RSSAuthor Archive for Brian Murphy

Brian Murphy

Brian Murphy, CPC, is director of the Association of Clinical Documentation Improvement Specialists (ACDIS). Brian is also an executive editor in the revenue cycle division of ACDIS’ parent company HCPro, Inc.

UnitedHealth Group, Inc. vs. the United States of America: The case for CDI

Brian-Murphy

ACDIS Director Brian Murphy

Part 4 (click here to view part 1, click here to view part 2, and click here to view part 3)

By Brian D. Murphy

In Part 1 of this series I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America. In Part 2, I detailed the facts of the case. Part 3 looked at the regulations and commentary regarding claims submission to Medicare Advantage and the ramifications for CDI. Part 4, discusses recent developments of the case.

Since I wrote my initial three parts of the developing case of UnitedHealth Group, Inc. vs. the United States of America there has been a huge development on the legal front. Round 1 of the case of UnitedHealth Group, Inc. vs. the Unites States of America is over, and the decisive winner (at least in the matter of one complaint filed by the DOJ) is United. [more]

Note from the ACDIS Director: Saying thanks to some key individuals and influences

Birthday cupcake

Thanks for celebrating ACDIS’ 10th birthday with us!

Ten years have passed since we founded the Association of Clinical Documentation Improvement Specialists, and to say I have met some good people along the way is a gross understatement. I have met some GREAT people over the last decade, without whom ACDIS would not be where it is today.

Here are just a few: [more]

UnitedHealth Group, Inc. vs. the United States of America: The case for CDI

Brian-Murphy

ACDIS Director Brian D. Murphy

Part 3 (to read part 1, click here. To read part 2, click here.)

By Brian D. Murphy

In part 1 of this series, I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America. In part 2, I detailed the facts of the case. Part 3 looks at the regulations and commentary regarding claims submission to Medicare Advantage and the ramifications for CDI.

Section III of the complaint United States of American ex rel. Benjamin Poehling, explains the payment methodology which UnitedHealth Group, Inc. allegedly manipulated for financial gain. The Medicare program pays Medicare Advantage (MA) organizations a pre-determined monthly amount for each Medicare beneficiary in the plan. The payment amount for each beneficiary is based on their particular risk adjustment factor (RAF) score, which among other factors including the beneficiary’s demographics is impacted by assigned Hierarchical Condition Categories (HCC). [more]

UnitedHealth Group, Inc. versus the United States of America: The case for CDI

Brian-Murphy

ACDIS Director Brian Murphy

By Brian Murphy

The work of a CDI professional can at times seem isolating and unimportant. Does it matter if a query gets answered? When we educate physicians and tell them what they document matters, are they listening?

Then a case comes along and demonstrates not just that the CDI profession does matter—but that it matters a lot.

That point was driven home to me while reading a May 16, 2017 court document, United States of America ex rel. Benjamin Poehling v. UnitedHealth Group, Inc., in which the Department of Justice (DOJ), alleges that UnitedHealth artificially increased Medicare Advantage (MA) reimbursement/Hierarchical Condition Category assignment by mining for non-supported diagnoses that were not documented/reported by the physician or through chart documentation.

The case is a qui tam—a lawsuit brought forward by a private individual. The plaintiff is Benjamin Poehling, the former Director of Finance for UnitedHealthcare Medicare & Retirement (and its predecessor Ovations), which was the group at United that managed its MA plans and its Medicare Part D prescription drug programs.

The lawsuit seeks to recover more than $1 billion under the False Claims Act. The total damages sought are unspecified but it’s a large case with a lot at stake.

This case has received quite a bit of coverage, too, from big newspapers like the New York Times and popular healthcare websites like Beckers Hospital Review and HealthLeaders Media.

There is a lot more to this case than this 103-page court document, though. In addition to Poehling’s case (filed in February 2017), another whistleblower, James Swoben, a former employee of Senior Care Action Network Health Plan and a consultant to the risk-adjustment industry, came forward with similar allegations in March.

In a very recent development, UnitedHealth Group’s lawyers are seeking to get the case dismissed, claiming that they are not required to validate the accuracy of diagnostic data submitted by healthcare providers.

I need to reiterate that, at this point, the claims asserted against UnitedHealth Group are only allegations and there have been no determinations of liability. It remains to be seen whether the case will even reach court.

However, the case ultimately resolves, it’s a very interesting, real-world, big-dollar example of the business of healthcare, raising the question of who is ultimately responsible for the accuracy of submitted diagnoses to Medicare (coders, CDI, administrative contractors, physicians?). It calls into question the oft-repeated adage that coders must code what the physician documents. It brings into even greater prominence the process of clinical validation, for which ACDIS recently released a new white paper.

Reading through these articles and the original court document, I thought to myself, if only UnitedHealth Group had a robust, compliant CDI process in place, this suit could have been prevented. More than anything, United States of America vs. UnitedHealth Group Inc. is confirmation that your work as a CDI professional matters, and that the broader CDI profession matters.

I plan to share my thoughts on this case in a series of blog posts here and I welcome your thoughts and commentary.

Editor’s note: To read the summary of the case, visit the DOJ website by clicking here. To read the court document in its entirety, click here. Brian Murphy is Director of the Association of Clinical Documentation Improvement Specialists (ACDIS). He can be reached at bmurphy@acdis.org.

 

 

Note from the ACDIS Director: It’s time for outpatient CDI to step out on its own

ACDIS Director, Brian Murphy

ACDIS Director, Brian Murphy

By Brian Murphy

We knew it was going to happen.

