Your Rights as a Client
Federal and state law provide for specific patient rights. At Thrive Counseling, we recognize our responsibility to respect these rights as well as to inform you of them. The following summarizes both federal law and the Massachusetts Patients’ Bill of Rights.
• You have the right to obtain the name and specialty of the doctor or other person responsible for your care.
• You have a right to confidentiality of all records and communications concerning your medical history and treatment to the extent provided by law.
• You have the right to participate in the development and implementation of your plan of care.
• You have a right to a prompt response to all reasonable requests.
• You have a right to request and receive an explanation of the relationship, if any, of Thrive Counseling and your care provider to any other health care facility or educational institution, insofar as any such relates to your care.
• You have a right to obtain a copy of any rules or regulations of Thrive Counseling which may apply to your conduct as a client.
• You have a right upon request to inspect your medical records, request an amendment to, or receive an accounting of disclosures regarding personal health information, and for a reasonable fee, receive a copy of your record.
• You have a right to refuse to participate as a research subject.
• You have a right to personal dignity and, to the extent reasonably possible, to privacy during treatment and other care.
• You have the right to have your cultural, psychosocial, spiritual, and personal values, beliefs, and preferences respected.
• You have a right to informed consent to the extent provided by law.
• You have a right to request and receive an itemized explanation of your bill.
• You have the right to file a grievance with Thrive Counseling if you have concerns regarding your care and treatment. In addition, you have the right to file a grievance with the Massachusetts Department of Public Health, Division of Health Care Quality (617-753-8000), 99 Chauncy Street, 2nd Floor, Boston, MA 02111.

You have the right:

To safe, considerate and respectful care, provided in a manner consistent with your beliefs.
To expect that all communications and records pertaining to your care will be treated as confidential to the extent permitted by law.
To know the mental health professional responsible for coordinating your care.
To receive complete information about diagnosis, treatment, and prognosis, in terms that are easily understood (alternatively, it will be given to a legally authorized representative).
To receive information necessary for you to give informed consent prior to any treatment, including any potential risks or benefits, and any alternatives.
To receive appropriate assessment and treatment, and to refuse treatment.
To expect that a medical summary be sent to your referring care provider.

Benefits

Individuals have the right to be provided information from the purchasing entity (such as employer or union or public purchaser) and the insurance/third party payer describing the nature and extent of their mental health and substance abuse treatment benefits. This information should include details on procedures to obtain access to services, on utilization management procedures, and on appeal rights. The information should be presented clearly in writing with language that the individual can understand.

Professional Expertise

Individuals have the right to receive full information from the potential treating professional about that professional’s knowledge, skills, preparation, experience, and credentials. Individuals have the right to be informed about the options available for treatment interventions and the effectiveness of the recommended treatment.

Contractual Limitations

Individuals have the right to be informed by the treating professional of any arrangements, restrictions, and/or covenants established between third party payer and the treating professional that could interfere with or influence treatment recommendations. Individuals have the right to be informed of the nature of information that may be disclosed for the purposes of paying benefits.

Appeals and Grievances

Individuals have the right to receive information about the methods they can use to submit complaints or grievances regarding provision of care by the treating professional to that profession’s regulatory board and to the professional association.

Individuals have the right to be provided information about the procedures they can use to appeal benefit utilization decisions to the third party payer systems, to the employer or purchasing entity, and to external regulatory entities.

Confidentiality

Individuals have the right to be guaranteed the protection of the confidentiality of their relationship with their mental health and substance abuse professional, except when laws or ethics dictate otherwise. Any disclosure to another party will be time limited and made with the full written, informed consent of the individuals. Individuals shall not be required to disclose confidential, privileged or other information other than: diagnosis, prognosis, type of treatment, time and length of treatment, and cost.

Entities receiving information for the purposes of benefits determination, public agencies receiving information for health care planning, or any other organization with legitimate right to information will maintain clinical information in confidence with the same rigor and be subject to the same penalties for violation as is the direct provider of care.

