Connect Archives

March 2013

Friday, March 15, 2013


Attribution of patients to our ACO (Accountable Care Coalition of Northwest Florida; ACCNWFL) is verified by CMS at 9100 Fee-For-Service Medicare beneficiaries, plus or minus a few, through Quarter 3 of 2012. This is great news; the initial projections by CMS were much lower. These figures will be updated quarterly, and we anticipate additional attribution with time.

The first delivery of claims data from CMS was received in Houston just after Christmas, and has been processed by our partners at CHS (Collaborative Health Solutions). We received our first reports on utilization in mid-January. The reports give detail down to the individual provider and patient level. The quality of the data and the detail of the reports is excellent, and has been presented and discussed at our Care Coordination and Quality Improvement committee in February. We have put in place two programs as a result of those discussions, to address care transitions from inpatient to a lower level of care, and E.R. use, with the programs being built around patient-specific needs.

Our Care Coordination nurses (Janet Blough-Black, R.N. and Pam Shelton, R.N.) have started working with the patients with complex issues and more intense needs. These patients are being identified by a concerted effort by our PCP’s AND the analytics team in Houston, which gives us a great opportunity to zero in on those who can benefit from a more intensely coordinated approach. This pro-active approach is already bearing fruit.

We have started weekly inter-disciplinary rounding with the nurses and other team members to best identify and utilize the great community resources that we have available so we can provide additional services, education, and other needs. Our experience has taught us that the closer we stay to the patients and their providers, the better the outcomes are.

The process of collecting and reporting the Quality data has begun. We are expecting to see some early results in the next 60-90 days. The ACO’s are required to report their Quality performance based on the enrolled physicians by way of the GPRO system defined by CMS for PQRS, which means the enrolled physicians will not have to report individually.

We are planning to pull our physicians and their staffs together in the second quarter of 2013 to see where we are, and how we are doing.

In the meantime please contact us (Richard Tuten, CEO; Pat Ast, Director of Medical Services; Jenny Caillouet, Director of Provider Relations; or me) for pretty much anything you need to know at 850-438-0818.

We are off to a great start, right in the middle of everything that is happening. I really appreciate what all of our docs and their staffs do for all of our patients…it’s the only thing that will make the difference.

William J. Whibbs, M.D.
Medical Director


You were previously notified by Health First Network that the claims address and referral process for Healthspring Medicare Product would be changing effective 4/1/13.

Due to circumstances beyond our control the effective date of that change has been delayed indefinitely. We will notify you as soon as a new date has been determined.

Please contact Jenny Caillouet at 438-4487 if you have any questions.


The HIPAA Mega-rule, enacted 1/1/13, made some sweeping changes to the HIPAA and HITECH rules.

1) “Business Associate” has been increased to include all downstream entities. If you are a Business Associate (BA) or a Covered Entity (CE), all of your downstream sub-contractors are now covered by the rules, EVEN IF you don’t have a contract with them! For example: your IT maintenance vendor has access to PHI that you generate. You probably have a contract with the provider that says that they will abide by the security and privacy rules. BUT, do you have a contract with the IT vendor’s sub-contractors? Probably not. The Mega-rule says that you need to update your contract with your direct contractors to include language requiring them and their subcontractors to abide by the security and privacy rules. Your contracts with your vendors must include language requiring them to include the privacy & security language in their contracts with sub-contractors.

2) Patients have the right to request changes to and restrictions on the release of their PHI. You must now comply with those requests unless there is an exception such as getting paid for providing care or disclosures required by law. Previously, you just had to consider the request.

3) Patients have the right to receive a copy of their PHI. AND, you have to provide it in the format requested by the patient. If the patient wants it electronically, you have to provide it in a usable format such as pdf or Word within 30 days following the patient’s request.

4) If there is an inappropriate “acquisition, use or disclosure” of PHI there is now a presumption that the CE/BA (you) has breached the patient’s privacy, even if there is a low probability of compromise (such as a password protected thumb drive being lost). The burden of proof has been shifted onto the CE/BA to prove that they have met all of the requirements of the privacy and security rules.

5) The BA MUST report the inappropriate disclosure to the CE. Beginning in September 2013, the BA/CE must inform the patients.


HealthSpring is paying additional reimbursement for completing 360's.

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Mandatory Payment Reductions in the Medicare Fee-for-Service (FFS) Program – “Sequestration”, is scheduled to go into effect on April 1, 2013, unless Congress acts.

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Medicare services have expanded to cover an increasing number of preventive screenings and benefits. This CMS-approved booklet is designed to help providers communicate with their patients about the Medicare-covered Annual Wellness Visit (AWV), as well as assisting providers in correctly billing for these services.

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Effective January 1, 2013, with an implementation date no later than January 25, 2013, the Centers for Medicare & Medicaid Services (CMS) has proposed coverage for eight new telehealth services for 2013. The new services include behavioral counseling services for cardiovascular disease, alcohol or substance abuse, and depression screening for beneficiaries. With the proposal, CMS is adding the eight Healthcare Common Procedure Coding System (HCPCS) codes to the list of Medicare telehealth services to reflect these code changes and replace several Current Procedural Terminology CPT® codes related to psychotherapy services. Affected codes include:
• G0396: Alcohol and/or substance (other than tobacco) abuse structured assessment and brief intervention, 15 to 30 minutes
• G0397: Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention greater than 30 minutes
• G0442: Annual alcohol misuse screening, 15 minutes
• G0443: Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes.
• G0444: Annual depression screening, 15 minutes.
• G0445: High-intensity behavioral counseling to prevent sexually transmitted infections, face-to-face, individual, includes: education, skills training, and guidance on how to change sexual behavior, performed semi-annually, 30 minutes.
• G0446: Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes.
• G0447: Face-to-face behavioral counseling for obesity, 15 minutes.
The attached article has been updated to reflect the release of HCPCS code (G0459) for inpatient telehealth pharmacologic management.

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Health First Network would like to welcome the most recent physicians to join the Network:

Jacque LeBeau, M.D. - Otolaryngology
Jason Ramirez, M.D. - Hospice and Palliative Medicine
Adam Anz, M.D. - Orthopaedic Surgery
Michelle Kraut, M.D. - Radiology

** To determine which health plans each physician is participating in check the “Find A Doctor” section on the HFNI website.