A look at the presidential candidates' health care proposals

Sunday, June 8, 2008
By Linda Redeffer
TBY | SOUTHEAST MISSOURIAN

As candidates campaign for the nation's highest office, they make promises about reforming health care. Actually delivering on those promises can be another matter entirely.

A visit to the Cape Girardeau Senior Center revealed that most retired people there that day had Medicare and a supplement and were, for the most part, satisfied with them. Some have found they unexpectedly had to dip into their savings to pay for health care costs.

Brenda Hargrave, part-time administrative assistant at the center, has looked at the health care proposals from candidates John McCain, Barack Obama and Hillary Clinton. She said that while she has not yet decided whom she will vote for, she believes Obama has the best proposal.

But any real kind of health care reform will not come from anyone running for office, Hargrave said.

"While [Obama] addresses concerns, there are things going on that if they would enforce what they already have in place, the government would be out a lot less money now," she said.

Hargrave said she has 30 years' experience in medical billing, collecting and management. She has seen first hand where reform needs to take place, she said.

Health care reform, she said, should start with the "usual and customary rates," or UCR, established by Medicare and Medicaid. Medicare/Medicaid providers say they will pay 80 percent of an insured person's medical costs, but in fact pay an amount based on what they consider "usual and customary," often less than what a doctor or hospital charges. Physicians and hospitals write off the difference and recoup it from patients with private insurance or uninsured patients who are expected to pay full price for procedures, often in advance of being treated, Hargrave said.

"If doctors participate in Medicare they're not allowed to charge more than a certain amount. Some doctors refuse to take any new Medicare patients because they know they can't get any more money," she said. "They leave room on their schedule for other patients with private health insurance because they know they will get more money."

"Everybody needs the same UCR, whether private, Medicare, Medicaid or whatever. No insurance should be charged more than the UCR; UCR should be established across the board."

Better oversight on Medicare/Medicaid billing could save hundreds of thousands of dollars, Hargrave contends.

"I have personal knowledge of one Medicare patient who had a problem with Medicare," she said. "I kept billing, trying to get them to pay. When they did pay, they paid 20 times for the same office procedure. The money went in that patient's account as a credit. I was told not to return credits until somebody found them."

When she made one company aware of double billing for a one-time procedure, she said "nothing was done about it. That's why insurance costs are out of line."

Hargrave said more people should monitor their doctors' office billing procedures and codes and compare what is being charged with the work actually delivered.

"If we could get that done, then health insurance will be within reason and the government will have a lot more money," she said.

Hargrave said she would like to see part-time employees have access to the same insurance as full-time employees. For a semiretired person not yet on Medicare, the cost of health insurance leaves little money for other living expenses. Yet some companies, she said, will hire several part-time people to avoid the cost of providing insurance for a full-time employee.

Monitoring costs and codes would be frustrating and time-consuming for most people. Karen Riley of Cape Girardeau said she and her husband, Dean, are both on Medicare and have a supplemental policy. Both Medicare and the supplement pay for mammograms.

"I called Southeast Missouri Hospital to see if it is in the network," she said. "They said yes. But the doctor who read it was out of network. Since Jan. 15, both insurance companies are arguing over who is going to pay the bill. It has still not been paid."

Riley said she and her husband pay high premiums for their supplemental insurance, partly because she has a pre-existing condition. They dipped into their savings to pay for medical costs and insurance premiums after her husband, who worked at Southeast Missouri State University in the facilities management department, required knee surgery and retired early as a result. While he was working, the university covered the cost of his health care premiums. Until both qualified for Medicare, their monthly costs after he retired meant "we were paying money we could have spent on something else," she said. "It's got to stop somewhere. We can't keep on paying and paying and paying. You can save for retirement, but when you're saving you don't anticipate your medical costs going up and up and up."

Nor did she anticipate that just changing doctors would result in the second doctor asking for lab tests that had already been done not long before that, "so they can get more money."

Riley said she believes Clinton has the best health care proposal.

"She is saying lower premiums and give better quality insurance," Riley said.

Harry Floyd, a retired business owner, said he was considering dropping his supplemental policy because he could pay out of pocket for health expenses for less than his $145-a-month premium. His table companions urged him to keep it, saying they envied him that low premium and warning him that his medical expenses could go up drastically with one illness. Floyd is one of the few not adversely affected by health care costs. He said he supports Clinton because "she has the background. Her husband was president, so she knows a little bit about the ins and outs.

"I figure most wives know what their husbands do and she has a little insight."

Hargrave said that at whatever level health care reform comes, it has less to do with whomever is elected than with the person at the bureaucratic level chosen to implement and manage it. She said she told that to U.S. Rep. Kenny Hulshof when he campaigned at the senior center in his bid for governor.

"I told [him] if anybody is going to reform the health system, it needs to be somebody who knows what he is doing and knows what the program is all about, not somebody who donated money to a campaign," she said.

This article was printed in the June edition of TBY (The Best Years), a special publication of the Southeast Missourian.

Which health insurance system do you favor?

Jun 03, 2008, By William McKenzie
Opinion Blog | The Dallas Morning News

There are essentially three ways to knock down the number of uninsured Americans:

1. The government can be responsible for insuring Americans between ages 25-65. Think a system like Medicare for all Americans.

2. Businesses should be responsible for covering all their workers.

3. Individuals should be responsible for their own insurance.

Which option do you favor? Why?

Reluctantly and slowly, I've come around to the last option. Here's why:

1. Employer-based insurance has been the model we've used for the last several decades, but it's hard to argue that the employer model is sustainable for the next few decades. It's revealing that the percentage of Americans covered by their employers has actually been declining, not increasing. With health costs so great, and businesses strapped to meet them and other expenses, it's hard for me to see how that trend will reverse itself.

If it could, I probably would favor continuing using it as the model. But I just don't see it. And I sure don't see how Congress can effectively argue that all businesses should be required to cover their employees or pay into a pool. Not with the conditions many businesses operate in today. (I do think big employers will continue to cover workers,or pay part of their insurance, as a way to attract them.)

2. So, I go to option three. There are several advantages to making the individual responsible for getting their own insurance.

For example, no longer would your insurance be tied to your job. Fewer workers would get locked in a job they hate solely to keep their health benefits. There would be much more freedom.

Second, individuals could find packages that most fit their needs. That could benefit families.

Third, any individual-based system will come with a combo of federal subsidies/credits/deductions for working families to afford their premiums.

As part of this new system, either insurers should have to cover people with preexisting conditions or those people should have the means to get insurance somehow, somewhere. Also, there must be ample opportunities for states, associations, etc. to set up pools for people to join and purchase coverage.

The advantage of this approach is that individuals could still purchase health care through their employers, if their employers are among the firms that keep offering insurance. I tend to think we will evolve into some hybrid, where individuals buy their insurance but some companies still offer it.

Undoubtedly, the individual-based system will have its own problems. In another decade or so, we would be tweaking those. But I think this is is the wave of the future, more so than employer-based insurance.

3. I didn't argue for government insurance because the costs of insuring the 25-64 population through a Medicare-like system would be astronomical for taxpayers.

That said, I sure want to keep Medicare for seniors and Medicaid and CHIP for poor families, especially for young mothers.

