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November 11, 2015

Using the CMS Five-Star Quality Rating System

Nephrologists are being handed a big challenge by Medicare’s insistence on a more integrated and comprehensive approach to kidney care. The expectation is clear: Deliver better outcomes at lower costs.

Fortunately, a new tool from the Centers for Medicare and Medicaid Services (CMS) is making it easier to help educate dialysis patients and their families.

The federal government’s newly updated guide, the CMS Five-Star Quality Rating System for dialysis, helps simplify the decision of where to receive treatment by giving patients and caregivers an easy way to compare kidney care centers. Yes, really! We, as physicians, can help with the education process, especially if we understand how the system works.

Read more…

October 7, 2015

Big Data, Big Deal

This is a guest post by Emily Bonham, director of product management for Falcon Physician, DaVita HealthCare Partner’s nephrology-specific EHR software

It seems to be everywhere: in the news and on TV, referenced by politicians and tech experts. And now it’s infiltrating healthcare. “Big data” is more than a trend—it has the potential to change the way physicians interact with and treat patients.

What exactly is big data? Essentially, it is the concept of gathering and curating massive data sets to track trends over time. Within the healthcare space, this is of particular interest for harnessing patient data to predict—and potentially prevent—issues before they become chronic conditions. It sounds like a physician’s dream: knowing a patient’s kidneys are going to fail before it happens could save thousands of lives.

The development of electronic health record (EHR) technology has allowed for continuously flowing, ever-growing patient data to become centralized and usable—not only to a specific doctor, but to physicians across the country and in all specialties. The devil, as usual, is in the details. In this case, that means how to leverage all this data into something tangible, usable and beneficial.

The EHR industry is shifting toward data-driven tools, rather than data collection measures. These tools will offer physicians new analytical insight when making treatment decisions at the point of care to reduce the overall cost of patient care. Data trend models, analytics and tracking features will potentially allow physicians to better treat patients’ ailments, and even avoid illnesses in the first place.

While these concepts are currently in development and will depend on a number of factors, including the interoperability between countless EHR systems and data sets, it is encouraging to know that all data being collected through EHR systems can be used for  a purpose beyond simply ticking a Meaningful Use box. This data is destined to improve the nature of the healthcare system, as well as aide physicians in making the most informed care decisions possible: definitely a big deal.

Emily Bonham is the director of product management for Falcon Physician, DaVita HealthCare Partner’s nephrology-specific EHR software. Ms. Bonham has 14 years of experience in health care software management and is passionate about solving health care issues and patient needs with technology-based solutions. Directing product management, user experience and marketing at Falcon Physician, Ms. Bonham ensures her teams’ focus toward understanding the ever-advancing nature of health care IT and anticipating the needs of nephrologists to serve patients in the most innovative, effective and compassionate manner possible. Her previous work includes independent physician medical practices specializing in nephrology, bariatric surgery and endocrinology in addition to organizations such as Blue Cross Blue Shield of Massachusetts, Tufts Health Plan, Cleveland Clinic, Kaiser and the Blood Institute of Wisconsin.

July 16, 2015

S61.451A and My Trip to the Denver Zoo

Not being a native to Denver and fancying myself a connoisseur of city zoos, I made my first visit to the Denver Zoo this past Sunday. I must admit I was impressed! Bigger than I imagined, clean, well kept and easily accessible with a broad representation of flora and fauna, it was everything a city zoo should be. While there I observed something I had not previously seen: a zookeeper hand-feeding a hippopotamus! I wondered; does that seem safe? Heaven forbid there should be an accident. As a physician my mind quickly shifted to the hand/arm trauma inflicted from the potential bite of a hungry hippo.


This morning I returned to work and the anxiety surrounding preparation for ICD-10. Remembering my experience on Sunday, I couldn’t help myself. I searched to see if an ICD-10 code exists for a Hippopotamus bite. The good news is, no worries, CMS got it covered: code S61.451A, “Hippopotamus bite, right hand, initial encounter.” Now for you obsessive coders out there, that is different from S61.451D, “hippopotamus bite, right hand, subsequent encounter.” Can that really happen twice? If so, ICD-10 has it covered!

This seems so silly. Understandably CMS is concerned with public health, and therefore is using ICD-10 to monitor health trends, but really – how many hippo bites happen each year?

What about code R46.1, “bizarre personal appearance” or code Z73.1, “type A behavior pattern?” Are these diagnoses public health concerns? That’s a lot of people! Better yet, code W56.22XA, “struck by Orca, initial encounter” or yes, W56.22XS, “struck by orca, subsequent encounter.”  With 68,000 codes, the ICD-10 update has everything covered from falling from a tree to being sucked into a jet engine. And yes, sucked into a jet engine, subsequent encounter is there, too!

