Employers who fail to properly complete and retain I-9 forms are subject to civil fines of up to $1,100 per form and, in some cases, criminal penalties.

Purpose of the form

Form I-9 is used for verifying the identity and employment authorization of individuals hired for employment in the United States. All U.S. employers must ensure proper completion of Form I-9 for each individual they hire for employment in the United States. This includes citizens and noncitizens. Both employees and employers (or authorized representatives of the employer) must complete the form. On the form, an employee must attest to his or her employment authorization. The employee must also present his or her employer with acceptable documents evidencing identity and employment authorization. The employer must examine the employment eligibility and identity document(s) an employee presents to determine whether the document(s) reasonably appear to be genuine and to relate to the employee and record the document information on the Form I-9. The list of acceptable documents can be found on the last page of the form. Employers must retain Form I-9 for a designated period and make it available for inspection by authorized government officers.

The new Form can be found under Human Resources forms when you log in to your account. The forms may be downloaded on the USCIS website USCIS FOR I-9 (Employment Eligibility Verification) (Revised 3-8-2013). Contact us if you have any questions.

For example, a provider may not know whether a beneficiary already had a particular laboratory test that Medicare covers only once a year or a supplier may suspect that the beneficiary already has the item it is providing.  Providers and suppliers may also use these modifiers when they are certain that the claim should not be paid, for example, when the beneficiary may need Medicare to deny the claim so that it can be submitted to the beneficiary’s secondary insurance.

Source:  CMS, Medicare Claims Processing Manual, Pub No 100-04, ch 23, §20.9.1.1(E)

OIG has been raising concerns about the use of GA and GZ modifiers and how Medicare is inappropriately paying for some claims with these modifiers.  The report looked at claims for pressure reducing support surfaces and found that Medicare paid for 72 percent of all pressure reducing support surface claims with GA or GZ modifiers.  This amounted to over $4 million in potentially inappropriate payments.

The outcome of the study found that in 2011, Medicare paid nearly $744 million for Part B claims with G modifiers that providers expected to be denied as not reasonable and necessary or as not being covered by Medicare.  Vulnerabilities were found in how Medicare processes and pays for these claims.  Contractors often did not consider the modifiers that providers use to indicate that they expect the services or items to be denied as not reasonable and necessary when processing the claim.  They also do not always consider the modifiers that providers use to indicate that services or items are not covered by Medicare.  Although contractors have checks and balances that affect how some of these claims are processed, such as whether or not the services and items met Medicare frequency limitations, they do not specifically check for claims that providers expect not to be paid.  In addition, the OIG found inappropriate combination use of the G modifiers that resulted in overpayment of $4.1 million from 2002 to 2011.

Memorandum Report

For education on these and other modifiers, contact Cheryl Baer, CPC, CPMA at 717.691.7100.  We can develop an education program specifically for you, your providers and your practice to ensure you don’t lose out on revenue because your claims were denied.

Unfortunately, one of the more unpleasant tasks those in management positions are responsible for can be handling negative or difficult employees and ensuring their negative or destructive behaviors do not spread throughout the organization.  While many leaders may choose to ignore these habits or simply attempt to wish these troubles away, the best way to handle these employees is to face them head on when the problem begins to occur.

Even highly assertive people can shy away from entering into difficult conversations; especially when they are aware of a defensive person they may be engaging with.   So, for those conversations we know we must have, what is the most effective way to enter into a difficult conversation with a disruptive employee?

1. Come out and Say It!

Whatever you do, don’t ignore the situation; especially if it isn’t improving or you can tell it is affecting others attitudes or work ethic.  Even though we tend to avoid confrontation, it doesn’t take care of the issue at hand and can even worsen the situation by allowing the activity or behavior to become habit.

2. Say It In a Way They Can Hear You

Everyone has a different personality and handles situations in a particular manner.  Understand the personality type you are dealing with and recognize how they react to receiving tough information; the more you tailor the message to their personality type, the more open they will be to hearing what you have to say.

3. Listen to What They Have to Say

Hear them out; give them an equal chance to respond rather than shutting them out after you have made your point.  Be sure to repeat back what you are hearing; being an active listener shows that you are open to what they are saying.