Why Does Your Practice Employ You? - For Physician Assistants

By Abby Jacobson, MS, PA-C

Why does your practice employ you? Can you answer this question? Employing PAs has many benefits, but of course, patient access to care always should be the primary objective when a practice or a hospital decides to start utilizing PAs. Improved physician quality of life is another reason. Nevertheless, the financial benefits of employing PAs cannot be overlooked. Besides offering high-quality patient care, you are a financial asset to the practice.

But how much of an asset are you? The easiest way answer this is to know how much money you bring into the practice. Here are tips to remember when determining how much of a financial benefit you are to your employer.

Ask for Your Data

You need to know how much you bill each month and how much is collected from those charges each month. I strongly recommend your physician assistant employment contract state that you will receive monthly (or at least quarterly) reports of your billings and collections. Ask for this data now. Don't wait until it's time for contract negotiations.

Be careful to not appear greedy or selfish when asking for this information. If you say you want the data to see how much you are making for the practice, implying that you will use the data during your next contract negotiation, you are already creating an adversarial situation and setting the stage to be denied access to the data.

Instead, explain that you want this information to review for consistency, to ensure that the practice is getting paid fairly from insurance companies, to review for compliance with reimbursement rules, to evaluate worthwhile contracts with particular insurance companies and to see whether your productivity for the practice is comparable with your colleagues.

Have you asked for this data in the past and been denied? You have a few options. A number of formulas are available to help you try to track collections, or you can calculate some average per-patient charges. Or you could use information collected from other PA colleagues who practice in a setting similar to yours. It's more difficult, but it can be done. But consider that if a practice is keeping this data from you, what else are they hiding? If your practice won't share this information, I think you need to ask whether this is the right practice to stay in.

Ask for Colleagues' Data

It's very helpful to know what other providers in your office are billing and collecting. This includes the physicians, PAs or nurse practitioners in your practice. Some professional societies, such as the Society of Dermatology Physician Assistants and the Medical Group Management Association, track average billing and collections as part of their salary surveys. If you are under-producing compared with your colleagues, you need to fix the problem. Are you not seeing enough patients? Do you need more support staff? Are you undercoding or overcoding? Do you need to start offering more procedure-based services?

Code and Bill Properly

The most important step in being a financial benefit to your practice is proper coding. As boring and difficult as it seems, you have to know when and how to use the proper codes to bill for the services you provide. You need to know everything from the appropriate level of evaluation and management visits (what makes a 99213 different from a 99212?) to when and how to use a modifier. Unfortunately, this stuff changes regularly, and you need to make it a priority to review it at least yearly.

The second step is to communicate with your billing department staff. Make sure they know how to submit claims properly, that they do it in a timely manner and that current information is collected on your patients. Ask them how rejected or bundled services are handled, and what is done for outstanding patient balances.

For example, one of my PA clients just found out her practice has been writing off charges when a patient's insurance has a deductible, regardless of whether the patient can pay or not. Her billing staff never even asks the patients for their portion! So the practice is losing hundred of thousands of dollars each year, and the PA is providing free care 25% of the time to a population that could pay at least a portion of their deductibles. You must be involved in the office coding, billing and collections from A to Z.

Know Your Billing-to-Collection Ratio

I recently was working with a client on her contract negotiations and we figured out that her accounts receivable (AR) rate was 48%, meaning that of everything she billed, less than half was ever collected! That's far below the average benchmarks for a strong practice with a good billing department.

To calculate your practice's AR rate, divide your collections by your billings and then multiply by 100 to get a percentage. So, for example, if you billed $300,000 and collected $215,000, your AR rate is 71.67%. Compare your rate to the other providers in your office and to other similar practices.

Are Charges and Collections Tracked?

With today's computers and electronic medical billing, there's no excuse for a practice not to keep track of your charges and collections. Even if services are billed out under your physician, you can put an internal code on them to track them. If your billing department or office manager doesn't know how to do that, offer to call the computer software company yourself to find a solution.

It does become more complex if you never see patients directly or if you spend at least part of your time doing things that won't result in a charge, such a pre-rounding, taking call or assisting during procedures. In this situation, you need to attempt to calculate whether these duties enable your supervising physician to bill more. For example, if you help the physician pre-round, does this save him an hour a day? And if he uses that hour to see patients, how much more has he collected? Or if he can perform two more surgeries a day because you speed the procedures, how much more money do those two surgeries a day bring in?

Start with a strong, ironclad contract, and pay attention to your gut-if you sense red flags, beware! Before accepting a position, find out about the practice's reputation. Seek opinions from former employees (especially PAs) and from referring clinicians in the community. Research the salaries of other PAs in similar settings. If you're being abused, look elsewhere. Change can be scary, but sometimes it's necessary.

By becoming involved with the billing and coding in your office, you can help your physician navigate the confusing and complicated work of running a medical practice. Doing this will give you an advantage in contract negotiations, and you'll also help your physician in yet another way that PAs can benefit their physician partners in medicine.

Abby Jacobson practice dermatology in Lancaster, Pa. She has held numerous leadership positions in the American Academy of Physician Assistants, the Pennsylvania Society of Physician Assistants and the Society of Dermatology Physician Assistants. She is owner of Strategic Medical Consulting LLC.

Copyright ©2008 Merion Publications

Who Benefits From Billing In Healthcare?

Posted in The Huffington Post on May 29, 2008
By Dr Deane Waldman

Have you ever been a patient? If so, you know how incredibly complex, user-unfriendly and inefficient the whole billing/insurance system is. Do you know a doctor, nurse or hospital administrator? Ask them and they will say the same thing, louder and angrier: billing is exceedingly cumbersome, under-paying, always late, and inefficient. If the doctors don't benefit from this mess and the patients certainly do not, then who does benefit? Good question, and is it really "inefficient?"

Pictured above is one of last year's medical billing code books, containing 8805 five-digit or longer codes - more than the number of identified human diseases. Typically, it is "updated" (expanded) at least once a year. This book gives information required for just one of the 57 (!) different steps used to submit a medical bill.

Efficiency is usually defined as the least resources used for the most money gained. In health care billing, who gets the gain? The people who make profit are not the doctors or hospitals: the profit-makers are the insurance companies.

How do insurance companies make money? The formula is simple: collect lots of premiums and avoid spending the money. That means the more they delay payments; the more they reduce the amount paid; the more they deny payment altogether, the more profit they make. In other words, delaying, paying less or not paying at all for your medical care...generates profit.

And before you blame the big bad heartless insurance companies, remember that they are behaving just the way their stockholders - which probably includes YOU - want them to act. Your pension plan does not hold stock in HCA, United Health, or Blue Cross because they lose money. Your insurance company is not the culprit. The dastardly villain smirking while twirling his handlebar moustaches is the system.

PS. If - a big if - so-called universal health care saves money, it will do so by simplification. This means three things: 1) The middleman profit will go away; 2) Reducing the bureaucracy and red tape will put thousands out of work; and 3) The value of your insurance stocks will end up in the toilet.

Dr Deane Waldman's articles - An Honest Approach towards the US Healthcare System

Only recently, I happened to read one of the articles posted by Dr Deane Waldman in his own blog Medical Malprocess and have started to like his brave and honest opinions about the US Healthcare System which he says is 'the sickest patient'. His opinions come out of his professional experience as a Pediatric Cardiologist for over thirty years and also from his Management background.