Information technology will be used for transmission, storage, or data management only with methodologies that remove individual identifying information and assure the protection of the individual’s privacy. Information should not be transferred, sold or otherwise utilized.

Choice

Individuals have the right to choose any duly licensed/certified professional for mental health and substance abuse services. Individuals have the right to receive full information regarding the education and training of professionals, treatment options (including risks and benefits), and cost implications to make an informed choice regarding the selection of care deemed appropriate by individual and professional.

Determination of Treatment

Recommendations regarding mental health and substance abuse treatment shall be made only by a duly licensed/certified professional in conjunction with the individual and his or her family as appropriate. Treatment decisions should not be made by third party payers. The individual has the right to make final decisions regarding treatment.

Parity

Individuals have the right to receive benefits for mental health and substance abuse treatment on the same basis as they do for any other illnesses, with the same provisions, co-payments, lifetime benefits, and catastrophic coverage in both insurance and self-funded/self-insured health plans.

Discrimination

Individuals who use mental health and substance abuse benefits shall not be penalized when seeking other health insurance or disability, life or any other insurance benefit.

Benefit Usage

The individual is entitled to the entire scope of the benefits within the benefit plan that will address his or her clinical needs.

Benefit Design

Whenever both federal and state law and/or regulations are applicable, the professional and all payers shall use whichever affords the individual the greatest level of protection and access.

Treatment Review

To assure that treatment review processes are fair and valid, individuals have the right to be guaranteed that any review of their mental health and substance abuse treatment shall involve a professional having the training, credentials and licensure required to provide the treatment in the jurisdiction in which it will be provided. The reviewer should have no financial interest in the decision and is subject to the section on confidentiality.

Accountability

Treating professionals may be held accountable and liable to individuals for any injury caused by gross incompetence or negligence on the part of the professional. The treating professional has the obligation to advocate for and document necessity of care and to advise the individual of options if payment authorization is denied.

Payers and other third parties may be held accountable and liable to individuals for any injury caused by gross incompetence or negligence or by their clinically unjustified decisions.

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Is it worth it?

$44,000 in Incentives! (Just not for you.)

On February 17, 2009, President Obama signed into law a $789 billion dollar economic stimulus package. Included in that legislation is the Health Information Technology for Economic and Clinical Health Act (HITECH). Under HITECH, qualified providers can receive up to $44,000 in Medicare bonus incentives if they demonstrate the “meaningful use” of an Electronic Health Record (EHR) system. Conversely, those who don’t elect to use EHR systems will be penalized beginning in 2015; initially a 1% Medicare reimbursement reduction, and, for those who do not adopt EHR by 2018, the penalty will jump up to 3%.

Does $44,000 sound good? Curb your enthusiasm. Unless you are an MD who is billing Medicare, you won’t be seeing a penny. The stimulus package doesn’t account for mental health professionals trying to turn the electronic corner.

EHR and Mental Health Professionals

Let’s talk real estate. Even in the midst of the “housing crisis,” the $8,000 government rebate for first and second-time home-buyers (expiring in April) seems to encourage home sellers to be more aggressive with asking prices. We think the same might be true for EHR, Electronic Billing and Practice Management Solutions. If you’re a physician with a $44,000 bonus coming your way via the Federal Government, EHR set up costs of $15,000 is a good deal–you’re pocketing north of 25 grand.

Today, medical software sales are booming. In March of this year, Fast Company magazine named the EHR software and billing company Athenahealth one of the World’s 50 most innovative companies. Like many EHR providers, they’re experiencing a boon, covering more than 23,000 providers and showing revenue growth that currently exceeds 35%. We contacted Athenahealth to get some quotes, and received estimated rates for a counseling practice of six clinicians.