4. Let It Go!

Now, after you have had the conversation; move on!  The response you receive to the conversation is NOT your responsibility.  Trying to control the outcome of a situation will leave you unsatisfied and stressed because you cannot do so!

Remember it is always best to do something, ignoring a difficult or disruptive employee will only lead to greater problems and will tarnish the way your employees view you if immediate action is not taken.  Sometimes all it takes to correct a situation is confronting the perpetrator and bringing to light the behaviors causing issues within the office environment.

If you are going to do business with the government, you are going to have to plan and prepare yourself to prove you followed the proper procedures and regulations in obtaining money from the federal government.  If not, you are just setting yourself up to fail.  The feds are going to verify that you did not commit fraud and that you legally obtained the money you received

If you are selected for an audit, at this point 5-10% of you will, you will receive a letter from Figliozzi & Company, with the CMS logo on the letterhead.  We have several clients that have already received these letters and some have received them for Year 1 and Year 2 of attestation.  Many cannot place their hands on the attestation reports.  Others are using different EHRs and are having to pay for upgrades to the old systems in order to gain access to pull the reports.  Failure to plan ahead will result in returning incentive monies and possibly create other untold issues, depending on your circumstances.

So now you have the letter.  What does it say?

Dear Doctor,

The Centers for Medicare and Medicaid Services (CMS) has contracted with Figliozzi & Company, CPAs P.C. to conduct meaningful use audits of certified Electronic Health Record (EHR) technology as required in Section 13411 of the health Information Technology for Economic and Clinical Health Act (HITECH Act), as included in Title XIII, Division A, Health Information Technology and in Title IV of Division B, Medicare and Medicaid Health Information Technology of the American Recovery and Reinvestment Act of 2009.  The HITECH Act provides the Secretary, or any person or organization designated by the Secretary, the right to audit and inspect any books and records of any Eligible Professional receiving an incentive payment.

This letter is to inform you that your practice has been selected by the CMS for an audit of your meaningful use of certified EHR technology for the attestation period.   Attached to this letter is an information request list.  Be aware that this list may not be all-inclusive and that we may request additional information necessary to complete the audit.

Please supply all request items by utilizing one of the following methods:

1. Electronically uploading the information to our secure web portal (see step by step instructions attached)
2. Mailing the information to:

Figliozzi & Company, CPAs P.C.
585 Stewart Avenue
Suite 416
Garden City, NY 11530

The contracts between CMS and its contractors contain a confidentiality of information clause that state propriety information or data submitted by or pertaining to an organization cannot be released without the prior written consent of the organization. Additionally, the contractors are required to obtain written permission from CMS’s contract officer whenever the contractor is uncertain on the proper handling of material under the contract. Further, if any information contained within the records your organization submits to CMS’s contractors constitutes confidential information, as such terms are interpreted under the Freedom of Information Act (FOIA) (5 U.S.C. § 552) and applicable case law, CMS will protect such information from release when requested under FOIA in accordance with the Department of Health and Human Services regulations (45 C.F.R. § 5.65 (c)).

If you have any questions, please contact the assigned auditor indicated in this e-mail.

Sincerely,

Peter Figliozzi CPA, CFF, FCPA

You will need to initially supply all the following information:

Eligible Professional Name
EHR Certification Number (associated with identified attestation period)
EHR Reporting Period

• As proof of possession of a Certified Electronic Health Record Technology system, provide a copy of your licensing agreement with the vendor or invoices.  Please ensure that the licensing agreements or invoices are for the product and version of the Certified Electronic Health Record Technology system utilized during your attestation period.

• Please provide a response to the following questions:At how many offices or other outpatient facilities do you see your patients?Please list each office or other outpatient facility where you see patients and indicate whether or not you utilize Certified Electronic Health Record Technology (CEHRT) in 3each office or other outpatient facility.If you utilize more than one office or other outpatient facility, could you please supply documentation which proves that 50% or more of your patient encounters during the EHR reporting period have been seen in offices or outpatient facilities where you utilize a CEHRT system?

• Do you maintain any patient medical records outside of your CEHRT system?