Dr Deane Waldman says:

" The combination of life and professional experiences with my knowledge of management and strategy makes me particularly qualified to help us understand why healthcare is sick and what we can do to begin healing. Medical Malprocess is my blog aimed at starting a national conversation that will lead to a process to cure healthcare. "

Check out his Background and Credentials:

• Education and Training: Yale (BA in History); Mayo Clinic; Chicago Medical School (MD); Northwestern; Harvard; Anderson Schools of Management (MBA).

• Practicing Physician – 30 years – in both private and academic practice

• Chief of Pediatric Cardiology: San Diego; Chicago; New Mexico.

• Research: $3 million in grant support; over 100 publications.

• Consultant, Professor and Author in Healthcare Strategy

So, I thought of writing this post here in this blog Healthcare BPO News in appreciation to his approach in finding a way to fix the Healthcare System...

. . . And Escape From New Jersey

Source: wsj.com - The Wall Street Journal
May 29, 2008

New Jersey is about the last place one might think to look for free-market policy reform. But this week Jay Webber, a Republican Assemblyman in Trenton, will introduce legislation to let Garden State residents buy low-cost health insurance from any registered policy in any of the 50 states.

Mr. Webber's proposal is a state version of Arizona Congressman John Shadegg's federal legislation to let individuals buy insurance across state lines, and John McCain has also endorsed the idea. But New Jersey would be a perfect test case, because its multiple mandates have made insurance too expensive for hundreds of thousands of families.

The average national cost for a family health plan is $5,799, according to America's Health Insurance Plans, but in New Jersey that same plan costs $10,398 on average. The state's politicians have driven up these costs by forcing insurers to provide gold-plated coverage – even for such voluntary medical services as in vitro fertilization. New Jersey also follows New York and Massachusetts – two other high-cost states – in requiring so-called "guaranteed issue." That allows New Jersey residents to avoid buying health insurance until they get sick, which means they can avoid paying premiums until they need someone to pick up the bill.

This one-policy-fits-all system tends to cause the young and healthy to drop insurance, which only raises the cost of insurance for the sick, which in turn makes coverage unaffordable for ever more families. It's no accident that about 1.2 million people – one of every eight residents – is uninsured in the state.

Under Mr. Webber's choice proposal, New Jersey residents could buy policies chartered in more enlightened states. For example, a healthy 25-year-old male could buy a basic health plan in Kentucky that now sells for $960 a year, about one-sixth of the $5,880 it would cost him in New Jersey. Residents of Pennsylvania pay health premiums that are one-half to one-third as high as do Garden State policy-holders. A new study by the National Center for Policy Analysis estimates that the availability of lower cost plans would reduce by 25% the number of uninsured.

Opponents of interstate insurance say families would be pushed into bare-bones health plans. Not so. Families could still buy the more extensive coverage, but those with modest incomes would have options other than going uninsured. The goal of public policy shouldn't be to cover every medical procedure or doctor's visit, but to prevent families from catastrophic expenses due to a health problem that is no fault of their own.

New Jersey is turning into a microcosm of the national debate on health care. Democrats in Trenton are rallying behind a plan to require that every uninsured individual in New Jersey purchase health insurance from a new state-administered program. So a state that is already so broke that its politicians are contemplating mortgaging its highways might now add a $1.7 billion health subsidy.

The Webber proposal offers lower costs and more choices for consumers, while the Democratic plan mandates public coverage and no choice, while putting a new burden on taxpayers. This is the kind of debate the country should have this election year.

States' Scorecard Finds Big Differences in Kids' Health Care

By Steven Reinberg
HealthDay Reporter
Wednesday, May 28, 2008; 12:00 AM

WEDNESDAY, May 28 (HealthDay News) -- The quality of children's health care in America varies widely from state to state, as does their access to insurance and care and the likelihood of living long and healthy lives.

That's the conclusion of a new scorecard produced by the Commonwealth Fund, a private foundation that seeks to promote better health care for all Americans.

According to the scorecard, if all states performed as well as the top few states:

an additional 4.6 million children nationwide would have health insurance; 11.8 million more children would get their recommended yearly medical and dental check-ups; 10.9 million more children would have a "medical home" -- a regular source of care; 1.6 million fewer children would be at risk for developmental delays;and nearly 800,000 more children would be up-to-date on their vaccines.

Iowa, Vermont, Maine, Massachusetts, and New Hampshire are the top performing states, according to the report, while Arizona, Florida, Louisiana, Mississippi, New Jersey, Nevada and Texas are at the bottom.

"States and the federal government have a very high stake in ensuring that children are healthy," Commonwealth Fund President Karen Davis said during a teleconference Tuesday. "In fact, more than one-third of children in the United States receive health care funded by the federal government as well as the 50 states and the District of Columbia."

The report,U.S. Variations on Child Health System Performance: A State Scorecardwas released Wednesday.

There are 28 million children covered by Medicaid and 6 million covered by the State Children's Health Insurance Program (SCHIP), Davis noted. And the key to providing health care to children is insurance, Dr. Edward L. Schor, the Commonwealth Fund's vice president for child development and preventive care, said during the teleconference.

"In this study, we found a four-fold difference in the rates at which children are uninsured," Schor said.

The number of uninsured children varied widely across the states, from a low of 5 percent in Michigan to a high of 20 percent in Texas. States that had the most insured children tended to have the highest scores on quality of care, Schor said.

If all states performed as well as Michigan when it came to providing insurance, then 4.6 million more children would have health insurance, Schor said. "That would cut the rate of uninsured children in half," he said.

Using vaccinations as a measure of access to care, the scorecard again found substantial variation among the states, Schor said. "In Massachusetts, 94 percent of children were up-to-date on their immunizations, whereas in Nevada it was only 67 percent," he said.

Another key is having a "medical home" -- a regular source of care, Schor said. "Whereas 77 percent of children in New Hampshire had a medical home, in Mississippi, 34 percent had a medical home," he said. "We know that children who have a medical home have a better quality of care."

The scorecard took into account 13 indicators of children's health, including access, quality, costs, equity and the potential to lead a long and healthy life. While no state scored high on all categories, some regions surpassed others. For example, states in the Northeast and Upper Midwest often ranked higher in several areas, while the lowest rankings were in the South and Southwest, the report found.

Studies have shown that in states with high numbers of uninsured children, those children are less likely to get recommended health care, vaccines, dental care and regular checkups. These children are also at greater risk for developmental delays and infant mortality, Davis said.

But even in the highest-ranking states, quality of care falls short of goals, the report noted. In Massachusetts, the top-ranked state in quality, 75 percent of the children were seen by a doctor and a dentist in the past year, compared with only 46 percent of children in Idaho.

"One of the major efforts states can take to improve quality of care is to provide health insurance coverage to children, particularly low-income children," Davis said. "States that do a good job on that are among the states that are highest ranked on the various dimensions of quality of care. They are also the states that tend to do well on equity measures to help ensure that minority children and low-income children have better access to care and better quality of care".

One expert believes it's essential to increase funding for Medicaid and SCHIP to get more children covered by health insurance.

"We think this is a great report and it shows what we have been trying to show for a long time, which is how important Medicaid and SCHIP are to children's health," said Jenny Sullivan, a senior health policy analyst with the nonprofit, nonpartisan health care advocacy group Families USA. SCHIP legislation was enacted in 1997 to cover children in low-income families.