Data on what it costs the government to design and implement this update is difficult to locate, but I am painfully aware that it costs physician practices way too much. Come October 1, 2015 practices will face another government payment uncertainty if there are any glitches in the transition from ICD-9 to ICD-10. There are several potential risks to your practice, including the following.

  • CMS has warned that your denial rates could soar to 100-200%
  • The American Health Information Association has reported that the majority of providers have not yet conducted ICD-10 testing[1]
  • If you do not have a bank line of credit, your cash flow may vanish thanks to potential payment or processing glitches with new codes, meaning there will be no payments made to your practice

So despite the comical nature of many ICD-10 codes, what physicians are facing is no laughing matter. There is still time to prepare. For helpful resources and more information on the services Nephrology Practice Solutions (NPS)* provides to help practices prepare for the transition to ICD-10, check out the NPS website.

*Dr. Provenzano consults with NPS.

[1] http://www.ihealthbeat.org/articles/2015/6/18/survey-providers-lag-in-icd10–testing-ahead-of-transition#.VYgnTGsuq9o.twitter

June 16, 2015

Meaningful Use Stage 3: What does it mean for nephrologists?

This post is by Mark Kaplan, M.D., vice president of medical affairs for DaVita Kidney Care

For many in the throes of demonstrating for CMS’ Meaningful Use (MU) Stage 2 requirements, it may be too overwhelming to even consider what Stage 3 has in store. CMS released the Stage 3 Proposed Rules on March 20, and while 301 pages may seem long, it is sparse compared to previous rules.

There are eight objectives to meet for Stage 3, some which have multiple measures associated with them. For example, the CPOE objective requires meeting measures related to Lab Order Entry, Medication Order Entry, and Diagnostic Imaging Order Entry. Some objectives allow for meeting only two of the three measures, providing at least a semblance of flexibility.

At a glance: Stage 3 Objectives

  1. Protect Patient Health Information
  2. Electronic Prescribing (eRx)
  3. Clinical Decision Support (CDS)
  4. Computerized Provider Order Entry (CPOE)
  5. Patient Electronic Access to Health Information
  6. Coordination of Care through Patient Engagement
  7. Health Information Exchange (HIE)
  8. Public Health and Clinical Data Registry Reporting

Not surprisingly “payment adjustments,” (the CMS term for penalty), are still being enforced. Not attesting to MU in 2015 will cause 2017 to sting, as you’ll be receiving a 3% reduction in your Medicare Part B billings: 3% translates to roughly $7,000 for the average nephrologist.

Audits are another fact of life, with 5-10% of providers being subject to audit with failure rates are somewhere between 21-24%. Failing to pass an audit means giving CMS back any incentive dollars received.

As interpreting the objectives of, and meeting the requirements for, Meaningful Use become more important for the financial health of your practice, you need a vendor who understands this. It’s more important than ever to find a vendor who works with you like a partner.

Mark R. Kaplan, M.D., previously practiced nephrology in Nashville, Tennessee, where he launched and developed the practice’s clinical research program. He served as the vice president of clinical research at Renal Care Group and Fresenius Medical Care, and was chief medical officer at DSI Renal, Inc. before joining DaVita Kidney Care. Dr. Kaplan earned his medical degree at Vanderbilt University, and then completed a year as chief resident in internal medicine at the Nashville Veterans Affairs Medical Center, and a clinical and research fellowship in nephrology and hypertension at Harvard University Medical School’s Brigham and Women’s Hospital in Boston.

January 30, 2015

Is the Grass Truly Greener?

Something is afoot in the ranks of nephrology and the cat is out of the bag. Kristina Fiore of MedPage recently published a telling piece, Match Reveals No Love for Nephrology, summing up a recent analysis done by American Society of Nephrology leadership and published in the Clinical Journal of the American Society of Nephrology. That analysis suggests that interest in nephrology is dwindling. The data shows that the number of applicants per nephrology position has dropped from 1.5 in 2010 to 0.68 in 2015 – resulting in 50 percent training-program vacancies.

Read more…

December 30, 2014

Top Two Landscape Changes for Nephrologists in 2015


As we find ourselves on the precipice of another new year, it seems only fitting to take some time to reflect on the past year and ponder what lies ahead.

How is the landscape changing for nephrologists in 2015?

Undoubtedly, there will be new trends in treatment methodologies and shifting government regulations. More than anything, I believe time will remain one of the top concerns for nephrologists in the coming year. Slow charting and manual documentation will continue to be the cause of many late nights working to get caught up. In addition, we are now expected to meet more complicated reporting measures, which will likely continue to increase. Though the task seems daunting, and converting to electronic methodologies may be bumpy at first, once the systems are up and running, documenting encounters can become a faster, easier and more efficient endeavor.

