The Medicare e-prescribing incentive is a new initiative authorized under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).

The program starts January 1, 2009 and offers incentives for eligible providers that meet certain criteria. The e-prescribing Incentive Program is currently based on one e-prescribing quality measure that is currently included in the Physician Quality Reporting Initiative (PQRI). Beginning in 2009 the e-prescribing quality measure will be removed from the PQRI and it will become the quality measure used in the e-Prescribing Incentive Program.

For 2009 the e-prescribing incentive amounts will be 2% of the total estimated allowed charges for professional services covered by Medicare Part B and provided by an eligible professional during the reporting period. To be a successful e-prescriber, you must report the e-prescribing quality measure through your Medicare Part B claims on at least 50% of applicable cases during the reporting year.

To participate in the e-prescribing incentive program you must use a "qualified" e-prescribing system. There are essentially two types of systems: a system for e-prescribing only (a "stand alone" system), or an electronic health record (EHR) system with e-prescribing capabilities.

To get the incentive in 2009, you have to report on the e-prescribing quality measure with one of the three appropriate G codes on more than 50% of applicable cases within your practice.

Eligible providers that are not "successful e-prescribers" by 2012 will be subject to a differential payment (penalty) beginning in 2012.

To learn more about Medicare's e-prescribing program, visit the following URL: www.cms.hhs.gov/ERXIncentive/.

It's certainly worth any practice that bills a substantial amount of Medicare to enroll in the e-prescribing program in order to reap the financial benefits and in essence, improve efficiency within your practice.

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, and other general medical practice consulting services.



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Dr. Brian: OK so let's start with Automated Reporting. What is that?

Automated Reporting

Erez: We need to track the quality of five key roles of the overall team on a continual basis and the reports need to come to us automatically. This is the opposite of manually spot checking and tallying up numbers to grade the performance of each one of these roles in the billing team.

1. Individual auditor performance - claims audited, errors found, and audit quality (errors found in auditor's samples)
2. Operator performance
3. BPO performance
4. SPOC performance
5. Overall quality - SPOC Manager

Dr. Brian: So now I understand who need to be audited and that there will be reports automatically generated to help you see the quality, but what is really being measured and, how can you trust that auditors are not making mistakes?

Multiple Audit Levels

Erez: To make sure that the auditors do their job properly, we need to do two things:

1. Measure audit progress
2. Audit the auditors

We envision four levels of independent auditors: 1st level auditor, 2nd level auditor, SPOC, and SPOC manager. The technology samples the claims for the audit automatically and allocates them in the corresponding audit workbench. For instance, the technology selects the claims for second-level audits by a random probability defined in the audit-risk database from the claim sample already selected for the first-level audit. Second-level auditors would in turn be audited automatically by the SPOCs, and the SPOCs would themselves be audited by the SPOC Manager.

The claim sample selected for a second-level audit increases whenever the independent QA team finds mistakes or oversight on the part of the first-level auditing teams. In this way, a single claim may be audited by up to four independent auditors. If one of the auditors finds a mistake, the entire chain of auditors and the processor who made the initial mistake will all have their "audit-risk" increased so that more of their claims are audited.

Dr. Brian: So Kind of like an immune response? The more mistakes the bigger the defense?

Erez: Something like that.

Dr. Brian: I understand how there are different levels of auditors but they still need to go and randomly select claims right? How can you be sure that they are selecting random claims and not ones that look like they will be easy to audit?

Workflow Management

Erez: As in standard billing processing, with automated problem discovery and manual resolution, the technology automatically selects the claims for audit and populates the audit workbenches with those claims to ensure audit task completion. Auditors get a list of claims with the notes entered by the processing teams, and then:

1. Audit the claim completely (including calling the insurance company or checking status online to make sure the information obtained by the operator is correct)
2. Record errors or mark the claim as clean

By working from a workbench, the audit teams will be able to do their job faster. More importantly, the technology will automatically measure the auditors' progress and productivity to make sure that all sampled claims are getting audited.

