Reprinted from the NYTimes – 4.12.2016 Written by on a Friday night. Dhruv Khullar, M.D., M.P.P. is a resident physician at Massachusetts General Hospital and Harvard Medical School.
Too good and spot on not to share – this gentle and beautifully written reminder for everyone in the healthcare field!
Friday night in the emergency department is about what you’d think. It starts off slow: a middle-aged man with a middling pneumonia; an older nursing home resident with a urinary tract infection that is making her delirious. Then come two heart attacks at the same time, followed by a drunken driver with a head bleed and half his rib cage fractured. At midnight, in roll the inebriated members of a bachelorette party that has not gone, one assumes, according to plan.
Amid the chaos, I break off to greet a thin, older man, quietly bundled up on a hallway stretcher. I look over his chart and prior scans. His prostate cancer has grown through several chemotherapy regimens. His spine is full of tumor and he’s been vomiting everything he eats or drinks for weeks. He can’t move the left side of his body after a recent stroke.
He smiles a charming, crooked smile. “It hasn’t been the best month of my life.”
“I’m sorry to hear that.”
I ask him about his symptoms, when they started, how bad they’ve gotten. He asks me where I went to medical school and if I have a girlfriend. I ask him if he’s dizzy and whether there’s blood in his stool. He tells me he emigrated from Greece 50 years ago, almost to the day. He won a scholarship to M.I.T. and studied electrical engineering. There he met his wife — “a fantastic cook” — and started his first company.
Now, decades later, he’s alone — in a crowded emergency room, on a Friday night, his wife dead, his two sons overseas, a nurse visiting him once a week at home to help him with some medicines and make sure the various tubes coming out of his body aren’t infected.
I ask him when he last moved his bowels. “Son, I’m dying. I’m alone. One day you’ll learn there’s more to a good death than how often I move my bowels.” I pause.
I am better at many things than I was when I started my journey to become a physician more than a decade ago. But I am not sure that understanding patients as people — and placing them in the context of their long, messy, beautiful lives — is one of them.
Doctors are trained first to diagnose, treat and fix — and second, to comfort, palliate and soothe. The result is a slow loss of vision, an inability to see who and what people are outside the patient we see in the hospital.
As we acquire new and more technical skills, we begin to devalue what we had before we started: understanding, empathy, imagination. We see patients dressed in hospital gowns and non-skid socks — not jeans and baseball caps — and train our eyes to see asymmetries, rashes and blood vessels, while un-training them to see insecurities, joys and frustrations. As big data, consensus statements and treatment algorithms pervade medicine, small gestures of kindness and spontaneity — the caregiving equivalents of holding open doors and pulling out chairs — fall by the wayside.
But all care is ultimately delivered at the level of an individual. And while we might learn more about a particular patient’s preferences or tolerance for risk while explaining the pros and cons of a specific procedure or test, a more robust, more holistic understanding requires a deeper appreciation of “Who is this person I’m speaking with?”
In Britain, a small but growing body of research has found that allowing patients to tell their life stories has benefits for both patients and caregivers. Research — focused mostly on older patients and other residents of long-term care facilities — suggests that providing a biographical account of one’s past can help patients gain insight into their current needs and priorities, and allow doctors to develop closer relationships with patients by more clearly seeing “the person behind the patient.”
In the United States, Medicare recently began paying doctors to talk with their patients about end-of-life planning. These conversations allow patients to discuss and explore their preferences about a slew of complex medical interventions, including clinical trials, transfers to the intensive care unit, use of mechanical ventilation or feeding tubes, and the desire to die at home or in the hospital. These discussions, too, may benefit from a biographical approach, in which patients are able to elaborate on what is and has been most important in their lives. To better serve patients, we need to see not only who they are, but also who they were, and ultimately, who they hope to become even at the end of life.
How much more effective would we be as diagnosticians, prognosticators and healers if we had a more longitudinal understanding of the patient in front of us? If we saw not just the shrunken, elderly Greek man on the emergency room stretcher in front of us, but also the proud teenager flying across the Atlantic to start a new life half a century ago?