Another noteworthy finding in the field of nephrology is the shortage of up-and-coming nephrologists. According to an analysis from the  American Society of Nephrology, interest in nephrology as a career has been on the decline for quite some time, which is quite discouraging when considering America’s aging population and the associated increased need for nephrologists. The reasons for the diminishing nephrology workforce are numerous, but one large factor is thought to be Medicare’s interest in a more integrated approach to patient care. In 2015 and going forward, nephrologists will need to be knowledgeable about so much more than kidney care. Nephrologists will need to converse more with other doctors and become experts on transition of care.

While the pressures on our profession mount with an aging population, increased regulations and declining number of physicians choosing nephrology, we need to be proactive in the way we manage our practices in the future. We will likely need to completely abandon paper documentation and choose nephrology-focused electronic tools that will help increase our efficiency, productivity and reporting capabilities. We will also need to expand our knowledge base so that we can properly care for patients. The coming year may prove to be a pivotal one in the field of nephrology; hopefully we will have the time to appreciate it.

October 28, 2014

It’s All About the Numbers


As nephrologists we are all “about the numbers.” It’s how we make our living; it’s what distinguishes us from our colleagues. It’s what makes us different, special.

BUN, creatinine, anion gap, electrolytes, blood gases and on and on—we’re the experts, and patients depend on our knowledge and expertise. We rock!

But what about the numbers we don’t know (or the ones we ignore)? The numbers we depend on others to manage. The numbers that make the difference between a successful practice and a failing one. The numbers that put food on our tables!

As a physician you know a few numbers going in the wrong direction can dramatically impact a patient’s outcome. Same with your practice. Knowing the numbers that influence the financial health of your practice can mean the difference between good and great. A thorough understanding of some key metrics can help you assess if your practice is operating at peak performance or if there is room for improvement.

Days in Accounts Receivable (DAR)

The DAR is the average number of days from when a claim is entered into a system until it’s paid. The national average is 45 days; the longer a claim is in limbo, the higher the risk of it not being paid. You have done the work and should expect to be paid in a timely manner, but you must have the right processes in place or you will be leaving money on the table.

It’s nothing to be embarrassed about; it’s not what we were trained to understand or deal with. But like any other responsible business owner, we must see to it that we have delegated practice management to competent individuals.

You deserve the highest return you can get on your hard work; that takes talented people with specialized skills. What should you focus on? What are the numbers?

Revenue Realization Rate (RRR)

This is simply the percentage of claims that are paid to your practice, also known as the net collection rate. The higher this percentage the more cash flow your practice is driving. When claims are denied or go unpaid someone in the practice must address it in a timely manner. Wait too long, and you will miss your window of opportunity for payment.

Consider this example: an RRR of 85% means you are making only 85 cents on the dollar—yikes! That along with other practice income erosions (risk contracts, Medicare, Medicaid and commercial cuts) could put you in more trouble than you may realize.

Denial Rate

This term describes the percentage of claims denied by the payor. The industry average is 5-12%. Numbers beyond this range usually stem from challenges with billing procedures (i.e., your billers are doing a poor job). Billing correctly the first time will speed up cash flow and reduce work on the back end (and save you money).

A good practice-management system can detect coding errors and missing information early on (called scrubbing of claims). Reworking a denial claim is costly. The Medical Group Management Association (MGMA) found the average cost to rework a denied claim is more than $25! A hundred denied claims cost your practice $2500 in administrative costs! Additionally, MGMA says 50-65% of denials are never reworked. Do you know how many of your claims are being denied? Reworked? Again, more financial opportunity lost.

Missed Billing Entries or Slips

This refers to tracking of patient encounters and/or services you provide. Encounters not tracked immediately following the patient visit (or misfiled) can result in payment delay or missed payment opportunity. Educating your staff, revising your procedures and having a good practice-management system in place are a few ways to help manage this.

Overhead (OH) Percentage

A well-run nephrology practice has an OH of ~42%. Each practice is unique and there is a bell-shaped distribution of OH costs. Your OH percentage does not necessarily mean your practice is successful or is failing. Some practices with high OH are very successful (maybe their OH is due to costly deliverables or equipment) while simply having low OH does not guarantee success (low OH could be due to such measures as cutting back on staff who could deliver more of your billings). What is important is to track this number over time, know what it represents and understand its positive or negative impact on you business.

We are entering a new era in the business of medicine: an era where professional management of your business has become much more attractive, if not a necessity. Successful management can drive your bottom line, sending the savings directly to the practice. You can reach out to me or any teammate at Nephrology Practice Solutions if you would like to discuss your concerns or ask any questions. Or stop by the DaVita booth, #601, at ASN and ask for us.

