Boston Counseling Therapy

Electronic Health Records (EHR), and Electronic Medical Billing, in Today’s Mental Health Counseling Practice

Websites, social media, e-commerce, e-billing, e-therapy, e-counseling…e-nough! The pressure to practice online and to document and bill paperlessly seems to be coming from all directions and with increasing frequency and fervor, but many counselors are finding that the transition is easier said than done. For some of us, the major road block to a paperless practice is the steep learning curve associated with gaining a working knowledge of paperless technologies. And, from our experience, an equally large cost of making the transition is, well…actual monetary cost.

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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