The emergency room is, by its nature, an arena designed for quick thinking and swift action. There are certainly other places, times and circumstances more conducive to probing goals-of-care discussions and lengthy forays into the internal lives of patients.
Still, there is always some moment of grace and meaning we can help patients find in the time they have left, a moment that recalls a time when they felt most alive — even if it’s just a fleeting conversation about gyros and electrical circuits in a busy emergency room, late on a Friday night.
“When I got married at the age of 52 my private practice flourished, because we built a separate building that housed my then-husband’s practice of psychotherapy on one side and my OT practice on the other. In 1984 we moved from New Jersey to Vermont and I was a consultant for the school system there.I tried to retire five times – as an OT, as a private practitioner, as an author – but it never works. I went back to school to become an artist in 1997 and that has been helpful in drawing my inventions.
In 2013, I saw David Kelley – the founder of the design firm IDEO – on the TV programme 60 minutes. When I realised he accepted, and really respected, people from a varied background, I thought, “I have a unique kind of life experience and designing skills – I could be of value to their firm.” I was 89.I typed a letter, which might have caught their attention because they don’t get many communications by “snail mail”- I have macular degeneration so my eyesight prevents me from using computers.”
Read more at:
(1) NYS has become the latest and last state to require licensure for OTAs!
(2) The OT/PT telehealth parity bill was also signed into law. The law states that deductibles, co-insurance or other conditions for coverage of telemedicine cannot differ from those for in-person visits. It also differentiates between telemedicine and telehealth. Telemedicine, it says, refers to real time, two-way electronic audiovisual communications, while telehealth can include telephones calls, remote patient monitoring devices or other electronic means of diagnosis, consultation, education and treatment.
1o. Job Descriptions – clinical and non clinical – new for 2015
Good communication is at the heart of patient safety, cultural sensitivity, and the pillar of quality care. Most of the time we focus on the message we are communicating, and how best to choose words that adequately communicate the message we are trying to convey, while using language that the patient and family fully understand. Yet, as pointed out in a great NY Times Op Ed Piece this week (Doctor Shut up and Listen by Nitmal Joshi ), we need to focus equally on the other side of the communication equation, listening.
The core skill of good communication is listening. Listening requires that we put aside any thoughts of what we want to say next and just attend to the person talking. It requires that we be curious enough and interested enough in the other person to make sure we are clear about what they are saying, asking for clarification and reflecting back to make sure we have heard correctly. It is about taking seriously that the conversation is not about us but about the other.
Good listening is about understanding that good listening is often enough. Do patients want an answer to a question or do they just want me — as the therapist — to listen to them? They want to be heard and, through that hearing, respected. Do they want my words or do they want my attention and presence? Even when the patient is looking for an answer, listening and creating a space for the patient to reflect may be all they need to come to the answer themselves rather than having me impose it on them.
Don’t minimize listening by saying we “just” listened. This so simple but so powerful that often it is one of the best interventions we can make with our patients and their families.
Medicare Claim Re-openings and How to Request a Reopening
In the case where a minor error or omission of your Medicare claim submission resulted in a claim denial, you can request Medicare to reopen the claim so the error or omission can be corrected, rather than having to go through the appeal process. There is no need to request an appeal/redetermination if you have made a minor error or omission in filing the claim, which, in turn, caused the claim to be denied. You can request a reopening for minor errors or omissions either by telephone, in writing or via NGSConnex. You have one year to request a reopening from the date on your RA.
The clerical error reopening process is not a part of the formal appeals process, but it allows providers to make a minor change to a previously filed claim, if the original claim has been denied or reduced. CMS provides the instructions for reopening activities conducted by MACs. Section 937 of the MMA required CMS to establish a process whereby providers, physicians, and suppliers could correct minor errors or omissions outside of the appeals process.
Clerical error reopenings can be done on the phone, in writing or via NGSConnex, for providers to correct minor errors, clerical errors, or omissions. The MAC reserves the right to refuse to adjust a claim as requested if it appears that such an adjustment would risk incorrect payment on any claims not identified for correction.