More information

To read the full report, visit the Commonwealth Fund.

SOURCES: May 27, 2008, teleconference with Karen Davis, president, and Edward L. Schor, M.D., vice president, Child Development and Preventive Care, The Commonwealth Fund, New York City; Jenny Sullivan, senior health policy analyst, Families USA, Washington, D.C.;U.S. Variations on Child Health System Performance: A State Scorecard

Dublin Doctor Defrauds Medicare, Medicaid, Gets Four Years Probation For Health Care Fraud

Source: rockbridgeweekly.com

Acting United States Attorney Julia C. Dudley announced today that Dr. Linda Sue Cheek, age 59, of Dublin, Virginia, was sentenced yesterday in United States District Court for the Western District of Virginia in Roanoke for defrauding Medicaid and Medicare.

“These taxpayer-funded health care programs are designed to allow our friends and neighbors who are in need of medical care, the opportunity to obtain it,” Acting United States Attorney Julia C. Dudley said today. “When physicians like Dr. Cheek take advantage of these programs in order to get rich, it is our job to hold them responsible for their actions.”

Cheek was sentenced to serve four years of probation for her role in a scheme to knowingly and willfully defraud the Medicaid and Medicare health care programs for her own personal, financial gain. In February Cheek pled guilty to one count of health care fraud, admitting that she had been stealing from the two programs from January 2002 to March 2006.

In addition, Cheek was ordered to pay a total of $24,210.37 in restitution to Medicare and Medicaid and will be required to serve 600 hours of community service in a non-medical field. As part of her sentencing, her license to practice medicine was also revoked.

The defendant, who was a licensed physician by the Commonwealth of Virginia, operated New River Medical Associates, Inc. located in Dublin, Virginia. The facility operated primarily as a pain management and alternative medicine practice.

Cheek previously admitted that between January 2002 and March 2006 she submitted a series of false Medicare and Medicaid claims relating to her medical practice, including the practice of billing Medicaid and Medicare for services she had not performed.

In addition, Cheek admitted to billing Medicaid for services she claimed to perform herself that were, in fact, performed by one or both of the two nurse practitioners employed by New River Medical Associates. Cheek admitted that during many of these procedures she was out of the office and, at times, out of the country.

Finally, Cheek admitted to billing Medicaid and Anthem Blue Cross Beneficiaries for individual treatments called “cleansing sessions,” an investigational service. These “cleansing sessions” were performed and billed as regular, individual office visits but were carried out in a group setting. Medicaid, Medicare and other insurance providers do not allow medical professionals to bill for group sessions.

This case was investigated for the United States Attorney’s Office, Western District of Virginia by the Virginia Attorney General’s Medicaid Fraud Control Unit, the Internal Revenue Service, the U.S. Department of Health and Human Services, Office of Inspector General, the Virginia State Police Drug Diversion Unit and the Financial Investigation Unit of Anthem Blue Cross Blue Shield.

Assistant United States Attorneys Patrick Hogeboom and Charlene Day prosecuted the case for the United States.

Private Equity Investors Favor India Over China

Economic Times of India May 27, 2008, 9:12AM EST

A report by Four-S Services shows India receiving about $19.5 billion worth of private equity investment in 2007, vs. $12.8 billion for China—a flip-flop from 2006

More PE funds flocked to India compared to China in 2007. For the first time, China PE investments were in the range of $12.8bn; nearly 34% less than the investments in India at $19.5bn. This was a huge change from 2006, when China received $12.9bn worth of PE investments, nearly 70% more than the $7.6bn received by India.

However, there was a qualitative difference in the way funds were deployed in China compared to India. China's traditional Manufacturing & Infrastructure sectors attracted $8.3bn, constituting 65% of total funds invested; compared to $6.2bn constituting 32% of the total for India in 2007, according to a Four-S Services report .

Interestingly, the core sectors were the main areas of PE interest. Infrastructure (Engineering & Construction) sector accounted for a lion's share of the deals in 2007 with nearly $4.0bn worth of investments (20.5% of total PE/VC investments announced during the Year).

As core development continues to be a high priority, Infrastructure is expected to be one of the fastest growing sectors in India, requiring huge investments worth $492bn over the next 5 years. The major growth driver within the Infrastructure sector was the Construction industry, accounting for 60.3% of the investments.

The top four sectors of Infrastructure, Telecom, BFSI and Real Estate (in that order) received nearly 72.3% of all PE investments during 2007.

Indian PE performance rocked last year mainly due to the fact that there are more private enterprises in India than in China that are attractive to PEs. Though India has always had a higher percentage of private sector companies compared to China, it is only in recent years that there has been a spreading of awareness among the investing community of the strong education system, English language proficiency, legal & financial structures and democratic governance in the country, says the report titled Indian Private Equity Report 2007.

This awareness, combined with sustained growth, has led to increasing investments in India. Also, the year saw some mega IPOs in China, drawing large investments from FIIs & PEs, leading them to limit their private deals and thus maintain their China exposure at certain levels.

Year 2007 saw Private Equity (PE) and Venture Capital (VC) investments 'Riding a Wave of Euphoria' in India. If 2006 was about PE/VC activity 'Bursting into Bloom', by 2007, the sentiment had risen to ecstatic levels as can be witnessed in the phenomenal growth of PE/VC investments in India, which hit an unprecedented $19.5bn in 2007, 2.5 times the $7.6bn figure of 2006, the report adds.

Total PE/VC investments announced in Indian companies was $19.5bn across 394 deals in 2007, compared to $7.6bn across 298 deals in 2006. The average deal size nearly doubled compared to 2006 ($41.7mn v/s $21.7mn), as even smaller investors that earlier used to look for $5-10mn deals began looking for $20-25mn deals. Also, there was a sectoral shift towards Infrastructure, Telecom & Real Estate,which witnessed the major big ticket deals of the year.

IT/ITES sector was the biggest loser, with investments dropping by 37.5% on YoY basis due to the slower profitability growth forecast. The slowdown in the sector was based on the adverse impact of the over 10% appreciation in the rupee and the depressed conditions in the US economy, which is a major source of revenue for Indian IT companies. Also, most of the big IT firms were not looking to raise funds. However, the sector still managed a record 84 small size deals, mainly in the web-based Information Services Industry and in the BPO/KPO Industry.

Traditional favourites like IT/ITES, Manufacturing and Healthcare together comprised only 18.5% of all investments by value in 2007, compared to 40.6% in 2006, mainly due to better and bigger opportunities in other areas of the economy and comparatively slower growth rates in these 3 sectors.

Medical Billing Opportunities: Worth a Second Opinion

Source: www.ftc.gov - Official website of the Federal Trade Commission, US.

If you're looking for a home-based business that can help you pull in $20,000 to $45,000 a year using your computer, a work-at-home opportunity doing medical billing may sound like the perfect choice. But before you part with your money, consider this: The Federal Trade Commission (FTC) has brought charges against promoters of medical billing opportunities for misrepresenting the earnings potential of their businesses and for failing to provide key pre-investment information required by law.