First, they explained that they don’t have an EHR solution for behavioral health, only practice management and billing solutions. Then, they explained that they don’t provide a full outsourced billing solution. Instead, they offer what they call “co-sourcing.” With co-sourcing, some of the work is outsourced to Athenahealth, but an administrator is still needed on the practice side to do a good amount of the legwork. For this, set up costs are $17,000, plus travel expenses for someone from Athenahealth to come onsite and train staff. In addition, they charge 7.12% (which includes a percentage of the co-pay) on claims of $75 (an average claim amount for behavioral health), and a higher percentage if the claims are less than $75. Part of the problem, a representative of Athenahealth explained, is that, since behavioral health practices receive so little per claim, a high percentage fee is needed to offset the cost of the work that could be involved in chasing down monies from insurance companies.

Here are some quotes from other EHR and Billing Software/Service Providers:

• Procentive: A minimum set up cost of $5,500.00 (without any customization), and $500.00 a month thereafter. They offer technical support for only one member of your staff, who acts as a “champion” (their term) to teach the rest of your clinical practice to use the software.
• Athena Software (unaffiliated with athenahealth): For 10 user licenses, they offer two options. First option, purchase the software and host it on your own server for $13,800. Option 2, have Athena host the software for your staff to access remotely. This costs $9,390 for the first year, and $8,400 each year afterwards.
• AdvancedMD: Rates are so high on a per-user basis (nearly 1,000 a month), that even if a behavioral health practice made infinity dollars, it wouldn’t be affordable because no MA or PhD behavioral health provider bills enough to justify the per-user cost.
• Practice Fusion: The EHR solution is free! However, they don’t offer billing or practice management software. They recommend using the billing software Kareo, which they are working to integrate with their software (integration isn’t available yet). Kareo costs $199.00 per user, per month.
• Boston Billing Solutions: This billing company is competitive, costing about 6% of gross revenue for behavioral health. They use AdvancedMD, which means you get access to software you couldn’t otherwise afford. The downside is that, if you ever want to stop using Boston Billing Solutions, you also need to change your practice management software. Also, the AdvancedMD EHR is not included.
• Office Ally: See Below.

Since mental health counseling practices bill considerably less per clinician than other medical practices (and non-MDs are ineligible for $44,000 in incentives) even the most forward-thinking and tech-savvy mental health professionals may have trouble finding a quality, affordable EHR solution. Still, everyone from the eco-friendly to insurance companies are pushing for paperless. So how can you get on board?

One Counseling Practice’s Journey into the Paperless

At Thrive Boston Counseling in Cambridge, MA, it is in our “DNA” to continually try new processes that could improve the care we provide our clients. We thought that an EHR system would help us to better organize records, and would make records easier to retrieve when clients request them. As director, I (Dr. Anthony Centore) also saw value in having a solution that combines note-taking with insurance billing.
In choosing an EHR platform, our team of therapists sorted through what features would be most helpful for our practice. We wanted to find a web-based program that didn’t need installation on every office computer. This eliminated many options (including Therapist Helper and Therascribe, two popular solutions which seem overrated anyhow). Price eliminated many more. Trying demo-versions of various software suites eliminated almost everyone else, as many look like a flashback to Windows 95. We investigated products by Siemens, Practice Fusion, ClinicSource, Emdeon, AdvancedMD, and dozens more. In the end, we found an extremely affordable program with good customer service called “Office Ally” (Cost: $29.95 for EHR access, plus $15 per provider, per month. Even better, use of the billing software is free for 3rd party payers. If you’re billing the government (Medicare/Medicaid) for more than 50% of total claims, they charge a modest $19.95 more per month).

We began using Office Ally on September 1, 2009, and the Thrive team was initially on board and excited about the program. However, once implementation began, feet started to drag. Therapists want to focus on client care, not learning new software. As it turns out, Office Ally was not nearly as user friendly as we had hoped, and the learning curve for staff was brutal. There was a lot of dialogue during the training process that sounded like this: “It’s not really intuitive, but you need to click here, then here, then click the drop down menu here, and ignore this section, and those sections, because those features don’t apply to us.”