A provider, physician, or supplier may request a reopening up to one year from the receipt of the initial remittance notice. If the provider, physician, or supplier would like to request a reopening after the one-year time limit has expired, they may request the reopening in writing. Documentation supporting good cause to waive the timeliness requirement must be included.
CMS issued interim final regulations, which state clerical errors (which CMS likens to MMA’s minor errors or omissions), are defined as human or mechanical errors on the part of the party or the contractor, such as:
- Mathematical or computational mistakes;
- Transposed procedure or diagnostic codes;
- Inaccurate data entry;
- Misapplication of a fee schedule;
- Computer error; or,
- Denial of claims as duplicates which are denied as a result of a clerical error or minor omission and require a change on the face of the claim (i.e., adding or removing a modifier) in order for the claim to be reopened. (Exception: We will reopen claims that denied as a duplicate when multiple services have been billed and some are denied due to a separate claim submission; i.e., when three radiology services have been paid on one claim and a fourth one denied as a duplicate due to a separate claim submission and a request is made to allow a total of four services. A reopening can be performed even though the claim was submitted correctly and no change is being made.)
- Incorrect data items, such as provider number, use of a modifier or date of service.
The basis of a clerical error or minor omission reopening is to correct the minor clerical or minor omission that resulted in an initial claim denial or reduction.
Types of Issues that can be performed as clerical error or minor omission reopenings:
- Increase number of services or units (without an increase in the billed amount)
- Add/change/delete modifiers such as 24, 25, 54, 57, 58, 59, 76, 77, 78, 79, 80, AS, or AQ (Note: Postoperative modifiers 24, 25, 57 and 58 can be added to a paid claim so the provider can submit a procedure code without having it reduced by the unrelated visit.)
- Procedure codes
- Place of service
- Add or change a diagnosis on a denied service
- Billed amounts
- Incorrect provider number to deny
- Incorrect HIC to deny
- MSP unrelated – non-GHP records
- Correcting rendering provider PTAN/NPI
- Addition of referring provider PTAN/NPI
- Add date last seen on the claim
- Date of service – the date of service change must be within the same year
- Services billed in error
- Refunds (except 935 refunds)
Types of Issues that cannot be performed as clerical error or minor omission reopenings. For these issues providers must submit a redetermination request in writing:
- Comprehensive Error Rate Testing (CERT)
- Provider enrollment issues
- Claim denial due to no response to a development request
- Established Recovery Auditor (RA) overpayment (Telephone only)
- Services with a high dollar amount ($7,500 or more)
- Wrong payee
- Complex claim situations (such as ambulance, anesthesia, Not Otherwise Classified codes, claims with modifiers 22, 23, 53, 62, 66, GA or GY or any other claim which requires analysis of documentation).
- CMS input (e.g. services after date of death)
- If there are multiple surgeries on multiple claims for the date of service in question
Some situations would not be appropriate for the reopening or redetermination process:
- If the original denial is rejected as unprocessable, submit a new claim
- If the claim in question is in process, you must wait until after the claim has processed before requesting a reopening
- If there has been no claim submitted, submit a new claim
|Level/Type||Time Limit||Amount in Controversy
Required (after deductible and coinsurance)
|Telephone Reopening||Within 1 year of receipt of the notice of initial determination.||No minimum|
|Written Reopening||Within 1 year of receipt of the notice of initial determination and within 4 years after the date of the initial determination, when the situation establishes good cause.||No minimum|
Providers may request a reopening of the original claims processing decision by contacting the Appeals Telephone Reopening Unit (TRU).
The TRU can be used when you wish to revise the initial determination or redetermination of a specific service or claim for minor clerical errors. If you have a general question or need to talk to someone about an issue that cannot be reopened, please contact our Provider Contact Center.
TRU representatives will reopen claims to correct minor, uncomplicated, provider or contractor clerical errors or omissions. However, TRU representatives cannot add items or services that were not previously billed. Please Note: Reopenings are granted at the contractor’s discretion; a claim may not be appealed if contractor decides not reopen the claim.
With the availability of the electronic remittance advice you can know the outcome prior to the complete finalization of a claim. Please ensure the claim has finalized prior to calling the TRU line to request changes to the claim.
