FAQs Sheet

Practice Management
Is quality patient care the most important aspect of a thriving healthcare organization?

Quality medical practice management is equally as significant as quality patient care in establishing healthcare organization practices that are efficient and effective in providing quality patient care.

Which healthcare staff members should be knowledgeable of medical regulations?

Successful medical practice management ensures that all staff members, providers, medical billing staff and clerical support staff are aware of all medical regulations and laws (e.g., HIPAA, Federal Deficit Reduction Act of 2005, DOH Waived Testing Regulations) that pertain to their job function. All staffing levels should be trained to implement and adhere to these regulations properly and notified when any updates take place.

Coding and Compliance
What is a prospective medical record review?

A prospective medical record review includes claims/encounters that have been submitted to and paid/denied by insurance carriers.

This type of audit allows for adjustments in coding to be corrected prior to claim submission.

What is a retrospective medial record review?

A retrospective medical record review includes claims/encounters that have been submitted to and paid/denied by insurance carriers. Retrospective audits are occasionally focused audits based on specific procedures or billing concerns.

How does RRHS determine the sample size/number of encounters?

Generally, a random sampling of 10-15 encounters/dates of service are selected for review. The sample may be selected by the client or RRHS. In some cases, a statistically valid sample is required and OIG's RAT-STATS software program is utilized for a sample selection.

What is Focused medical record review?

A focused audit concentrates on a particular element, type of service, place of service or provider of service to determine the appropriateness of documentation and associated coding/billing.

How will our practice/MD receive the audit results?

RRHS provides a customized, detailed report summarizing key audit findings and associated recommendations. The Department and/or provider overall compliance score in all areas (E/M, Procedures, Modifiers, ICD-10 Codes) is provided in an easy to understand format.

What is the expected timeline for completion?

The audit process can typically take 1-3 weeks for completion. The time frame varies based on the size of the audit.

What measures does RRHS take to ensure patient information remains confidential?

RRHS utilizes a secure File Transfer Protocol (FTP) website which assists in transferring files between two remote locations.

PCMH
What is a Patient Centered Medical Home?

The Patient Centered Medical Home (PCMH) is a care delivery model for primary care practices in which the patient is the center of all processes and decisions. This model describes an approach to the delivery of primary care that is patient centered, comprehensive, coordinated, accessible and committed to both quality and safety.

How does my practice become recognized as a PCMH?

Your practice will be guided through the entire PCMH process by RRHS' expert facilitators. Weekly webinars will assist with the implementation of NCQA's requirements. Our facilitators will also take part in the submission process, which entails three scheduled "check-ins" with an NCQA assigned representative.

Who is NCQA?

The National Committee for Quality Assurance (NCQA) is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Founded in 1990, NCQA has been a central figure in driving improvement throughout the health care system, elevating the issue of health care quality to the top of the national agenda.

What are the benefits of being a PCMH?

Benefits include improvements in quality of care, patient experience and access, enhanced work environment, and reimbursement from key payers, including Medicaid. PCMH recognized practices also see a reduction in cost related to preventable, duplicative and unnecessary care. As a result of medical homes, hospitals are experiencing a reduction in ER visits and inpatient admissions.

How long does it take to become recognized as a PCMH?

The initial recognition timeline varies based on practice and RRHS level of support. Historically, practices attain recognition within 12 months.

How long does recognition last?

Recognition is for one year with annual reporting requirements thereafter. There is only one level of recognition based on the 2017 PCMH redesign.

Does recognition help me with other practice improvement initiatives?

Yes, PCMH recognition also aligns with Delivery System Reform Incentive Payment (DSRIP), Medicare Access & CHIP Reauthorization Act (MACRA), Merit-Based Incentive Payment System (MIPS) and Healthcare Effectiveness Data Information Set (HEDIS).

Does recognition level affect the amount of reimbursement I will receive?

Yes, the amount of reimbursement is as follows:

PCMH Statewide Incentive Payment Program (PMPM) 2017
Medicaid Managed Care (MMC - PMPM) $7.50
Fee For Service (FFS) - Institutional, Per Visit $29.00
Fee For Service (FFS) - Professional, Per Visit $25.25
How do I maintain my recognition after it expires?

PCMH is not a one-time process, the practice must continue performance improvement initiatives and providing care in a patient-centered manner to maintain their recognition status.

How does RRHS help me become a PCMH?

At RR Health Strategies, we have the tools and knowledge to simplify the PCMH process for you. Our consultants will conduct a gap analysis and develop a personalized workplan for your practice. The workplan aligns with the required elements needed to obtain recognition.

What are the benefits of using a PCMH Consultant rather than seeking recognition on my own?

Research has shown that practices are more successful obtaining PCMH recognition when they use a PCMH Consultant. Working with a consultant will streamline the recognition process and alleviate any guesswork involved and allow you to focus on what's important - patient care.

At RR Health Strategies, we have the tools and knowledge to simplify the PCMH process for you. Our consultants will conduct a gap analysis and develop a personalized workplan for your practice. The workplan aligns with the required elements needed to obtain recognition.