•  If yes, please supply documentation which proves that more than 80% of the medical records of unique patients seen during the attestation period are maintained in a CEHRT system at each office or other outpatient facility where a CEHRT system is being used

• Provide the supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses (i.e. a report from your EHR system that ties to your attestation).Please Note:If you are providing a summary report from your EHR system as support for your numerators/ denominators, please ensure that we can identify that the report has actually been generated by your EHR (i.e. your EHR logo is displayed on the report, or step by step screenshots which demonstrate how the report is generated by your EHR are provided.)To support Y/N attestation measures, please supply documentation such as screenshots from your EHR system.

• Provide the supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses (i.e. a report from your EHR system that ties to your attestation). Please Note:  If you are providing a summary report from your EHR system as support for your numerators/ denominators, please ensure that we can identify that the report has actually been generated by your EHR (i.e. your EHR logo is displayed on the report, or step by step screenshots which demonstrate how the report is generated by your EHR are provided.)To support Y/N attestation measures, please supply documentation such as screenshots from your EHR system.

If you are going to take advantage of the incentive monies, you should plan ahead and ensure you are following the regulations properly, utilizing the proper data to report to CMS.  Keep copies of all reports used and keep a record of the EHR certification number.  Depending on the vendor, type and version of the EHR, you are using, certification numbers CAN change.  Keep all of this information in a safe place that you can locate once you receive the audit notice.

We have been able to obtain countless extensions to audit requests for our clients based on the circumstances they found themselves and have been able to assist many with positive outcomes to the audits.  If you plan ahead and know what you are getting into, the audit will be nothing but a quick response and an afterthought.  If not, it will consume your time, effort and money to comply with the audit or possibly return incentive monies.  Then all that pain and suffering and hard work were all for not.  Don’t let this happen to you and your practice.

The new hazard communication standard still requires chemical manufacturers and importers to evaluate the chemicals they produce or import and provide hazard information to employers and workers by putting labels on containers and preparing safety data sheets. However, the old standard allowed chemical manufacturers and importers to convey hazard information on labels and material safety data sheets in whatever format they chose. The modified standard provides a single set of harmonized criteria for classifying chemicals according to their health and physical hazards and specifies hazard communication elements for labeling and safety data sheets.

Benefits: The new standard covers over 43 million workers who produce or handle hazardous chemicals in more than five million workplaces across the country. The modification is expected to prevent over 500 workplace injuries and illnesses and 43 fatalities annually. Once fully implemented it will also:

• Enhance worker comprehension of hazards, especially for low and limited-literacy workers, reduce confusion in the workplace, facilitate safety training, and result in safer handling and use of chemicals;
• Provide workers quicker and more efficient access to information on the safety data sheets;
• Result in cost savings to American businesses of more than $475 million in productivity improvements, fewer safety data sheet and label updates and simpler new hazard communication training; and
• Reduce trade barriers by harmonizing with systems around the world.

Rulemaking background: OSHA published a Notice of Proposed Rulemaking to update the Hazard Communication Standard in September 2009 and held public hearings in March 2010.

Major changes to the Hazard Communication Standard:

• Hazard classification: Chemical manufacturers and importers are required to determine the hazards of the chemicals they produce or import. Hazard classification under the new, updated standard provides specific criteria to address health and physical hazards as well as classification of chemical mixtures.
• Labels: Chemical manufacturers and importers must provide a label that includes a signal word, pictogram, hazard statement, and precautionary statement for each hazard class and category.
• Safety Data Sheets: The new format requires 16 specific sections, ensuring consistency in presentation of important protection information.
• Information and training: To facilitate understanding of the new system, the new standard requires that workers be trained by December 1, 2013 on the new label elements and safety data sheet format, in addition to the current training requirements.

Changes from the Proposed to the Final Rule: OSHA reviewed the record and revised the Final Rule in response to the comments submitted. Major changes include:

• Maintaining the disclosure of exposure limits (Threshold Limit Values [TLVs]) established by the American Conference of Governmental Industrial Hygienists (ACGIH) and carcinogen status from nationally and internationally recognized lists of carcinogens on the safety data sheets;
• Clarification that the borders of pictograms must be red on the label;
• Flexibility regarding the required precautionary and hazard statements to allow label preparers to consolidate and/or eliminate inappropriate or redundant statements; and
• Longer deadlines for full implementation of the standard (see the chart below).