Note: Unsolicited faxes will be returned to the sender unprocessed.
Using NGSConnex to Submit a Redetermination or Reopening Request
NGSConnex, a free and secure web-based application, has a convenient option available that providers can use to submit an appeal request for a claim redetermination or reopening online instead of submitting a paper appeal. Providers can also check the status of redeterminations/reopening requests.
For complete instructions on using NGSConnex for submitting a reopening request, visit our Reopenings for Minor Errors and Omissions section of our website.
Written Reopening Requests
Jurisdiction 6 providers in Illinois, Minnesota and Wisconsin should mail written reopening requests to:
National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475
Jurisdiction K providers in Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont should mail written reopening requests to:
National Government Services, Inc.
P.O. Box 7111
Indianapolis, IN 46207-7111
Be sure to include the following information with your reopening request:
- The beneficiary’s name
- The Medicare HICN of the beneficiary
- The specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and
- The name and signature of the person filing the request
Reopening requests for issues requiring documentation such as adding modifier 22 and redetermination of overpayments are not permitted. These must be submitted as a written redetermination request.
Info from: http://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/job-aids-manuals/
Many of us remember the merger mania in healthcare that occurred in the 1990’s, and how the push toward consolidation that started with hospitals trickled down to the private practice therapy sector. If we fast forward to 2014, it is readily apparent that the “urge to merge” is back. We see local hospitals in a merger frenzy, and local MDs leaving private practice to become hospital employees. I have more and more therapists contacting me about practice sales. Yet, a strong but dominant voice, namely the Federal Trade Commission, is beginning to weigh in on the topic. Citing antitrust laws, particularly the Clayton Antitrust Act of 2014, they have successfully blocked some deals using antitrust enforcement as a powerful tool to dampen conglomeration fever.
Hospitals say they are acquiring other hospitals and physician groups to comply with provisions
of the Affordable Care Act and take advantage of incentives that encourage hospitals and doctors to integrate their operations and collaborate to control costs and improve care. The concern is that hospitals that face less competition can charge substantially higher prices, which according to Martin Gaynor, Director of the FTC’s Bureau of Economics could be as high as 40-50%. In the last two years the FTC intervened and blocked hospital mergers in Albany Georgia, Toledo Ohio and Rockford Illinois. Although the decisions are currently being appealed, the message is strong. “Vague promises and aspirations that an acquisition will reduce costs and improve care are not sufficient” said Julie Brill, a member of the FTC.
When hospitals and doctors join forces, their goal is not just to control costs or improve care, but to “get increased leverage” in negotiations with health insurance companies and employers, according to Ms. Feinstein, Director of the Bureau of Competition at the FTC. “They say they need better rates so they will have more money to invest in their facilities.When you strip that down, it’s basically just saying, ‘We want a price increase.’ Even if the price increase is motivated by a desire to invest more in the business, that’s problematic. That incentive to invest may not be there if you don’t have competition as a spur to innovation — if you’re not worried about losing business to the hospital down the street.”
Look back to the first merger mania in the 1990’s particularly the state of Massachusetts, which let its two most prominent hospitals — Massachusetts General Hospital and Brigham and Women’s Hospital, merge into as Partners HealthCare. Investigations by the state attorney general’s office of that state have documented that the merger gave the hospitals enormous market leverage to drive up health care costs in the Boston area by demanding high reimbursements from insurers that were unrelated to the quality or complexity of care delivered. Twenty years later, the current Massachusetts Attorney General, Martha Coakley is trying to rein in the hospitals with a negotiated agreement that would at least slow the increases in Partners’ prices and limit the number of physician practices it can acquire.
What’s the take away for therapy practices?? Carefully examine your “urge to merge” or be acquired, probably the second most important decision of your professional career. Make sure your motivation is not based on panic, and that you are not being re-active rather than pro-active. As hard as it is to bring a merger to fruition, it is harder still to undo!
There is no denying that the ice bucket challenge continues to be an unqualified success, despite the naysayers who have negated and criticized it from many angles – waste of water, and more of an exercise in raising awareness of one’s own craziness, altruism, “slacktivism” and/or attractiveness in a wet T-shirt.