Medical Billing Scams

Ads for medical billing business opportunities appear on the Internet and in the classified sections of local newspapers and "giveaway" shopper's guides. In the "Help-Wanted" classified sections, the ads may appear next to legitimate ads for hospital medical claims processors, leading consumers who respond to think they're applying for a job, not buying a business opportunity.

The ads lure consumers with promises of substantial income working from home full- or part-time - "no experience required." They direct consumers to call a toll-free number for more information.

If you call, a sales representative will entice you to sign up by telling you that the processing of medical claims is a lucrative business, that doctors are eager for help with electronic claims processing, and that you - even without any experience - can do this work from the comfort of your home.

Medical billing scammers charge a fee of hundreds, or even thousands, of dollars. In exchange, they claim to provide everything you supposedly need to launch your medical billing business: the software program to process the claims and a list of potential clients.

But the reality is that few consumers who pay for medical billing opportunities find clients or make any money, let alone earn the promised substantial income. Competition in the medical billing market is fierce, especially for those who are new to it. Many doctors' offices process their own medical claims. Doctors who contract out their medical billing often use established firms, not individuals working from home.

Promoters of fraudulent medical billing opportunities are not interested in helping consumers, either. They only want their money. Many times, the client lists they provide are based on out-of-date databases of doctors who haven't asked for medical billing services. The software they send may not work or may not have been properly authorized and so is useless. And the money-back "guarantees" often prove worthless. Even after making repeated calls to the promoter or complaining to their credit card companies, government agencies or consumer groups, only a few people actually get refunds.

How to Protect Yourself

To avoid losing your money to a bogus medical billing business opportunity, the FTC advises you to:

• Ask the promoter to give you the names of many previous purchasers so that you can pick and choose who to call for references. Make sure you get many names from which to choose. If the promoter provides only one or two names, be careful: The contacts may be "shills" - people hired to give favorable testimonials. Interview the references, preferably where the business operates, to get a better sense of how the business works. Ask for the names of their clients and a description of their operation.
• Consult with organizations for medical claims processors or medical billing businesses and with doctors in your community. Ask them about the medical billing field: How much of a need is there for this type of work? How much work does medical billing entail? What kind of training is required? Do they know anything about the promotion or promoter you're interested in?
• Check with the state Attorney General's office, consumer protection agency and the Better Business Bureau in your area and the area where the promoter is based to learn whether there are any unresolved complaints about the business opportunity or the promoter. While complaints may alert you to problems, the absence of complaints does not necessarily mean the company is legitimate. Unscrupulous companies may settle complaints, change their names or move to hide a history of complaints.
• If the medical billing opportunity sells another company's software, check with the software company to find out whether company representatives know of any problems with the medical billing promoter.
• Consult an attorney, accountant or other business advisor before you sign any agreement or make any payments up front. An attorney can review the promoter's contract and advise you on how best to proceed.

Where to Complain

If you think you've been defrauded in a medical billing business opportunity scheme, contact the company and ask for your money back. Let the company representatives know that you plan to notify law enforcement and other officials about your experience. Keep a record of your conversations and correspondence. If you send documents to the company, send copies, not originals. Send correspondence by certified mail - and request a return receipt - to document what the company received.

If you can't resolve the dispute with the company, file a complaint with:

• the Federal Trade Commission. Call 1-877-FTC-HELP (1-877-382-4357) or log on to www.ftc.gov.
• the Attorney General's office in your state or in the state where the company is located. The office will be able to tell you whether you're protected by any state law to regulate work-at-home programs.
• your local consumer protection offices.
• your local Better Business Bureau.
• your local postmaster. The U.S. Postal Service investigates fraudulent mail practices.
• the advertising manager of the publication that ran the ad. The manager may be interested to learn about the problems you've had.

The FTC works for the consumer to prevent fraudulent, deceptive, and unfair business practices in the marketplace and to provide information to help consumers spot, stop, and avoid them. To file a complaint or to get free information on consumer issues, visit ftc.gov or call toll-free, 1-877-FTC-HELP (1-877-382-4357); TTY: 1-866-653-4261. The FTC enters Internet, telemarketing, identity theft, and other fraud-related complaints into Consumer Sentinel, a secure online database available to hundreds of civil and criminal law enforcement agencies in the U.S. and abroad.

Feds in Indy seek $789K from medical supplier

May 23, 2008. IndyStar.com

A lawsuit filed by the federal government in Indianapolis accuses a medical products supplier based in northeastern Illinois of falsely billing Medicare for $789,579 in medical equipment.

The government claims Criterion Medical Corp. of Braidwood, Ill. submitted 1,427 false claims between May 2002 and October 2007, billing the government for knee and calf replacement liners.

A government investigation determined those liners were not medically necessary and that Criterion acted recklessly.

The government seeks reimbursement and unspecified damages.

Attempts today to reach Criterion were unsuccessful.

Although the company has an active Web site, phone numbers listed for Criterion are disconnected.

The billings were for Medicare patients in Indiana.

Highmark Medicare Services to Begin Processing Claims in New Jersey

Posted on : 2008-05-22 | Author : Highmark Medicare Services News Category : PressRelease

CAMP HILL, Pa., May 22 NJ-Highmark-NJ-claims

CAMP HILL, Pa., May 22 /PRNewswire/ -- Highmark Medicare Services will begin processing Medicare Part A claims in New Jersey on September 1, 2008 and Part B claims on November 14, 2008. In October 2007, the Centers for Medicare & Medicaid Services awarded Highmark Medicare Services the Jurisdiction 12 (J12) Medicare contract to provide the Medicare Fee-for-Service Part A and Part B administrative services for the states of Pennsylvania, Maryland, New Jersey, Delaware and the District of Columbia. The award is part of a Congressional requirement to replace all current Medicare Part A and B contracts with new contract entities called Medicare Administrative Contractors (MACs).

In fiscal year 2007, Highmark Medicare Services processed about 48.8 million claims and served approximately 2.3 million beneficiaries and 57,000 providers. As the MAC for J12, Highmark Medicare Services is expected to process approximately 131 million claims annually, accounting for more than 11 percent of the national Medicare fee-for-service workload. Highmark Medicare Services will be working on behalf of approximately 4.2 million beneficiaries and 137,000 physicians and practitioners.

As a MAC, Highmark Medicare Services will serve as a single point-of-contact entity processing Medicare Part A and B claims from hospitals and other institutional providers, physicians and other practitioners within the J12 region. Highmark Medicare Services currently administers the Medicare Fee-for-Service Part A business for Pennsylvania, Maryland, and the District of Columbia, and the Part B business for Pennsylvania.

"As this work transitions from other contractors to Highmark Medicare Services, we are committed to making this as seamless as possible for Medicare beneficiaries and health care providers," said Patrick Kiley, president of Highmark Medicare Services. "We understand that one of the keys to accomplishing this is through timely and direct communications by the MAC and timely response by those who need to react to changes due to the transition."

If you have any questions related to the transition or Highmark Medicare Services, visit http://www.highmarkmedicareservices.com.

About Highmark Inc.

Highmark Medicare Services is a wholly owned subsidiary of Highmark Inc.

Highmark Inc. is a major force for Pennsylvania's economy. According to a Tripp Umbach study, Highmark has a $2.5 billion impact on the economy and that includes about 11,000 employees of Highmark in Pennsylvania. Overall, Highmark and its subsidiaries have 19,000 employees.