What you need to do and when:

• Chemical users: Continue to update safety data sheets when new ones become available, provide training on the new label elements and update hazard communication programs if new hazards are identified.
• Chemical Producers: Review hazard information for all chemicals produced or imported, classify chemicals according to the new classification criteria, and update labels and safety data sheets.

* This date coincides with the European Union implementation date for classification of mixtures.

Q. What pictograms are required in the revised Hazard Communication Standard? What hazard does each identify?

A. There are nine pictograms under the GHS to convey the health, physical and environmental hazards. The final Hazard Communication Standard (HCS) requires eight of these pictograms, the exception being the environmental pictogram, as environmental hazards are not within OSHA’s jurisdiction. The hazard pictograms and their corresponding hazards are shown below.

HCS Pictograms and Hazards

Health Hazard	Flame	Exclamation Mark
• Carcinogen • Mutagenicity • Reproductive Toxicity • Respiratory Sensitizer • Target Organ Toxicity • Aspiration Toxicity	• Flammables • Pyrophorics • Self-Heating • Emits Flammable Gas • Self-Reactives • Organic Peroxides	• Irritant (skin and eye) • Skin Sensitizer • Acute Toxicity (harmful) • Narcotic Effects • Respiratory Tract Irritant • Hazardous to Ozone Layer (Non Mandatory)
Gas Cylinder	Corrosion	Exploding Bomb
• Gases under Pressure	• Skin Corrosion/ burns • Eye Damage • Corrosive to Metals	• Explosives • Self-Reactives • Organic Peroxides
Flame over Circle	Environment (Non Mandatory)	Skull and Crossbones
• Oxidizers	• Aquatic Toxicity	• Acute Toxicity (fatal or toxic)

Other U.S. Agencies: The Department of Transportation (DOT), Environmental Protection Agency, and the Consumer Product Safety Commission actively participated in developing the GHS. DOT has already modified its requirements for classification and labeling to make them consistent with United Nations transport requirements and the new globally harmonized system.

Global implementation: The new system is being implemented throughout the world by countries including Canada, the European Union, China, Australia, and Japan.

Additional information: More information on the hazard communication standard, including the link to the Federal Register notice, can be found on OSHA’s hazard communication safety and health topics page at www.osha.gov/dsg/hazcom/index.html.

FAQs: Frequently asked questions and answers may be found here.

In the past, most have regarded telemedicine not as a specialty but rather as an aspect of a healthcare provider’s practice. Therefore, most payers will still credential a provider according to their area of training and expertise — Internal Medicine, Cardiology, Dermatology, etc. Many payers are currently reviewing their credentialing criteria and practices related to this growing field.

In the meantime, most payers rely on providers who perform telemedicine as part (or all) of their practice to be in compliance with current state guidelines. In general, a state license is required for each and every state where a patient encounter occurs. In addition, 10 states require a “special purpose” telemedicine license as well. We would urge you to research your state requirements and also to take time to review the recent excellent Telemedicine Overview, a state-by-state summary regarding telemedicine licensing guidelines on the Federation of State Medical Boards website at http://www.fsmb.org/.

What does this mean?  For a short time two different diagnoses coding systems will be used.  On 10/01/14 if you are working on a DOS that is prior to 10/1/14 whether an initial claim (09/30/14) or working your accounts receivable, you will need to use diagnoses codes from ICD 9.  However, if you are entering charges for that day (10/01/14) you will be required to use diagnoses codes from ICD 10.

The implementation of ICD-10 will require significant changes to clinical and administrative systems that capture and report diagnosis codes.  With five times as many codes as the previous code set, there’s no doubt that the new ICD-10 codes will drastically impact all physician practices.

Here are six key functional areas within your practice operations that can be expected to have some impact with the change in the diagnosis coding system.

1. Cash flow disruption.
2. Staff education and training. Clinical and administrative staff will require significant time simply to learn about the new codes.
3. Health plan contracts, coverage determinations, and documentation.
4. Changes to superbills.
5. IT system changes. Practice management systems and software modifications will be necessary.
6. Increased documentation costs. With more specific codes, additional documentation will be required to support a patient’s diagnosis.