October 2, 2014

Managing Your Practice Wisely—What’s Next?

practice management-blog

For those of you who know me, what I am about to opine on will not come as a surprise. For those of you who are new to me, my thoughts and my opinions, I welcome your feedback!

Let me start by laying out a historical timeline of nephrology practices over the past 20 years.

When I started practicing in 1988, the focus of most practitioners was to see patients, render good care, submit your billing, collect a paycheck and, at the end of the year, determine how the practice was doing financially.

Reimbursement was robust, so practices didn’t need to be efficient; we could be a little “loosey-goosey.” Our practice managers and billers were trained on the job, rarely experienced and never certified. This couldn’t and didn’t last long!

As regulations proliferated and reimbursement decreased, it became apparent to me that we needed to treat our practices as the small businesses they are. I began speaking and writing on this topic first as a Renal Physicians Association (RPA) board member and then as the RPA president. Many of you listened and benefited.

What are the key focuses in a fee-for-service world? Market what you are “selling,” do it well, increase your market, stratify your income streams (joint ventures, real estate, vascular access centers, etc.) and manage costs!

Many practices related to renal disease grew, expanded and prospered. But the majority of us have smaller practices (the average size is four nephrologists) and these account for 80 percent of care delivered. They render expert care in smaller markets. This puts extreme pressure on them to squeeze efficiencies from a relatively small book of business and remain viable.

As if that is not enough, the future will be risk management and integrated kidney care. You will be expected to focus on “patient-centered” care to consistently deliver better outcomes at lower costs; i.e., value-based care.

So, what is one to do to? How does one remain focused on excellent patient care while staying viable, profitable and not so stressed that it is no longer fun to practice?

Professional nephrology management!

Outsourcing expense management and achieving operational efficiency are key to your future success.

Determining your practice’s optimal staffing, overtime management, copay collections and collection ratios while maintaining cash flow is critical! There is no doubt that outsourcing these tasks to professionals is the most cost-effective path forward. Its gives you economy of scale and saves you time and grief.

An additional benefit: professional management will assist you in regulatory management (the Physician Quality Reporting System will put 4 percent of your reimbursement at risk in 2017).

Assistance managing your clinical data to present to and negotiate with payers, as well as help with intelligently participating in risk contracts, is critical to staying viable.

Costs—do you even know what it costs you to provide care? How can you accept a payment for a service if you do not know what that service costs you?

Stop the madness! You can stay independent and be professionally managed.

As nephrologists, partnerships are important. We have witnessed our colleagues in primary care, oncology, cardiology and other fields flock to the hospitals. This makes sense for them clinically and financially, but hospitals have absolutely no expertise in our world!

Our natural ally in caring for ESRD patients, when and where appropriate, is our dialysis partner. We have already tested the water with dialysis joint ventures, and while rarely perfect, they have been outstanding at providing great care for our patients in an economically responsible partnership.

Taking that relationship to the next level is appropriate and sensible. It is a smart business decision.

July 24, 2014

Socioeconomic Impact on ESRD?

Before I get started opining about my observations of the socioeconomic impact on end stage renal disease (ESRD), let me state that I am not an expert on this critical science and its implication on healthcare. Rather—after practicing 25 years in Detroit, once a proud city boasting the highest per capita income in the world (in 1960)—I am, as a physician, a keen observer of the impact of a failing city, its resources and its support systems on our most vulnerable citizens.

Priorities. We all have them, right? Family. Work. Church. Oh yes, and healthcare. Of course it’s there if or when you need it, right? That little card in our wallet is our safety net. Our focus on healthcare as a priority changes as we age or if we develop a chronic condition requiring attention.

One may argue that the above image is a concocted anomaly predicated on employment and therefore a vision held by the employed. So what of others, the chronically unemployed or even the recently unemployed, the less fortunate among us? What happens when the support system collapses around them?

Read more…

December 13, 2013

Working Can Benefit Those Suffering with a Chronic Illness

Physicians are trusted resources for patients. We have the ability to reinforce patients’ understanding of how they may live longer, healthier and happier lives. Assisting them in deciding whether to continue working when they start dialysis falls within the realm of being a resource. We can help patients evaluate many factors, such as the health conditions surrounding their kidney disease, dialysis modalities appropriate for them, their family life etc. Take Robert Gandy (mentioned below) for instance. Robert was able to fit dialysis into his lifestyle and continue working. He states, “Going to my job takes me away from the fact that I have end stage renal disease”—a sentiment that’s been echoed by many of my patients over the years. After reading about Robert and the benefits of working on dialysis, I hope you’re able to approach your next patient, the one after that, and so on and so on with the dedication and care of an educator. Read more…

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