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Consumers Need Protection from Health Insurance Company Plan Year Manipulation


It was disappointing—infuriating actually—to learn that some of the nation’s health insurance companies are trying to take advantage of their current customers by manipulating plan years. They are doing so to avoid having to pass on to these customers the benefits of national health reform.

These insurers are reaching out to current customers, taking advantage of their uncertainties, and luring them to switch to health plan years that begin in 2013. By substituting 2013 plans for their current plans that run through early 2014, customers will lose important Affordable Care Act (ACA) protections that must apply to plans issued on or after January 1, 2014. For example, plans issued in 2014 must offer a comprehensive range of benefits and have rates based only on the customer’s age, geographic location, number in family, and tobacco usage. Discrimination based on gender or pre-existing conditions is banned by federal law in 2014 plans. Health insurance insider turned critic, Wendell Potter, recently wrote in detail about this outrage in the Huffington Post.

So insurers are trying to have the best of both worlds. They want all the goodies the ACA offers them, including hundreds of millions of new customers (many of whom will only be able to afford coverage because they qualify for the federal financial help in the form of advance premium tax credits and cost sharing subsidies available under the ACA), but they also want to deprive their existing customers of the benefit of ACA reforms.

Fortunately, insurance regulators can and are protecting customers from such manipulation. Illinois Department of Insurance Director Andrew Boron issued Bulletin 2013-07 on April 29, 2013, telling Illinois health insurers that they won’t get away with such manipulation. “The Department will not approve…filings for such arrangements,” the bulletin says. That should bring these threatened manipulations to an end in Illinois, and we hope regulators in other states take similar actions.

Health insurance has been baffling to most individuals and small businesses. The federal government, many states, and many non-profit organizations are working hard to inform citizens of the reforms, benefits, and opportunities the Affordable Care Act has already brought and the major improvements coming in 2014. Actions like these plan date manipulations simply have no place in the picture. Thank goodness regulators can and are stepping it to ensure a happy ending.

Margaret Stapleton

Community Justice Director
Sargent Shriver National Center on Poverty Law

99213 CPT® Code Description, Progress Notes, RVU, Distribution.

This 99213 CPT® lecture reviews the procedure code definition, progress note examples, RVU values, national distribution data and explains when this code should be used in the hospital setting.  CPT stands for Current Procedural Terminology.  This code is part of a family of medical billing codes described by the numbers 99211-99215.  CPT® 99213 represents the middle (level 3) office or other outpatient established office patient visit and is part of the Healthcare Common Procedure Coding System (HCPCS).   This procedure code lecture for established office patient visits is part of a complete series of CPT® lectures written by myself.  I am a board certified internal medicine physician with over ten years of clinical hospitalist experience in a community hospitalist program providing physician services for a large regional hospital system.  I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and other non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex and archaic world of hospital and clinic based coding requirements.

These original lectures and accompanying resources are used by myself to stay compliant with the rules and regulations of the Centers for Medicare & Medicaid Services (CMS). All my CPT® lectures (including  CPT® 99214 and CPT® 99215) have been organized in one easy-to-find resource on Pinterest and can be accessed by clicking this link. You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these CPT® E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.

99213 MEDICAL CODE DESCRIPTION

 

My interpretations detailed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion.  I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding.  I have provided access to Amazon through the 2015 CPT® standard edition pictured below and to the right.  CPT® 99213 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient established patient services. The American Medical Association (AMA) describes the 99213 CPT® procedure code as follows:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components:  An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity.  Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.  Usually, the presenting problem(s) are of low to moderate severity.  Physicians typically spend 15 minutes face-to-face with the patient and/or family.

An established patient is defined as an individual who has received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.

This medical billing code can be billed based on time when certain requirements are met. Documentation of time is not required to remain compliant with CMS regulations.  If billed without time as a consideration, CPT® 99213 documentation should be supported by the  1995 or 1997 E/M guidelines referenced above. The three important coding components for an established outpatient clinic note are the:
  1. History
  2. Physical Exam
  3. Medical Decision Making Complexity
For all established office patient billing codes (99211-99215), the highest documented two out of three above components determines the correct level of service code. Compare this with the requirement for the  highest documented three out of three above components for new office patient care encounters (99201-99205).  Again, only the highest two out of three components are needed to determine the correct level of care for CPT® 99213. The following discussion details the minimum requirements necessary to remain compliant with CPT® 99213.    In addition, as with all E/M encounters, a face-to-face encounter is always required.  However, in the case of outpatient clinic codes, Medicare does allow incident to billing, where the the service is provided by someone other than the physician.  If certain requirements are met, the physician may collect 100% of allowable charges in these situations.  Services billed incident to are billed under the physician's provider number.
  • Expanded problem focused history:  Requires only 1-3 components for the history of present illness (HPI) OR documentation of the status of THREE chronic medical conditions. No past medical history or social history or family history is needed.  Only 1 problem pertinent review of systems (ROS), that inquires about the system related to the problem identified in the HPI, is required.
  • Expanded problem focused examination:  1997 guidelines require documentation of at least six elements identified by a bullet in one or more organ systems(s) or body area(s).  1995 guidelines require a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).  The CMS E&M guide on pages 31 and 32 describes the acceptable body areas and organ systems on physical exam.
  • Medical decision making of low complexity (MDM):  This is split into three components. The 2 out of 3 highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and what are the minimum required number of points and risk level as defined by the Marshfield Clinic audit tool? 
    • Diagnosis (2 points) 
    • Data (2 points) 
    • Risk (low); The risk table can be found on page 37. 
The medical decision making point system is highly complex. I have a detailed reference to it on my E/M pocket cards described below. These cards help me understand what type of care my documentation supports. I carry these cheat sheet cards with me at all times and reference them all day long.  As a hospitalist who performs E/M services almost exclusively, these cards have prevented me from under and over billing thousands of times over the last decade.

