Updates | CMM Study Guide
Providing approved approved updates even before the next edition is published!
Approved updates to the 5th Edition Fundamentals of Health Care Management for Physician Practices and Ambulatory Health Service Organizations (CMM Study Guide) will be listed here by page number.
Please feel free to suggest an update. If approved, your suggestion will be listed on this page and appear in the next published edition of the manual.
Updates and corrections pending the 6th Edition
Page 5
Ensure the most specific and appropriate ICD-10 codes reflect the accurate level of medical necessity that justifies each Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) Level II code.
Page 10
Medicare Overview
Medicare has four parts (Part A, Part B, Part C, and Part D). Understand when Medicare is secondary payer (MSP). Medicare would be the secondary payer (MSP) under these conditions:
• Patient is age 65+ with a Group Health Plan (GHP) through their own or through their spouses employer if the employer has 20 or more employees
• Patient is disabled, under 65 and covered by a family members GHP, if the employer has 100 or more employees
When Medicare is primary, coordination of benefits works with a Medigap plan. There are many different levels of Medigap plans. Medicare coordinates with a patient that has both Medicare and Medicaid.
Page 29
False Claims Act [31 U.S.C. §§ 3729–3733]
… In 2020 2023, the maximum penalty is $23,331 $27,018 per claim.
Page 67
Americans with Disabilities Act (ADA)
…Title 1 Title I applies to any employer who has had 15 or more employees for each workday in 20 or more calendar weeks in the current or preceding calendar years. (changing the #1 to capital letter I)
Page 105
HIT use (most specifically EHRs with a practice management system or PMS) can provide small practices the following benefits:
EHRs integrated with a PMS e (most specifically EHRs integrated with a practice management system or PMS) can provide small practices the following benefits:
Page 159
Telephone calls
It is important to notify patients that an answering service will respond to calls after normal office hours, or an answering machine is used with a number provided for emergency problems. Patients appreciate knowing your practice and physicians are always accessible by phone. Never print the physician’s beeper cell phone number.
Page 165
Tracking by Source
Tracking by source is a broad category that includes patient referrals, colleague referrals, Yellow Pages internet/Google, open house, newsletter, health fair, etc.
APPENDICES
Page 190
Marketing
The compliance program will require Physician marketing requires honest, straight forward, fully informative, and non-deceptive marketing devices for their laboratory and for the medical practice as a whole.
Page 190
Medical Insurance
The part of Medicare that helps pay for medically necessary physician services, outpatient hospital services, and a number of other medical services and supplies not covered by the hospital insurance part of Medicare, as well as some home health services.
A form of entitlement that allows you to receive payment or reimbursement for your healthcare expenses. This benefit is typically offered through a contract with a health insurance company, an employment-based group health plan, or a government program such as Medicare, Medicaid, or the Children's Health Insurance Program (CHIP).
FORMAT & TYPOS
Page 9
NOTE: If secondary insurance exists, and the secondary is not automatically billed by the primary, the claim will have to have the ERA or explanation of benefits (EOB) attached when the claim is sent to secondary insurance. Medicare will automatically generate claims to any plan that offers a CMS approved MediGap Medigap plan. Supplemental insurance covers many of the out-of-pocket expenses not paid by Medicare.
Page 50
– With the physician(s)/owner(s)
In this meeting, the practice manager reports what is going on with the practice and employee staff and discusses problems and alternative solutions. The practice manager should structure the meeting around the Five Functions of Management, five functions of management, discussing each element in turn.
Page 52
The Employee Handbook should include:
– The welcome and introduction
– General employment policies
– Benefits
– Employee responsibilities including safety policies and discipline procedures. (remove the period)
– At Will Employment
Page 57
Engineering Cooperation Consent from Employees
Page
Page 88
General considerations for vendors and contracts for routine supplies include some basic concepts:
(bullet the list, keep all original text)
Vendor relationships…
Establish accounts…
Order bulk…
Be familiar…
Don’t allow…
Purchase office…
Every six…
The employee…
Refrain from…
Communicate with…
Page 90
References from current participants
(revise bullet format, text is the same)
Contact the offices of several physicians who participate in the plan(s) you are considering.
Ask the practice manager or reimbursement specialist in that practice the following questions:
If this is a fee-for-service plan, what is the turnaround time for payment of a submitted bill?