Here you will see some of the differences between ICD-9 and ICD 10.

Need assistance in readying your practice and providers for ICD-10?  Contact Cheryl Baer, CPC, CPMA at 717.691.7100.  We can develop a specific education program just for you, your providers and your practice to ensure you don’t loose out on revenue because your claims were denied.

Under the health law, a primary care doctor – a family physician, a pediatrician or an internist – who treats a Medicaid patient will see their reimbursement rise to the level of the Medicare health insurance program for the elderly for scores of primary care services.  Doctors do have to apply to their state Medicaid programs and meet certain criteria in part proving that they have historically treated certain numbers of Medicaid patients.

Though the pay increase will vary because Medicaid rates differ from state to state, the average pay increase will be about 73 percent given Medicare last year paid on average 66 percent of what Medicare pays for certain primary care services, according to a Henry J. Kaiser Family Foundation study.  Doctors in some states could see payment increases of 100 percent or more.

The idea behind the pay increase, which is funded by federal dollars for two years, is to get more doctors to accept Medicaid patients and prevent other physicians from dropping out of a government program that hasn’t been well funded.  Amid a primary care doctor shortage, eligible patients will need all of the doctors they can get given the health law expands Medicaid coverage to millions more Americans effective Jan. 1, 2014 for participating states.

Because Medicaid is funded via a match of funds from states and the federal government, cash-strapped states that have cut from their programs in also lost federal dollars, allowing payment rates to fall far behind.

“The purpose of the increase in Medicaid physician fees for primary care is to encourage greater Medicaid participation among physicians as the program expands in 2014 and demand for care increases,” the Kaiser report said. “If the enhanced payment rates succeed in increasing physician participation and beneficiary access as intended, interest in extending the higher Medicaid rates beyond 2014 is likely to be high.”

But the Obama administration says the checks will eventually reach doctors and payments will be retroactive to January 1 of this year so physicians who are approved to participate in their states will get what they are due.

“The Medicaid enhanced payments for primary care physician fee was made possible by the Affordable Care Act and is in full effect for calendar years 2013 and 2014,” a spokesman for the Centers for Medicare & Medicaid Services says. “States are moving quickly to implement the higher payment and a number of states have already submitted State Plan Amendments (SPAs) which will permit federal funding to flow to states for the increases.  In addition to submitting the required SPAs, states are also in the process of reprogramming their claims processing systems to pay at the appropriate, higher rates.  CMS has made it very clear that states must make enhanced payments to eligible providers retroactive to January 1, 2013.”

Exactly how federal dollars will be doled out to doctors is unclear in part because an increasing number of states in recent years don’t pay physicians on a fee-for-service basis.

Many doctors are paid bundled rates by health plans or physicians may be employees and are therefore paid through their clinic, practice or other entity, complicating the rollout of the pay increase.  Therefore, the payments for services aren’t necessarily apples to apples comparison when it comes to paying the same as Medicare rates.

Some estimate the money might not reach doctors until late in the second quarter of this year, which would be by June 30.

Meanwhile, doctor groups wait patiently for their funds.

Prior to the decision, The Hospital & Health System Association of Pennsylvania submitted a 29-page request that CMS delay the rulemaking pending assessment.

Among other things, the HAP letter said electronic health records have occasioned “dramatic increases in IT expenditures between 2009 and 2011 that are simply not sustainable given our fiscal realities.”

On average, HAP said, hospitals estimate that Medicare and Medicaid EHR incentives will offset only 10 to 15 percent of the total cost of adoption.

The Physicians Payments Sunshine act requires reporting on a yearly basis and also requires reporting of ownership or investment interests of physicians or their immediate family members in these companies.

Data will start being collected on August 1, 2013. The final rule exempts speakers and attendees of accredited CME programs; manufacturers of over-the-counter drugs and class I and II medical devices; educational material intended for use by patients; discounts or rebates; and samples for patient use. Physicians will have an opportunity to review and correct their reports before they are posted online.

Information from CMS is available here.