CLINICAL EXAMPLES OF 99213


What are some progress note documentation examples for a CPT® 99213, the level 3 established patient visit in an office or other outpatient setting?  Most doctors use the subject, objective, assessment and plan (SOAP) note format.  A 99213 note could  look like this:
S)  No more abdominal pain (1 HPI).  Mild Nausea (1 problem pertinent ROS)
O) 120/80   80    Tmax 98.9 (three vital signs = one bullet) abdomen no masses; lungs clear; heart no murmur; legs no edema; skin no rash. (at least 6 total bullets)
A) Nothing needed
P)  Nothing needed
In this example  history (subjective) and physical (objective) meet the requirements to get paid for a 99213.  Remember, the highest  2 out of 3 components determine the highest level of service for established patients in the clinic or other outpatient setting.  Do note that linking an ICD code to a CPT® medical code is required for all visits submitted to CMS for reimbursement.  Therefore, most progress notes should provide at least one ICD code  to clearly indicate a purpose for the visit.  I suspect this is necessary  to meet the reasonable and necessary threshold, unless that can be inferred from other chart documentation.  Medicare doesn't want to pay for doctors to talk about politics with their patients.  There must always be an approved ICD code linked with the CPT® medical code when billed to CMS and most other insurance companies.  

I think it's always a good habit to include at least on ICD code in your note documentation, even though it's not technically required for established patient clinic follow-up visits that can achieve compliance with history and physical elements alone.  Remember, the highest supported level of documentation for 2 out of 3  from  history, physical and medical decision making on established clinic patients determines the overall level of CPT®  code service.    For history, just one component of the HPI  (character, onset, location, duration,  what makes it better or worse etc...) or  documentation of  the status of three chronic medical conditions PLUS one problem pertinent review of system is required for this level three  progress note.  For physical exam, using 1997 E/M guidelines, documentation of six bullets from at least one organ system or body area is required.  Remember, documentation of three vital signs can count as one bullet element.   Here is another clinical example of a SOAP note for a CPT® 99213 established patient clinic visit:  
S)No SOB (1 problem pertinent ROS)
O) 120/80   80    Tmax 98.9 (three vital signs = one bullet) abdomen no masses; lungs clear; heart no murmur; legs no edema; skin no rash. (at least 6 total bullets)
A)HTN-stable, no changes planned.
    DM-stable, no changes planned.     
    COPD-stable, no changes planned.  (the status of three chronic medical conditions in place of HPI)
P)  Nothing
As you know, documenting the status of three chronic medical conditions can substitute for the HPI. Add in one problem pertinent review of system and this is the minimum history documentation required for CPT® 99213.  With at least 6 bullets documented in the physical exam, this note is complete and accurate and meets documentation requirements to get paid for a 99213.  Here is another clinical progress note example of appropriate documentation for a CPT® 99213:
S)  Nothing needed
O) 120/80   80    Tmax 98.9 (three vital signs = one bullet) abdomen no masses; lungs clear; heart no murmur; legs no edema; skin no rash. (at least 6 total bullets)
A) 1) HTN, controlled  2) DM II, controlled  (two points for diagnosis)
P)  Nothing needed
According to the guidelines E/M risk table guidelines linked above,  documenting the status of one chronic medical condition qualifies as low level risk in the medical decision making process.  I have documented the status of two chronic medical conditions and that meets the criteria for diagnosis (2 points) and risk (low) for CPT® 99213 in MDM.  This qualifies for low risk in the risk table based on their qualifying description as "one stable chronic illness, eg, well controlled hypertension, non-insulin dependent diabetes, cataract, BPH".    I have meet my 99213 note requirements for 2 out of 3 areas by meeting minimum criteria  for physical exam (6 bullets) and the decision making component (by documenting the status of two chronic medical conditions).  Remember, reasonable and necessary is always  part of any evaluation, as is the requirement for the visit to be face-to-face in nature.

The complicated  table of risk, one of the elements used to determine overall complexity in medical decision making, can be reviewed once again on page 37.  What I have on my quick reference E/M card below only represents examples of moderate and high risk elements due to space limitations. At least for the hospitalist population (as a consultant on observation status scenarios), most established outpatient coding decisions will not be determined based on low risk medical decision complexity.  I rarely use low risk in the table for any progress note because I'm just not smart enough to memorize it.  I generally only use the table of risk when determining moderate and high risk encounters.  In addition, most of my patients in the hospital present with moderate or high risk complexity. However, I have linked to it on page 37 above for your quick reference should you desire a more detailed understanding.  Here is another clinical example that meets minimum  documentation requirements  for a CPT® 99213:
S)  HA present (one HPI). No nausea (1 problem pertinent ROS) 
O) Nothing
A) Chronic HA, stable.   (one stable chronic illness is low risk)
P)  I discussed HA history with Neurologist Dr Smith today and I plan to get their formal opinion. (two points under data for discussing case with another healthcare provider)
That's all you need folks.  Documentation of 2 out of 3 areas at their defined minimum requirements.  That means one HPI (HA present), one problem pertinent ROS (no nausea) and  low complexity medical decision making.  Documentation of one stable medical problem (HA) is low risk on the risk table.  Discussing the case with another healthcare provider gets two points under the data section for MDM.  This is level three 99213 history and medical decision making complexity for established outpatient clinic visits. Notice the volume of documentation matters much less than the quality of what is written to support the E/M charge appropriate for the visit.

In my discussions above, I have detailed several examples of the minimum documentation required to meet compliance for level three established patient clinic visits.     This is not my patient population in the hospital, however, this well may be common in the outpatient world for a clinic full of mostly healthy adults.  For hospitalists, most observation status patients in the hospital these days are much more complex than what a level 3 established clinic patient progress note would support.  When would a hospitalist bill an established patient clinic procedure code in the hospital setting?