Today, seven months into our Office Ally subscription, some staff like the program, and have more or less mastered it. Others still dislike it. Our in-house biller complains about it, and forewarns that the software will become decreasingly able to meet our needs as the practice grows. Also, it only works well on Internet Explorer, and it has periodic bugs, crashes, and downtime.

Office Ally support has been helpful. They’re available to talk by phone during normal business hours, and they’ll walk customers through the program. However, I don’t have my counselors call them anymore because they tend to teach things that my staff doesn’t need to know: After the recommended initial two hours of phone training, my counselors are overwhelmed and still haven’t mastered the basics. Now, to train new staff more efficiently, I have my office manager give 25 minutes of in-house training, which often needs repeating over the counselors’ first weeks of program use.

We consider changing our EHR and Billing software all the time. However, while there might be a better solution on the market somewhere, I feel it will take us about a year to feel ready to try out a new system, as we’re still nursing our wounds from the first transition from paper to online (as I write this, my biller can’t process claims because some features of the software are down today). I cross my fingers that Office Ally has the software update of my dreams in production, and coming out soon.

Overall, EHR, electronic billing, and practice management software has helped. It seems our note-taking has improved, as has the organization of files. In addition, it’s easier to view a history of sessions at a glance, and I can easily see how much each clinician has billed, and how much money has been paid from insurance and co-pays. It’s also nice not to have a growing mountain of filing cabinets in the office. All of this said, we are still not entirely paperless. We use paper during the first session for some intake documentation. After that, it’s all online!

The One Benchmark Question You MUST Ask During a Demo of an EHR System

When someone is trying to sell you on an EHR or Practice Management system, in addition to questions about features your practice needs, ask this basic question (it stumps 99% of sales representatives): “If I provide a session to a client and she pays $100 cash for her appointment, how do I quickly log that into the system?” Some representatives will outright explain, “our EHR system doesn’t deal with the payment side of things.” For those that do provide a solution, it often takes over 12 steps and sounds like this: “No problem! Simply click here, then scroll down, then select the second tab on the left, then the third drop down option, then here, then there, select the patient, select the appointment, sign the clinical note, click billing options, enter a diagnosis and procedure code (necessary even for cash pay), enter the amount charged, enter the amount received, click submit, go back to the billing page, click edit, then apply, then confirm. Done!”

Brass Tacks: EHR, HIPAA, and Client Privacy

Client data privacy is a hot topic when talking about EHR solutions.

A decade ago, people were really, really, concerned about online security. Many seemed paranoid, certain that electronic data would jeopardize their privacy and increase their susceptibility to identity theft. They were right to be concerned. To be fair, privacy was a concern for paper health records as well, but the sheer volume of information that can be lost in an instant with paperless systems is staggering. And this isn’t just “in theory”.

Over the last several years, government agencies have lost personal information of U.S. citizens, including the Office of Inspector General at the U.S. Department of Transportation which, in 2006, lost a laptop containing data on 133,000 Florida residents. In March of 2008, 2,500 patients’ protected health information (PHI) was lost by the National Institutes of Health (NIH). Not to be outdone, that same month, Hannaford and Sweetbay supermarkets lost 4.2 million customer credit card numbers to hackers—oops! There are hundreds, if not thousands, of stories like this; and some estimate that 1 in 5 persons in the U.S. has been a victim of identity theft.

Microsoft CEO Steve Ballmer, recently (July, 2009), described a huge need for cyber security, stating, “The president needs to use his ‘bully pulpit’ to make sure businesses and local governments are protecting their data. Information technology departments’ vigilance has trended down over the past few years.” Not a bad sentiment, but it is unclear whether reprimands and more vigilance will be enough. Today, a clinician can be vigilant 99 percent of the time, but one small error—connecting to the wrong wireless network, losing a USB flash drive, failing to log out of a program, or even forgetting to “blind carbon copy” (bcc) an email can mean the PHI of hundreds, or hundreds of thousands of patients / clients, is compromised. And with partnerships between various health information organizations (HIO) (e.g., Orion Health, or regional HIO’s like the Wisconsin Health Information Organization, etc.), you can be tethered to the mistakes of others as well.