As one of the leading health insurers in Pennsylvania, Highmark Inc.'s mission is to provide access to affordable, quality health care enabling individuals to live longer, healthier lives. Based in Pittsburgh, Highmark serves 4.6 million people through the company's health care benefits business. Highmark contributes millions of dollars to help keep quality health care programs affordable and to support community-based programs that work to improve people's health. Highmark exerts an enormous economic impact throughout Pennsylvania. The company provides the resources to give its members a greater hand in their health.

Highmark Inc. is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

SOURCE: Highmark Medicare Services

© 2008 earthtimes.org.

Now doctors jump into BPO bandwagon

18 May, 2008, 1410 hrs IST, PTI
Source: The Economic Times

NEW DELHI: After engineers and lawyers, now doctors are also gearing up to join the BPO brigade, with the outsourcing firms opening up alternative career options for medicos.

With more and more outsourcing firms moving into healthcare sector and medical transcription, the job opportunities for doctors and nurses in the country are getting widened, an industry expert said.

In a BPO firm, the job of a doctor can include medical billing, transcription and coding for the US hospitals.

Medical transcription, also known as MT, is an allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals into text format.

However, some companies like the Patni also provides high-end knowkledge process outsourcing where a doctor is required to study the reports of elderly patients and do risk assessment and prepare reports for health Insurance companies in the US.

At present, the IT services and business outsourcing company has 10 doctors in its team who does insurance claim processing, claim and long-term care management.

Nishikant Kadam, Head of HR of medical BPO CBay said: "We generally hire doctors for training our workforce. The doctors in our firm also works as quality analyst for our medical transcription work."

CBay currently has 11 doctors on its roll. The doctors are also enjoying this corporate job which comes with fat pay-packet.

"It takes at least three to four years for a fresh medical graduate to establish a successful medical practice. In this period a person can work in a medical BPO and earn good cash," a doctor working with a Noida-based BPO said.

"Salaries are lucrative compared to regular medical job. A senior doctor with three-five years experience could earn about Rs 8-20 lakh per annum in KPO," Patni Senior Vice- President Sanjiv Kapur told PTI.

As more medico-related work comes to India, the opportunity for more doctors in the business is rising.

The concept of the "greying of America" is widely accepted today. By 2020, the US population over the age of 65 is projected to grow to 55 million and 42 per cent of them would enter a nursing home in their lifetime. This has opened alternative career options for Doctors in KPO," Kapur added.

"By outsourcing these jobs, the hospitals and clinics in the US aim to reduce your administrative burden," Kadam said.

Are MTs Necessary?

This column explores the realm of the medical language specialist. This week, read about "Are MTs Necessary?"
By Rebecca A. McSwain, PhD, CMT, CPC-H-A

Experienced transcriptionists spot mistakes or inconsistencies in a medical report and check to correct the information. Their ability to understand and correctly transcribe patient assessments and treatments reduces the chance of patients receiving ineffective or even harmful treatments and ensures high-quality patient care. US Department of Labor, Bureau of Labor Statistics, www.bls.gov/oco/ocos271.htm

The above paragraph, at the US Department of Labor's Bureau of Labor Statistics Web site, mentions an aspect of our job that seems underappreciated: quality assurance. Patient by patient, report by report, for every one of the millions of files that pass through our hands every day, the MT is closely scrutinizing the medical record for accuracy, our own and others'. Currently, there is no one else, and no machine, doing this job. Health care providers, though ultimately responsible for the content of records they create, do not have the time or inclination to control quality at this level of detail in their documents. Health care institutions can (and do) conduct random assessments of medical record quality in various ways. But it is literally impossible for such programs to scrutinize every narrative record. Fortunately, medical transcriptionists are doing it. Unfortunately, various systems that eliminate or drastically reduce the role of the MT are also getting rid of this quality assurance (QA) function, thus throwing a pretty important baby out with the bathwater.

Anyone who honestly assesses documents currently created by voice recognition systems, and those created through self-entry by health care personnel, must acknowledge that these documents today pose a major quality risk. It's likely that in the future--and, by the way, after extensive feedback training provided to the machines by human MTs--VR systems will improve. But will it be enough?

As for self-entry: there may come a day when health care providers can evaluate, diagnose and treat patients while at the same time writing and keyboarding accurately and efficiently--with a mastery of spelling (even in areas outside their expertise) and grammar (even if English is their second language)--but I suspect that day is not now dawning. I think it may arrive about the same time that all health care providers are capable of doing their own coding accurately and efficiently.

And the medical transcriptionist brings something else to the creation of the medical narrative: a global understanding of language (medical and secular) and medical practice, combined with a comprehension of relevant community, provider, technology and individual patient circumstances for each of millions of encounters. This wide knowledge base, of course, grows bigger and better the longer an MT works in a particular context. But an experienced MT brings a store of information into any clinical situation, even an unfamiliar one. This specific kind of knowledge is not really held anywhere else in the health care system. Individual providers don't have it--they have pieces of it, but not the whole picture. Electronic data bases don't have it. I won't assert that computers will never be capable of this level of value, but they are far from it now. And this MT knowledge is a source of quality in the medical narrative for which there is currently no substitute.

If this QA function is, in fact, important, then HIM managers, administrators, planners, need to consider how to preserve it, whatever the mode of record-creation may be in the future. If not MTs, then who?

Rebecca A. McSwain is currently working as a production MT for a national service. She has worked as an MT supervisor, business owner, instructor and QA manager. She's a member of AHDI and the American Medical Writers Association. She has a PhD in anthropology and continues to work on anthro-related writing projects in her spare time. She can be reached at rmcswain_985@fuse.net.

Copyright ©2008 Merion Publications

Coding Multiple Conditions

Coders must be familiar with combination codes, multiple codes and manifestation coding guidelines.
Prepared by Ingenix Staff

A coder with any experience knows that coding involves more than merely looking up words and selecting corresponding codes on a one-to-one basis. Coding also requires that the coder review the clinical relationship between the multiple conditions that a patient may have and make code selections based upon that clinical relationship. Many medical conditions are inter-related, and the ICD-9-CM coding system allows the capture of these relationships through the use of several different types of diagnosis codes: combination codes, multiple codes (whether mandatory or discretionary) and the related manifestation codes. Each will be discussed.

A combination code is used to report two diagnoses or one diagnosis that is associated with a secondary condition. Combination codes are located in the ICD-9-CM alphabetic index as subterms that follow connecting words such as "due to," "with," "associated with" or "in." The coder may also be able to locate combination codes by reading inclusion and exclusion notes in the tabular list. The new coder may ask, "How do I know when to assign a combination code?" The answer is through thorough coding and paying attention to all coding instructions. The coder then becomes familiar with the types of conditions that require combination codes. Some are more readily apparent than others: acute cholecystitis with cholelithiasis should be assigned to code 574.00 instead of reporting separate codes of 575.0 and 574.20. The combination code is present in the alphabetic index as follows:

Cholelithiasis

with

cholecystitis

acute 574.0

The fifth digit of 0 is added after ascertaining that no obstruction was present.