USING ESTABLISHED PATIENT CLINIC CODES IN THE HOSPITAL SETTING


The CPT® medical billing code group 99211-99215 should used by hospitalists and other physicians or non-physician practitioners in the hospital setting under certain circumstances.  I have previously discussed all the possible CPT® admission codes that could be used in the hospital setting  These established patient clinic and other outpatient visit codes are included as possibilities.  I have provided a detailed discussion of  that decision tree analysis at the link provided just above.  However, I will discuss the pertinent portions of that analysis here.

The attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge.  Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may apply as well.

But what codes should a consultant use?  This is where the correct code decision can get very complicated.  Medicare no longer recognizes consult procedure codes. Consultants should pick the appropriate level of service from code group 99211-99215 for their initial encounter and all subsequent care visits (including the day of discharge) IF the patient has been seen previously  by the physician or a physician partner of theirs in the same group and exact same specialty within the previous three years, unless documentation supports the use of critical care codes or until the patient becomes inpatient status.

If the patient has not been seen in the last three years by the same physician or partner physician in the same group and exact same specialty, the consultant should use the new patient clinic code group 99201-99205 on their initial date of service and then choose a code from the established outpatient code group 99211-99215 for all subsequent observation services, including the day of discharge.  Remember, all hospital observation CPT® code groups are reserved only for the attending physician.

The above discussion relates to Medicare because Medicare does not accept consult codes.  Other insurances may still accept consultation codes.  In that case, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge,  while the patient is hospitalized for observation services.  

DISTRIBUTION OF ESTABLISHED PATIENT CARE CODES


What is the distribution of CPT® code 99213 relative to other levels of service in this medical code group?  The graph below was published in  May, 2012  by the OIG in a report titled Coding Trends of Medicare Evaluation and  Management Services.  You can find these charts and graphs starting on page 9 of the link provided here.   As you can see, between 2001 and 2010, the distribution of established patient office visits has shifted higher.  The proportion of  level four 99214 and level five 99215 reimbursements has increased by 15% and 2% respectively, while the proportion of level three  99213 services billed for payment has decreased by 8% between 2001 and 2010.  On an absolute percentage basis, in 2010, CPT® code 99213 was being billed 46% of the time, down from 53% of the time ten years previously.

E/M-Established-Patient-Clinic-Outpatient-Distribution-Curve-Graph

photo efd067cb-81b9-4b36-a65a-61723256119a_zps2d121e07.jpg


Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99213 encounters were billed and the dollar value of their services for Part B Medicare.    As you can see in the image below, E/M code 99213 was billed 100,268,652 times in 2011 with allowed charges of $6,790,211,816.94 and payments of $4,709558,960.68.

2011 CMS Medicare Part B National Procedure Summary File 99211-99215

RVU VALUE


How much money does a CPT® 99213 pay?  That depends on what part of the country you live in and what insurance company you are billing.  E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs).  This complex  RVU discussion has been had elsewhere on The Happy Hospitalist. For raw RVU values, a CPT® 99213 is worth 1.44 total RVUs for facility services and  2.05 total RVUs for non-facility.   The work RVU for 99213 is valued at 0.97.  A complete list of RVU values on common hospitalist E/M codes is provided at the attached URL.  What is the Medicare reimbursement for CPT® code 99213? In my state, a CPT® 99213 pays about $48 (facility) and $68 (non-facility) in 2016.  The dollar conversion factor for one RVU in 2016 is $35.8043.

My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through to the link provided here.  If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.
 

LINK TO E/M REFERENCE CARD POST

EM Pocket Reference Cards Using Marshfield Clinic Point Audit

Click image for high definition view


Governor Quinn Enacts Largest Increase in Health Care Coverage in State History


Governor Pat Quinn today signed legislation that enacts a critical part of President Obama’s Affordable Care Act (ACA) by making Medicaid coverage available to all low-income adults in Illinois. Today’s action delivers on a major priority announced by Governor Quinn in his 2013 State of the State address and is part of his agenda to improve the health of the people of Illinois and increase access to quality health care.

“In the home state of President Obama, we believe access to quality health care is a fundamental right and we proudly embrace the Affordable Care Act,” Governor Quinn said. “This legislation will greatly improve the health of hundreds of thousands of people across Illinois, strengthen our health care system and create thousands of good jobs in the health care field. Thanks to this law and our shared commitment to increasing access to health care coverage in Illinois, the people of Illinois will be healthier and have a higher quality of life.”

Sponsored by State Senator Heather Steans (D-Chicago) and State Representative Sara Feigenholtz (D-Chicago), Senate Bill 26 will make Medicaid coverage available to adults with annual income below 138 percent of the federal poverty line, which is $15,860 for individuals and $21,408 for couples. The measure is expected to enroll 342,000 people by 2017. Currently, Medicaid is only available to children, their parents or guardians, adults with disabilities or seniors. Enrollment for the newly eligible population will begin Oct. 1 with coverage starting on Jan. 1.

Under the ACA, for the first three years, coverage of newly eligible adults will be 100 percent federally funded. The reimbursement rate will phase down to 90 percent by 2020. State officials estimate this will bring more than $12 billion in new federal funding to support the state’s health care system from 2014 to 2020.

“The Affordable Care Act gives Illinois the resources to provide critical health care services to a population that desperately needs it,” Illinois Department of Healthcare and Family Services Director Julie Hamos said. “Under Governor Quinn’s leadership, we are reforming our health care system so that it focuses on delivering coordinated care and keeping people healthy through better preventive care, not just paying the bills when they become sick.”