Here’s why I am so happy it has taken off. Back in the day (30 plus years ago), I was one of the first OTs to consult with the MDA ( Muscular Dystrophy Association), and provided services to children and adults with many neuromuscular diseases. I was always hardest hit by the people with ALS. The decline in function, and decrease in strength was steady, apparent and ongoing. The impact on families was huge. Living rooms became makeshift bedrooms to accommodate hospital beds, hoyer lifts and the like. Spouses became caretakers, while secretly mourning the loss of their spouse as they knew them. Looking back, the challenges as an OT were paramount. With the physical and functional decline so swift and non forgiving, I was constantly challenged to think on the spot, make immediate accommodations, re-purposing and intuitive adaptations to the environment. All in the hope of making the moment, or the day more tolerable for the family and patient. What worked one day didn’t the next as the disease ran its course. My feelings of inadequacy and frustration matched the family’s feelings of desperation and isolation, yet in a way it was OT at its finest.
The Ice Bucket Challenge is raising public awareness of ALS in addition to raising money for research on the disease. Like most fundraising, the efforts will focus more on the cure while families and therapists focus on making day to day living as tolerable as possible. ALS is classified as an “orphan disease”, since fewer than 200,000 people get the diagnosis annually. Generally that means there is less research and clinical trials for treatment. ALS has never been and never will be as profitable a target for pharmaceutical companies to invest millions of dollars in as they do with more prevalent diseases ( ie cancer, arthritis etc.).
The New York Times reports that in the last few weeks, ALSA has received $13.3 million and welcomed 260,000 new donors. While the President of the Association Barbara Newhouse says she appreciates the monetary aspect of the Ice Bucket Challenge, she says, “the visibility that this disease is getting as a result of the challenge is truly invaluable.” Monetary donations coupled with social-media-friendly stunts build awareness and encourage others to give in a way that quietly donating cash does not. That’s what that silly tub of cold water does; audiences get a little entertainment, which helps the viralness of the cause and encourages donations. It also strives to make people want to learn more about the disease, and what organizations like the ALS Association are doing to fight it and provide assistance to those living with it.”
Practice owners who work with neuromuscular conditions may want to jump on this bandwagon- a twin win situation, and what I call “cause –related” marketing. It can be great publicity for your practice and a great way to help raise money and awareness. ALS is not only an incurable disease, it is an underfunded one as well.
By my second lecture, I have taught my students about the healthcare dollar pie and its 3 pieces:
Piece 1 for the patient or consumer
Piece 2 for the service/medical provider
Piece 3 for the insurer/payor
I always tell them how the size of the pieces shift over time reflecting the cycles within healthcare delivery. Most of my students were not even born when patients got a big piece of the pie – that is, when patients received the services they needed for the amount of time that they needed them, all without pre-authorization! Many students can barely remember when the piece for the medical provider was big- when doctors were “rich” and therapists could become financially successful. My students do learn about the big piece of the pie that the insurers are eating, how well their stocks are doing, how much their CEOs are making, and how big their pended/denied departments are. And just in time for this fall’s lecture, the pie is shifting again, and in the wrong direction.
Yesterday, I received a letter from my insurance company (BCBS), informing me, as is required by law, that they are seeking a 17% increase in the premium for the new policy I got in January 2015. This both shocked and bothered me on many levels. Year one and the insurers are already taking “affordable” out of the Affordable Health Care Act. More disturbing is that this insurance company has systematically been lowering the fees paid to private practitioners –lowering the fee, eliminating CPT codes and time/ modality based payment in favor for flat fee methodology and bundling. While they systematic deny therapists a rate increase, even one based on cost of living and instead are lowering fees or canceling contracts, they claim they need a 17% increase in part because of the rising costs of medical care, a new pool of customers, and new providers.
I am beginning to no longer see the 3 pieces of the healthcare dollar pie. Instead, slowly it is becoming one pie solely for the insurers and payors, with 2 crumbs, one for providers and the other for patients.