If it is a capitated plan, do payments arrive as promised?
Does an updated list of current enrollees accompany the capitation check each month?
How many claim denials do they average each month?
What are the specific administrative or procedural problems?
What is the average age of their accounts receivable in the plan?
If the plan is a fee-for-service, what percentage of their full fee does it cover?
Has participation in the plan increased the patient base and added revenue to the practice?
Page 99
An example of facilities management concepts that are covered in other sections of this manual, is the fact that there are physical access controls required under HIPAA to protect the security of secure protected health information.
Page 102
Although CAQH started a uniform credentialing program around 2000, the UPD has simplified and standardized the process. Most payers in the nation have adopted this program. Physicians who participate and regularly update (UPD requires updates 3 times per year – CAQH automatically sends an email message reminder to review, update any information that has changed and to attest.
Page 123
Practice 5: Practice 5. Physical Access Checklist
ONC Checklist: checklist http://www.healthit.gov/sites/default/files/security-checklist-practice-5.pdf
Practice 6, Practice 6. Network Access Checklist
ONC Checklist checklist http://www.healthit.gov/sites/default/files/security-checklist-practice-6.pdf
Practice 7. Backup and Recovery Checklist
ONC Checklist: checklist http://www.healthit.gov/sites/default/files/security-checklist-practice-7.pdf
Practice 8. Maintenance Checklist
ONC Checklist checklist http://www.healthit.gov/sites/default/files/security-checklist-practice-8.pdf
Practice 9. Mobile Devices Checklist
ONC Checklist checklist http://www.healthit.gov/sites/default/files/security-checklist-practice-9.pdf
Page 136
Marketing in the age of e-Tools
Websites, Patient Portals, Patient Health Records, Telehealth, Provider Rating Sites and Social Media are all useful e-tools.
Page 142
Characteristics of consumers (remove the periods)
Knows more about consumer products in general.
Is more knowledgeable about healthcare issues, medical problems, and alternatives.
Asks questions, seeks second opinions, and searches out alternatives from a wide range of choices.
Is more critical and independent.
Is less tolerant of delays.
Is less likely to develop long term relationships.
Changes loyalties quickly.
Does not want to be inconvenienced.
Is very concerned about the future structure of healthcare and the government’s involvement.
Page 142
There are four key elements comprising the marketing mix.
Product (remove the periods)
Each physician’s expertise, training, services, the office staff, and office hours. Place
The office’s location, accessibility, and parking facilities. Price
Fee schedule, financing/credit policies, contracted insurance plans, free screenings, and discounts.
Page 142
Promotion
Personal selling, public relations, practice brochure, educational materials, and advertising. (remove the period)
Generally, you think of a product as something tangible. However, in marketing, one must look at the whole patient encounter as the product. Evaluate the encounter for quality of care communication, privacy, and so forth.
Page 147
Use
Analyzing Analyze the perceptions and opinions of patients regarding your practice.
Identifying key areas that may be contributing to the success or decline of your practice.
Evaluating Evaluate patient responses to recent changes in your practice.
Page 147
Use
Obtaining firsthand information about your practice.
Obtaining immediate feedback on changes.
Addressing issues before they get out of control.
Page 155
Tips for Physician Time Management & Productivity
Meet briefly each day with manager and nurse on priorities and special patient concerns
Dictate medical record documentation
Set up special phone line or electronic service for pharmacy links. (remove the period)
Page 165
(remove the periods)
Objectives
To enhance and solidify referral relationships.
Identify those areas of your practice that referring physicians and staff have difficulties with.
Introduce staff so they can identify voices, names, and faces.
Identify areas in which you can facilitate a better relationship with colleagues and their patients.
Page 165
(remove the periods)
Use
Analyzing the perceptions and opinions of referral sources regarding your practice.
Identifying areas that may be hindering your practice growth.
Page 186
(remove the periods)
A claim for a service or supply that was never provided.
A claim indicating the service was provided for some diagnosis code other than the true diagnosis code in order to obtain reimbursement for the service (which would not be covered if the true diagnosis code were submitted).
Page 187
(remove the periods)
A claim indicating a higher level of service than was actually provided.
A claim for a service that the provider knows is not reasonable and necessary.
A claim for services provided by an unlicensed individual.
Page 191
Minor
A person who has not attained legal age as defined in by the state.