Under Governor Quinn's leadership, Illinois is also increasing access to health coverage through the Illinois Health Insurance Marketplace, another major feature of the ACA. The Marketplace, which also launches enrollment Oct. 1 with coverage starting Jan. 1, will be accessed through a user-friendly website where individuals, families and small businesses will be able to compare health care policies and premiums and purchase comprehensive health coverage. Those with income between 138 percent and 400 percent of the federal poverty level will receive subsidies on a sliding scale if they obtain coverage through the marketplace.

Governor Quinn has long championed access to decent health care for all people. In August 2001, he joined his then 78-year-old Doctor, Dr. Quentin Young, to walk 167 miles across Illinois to advocate for health care for all.

For more information about Illinois' implementation of the ACA, go to HealthCareReform.illinois.gov.

Related Documents
Senate Bill 26 and the Affordable Care Act (PDF)

(This post was taken directly from the Illinois Government News Network press release)

Accountable Care Entities (ACEs): A New Coordinated Care Model in Illinois

SB 26 to be signed by the Governor into law on July 22, 2013, will expand Medicaid to over 600,000 new potential enrollees but it will also usher in a new form of coordinated care in Illinois for these new Medicaid enrollees as well as existing families on Medicaid - the Accountable Care Entity.

An Accountable Care Entity (ACE) will be a new Illinois model of an integrated delivery system. This will be the fourth model providing “care coordination services” for Medicaid clients, which now includes Managed Care Organization (MCO), Managed Care Community Network (MCCN) and Care Coordination Entity (CCE). This infographic provides a great overview of the system so far.



The ACE will have these elements:
  • Will be a provider-organized network of care -- providers working together collaboratively
  • Will be large enough to have impact for a population: initially children and their family members in Illinois Medicaid, at least 40,000 in Cook County, 20,000 in collar counties, 10,000 downstate
  • Will have at a minimum the following types of providers: primary care, specialty care, hospitals, and behavioral healthcare; will have a governance structure that includes each type of provider and works to create a shared culture of collaboration/transformation
  • Will build an infrastructure to support care management functions among the providers in the network, such as health information technology, risk assessment tools, transparent data and data analytics, communication with Medicaid members, etc.
  • Will work toward a new payment structure different from the current fee-for-service: shared savings within first 18 months, partial risk after 18 months and full risk after 3 years, which means capitated payments with financial incentives for the providers within the network
This is an opportunity for the hospital community and other providers to develop integrated delivery systems in Illinois that will manage Medicaid populations but are not traditional MCOs. Under SB 26, HFS will post a solicitation by August 1, and give 5 months to new entities to organize and apply.

The initial population assigned to ACEs will be children and family members (and likely newly eligible Medicaid clients under the Affordable Care Act.)

For more information check out the HFS Care Coordination Site

Stephanie Altman
Health & Disability Advocates

Illinois to Be Awarded Over $90 Million in Medicaid Funds for Home- and Community-Based Care

The Affordable Care Act (ACA) section 10202 establishes the Balancing Incentive Payments Program or BIP. BIP offers State Medicaid programs a financial incentive to offer home- and community-based services (HCBS) as an alternative to institutional care in nursing homes. In exchange for an increased federal matching rate (Medicaid is a State-Federal jointly paid program), States must implement 3 structural changes to their long-term services and supports (LTSS) system:

1. A No Wrong Door–Single Entry Point system (NWD/SEP)

2. Conflict-free case management services

3. A core standardized assessment instrument

In March, 2013, Illinois’ State Medicaid Agency, the Department of Healthcare and Family Services, submitted a proposal to the Centers for Medicare and Medicaid Services (CMS) to participate in BIP. On June 12, 2013, CMS announced their approval of Illinois’ BIP application, which will bring in $90.3 million of Federal matching funds into the State for Illinois projected HCBS expenditures over the next 2 years.

What Does Illinois’ Proposal Look Like?

Illinois’ BIP proposal is the most comprehensive overview of the State’s various LTSS programs: from aging, to development disabilities, to physical disabilities, to mental health, to substance abuse—Illinois’ BIP proposal covers it all. For anyone who wants a crash course on what Illinois is doing in the area of LTSS balancing—the development of a LTSS system that is more home- and community-focused than institutional focused—the BIP application is a great place to start.

In reading through the BIP proposal, you will see that Illinois is planning to integrate LTSS through collaboration across governmental department silos. The BIP operating agency will be the State Medicaid Agency: the Illinois Department of Healthcare and Family Services (HFS). HFS is already working in partnership with its sister agencies on implementing BIP:


Further, Illinois’ BIP goals will build off the existing work that Illinois is doing to balance LTSS in favor of HCBS. Existing LTSS balancing projects in Illinois include:


The work described in the BIP application details how Illinois will implement the 3 structural requirements of BIP: a no wrong door–single entry point system (NWD/SEP), conflict-free case management services, and core standardized assessment instrument. These 3 areas are described below briefly. It is important to note that currently Illinois has separate systems for each sub-population served in its LTSS programs: aging, physical disability, mental health, substance abuse, development disability. BIP provides Illinois with the opportunity to coordinate across the population groups from the community and consumer level, all the way up to the State government level.

1. Illinois’ No Wrong Door–Single Entry Point system (NWD/SEP)
Entry points for LTSS are not currently coordinated across aging and disability populations. Current access points include: DHS local offices, Aging and Disability Resource Centers (ADRCs), Area Agencies on Aging (AAAs), Division of Rehabilitation Services local offices, Pre-Admission Screening agencies that serve persons with intellectual/developmental disabilities, community mental health centers and regional mental health points of contact, and State agency websites.