That in mind, here are a few of the most frequently asked HIPAA and Client Privacy questions as they relate to EHR paraphrased from the U.S. Department of Health and Human Services:

Q: What is my liability for sharing data inappropriately through an electronic health information (EHI) exchange network?

A: Essentially, you are only responsible for yourself (you, your practice, and your employees)! You are not directly liable for a violation of HIPAA by an HIO with which you are associated, provided an appropriate business agreement is in place, and neither you nor your HIO business associate(s) can be held liable for civil money penalties arising from HIPAA violations by the other. You’re not required to “police” your partnered HIO’s, either. Rather, the HIO will be contractually obligated to take adequate safeguarding measures regarding PHI and to report noncompliance to you. However, you will be held accountable for taking appropriate action to help remedy known noncompliance by the HIO, and if you can’t rectify it, to terminate the HIO relationship.

Q: How do HIPAA authorizations apply to EHI exchanges?

A: HIPAA requires clients’ written authorization for any use or disclosure of PHI not otherwise expressly permitted or required by HIPAA, the same as it would for non-electronic PHI exchanges. For example, electronic PHI disclosures for treatment, payment, or health care operations purposes don’t require HIPAA authorizations, almost without exception. So, if the purpose of your EHI exchange is to share clinical information among health care providers for treatment, you’re fine. However, if the purpose of sharing PHI is for a purpose not otherwise permitted by HIPAA, then authorization would be required (i.e., a valid and signed authorization). The good news is that HIPAA allows authorizations to be obtained electronically (if permitted by other applicable laws).

Q: May I provide clients with their HIPAA Notice of Privacy Practices (NPP) electronically?

A: Yes, provided that clients agree to receive the NPP electronically. For electronic services, such as eCounseling methods like videoconferencing, email, etc., the provider must send an electronic NPP automatically in response to the individual’s request for service. At eCounseling.com, we recommend this as part of the eCounselor’s informed consent disclosures. Also, it is worthwhile to note that, except in an emergency treatment situation, a covered entity (e.g., a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form) who is providing electronic services should also make a good faith effort to obtain a written acknowledgment of receipt, electronically or through other means. In addition, HIPAA requires electronic service providers to post NPP’s on company websites as well.

Final Thoughts:

So, there is a lot to know and a lot to learn. The time, costs, rules, and knowledge base required for the paperless office makes running one a daunting, but (we think) worthwhile task. We encourage you to take a deep breath, and dive in. Ask for help, and by all means, use the web to find tons of free advice. The paperless trend doesn’t seem to show any signs of relenting, and we doubt very much that you’ll be hearing Presidential initiatives mandating a return to hard copies anytime soon.

This is indeed a whale of a project. But, remember how you eat a whale – one byte at a time.

Bios:

Anthony Centore, Ph.D., is the Founder of Thriveworks, a company that helps professionals build a counseling practice. He is also a Therapist at Thrive Boston Counseling in Cambridge, MA.

Ryan Thomas Neace, MA, is the Founder and Therapist at The Change Group, a Counseling practice in Lynchburg, VA.

visit Boston Counseling and Boston Life Coaching at www.thriveboston.com

POSTSCRIPT

Brian O’Neil, Founder and CEO of Office Ally contacted me after this article was published. During our conversation, Mr. O’Neil expressed his pursuit of creating an excellent product and service for EHR/EMR and Billing/Practice Management Software. He states that many of the complaints I listed in the article above are in process of being resolved. The biggest news Mr. O’Neil presented was the launch of a completely re-hauled version of Office Ally, which is slated to be released by April 16th. We, at Thrive Boston Counseling, are excited about this new software release, and will be reviewing it as soon as it is available.

