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ICD-10 is 'Last Straw' for TX Physician Group

 |  By jfellows@healthleadersmedia.com  
   September 03, 2015

As a veteran internist prepares to close her practice for good in advance of the mandatory transition to ICD-10, she says running a medical office is "not efficient at all" and describes being "overwhelmed by the administrative burden."

Instead of spending the last few months preparing in haste for the transition to ICD-10 on October 1, internist Isabel Hoverman, MD, has been transferring medical charts, selling supplies and tables to other physician offices, and saying goodbye to patients she's taken care of since 1992.

Hoverman, who along with three other physicians is part-owner of Austin, TX-based Austin Internal Medicine Associates, decided to stop seeing patients because the administrative burden was too expensive, too complicated, and took away from patient care.


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"This is not me being a dinosaur and refusing to move into the future," says Hoverman, who was chair of the Joint Commission's Board of Commissioners in 2011. "We are so overwhelmed by the administrative burden that we forget to step back and ask, 'Why are we doing this?' "


Isabel Hoverman, MD

Hoverman, who was on Austin Monthly's Best Austin Doctors roster in 2013, will see her last patient on Friday, September 4, and she anticipates it will be hard because of the emotional connection the patients have to her and the practice.

But, Hoverman says, it will also be a relief.

"How you run a medical office has changed greatly," she says. "It's not efficient at all, especially if you look at all the administrative requirements, and the lack of uniformity in how payments are made. All of that trickles down to how it works out on the front line."

At 70 years old, Hoverman says it would be easy for critics to point to her age as the real reason for closing her practice, but she says it is the combination of administrative red tape and unorganized regulations that pushed the practice to decide to close.


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"I don't have a set plan," says Hoverman about what's next. "We have patients who ask, "Where are you going to go?' I'm going home. I think any time you make a big change, you need to stop and take into account what is out there."

Fed up With Red Tape
While ICD-10 was the "last straw" for Hoverman and the other physicians, the decision to close a practice that has a 40-year history was not a reactionary one. The practice began thinking about closing its doors last year.

The hiccups with insurance, varying quality programs, and CMS added to a long list of frustrations that took physicians away from patients. When it was clear the ICD-10 start date would not be delayed this year, the partners approved the closure and aimed for seeing its last patients in early September to avoid any code confusion with its payers. Letters went out to patients in April.

"[ICD-10] is not a problem for me as a physician, but to have this big huge transformation, would be another huge administrative burden," she says.


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Austin Internal Medicine Associates does not have an EHR system. The practice does electronic billing and e-prescribing, but implementing an EHR system was not financially feasible, she says. "If we had an EHR that worked, I'd be very excited; I don't think I'd retire."


A. Tomas Garcia III, MD

The frustration physicians feel is real, and Hoverman's absence is something Texas Medical Association (TMA) President, A. Tomas Garcia III, MD, a practicing cardiologist in Houston, fears he will see more of across Texas.


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"Doctors may need to walk away, and those patients have to go somewhere," says Garcia. "In the TMA, we think 60%–65% of physicians have an EHR, which means 30% to 40% of doctors are not up to speed, and that gives them the opportunity to quit or go to cash only."

The patients from Austin Internal Medicine Associates have found other physicians, says Hoverman. But Garcia worries about not only the practices that close for good, but also the ones that close for a day or two because they are overwhelmed by the additional details that can cause a delay.

"My concern is access," he says. A few minutes here or there in one physician's office may not be a big deal, but he suspects it's more than one physician office that is not prepared.

Physician and Payer Mistrust
He's right. By and large, physician groups are unprepared for the transition to ICD-10, especially when compared to hospitals. Garcia himself is prepared, but like other physicians, frustrated, too.

"It's going to be awful," Garcia says, referring to ICD-10. "They're using it for research—I get that—but uncouple it from reimbursement. When you couple ICD-10 with reimbursement there are [payers] who will play games."

The Centers for Medicare & Medicaid is giving physicians a one-year reprieve from being financially penalized or audited for submitting the wrong ICD-10 codes (as long as the codes submitted are in the correct family of codes), but it's not clear whether commercial payers will follow suit.

Garcia tells me he has not received any guidance from payers, other than CMS. "I'm ready for ICD-10," he says. "I know I'm not going to get paid, but the payers are going to play games. Why? Because they can."

Garcia is not the only one who says commercial payers have been silent on whether they will work with providers or deny claims submitted incorrectly. Gregory Fuller, MD, a primary care physician at North Hills Family Medicine, a five-physician primary care practice in the Dallas–Fort Worth area, says he doesn't know if payers will follow CMS's lead.

"We've gotten no communication from payers on this," says Fuller. "We're able to champion the grace period with CMS, but we don't have that information from commercial providers."

Fuller, who is prepared for the ICD-10 transition, estimates the payer mix at the practice breaks out to 91% commercial, 8% Medicare, and 1% cash pay. That means any delay in reimbursement would significantly impact the practice's the revenue stream.

"I laugh when these experts say you need to have 3–6 months of operating revenue saved up," says Fuller. "We operate month-to-month. There is not a big pile of money to be used. We have an open line of credit at the bank, and we haven't had to use any, but we aren't going to be very happy if we have to draw money on that to keep us going."

Like Garcia, Fuller is concerned about access to care for patients, especially in rural areas of Texas where some counties have no physicians.

"This has the potential to hamper medical care in the state of Texas, that's the worst case scenario," says Fuller. "Rural practices tend to have more Medicare and Medicaid patients, and they do have a buffer for the first year, but they are the most vulnerable practices, even without ICD-10 looming."

The transition to ICD-10 will no doubt be a bumpy road for most physician practices, but it will also likely exacerbate tensions among an already frustrated group of providers.

HealthLeaders Media Webcast: How Health Systems Prep for ICD-10—Physician Alignment, Support and Technology, will be broadcast on Tuesday, October 20, 2015, from 1:00 to 2:00 p.m. ET. Hear from the University of Mississippi Medical Center's chief health information officer as he describes how to overcome the obstacles of implementing ICD-10.

Jacqueline Fellows is a contributing writer at HealthLeaders Media.

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