But some combination codes are not so straightforward and may involve conditions that are clinically and inherently related. For instance, when chronic renal failure and hypertension are both documented on a patient record, the coder may be tempted to assign the very common codes 585.X and 401.9. But the ICD-9-CM Official Guidelines for Coding and Reporting (section I.C.7.a.3) indicates:

"Assign codes from category 403, Hypertensive chronic kidney disease, when conditions classified to categories 585 - 587 are present. Unlike hypertension with heart disease, ICD-9-CM presumes a cause-and-effect relationship and classifies chronic kidney disease (CKD) with hypertension as hypertensive chronic kidney disease."

Note that this guideline involves chronic renal failure only, and if acute renal failure and hypertension are present without documentation of co-existing chronic kidney disease, the conditions are reported separately with codes from the 401 and 584 categories.

Another example of the appropriate assignment of a combination code in lieu of separate, more commonly reported codes involves chronic obstructive pulmonary disease (COPD) and asthma. Coding Clinic, 2^nd Quarter, 1990, page 20 includes the following:

"The new code 493.2x, Chronic obstructive asthma, was developed because of the need to distinguish between non-obstructive and obstructive asthma (that in chronic obstructive lung disease), within the classification. When a patient has COPD with asthma, there is continuous obstruction to airflow on expiration, unlike a patient with non-obstructive asthma, where the patient wheezes during an asthma attack, but then returns to normal breathing once the attack subsides. When a diagnosis of asthma is documented with COPD, 493.2x is assigned whether or not the physician states 'chronic obstructive' asthma."

Multiple coding involves the use of more than one code to fully describe the components of a particular disease process or complex diagnostic statement. When combination codes are not available, but the documentation includes terms such as "due to," "with, "secondary to" or "incidental to," multiple codes should be assigned to most fully describe the conditions.

Multiple coding can be considered mandatory or discretionary. Mandatory multiple coding is designated in the alphabetic index by the use of the second code in brackets, which designates the manifestation code. The first code reflects the main underlying condition, and the second code identifies the manifestation of that main condition. Both of these codes must be assigned, and they must be sequenced in the order specified. In the tabular list, the coder will know that another code is required because the terminology "use additional code" appears with the main code and "code first underlying condition" appears with the manifestation code. Regardless of the circumstances of the admission, a manifestation code can never be sequenced as a principal or first-listed diagnosis. If submitted to a Medicare fiscal intermediary, or to another payer that follows national coding guidelines, the case will not be reimbursed until another code is sequenced as the principal or first-listed diagnosis.

For example, a patient with bleeding esophageal varices is admitted to a hospital for treatment of the varices. The documentation indicates that the varices are due to cirrhosis of the liver. The alphabetic indexed entry appears below:

Varix

esophagus

bleeding

in

cirrhosis of liver 571.5 [456.20]

This indicates that the code for the cirrhosis (571.5) must be sequenced first and the manifestation (the varices, code 456.20) must be sequenced as a secondary condition. This is considered mandatory multiple coding.

Discretionary multiple coding involves assigning multiple codes only if the additional condition is documented as actually being present. The coding instruction in the tabular list is "use additional code," which then instructs the coder to look for the presence of the condition in the medical record documentation before assigning an additional code.

A common example is a urinary tract infection due to E.coli infection. Under code 599.0 in the tabular list, the following appears: "Use additional code to identify organism, such as Escherichia coli [E.coli] (041.4)." This specific type of organism will not be present on all cases, but the coder is alerted to look for documentation of an underlying organism that is causing the infection and assign a separate code accordingly.

Another common coding scenario involves guidelines for cases in which terminology for both "acute" and "chronic" are documented. Whether or not both are coded depend upon the alphabetic indexed entries for that term. For example, a coder may commonly see "acute and chronic bronchitis" documented. The indexed entry appears below:

Bronchitis

acute or subacute 466.0

chronic 491.9

If separate subterms for acute or subacute and chronic are listed at the same indentation level in the index, both conditions are coded, with the code for the acute condition sequenced first. In this particular example, both the acute and the chronic conditions appear at the same indentation level so both would be assigned, with code 466.0 sequenced first. Conversely, if a patient has acute and chronic poliomyelitis, the indexed entry appears as below:

Poliomyelitis (acute) (anterior) (epidemic) 045.9

chronic 335.21

When only one term is included in the index as a subterm, and the other is in parentheses as a nonessential modifier (after the main term), only the code listed for the subterm is assigned. In this case, only code 335.21 would be assigned.

Multiple coding is also required for cases involving patients with late effects, which are residual conditions that remain after the end of the acute phase of an injury or illness. There is no time limit for when a late effect code can be assigned, but coders should review documentation carefully to ensure that the physician makes the connection between the current condition and the fact that it is due to the previous, but now healed, original condition. The nature of the late effect is sequenced first, with the code for the late effect sequenced second.

Many conditions related to previous trauma are inherently late effects, such as fracture nonunion or malunion. Others may not be as readily apparent, such as neural deafness from childhood measles. The vast majority of late effects require two codes for appropriate coding, unless the alphabetic index or tabular list directs otherwise. Also, when the late effect code has been expanded to the fourth- or fifth-digit level that includes the specific late effects for the residual conditions, only the cause of the late effect code is assigned. A good example of this is the late effect of cerebrovascular disease (438.0 - 438.9) category.

It should be noted that although reporting multiple codes to fully describe an episode of care is necessary, indiscriminate multiple coding is not appropriate. An example involves assigning secondary codes for signs and symptoms that are an inherent part of a definitive diagnosis that has already been coded. If a patient is admitted for treatment of congestive heart failure (CHF) and has an associated pleural effusion that is not addressed during the admission, it would not be appropriate to assign a secondary diagnosis for pleural effusion on the same case. Likewise, assigning codes solely on the basis of lab or other tests that have not been substantiated by a physician is not allowed. This is especially crucial when assigning codes under the new MS-DRG system, whereby finding CC or MCC conditions may be more difficult than it was under the previous CMS DRGs.

Coders should not assign codes for conditions that are considered incidental findings and have no significance for the current episode of care. For example, atelectasis on a chest X-ray or right bundle branch block on an EKG is not unusual, and unless the physician documents the significance of the finding and how it relates to the current episode of care, it should not be coded.

To brush up on the ICD-9-CM Official Guidelines for Coding and Reporting that are referenced above, please review the following:

A. Conventions for the ICD-9-CM

6. Etiology/manifestation convention ("code first," "use additional code" and "in diseases classified elsewhere" notes)

B. General Coding Guidelines

9. Multiple coding for a single condition

10. Acute and Chronic Conditions

11. Combination Code

12. Late Effects

* * * * * * *

After you've completed your review, check yourself with the quiz below.