The ADRC network offers a starting place to coordinate across all of these different access points. Under the leadership of Illinois Department on Aging, the vision for the ADRC system is “a highly visible and trusted resource for all persons regardless of age, income and disability, to access a coordinated point of entry to public long-term support programs and benefits, and to obtain information on the full range of long-term support options”. [See page 31 of the BIP proposal].

Illinois’ ADRC system is already in development with 7 ADRCs up-and-running across the state—through AAAs in collaboration with disability organizations. It is anticipated that by September 2016, all of Illinois’ 13 Planning-and-Service-Areas (PSAs) will have designated ADRCs through leadership from Illinois’ AAAs. ADRC entities also currently include Care Coordination Units, Community Care Program providers, Centers for Independent Living, and DoA’s Senior Help Line (a State-wide toll-free phone number).

The NWD/SEP system will allow for individuals to receive a level 1 screen to determine which LTSS an individual should be assessed for. Access to this level 1 screen will be available online through a coordinated network of ADRC partners.

2. Illinois’ Conflict-Free Case Management Services
Illinois has different case management systems for each population group served. To ensure conflict-free case management, per Federal guidance, Illinois will work to separate the determination of eligibility process from case management, and from the direct delivery of services.

In the BIP proposal, Illinois describes the current developmental disability and physical disability processes to be conflict-free. However, more work needs to be done in the area of mental health/substance abuse and aging to ensure conflict-free case management [see pages 23-24 of the BIP proposal].

The expansion of managed care models in Illinois will help to promote conflict-free case management. With the help of BIP funds, Illinois will also continue to work with CMS to identify potential conflicts of interest and to develop the proper firewalls between eligibility determination, case management and service delivery.

3. Illinois’ Core Standardized Assessment Instrument
Over the past year, Illinois human service agencies have collaborated with Navigant consulting to review Illinois’ current assessment tools and methodology (each population currently has their own assessment tool). With Navigant, Illinois will develop a uniform assessment tool (UAT) for access to LTSS. Recently, HFS released a Request for Information related to the development of the UAT as the State seeks out vendors who can integrate and coordinate across populations and State departments.

A UAT will allow Illinois’ to develop a more consumer-centered LTSS system. Many individuals with LTSS needs require complex care and fall into more than one category across the current Medicaid HCBS waiver system. This means that consumers with mental health needs who are also 60 years or older must access two separate programs to have their needs meet: one in mental health and the other in aging. This makes it very challenging for consumers, and cumbersome and redundant for State agencies. BIP is intended to fix this, to ease access to LTSS in a more timely and appropriate way.

Further, Illinois is also replacing the 30-year old COBOL-based system that is currently in use to determine eligibility for: Medicaid, the Supplemental Nutrition Assistance Program (SNAP, formerly ‘food stamps’), Temporary Assistance for Needy Families program (TANF), and the new Health Benefits Exchange, or Marketplace, required by the ACA. The new Integrated Eligibility System (IES) is branded as Application for Benefits Eligibility, or ABE.

What all of this means for professionals and consumers is that Illinois is moving towards a system that will significantly streamline the determination of eligibility process for a variety of different programs, including LTSS. Part of this systemic upgrade includes ensuring better Information Technology (IT) integration and easier access to data about these publicly funded programs across population types.

Stay Tuned as Illinois Continues to Balancing LTSS in Favor of HCBS

As Illinois implements BIP and its other LTSS balancing programs, the State’s goal is to develop a new HCBS infrastructure that is consumer driven and easy to access and navigate. We look forward to reporting back as consumers across the State find it easier to live and receive care in their homes and communities.

Please let me know if you have questions, comments or responses to this blog post. You can reach me at: 312.372.4292 or kpavle@hmprg.org.

Kristen Pavle
Associate Director, Center for Long-Term Care Reform
Health & Medicine Policy Research Group

Effect of Delaying Employer Penalties under the ACA


The Treasury Department posted a blogpost late yesterday noting that it would (i) publish rules about employer reporting requirements later this summer and also (ii) delay the employer “shared responsibility” payments under § 4980H of the Internal Revenue Code until 2015 (as added by § 1513(a) of the ACA). For reference, IRC § 4980H imposes the $2,000/$3,000 penalty on employers with 50 or more full-time equivalent employees if the employees enroll in the ACA’s new premium assistance tax credits

Based on our understanding of the forthcoming guidance, Jackson Hewitt Tax Service notes the following potential effects of Treasury’s announcement:

  • Fewer employers may cut employee hours in 2014. This one-year respite may make employers (e.g., restaurant and retail establishments) less likely to reduce employee hours below 30 hours per week (so as to classify such employees as part-time for § 4980H penalty calculations).
  • Many families with children will have an unexpected benefit. For employers who offer employee but not dependent coverage, this one-year delay may also cause employers to postpone any offer of coverage to dependents. Interestingly, this may have a positive effect on such families for two reasons. First, children without an offer of employer-sponsored coverage may be eligible for the Children’s Health Insurance Program (CHIP) if they meet the state-specific income and other eligibility requirements. Second, children without an offer of employer coverage may be eligible for the new premium assistance tax credits in 2014 even if their incomes are above the state-specific CHIP limit. Indeed, employers may be more likely to cooperate with enrollment efforts to get uninsured employees and their uninsured dependents covered under various ACA programs because they know with certainty that they will not face a penalty in 2014.
  • States may face less pressure from business interests to expand Medicaid. Jackson Hewitt had released a report earlier this year estimating that American employers would incur $876 million to $1.3 billion in penalties in 22 states that were refusing to expand their Medicaid programs as contemplated under the ACA. Today’s decision effectively removes that penalty liability for 2014. However, employers will continue to face such penalties in 2015 and thereafter in states that do not expand their Medicaid programs.
  • The Treasury action today addresses anxiety among employers about the lack of final regulations from the IRS. While many employers with large part-time and seasonal employees embraced the flexibility afforded to them by the IRS’ proposed approach, they voiced increasingly loud concerns that the IRS had yet to finalize this approach in a final rule. Indeed, the IRS has not publicly pledged to finalize these proposed rules before the major provisions of the ACA take effect in 2014. In an unexpected development late Tuesday, though, the Treasury Department effectively moots this issue for 2014.