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Thrive Counseling in the Examiner

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http://digitalcommons.liberty.edu/doctoral/46/

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This article is written by –Antonello Bonci, MD, published on March 8, 2010. We don’t have a backlink because Thrive received this article by email.

About Ritalin Research:
Doctors treat millions of children with Ritalin every year to improve their ability to focus on tasks, but scientists now report that Ritalin also directly enhances the speed of learning.

In animal research, the scientists showed for the first time that Ritalin boosts both of these cognitive abilities by increasing the activity of the neurotransmitter dopamine deep inside the brain. Neurotransmitters are the chemical messengers neurons use to communicate with each other. They release the molecule, which then docks onto receptors of other neurons. The research demonstrated that one type of dopamine receptor aids the ability to focus, and another type improves the learning itself.

The scientists also established that Ritalin produces these effects by enhancing brain plasticity – strengthening communication between neurons where they meet at the synapse. Research in this field has accelerated as scientists have recognized that our brains can continue to form new connections – remain plastic – throughout life.

“Since we now know that Ritalin improves behavior through two specific types of neurotransmitter receptors, the finding could help in the development of better targeted drugs, with fewer side effects, to increase focus and learning,” said Antonello Bonci, MD, principal investigator at the Ernest Gallo Clinic and Research Center and professor of neurology at UCSF. The Gallo Center is affiliated with the UCSF Department of Neurology.

Bonci is co-senior author of the paper, which will be published online in “Nature Neuroscience” on Sunday, March 7, 2010.

Bonci and his colleagues showed that Ritalin’s therapeutic action takes place in a brain region called the amygdala, an almond-shaped cluster of neurons known to be critical for learning and emotional memory.

“We found that a dopamine receptor, known as the D2 receptor, controls the ability to stay focused on a task – the well-known benefit of Ritalin,” said Patricia Janak, PhD, co-senior author on the paper. “But we also discovered that another dopamine receptor, D1, underlies learning efficiency.”

Janak is a principal investigator at the Gallo Center and a UCSF associate professor of neurology. Lead author of the paper is Kay M. Tye, PhD, a postdoctoral scientist at the Gallo Center when the research was carried out.

The research assessed the ability of rats to learn that they could get a sugar water reward when they received a signal – a flash of light and a sound. The scientists compared the behavior of animals receiving Ritalin with those that did not receive it, and found those receiving Ritalin learned much better.

However, they also found that if they blocked the dopamine D1 receptors with drugs, Ritalin was unable to enhance learning. And if they blocked D2 receptors, Ritalin failed to improve focus. The experiments established the distinct role of each of the dopamine receptors in enabling Ritalin to enhance cognitive performance.

In addition, animals that performed better after Ritalin treatment showed enhanced synaptic plasticity in the amygdala. Enhanced plasticity is essentially increased efficiency of neural transmission. The researchers confirmed this by measuring electrical activity in neurons in the amygdala after Ritalin treatment.

The research confirmed that learning and focus were enhanced when Ritalin was administered to animals in doses comparable to those used therapeutically in children.

“Although Ritalin is so frequently prescribed, it induces many brain changes, making it difficult to identify which of those changes improve learning.” said Kay Tye. “By identifying the brain mechanisms underlying Ritalin’s behavioral enhancements, we can better understand the action of Ritalin as well as the properties governing brain plasticity.”

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Joint Commission Policy and Procedure Docs

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Genius can appear anywhere, but the origins of Carlsen’s talent are particularly mysterious. He hails from Norway — a “small, poxy chess nation with almost no history of success,” as the English grand master Nigel Short sniffily describes it — and unlike many chess prodigies who are full-time players by age 12, Carlsen stayed in school until last year. His father Henrik, a soft-spoken engineer, says he has spent more time urging his young son to complete his schoolwork than to play chess. Even now, Henrik will interrupt Carlsen’s chess studies to drag him out for a family hike or museum trip. “I still have to pinch my arm,” Henrik says. “This certainly is not what we had in mind for Magnus.”

Read on:Chess Mind

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