1. A patient is seen in the physician's office with a diagnosis of chondrocalcinosis of the shoulder due to calcium pyrophosphate. Which of the following would be the appropriate diagnosis code(s) selection?

a. 275.49, 712.21

b. 712.11, 275.49

c. 712.21, 275.49

d. 275.49, 712.81

2. A patient is admitted to the hospital with an admitting diagnosis of GI bleeding. Underlying chronic conditions include hypertension, S/P MI, COPD, atrial fibrillation and asthma, all of which are currently treated. After GI endoscopy, diverticulitis of the colon is diagnosed as the cause of the bleeding. Which of the following would be the appropriate diagnosis code(s) selection?

a. 578.9, 562.11, 401.9, 412, 496, 427.31, 493.90

b. 562.13, 401.9, 412, 496, 427.31, 493.90

c. 562.13, 401.9, 412, 493.20, 427.31

d. 578.9, 562.11, 401.9, 412, 493.20, 427.31

3. The patient is seen in the ambulatory surgery center for treatment of a scar contracture of the left hand secondary to a burn that was suffered during the previous year. Which of the following would be the appropriate diagnosis code(s) selection?

a. 944.00, 709.2

b. 709.9, 944.00, 709.2

c. 709.2, 906.6

d. 906.6, 709.2

4. An elderly patient is admitted to the inpatient unit of the hospital with shortness of breath and fever. She is found to have influenza and pneumonia and is treated accordingly. She also has flaccid hemiplegia due to an old CVA. Which of the following would be the appropriate diagnosis code(s) selection?

a. 487.1, 486, 438.20

b. 486, 487.1, 438.20

c. 487.0, 438.20

d. 487.0, V12.59

5. A patient was admitted with a diagnosis of subacute and chronic pyelonephritis. He has underlying conditions that include diabetic retinopathy, COPD and a traumatic arthritis of the ankle, S/P ankle fracture two years ago. Which of the following would be the appropriate diagnosis code(s) selection?

a. 590.00, 590.80, 250.50, 362.01, 496, 716.17, 905.4

b. 590.10, 590.00, 250.50, 362.01, 496, 716.17, 905.4

c. 590.80, 250.51, 362.01, 496, 716.17, 824.8

d. 590.10, 590.00, 250.51, 362.02, 496, 716.17, 905.4

This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic is published quarterly by the AHA.
CPT is a registered trademark of the AMA.

Answers:
1. a: The underlying condition (the calcium pyrophosphate problem) is sequenced first, and then the chondrocalcinosis is sequenced second. The instruction note in the tabular list under cde 712.2X indicates, "Code first underlying disease (275.4)."

2. c: Combination codes are assigned for the colon diverticulitis with bleeding (562.13) and for the COPD and asthma (493.20).

3. c: Following the late effect guidelines, the code for the residual condition (the scar) is sequenced first, and the code for the late effect itself is sequenced second. The burn happened during the previous year and is no longer considered acute; it should not be coded separately.

4. c: Combination codes are assigned for the influenza with pneumonia (487.0) and the hemiplegia late effect of a CVA (438.20).

5. b: Both subacute and chronic pyelonephritis codes are listed at the same indentation level in the index and so both are coded, with the acute code sequenced first. The diabetes is not specified as Type I, nor is the retinopathy specified as proliferative, so codes 250.50 and 362.01 should be assigned. The ankle fracture is no longer acute, so code 824. 8 should not be assigned at this time. Assign codes 716.17 for the traumatic arthropathy and 905.4 to represent a late effect of an ankle fracture.

Copyright ©2008 Merion Publications

Despite US recession, BPO's future looks bright

Rincy, 22 May 2008, Thursday
Merinews

The economic recession in the United States has affected the BPOs in India. But this has not totally fractured the outsourcing industry, as there are scopes opening up beyond US like Europe and Australia or changing client exposure.

THE BUSINESS Process Outsourcing (BPO) vendors having United States based clients share mixed reactions due to the temporary slump in the US economy. This will be further heightened till the time final election results are not out and the new president doesn’t announce some relief with string of measures to combat the credit crunch heat.

Those BPOs or KPOs, which focus on large US companies or big ticket outsourcing contracts, are facing the recession crisis as seen by the delays in contract renewals or temporary freeze in awarding of new contracts. One of the associated factors is the lengthened decision-making time with a lot of top heads losing their jobs under the recession pressure.

Large companies have now focussed their energies on restructuring their companies through vertical acquisitions or major divestitures besides analysing their internal processes. This has chiefly been observed with IT and financial service companies. It seems that ’outsourcing’ is now on the back-burner for them, as they focus more on meeting their budgeted business targets first.

But there’s some hope in these tough times. The economic crisis has forced the small to mid-sized US companies to assess outsourcing as an option as they struggle to survive against the big mammoths. They are re-evaluating their internal processes to find solutions within tight business budget constraints. This, in fact, opens up a galore of opportunities for BPOs and KPOs from India, which focus on small to mid-sized US clients with revenues lesser than $5 million.

There are few other smart choices available too, like looking beyond the US to stretch the sights to Europe and Australia or changing the client exposure from the typical IT and financial service clients to other industry verticals.

Indian BPO firms should head to hinterlands, says Karnik

BS Reporter / Chennai/ Hyderabad May 20, 2008, 4:00 IST

Rural India not only offers lower costs, but an abundant pool of highly-motivated talent. The future of India's BPO sector lies in moving more of its operations to rural India, according to former Nasscom president and member of IDG's Global Advisory Board Kiran Karnik.

"Indian companies have been setting up BPOs in various countries including Sri Lanka, Vietnam, China and Thailand. However, the biggest unexplored market is pretty much here in India. The future destination for the Indian BPO industry is within the country," he said.

Delivering his keynote address at the first national rural BPO conference organised by Byrraju Foundation, the NGO arm of Satyam Computer Services Limited, in Hyderabad on Friday, Karnik said Indian BPO companies were moving slowly towards rural areas in setting up facilities.

"Going ahead, we see challenges coming up in the form of competition as a result of the success that we have achieved in the IT and BPO industry, coupled with the already existing problems such as lack of talent and related issue of attrition. Clearly, there is a huge untapped talent in smaller towns and the industry should find ways and means to identify this and go where the talent is."

Stating that the Indian IT and BPO facilities are being set up as world-class ones, he said companies should look at small and cheaper facilities for services like data entry to tide over infrastructure and hiring costs.

"We should think of these rural BPO centres as the ones in Hyderabad or Delhi. Quality and standards have to be the same, and work at the same level of intensity using ‘appropriate' technology," he added.

HIL to pick up 8.5% in Apollo BPO

21 May, 2008, 0029 hrs IST,Khomba Singh & Sanjeev Choudhary, TNN
News Article from The Economic Times.

NEW DELHI: Mauritius-based firm Healthcare Investment (HIL) is picking up around 8.5% stake in Apollo Health Street (AHS), the healthcare BPO arm of India’s largest healthcare company, Apollo Group, for around Rs 61 crore. This values the company at just over Rs 700 crore. HIL is learnt to the healthcare investment arm of a leading financial firm. However, ET could not identify the name of the financial firm.

AHS is planning to offload 20% stake of its post-issue paid up capital to raise around Rs 160-170 crore from the capital market through its initial public offer (IPO). According to sources, AHS is now allotting 23 lakh shares to Healthcare Investment at Rs 260 per share through issue of equity shares or compulsorily convertible preference shares as part of the pre-IPO placement.

At present, the Reddy family, the promoters of the Apollo Group, holds around 60% stake in AHS, which is expected to come down to around 48% after the IPO. AHS officials declined to respond to a query from ET citing company’s silent period.

The company would use the funds issue to repay the $120 million debt to Bank of India and Barclays Bank. Last year, the healthcare BPO firm raised debt to fund the acquisition of the US-based BPO Zavata for $170 million. AHS plans to repay about Rs 96 crore to these banks while the rest of the fund would be used for the expansion of its upcoming facility in Chennai.