Jackson Hewitt also issued a statement today in response to Treasury’s announcement. “Today’s announcement from the Treasury Department alleviates several key concerns held by a large number of American employers that have a significant part-time and seasonal workforce,” said Brian Haile, Senior Vice President for Health Care Policy at Jackson Hewitt. “The federal approach acknowledges the challenges with implementing a policy that will affect so many employers – and strikes the right balance between speedy implementation and thoughtful policy-making.” Haile further noted that, “Notwithstanding the Administration’s announcement today, we continue to expect the launch of the health insurance marketplaces on October 1, 2013.”

Please feel free to contact us if we can answer any questions or be helpful in any way.

Brian Haile
Senior Vice President for Health Policy
Jackson Hewitt Tax Service Inc.

Funny Allergy Quotes, Jokes, Stories and a List of Crazy Reactions.

If you're looking for funny allergy quotes, jokes and stories you've come to the right place.  I asked my readers from facebook to provide me with their experiences they've had regarding crazy allergy reactions and they did not let me down.  They relayed dozens of incidents they've experienced through the years.  Over the years I've discovered several  funny allergies myself, including allergies to prednisone, diet products and the color red.  Some patients have dozens of allergies.   My experience is that most of these allergies are not allergies in the physiological sense.   The terms "drug allergy", "drug hypersensitivity" and "drug reaction" are often used interchangeably but they are not the same.  The science behind them is quite different.   This resource from the American Family Physician provides a nice detailed summary of adverse drug reactions.

A detailed allergy history is part of the admitting H&P process.  For many hospitals, the nurse or pharmacist obtains the  list of allergies from the patient and stores that information in the hospital's patient data base for future reference.  Once you're labeled with an "allergy", you will never get that medication or any drug from that class of medication again.  In fact, even other classes of drugs must be used with caution with certain listed allergies.  For some patients with multiple allergies, this process of detailing an allergy list can be quite time consuming painful.  Patients with 20, 30, 40 or more allergies often provide a detailed list of every pharmaceutical, grain, food, animal, smell, and abstract thought that causes any kind of discomfort to their psyche.  FBI profiling techniques have confirmed this is limited to women with a dual diagnosis of fibromyalgia.  Some of my colleagues in the medical profession have actually coined the term systemic fibromyallergia to define the relationship between fibromyalgia and multiple drug allergies.

