP.”
As PDA prepares for the kickoff of its Flagship Community Health Program, we have a timely opportunity for a reminder about referral patterns.
PDA is about adding value. A basic way to make that happen is patient referrals within our group. We have great practitioners in every specialty and most geographic areas of service. It is in our interest, as we seek the best managed care contracts, to be a band of colleagues that support each other. Action does speak so much louder than words. Healthcare is a local enterprise. By focusing on community-oriented referrals, PDA physicians can multiply their impact on their patients’ welfare.
Emphasizing PDA patient referrals to PDA physicians, we can significantly increase the income of our members. As you prepare to make referrals, feel free to contact the PDA office for the names, locations and contact information of member physicians in the desired specialty. PDA continues to build on its core IPA functions as we grow and expand.