Dr. Brian: The system tells the auditors what and when to audit and also measures how clean the claims are?

Erez: Yes

Dr. Brian: What exactly is fair game for auditing?

Automated Audit Sampling

Erez: The operator actions subject to audit include EOB posting, a follow-up action, or a request for info to the provider. Every action performed by an operator is automatically compared to a "audit-risk" database that determines the chances that the action will be audited. The "audit-risk" is configured in the technology by entering a percentage chance of auditing an action, for an individual operator, an auditor, or an entire team.

For example, if we bring on a new follow-up team, we may configure their "audit-risk" at 100%, ensure that every action they perform on every claim will be audited. As the team proves themselves, we can reduce this "audit-risk" to 50% and later to 20%, as long as the auditors find few errors in their audits.



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Most doctors I talk to today are worried about post payment audits but few of them ask the question, who is auditing my billing company? If they are looking for a billing company they should also be asking how that billing company measures quality and what the internal process is for this at that company. Below is an interview I conducted with Erez Lirov.

Most doctors I talk to today are worried about post payment audits but few of them ask the question, who is auditing my billing company? If they are looking for a billing company they should also be asking how that billing company measures quality and what the internal process is for this at that company. Below is an interview I conducted with Erez Lirov.

Erez's experience spans heading technology innovation for both startups and established companies in healthcare and financial services at Vericle, TradeMD, Sparta Systems, National Bank of Canada, PIMCO, and Harris Bank. Erez was awarded US patent 6,785,810 in data security. Erez also graduated with a BSc degree from Princeton University in1999.

Dr. Brian: Erez. When you started your billing company there were just a few doctors and hundreds of claims. Now there are hundreds of doctors and 80,000 plus claims/month. Some docs I talk to want a smaller company. Can you explain to doctors who are thinking about joining this "network" why they should see a big billing company as a positive thing?

Erez: A continuously growing billing network in terms of claim volume allows real-time audit of payer performance, timely discovery of underpayments and delays, reconstruction of payer's underpayment rules, and effective and informed follow up. However, the risks of errors and sabotage increase too in step with billing network volume because some data entry and most payment denial follow-up require manual processing.

Dr. Brian: So the bigger we grew the more error prone the things became and so more errors occurred?

Erez: Yes.

Dr. Brian: Why is that?

Erez: Early quality assurance (QA) processes, limited to occasional and random spot-check of data and follow up records, proved sufficient in discovering sub-standard data entry and follow up performance or saboteurs in small-size billing networks but failed to adequately mitigate error and sabotage risks in a larger size billing network. Accordingly, a billing network requires scalable audit processes to effectively catch and correct processing errors or sabotage attempts.

We need a way to be able to immediately pin-point problem areas so that they can be corrected. If an operator or an auditor is not improving their overall quality and continues to make mistakes, then they must be replaced.

Dr. Brian: How do you manage this problem across hundreds of operators and dozens of auditors?

Erez: The new and improved auditing process must make sure that it is:

1. Timely: We plan on a 24-hour turn-around-time
2. Comprehensive: Enough claims are being audited
3. Effective: Operators or auditors with a high error rate are flagged for retraining or replacement
4. Efficient: BPOs fund each level of increased scrutiny caused by their error

Dr. Brian: That is a huge task when we are talking about potentially hundreds of thousands of claims each month. How do you plan on accomplishing this?

Erez: Yes, and to accomplish this we have introduced our vision of a Multi-Level Quality Control (MLQC) program which is made up of four has four main improvements over the traditional, manual audit process:

1. Automated reporting (Pin-point "bad apples")
2. Multiple audit levels (BPO, QA Team, SPOC, SPOC Manager)
3. Audit workflow management (QA Workbench)
4. Automated sampling ("audit-risk" database)

See Part 2 coming soon!



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