For doctors and nurses, having drug allergies that interfere with their ability to provide high quality, evidence based and cost effective medical care can be frustrating.  For many patients, they only care about how the drug made them feel and they consider any side effect to be an allergy.   Any transient headache or abdominal discomfort or muscle ache will be labeled as an allergy in their mind and forever prevent physicians from providing the right medicine for the right situation.  You can see, quite clearly, this problem is rampant in American healthcare.  Without further delay, I present to you a list of crazy allergy reactions, quotes, jokes and stories provided by my facebook readers.  Whether you laugh or cry, please remember, we are all human, except for the ones that have allergies to every drug known to man, except the one that starts with a d, duh, dililah....
  • Greater than three medication allergies triggers a psych consult.
  • She was allergic to the direction East. I love that one.
  • I was making a joke, put "soap" as an allergy on a homeless patient. Little did I know, you can't delete that, only a strikeout.  No delete.
  • I've had a patient claim a normal saline allergy.
  • Probably allergic to epinephrine and Benadryl too. She needs a naturopath, STAT!
  • A nursing student in the class before mine claimed an allergy to normal saline to avoid receiving a shot in class.  In order to avoid similar incidents the school directed that we simulate drawing up an injection and insert the needle of an empty syringe into each other, but under no circumstance were we to inject any thing!  Believe it or not this idiot passed the course and is now practicing!
  • "Penicillin, sulfa, dental fillings, and certain radio frequencies".
  • "Antabuse." Me: What was your reaction? Patient: It would make me crazy sick every time I drank beer!"
  • My favorite was the patient who had an allergy to Risperdal, Haldol, Cogentin and "all MAOIs" but emphatically denied any and all behavioral health history. He had "been exposed" to these drugs when he was "accidentally thrown in the psych ward because I had the same name as another patient".
  • Everything for pain "except that D one."
  • Allergy:  Succinylcholine.  Reaction: Paralysis.
  • Tomatoes after 6pm.  Seriously.
  • I had a patient tell me they were allergic to 2mg Dilauded but could take 4mg of Dilauded just fine.
  • "I can't take any pains meds except that one that starts with a D...what is it? ...dilada? No...dilaudid...ya that's it."
  • Pitocin: It made her stomach cramp (Im a L&D RN).
  • Allergic to Benadryl. Reaction: "Fatigue".
  • Go Lytely caused diarrhea. Not joking. I just nodded and pretended to write it down.
  • I like it when patients have an allergy to acetaminophen but not to Vicodin. I don't even bother questioning them anymore.
  • "I'm allergic to ibuprofen.  It makes me itchy.  I have to take Motrin instead." Three of us had to leave the triage area.
  • Haldol and Geodon. This is always a red flag for the impending crazy train. There's only one way you know you're allergic to these meds.
  • Allergic to water. Her doctor told her to only drink soda.
  • I've had a client who was allergic to water too. They even convinced the doc to order 'distilled water'. Doctor said to fill bottle from the tap after it ran out. This continued for over two years before the client figured it out.
  • I had a patient tell me he was allergic to "ass-it-am-in-o-fin" (acetaminophen) but that he could take Tylenol just fine!
  • Everything BUT dilaudid.
  • Xanax, because it made them pull a gun on a neighbor.
  • I love the list of -Tylenol, aspirin, Toradol, ibuprofen, Demerol, Percocet, OxyContin, ......Basically everything but the one that starts with "D"......"Dilatin ?"....Then I say, "Dilaudid ?" .....Oh yes ... But it doesn't work in pills.... I need the shot....And Benadryl with it.
  • Okay had a patient with over 31 allergies and the most frequent funny allergy is when a patient says they're allergic to lasix because it makes them pee.
  • No surprise but an old favorite: A chronically psychotic patient with allergies to *every* *single* *anti-psychotic* *ever* *made*.
  • Epi. It made her heart beat fast.
  • Normal saline. I couldn't believe it when I saw it on the chart.  Just had to laugh.
  • Epinephrine cause cardiac arrest.
  • I had a patient whose allergies varied depending on what "the barometer in her brain" decided.
  • Narcan caused nausea and vomiting!
  • Eggs, then she demanded to speak to a supervisor after dietary wouldn't bring her custard for dessert.
  • Epinephrine caused tachycardia. No kidding!
  • I had a patient that was allergic to ice packs. They said when they left it on too long it would turn their skin red. Imagine that!
  • Horse urine.  Don't ask me how they determined this.
  • Erythromycin:  Patient reports it made her vagina swell shut.
  • A homeless guy came into ER and stated "I'm allergic to that TB shot.  It makes my arm swell up."
  • Oxygen.  Not kidding although I don't remember what it caused.  Also Neosporin  caused Guillian-Barre Syndrome.
  • Pepperoni. Sure it's an allergy, but after years of the same guy telling me "pepperoni" and me telling him I promise I won't give him any, his tray had, you guessed it, pepperoni. He was pissed.  I laughed and then he laughed. I bought him a burger.
  • Bologne tops the list followed by "everything but dilauda".
  • Prednisone.
  • Hamburgers. Not the individual ingredients that make up a hamburger. The hamburger as a whole.
  • I saw someone with an allergy to "water".
  • After reading all this post I am happy to realize that we all probably have seen the same patients at one time or another, except for the one that had 54 allergies.  Max I have seen is 30.
  • Niacin:  I makes my face flush.
  • Last week Narcan:  It makes the pain worse.
  • One patient said she was allergic to "all antibiotics." Also, had a patient who thought he might be allergic to lawn mowers.  Right after the lawn mower ran over his foot!
  • Every pain medicine known to man, except for Dilaudid.
  • I don't understand why anyone would be allergic to Prednisone, and Solumedrol.  It's like they just want to just sit there wheezing.
  • Anaphylactic reaction to Tylenol and NSAIDs with 20 other things while wondering why I can't give her something for her fever and make her heart stop racing.  ce packs it is.
  • Cyclobenzaprine, causes fatigue and dizziness.
  • Dextrose.
  • Sodium chloride.
  • Colostrum!
  • Oxygen!
  • Nitroglycerin.  Reaction: makes my blood pressure go down.
  • Narcan. "It makes me crazy."
  • Rabbit. No lie. We will be sure to NOT serve you the customary Hasenpfeffer for dinner then.
  • Allergic to high fructose corn syrup (as he sips on soda) and plastic wrap.
  • I think the most I have seen for one patient was 45, but personally I think I have the worst allergies ever:  Onion and hops. So no beer and onion rings for me.
  • Patient said, "I can't take anything but Dilipidid!"
  • Silk sutures.  He said it caused a scar where his incision was. Really?
  • Succinylcholine - the patient said that it caused her to stop breathing.  Really?  The other one was sweat- made her break out in a rash.
  • Normal saline. I can't make up that stuff!
  • Chicken! I think he was actually just afraid to tell his wife he hated her chicken.
  • Lactulose gave them diarrhea and epinephrine makes their heart race.  My personal favorite are those allergic to every pain medication but Dilaudid.
  • Estrogen.
  • There are actually people who are allergic to hormones. Saw it on discovery medical.  A woman suffered from hives, angioedema, and wheezing for years before they finally figured out it was always during her menstrual cycle. They put an estrogen patch on her arm and voila! Hives!
  • I saw a chart with 23 allergies.
  • Cabbage, because it causes severe flatulence.  This was told to me by an adorable old lady who was dead serious.  I had to leave the room.
  • Two nights ago my patient listed that she is allergic to cocaine. Yes, cocaine.
  • I b profen that is what they wrote.
  • Ipecac made him have nausea and vomiting.
  • I'm allergic to: penicillin, sulfa, potatoes, shellfish, nuts (all anaphylactic); chocolate, mangoes, oil paint, fresh basil (but not dried) and all cats except orange ones. Makes it lots of fun for people to have me over for dinner, or for me to buy processed foods.
  • I'm allergic to all kinds of foods too! They all cause anaphylaxis. I use epi on a regular basis.
  • Bubblegum.
  • A lady in our practice has 54 listed and decided the newest one should be added since she woke up with a headache. Thanks to CPO, I don't have to count, they're listed numerically!
  • Benadryl and Prednisone.
  • Dolphins!
  • Cardboard.
  • Allergic to morphine, Fentanyl, oxy and hydrocodone, Dilaudid, codeine and Nubain, but "...Demerol works really good!"
  • I think there could be a number of allergies to craziness ratio. My best guess is any number greater than three! Probably should start a study.
  • Oxygen.  Said it hurt the patient's nose too much and caused a bad burning sensation.
  • Morphine causes me pain.
  • Metoprolol because it decreased their heart rate. And my new favorite - potassium, but only IV.  They can take the pills just fine!
  • Oxygen.
  • I had someone give me a four typed, single spaced pages of drug, food, and environmental allergies. It might have included "air".
  • Time to apply the "porcelain exam". Otherwise known as .... FOS. (full of ****).
  • Allergy: Brazilian nuts. NOT Brazil nuts. Brazilian. Looked at MD blankly when asked what her reaction was.
  • Hair. Her hair was cut short, her skin was very dry with tiny scabbed areas.
  • "Animals".  No specifications.  We all laughed every time we saw it.
  • My mom says she's allergic to 24 meds and won't even take Tylenol! Right!  She works herself into an anxiety attack over most meds, but takes her chemo pill without blinking. She ain't right!
  • My personal favorite: LION DANDER! The conversation went like this... Me: Oh? Um. You said lion dander? Patient: Yep. Me: And how exactly did you find this out? Patient: Dunno. My Momma told me it happened when I was a girl. Me (stifling a laugh): Sooo, um, did you grow up near a lot of wild animals? Patient: Child please. Ain't no jungle animals in the ghetto. Me (... so hard not to laugh!): Ok.. could your mom maybe have meant dandelions? Y'know, like the flower? Patient: No. It was lion dander. I'm sure. She says it makes me all wheezy. Me: Ok.... so Lion Dander it is.
  • Normal saline flush.
  • Had a DNI patient allergic to Epinephrine.
  • My mom, who is an RN, insists that my dad is allergic to epinephrine, because it caused his heart to race and he started sweating and getting shaky. I don't know how many times I've explained to her that is an expected side effect of epinephrine, NOT an allergy. My mom thinks side effects are allergies.
  • I had a patient who was "allergic" to treadmills and stress tests because his heart was pounding when he had an exercise stress test!
  • Longest list- 35 "Allergies" including oxygen and saline.
  • Oxygen. Really?
  • The tanins in wine!
  • Weirdest was Dopamine and Narcan.
  • I had a patient tell me last week she was allergic to potassium. I was dumbfounded for a minute after she said it.
  • I had a patient who reported she was allergic to oxygen and needles.
  • Patients chart stated "allergic to ALL pain medications" and listed about 200 meds (no joke). This was a patient referred to home care for "Pain management education".
  • My cousin is allergic to all narcotic meds. He is so screwed if he is ever in serious pain. All he can takes is Motrin and Tylenol.
  • Allergic to tap water. No joke!
  • I'm allergic to chocolate. (Sigh).
  • I have seen an allergy to NS listed. Might have been a fibro patient.
  • Here's mine-thank you, immune system-last 2 years at age 40, these all started, which cause hives, angioedema of lips, eyes, and throat-strawberries, eggs, dairy, nitrates, nitrites (no bacon, lunch meat!), aspartame (no fat-free/low-fat/sugar-free stuff), nuts, then there's Flagyl, Lomotil, Droperidol, Bactrim. For now. But, if the egg is cooked in a meatloaf and diluted enough, I can eat it. No butter. Gotta use olive oil. (Just got back from Outback Steakhouse, where I had broccoli that was cooked in butter, so my upper lip is currently swelling, and I just took a dose of epi) Yup. Lovin' my immune system. Good luck giving me meals if I'm ever in the hospital again!
  • When I worked in the ER there was one who had 32 allergies and at the top of the list was "salazine" aka saline. I about flipped my lid. I felt like telling them that they was just screwed cause there was nothing that could help them.
  • I've had pateints say they were allergic to heparin because it caused bruising on their stomach. Imagine that.
  • Cat urine. Craziest one I've heard.
  • I had a patient tell me they were allergic to Atropine because it made her heart race! Imagine that! I also had one say he was allergic to wheat bread because it made him sleepy!
  • "Allergic to ALL generic medications". Patient demanded to only get RX's for name brand drugs. They're almost all squirrels Dr. Happy. We just have to figure out which ones are the sick squirrels.
  • Our medical record doesn't distinguish between adverse reactions, allergies, or side effects. Sleepiness, drowsiness is common for Benadryl.
  • I'm allergic to hydrogen peroxide and mag sulfate. The nurses never believe me. I get hives for both.
  • Allergy is orange blossoms?
  • A few years back I had a prisoner from the State Pen brought in for fever and malaise. Big, ol' useless, fat slob of a guy made Jabba the Hutt look fit. His allergy? Uppers, especially PCP.
  • Television and snoring.
  • My patient was allergic to women.
  • "99% of everything" - really. That's what she said.
  • Water.
  • Oh, I forgot normal saline!
  • Perca...perco....?!?!
  • 32 med "allergies".
  • Benadryl caused hives.
  • Epi!
  • All kinds of soap. It caused a rash.
  • "Food".
  • "Smells".
  • Prednisone allergy. Really?
  • I actually know someone who claims they're allergic to tap water. I mean seriously?? I'm 99% sure an MD did not diagnose them.
  • Air and rain.
Join the discussion, insight, humor and general nonsense by "liking my facebook page now!  Feel free to add your experience with funny allergies or unusual or seemingly ridiculous reactions in the comments section below.  And make sure to check out the hundreds of Happy Hospitalist original nurse and doctor ecard memes on Pinterest.

"I have your allergy list listed as an allergy.  And by allergy, I mean it makes me nauseated."

Allergy list listed as an allergy Ecard humor photo



"I've decided to list those 400 questions nurses ask on hospital admission as an allergy.  Oh, and a barrier too."

I've decided to list those 400 questions nurses ask on hospital admission as an allergy and a barrier too nurse ecard humor photo



"I think I've developed an allergy to your allergy list.  And by allergy I mean plotting my escape from your room to save MY sanity."

I think I've developed an allergy to your allergy list. And by allergy I mean plotting my escape from your room to save my sanity doctor ecard humor photo



This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.


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