Eventually, the ACDIS Conference was going to get so big that we couldn’t give every CDI topic justice or the full coverage it deserved. Outpatient CDI was one of those topics. There is so much going on between Medicare Advantage and Hierarchical Condition Categories (HCCs), the complexities of patients admitted versus treated in observation, to outpatient opportunities in the emergency department and in the physician office setting, that the time had come to give outpatient CDI its own event.

Enter the ACDIS Symposium: Outpatient CDI.

This all-new ACDIS event will be held September 18-19 at the Hilton Oak Brook Resort & Conference Center, located just outside of Chicago.

Back when inpatient CDI was still relatively new in 2007, we received large numbers of basic questions, and there was an overwhelming need for nuts and bolts “how to get started” ideas and education. Because we anticipate the same kinds of concerns at the ACDIS Symposium: Outpatient CDI we are accommodating with three specific ideas:

  1. Case studies of how programs have implemented successful outpatient CDI programs. Hear from Cooper University Health Care, Novant Health, Mount Carmel Health System, and others about how they got started, their challenges and their successes.
  2. A “Morning Ideas: Lightning Round” general session on Day 1. This innovative one-hour session combines four to five quick-hit, “here was a problem we had and a solution that worked/here is a process that worked for us and might work for you” ideas from your peers that have worked in the field. This will get your brain working overtime!
  3. A dedicated Q&A panel session to conclude the program. Ask your top questions at this session—and listen to your peers’ questions. Chances are you might have the same questions.

Just like the ACDIS Conference, the Symposium will feature plenty of networking opportunities and idea-sharing over our breakfasts and lunches (food, including breaks, is provided with registration) as well as in our exhibit hall. Come see the many innovative outpatient CDI solutions several vendors are offering in this space.

There is far more on the agenda than I could mention here—sessions on the nuts and bolts of evaluation and management coding (E/M) and how to improve physician E/M billing, a session on the key differences between inpatient and outpatient coding (as taught by our top coding instructor Shannon McCall, RHIA, CCS, CCS-P, COC, CPC-I, CEMC, CRC, CCDS), and much more.

In short, I hope you can make our inaugural ACDIS Symposium. To learn more or to register, please click here.

Editor’s note: If you have specific questions about the Symposium’s content, please send them to ACDIS Associate Director of Membership and Product Development Rebecca Hendren at rhendren@acdis.org. Murphy is the director of ACDIS. Contact him at bmurphy@acdis.org.

Note from the Director: ACDIS conference turns 10

Brian-Murphy

ACDIS Director Brian Murphy

By Brian D. Murphy

Wow, ACDIS is turning 10. Sometimes I still find it hard to wrap my head around that fact.

We’ve managed to accomplish a lot in our first decade, growing from little more than an idea in 2006, to launch in October 2007, to more than 5,400 members nationwide.

What am I most proud of? That we’ve brought so many people together. That’s what we do. Here is just a sample:

  • 40 local chapters under the banner of ACDIS
  • Thousands on our membership conference calls and ACDIS Radio
  • Thousands more in the classrooms of our boot camps
  • And tens of thousands of CDI specialists from around the country, here at our national conference

That’s what ACDIS is all about—fellowship, networking, and learning from each other. The plan is, 10 years from now we’ll still be bringing people together. Because in the end, that is what CDI is all about. It’s the ultimate team sport. What do I mean by that?

Patient registration, up front, doing their job so the process of review can begin.

All the efforts of the query go nowhere without an HIM/coding professional applying the code which he or she believes is supported by the documentation.

All those efforts go for naught without billing professionals submitting the claim on the back end.

And of course, CDI is completely hamstrung without an engaged physician willing to put pen to paper, or fingers to the keyboard. Or just to listen.

It’s a team, all working together, to move an object that can seem very heavy.

And CDI is the tie that binds all this together. CDI is the glue, the jet fuel that makes this engine run. How many more clichés can I spout? You get the idea. Every day you accomplish amazing things in your pursuit of the integrity of the medical record.

CDI specialists move that heavy object every day, meeting regulatory burdens head-on and marrying administrative codes to clinical practice.

And I like to think we at ACDIS have played a part, taking a turn and shouldering some of the burden right alongside you.

So, thank you for 10 years of ACDIS.

For 10 years of crossing the country to come to our conferences, 10 years of learning from us while we learn from you.

For 10 years of memories, and many fond meetings.

Team ACDIS is looking forward to the next 10!

–Brian

Note from the Director: ACDIS announces new timeline for advisory board applications and elections

The ACDIS advisory board recently announced a new timeline for applications and elections to serve on the board. Beginning in 2017, the application period will open in mid-January. Candidates will have three weeks to complete their application. A committee will review applications and narrow the pool of applicants down to a group of finalists, who will be selected by a popular vote of the membership in mid-March. The results of the election will be announced in early April and our new board members will be introduced at that time.

Each year four new board members are voted on and four rotate off.

In 2017, ACDIS will open up the application period on Monday, January 9, and it will run through Monday, January 30.

Why should you run for the ACDIS advisory board? ACDIS advisory board members are engaged in the CDI profession. They are forward thinkers, with a positive vision of evolution of the CDI profession. They must be ACDIS national members in good standing and possess the CCDS certification.

ACDIS advisory board members learn from each other and the ACDIS membership, whom they serve. They are content experts who provide insight on our quarterly membership calls, contribute to our position and white papers, and speak on panel sessions at the ACDIS conference.

Above all they care about the CDI profession and want to make a difference in healthcare.

If the above sounds like you and something you want to be a part of, we encourage you to apply.

You can view the complete list of qualifications here, as well as the nomination and election process and frequently asked questions: http://www.acdis.org/membership/boards#advisory.

You will also find a list of presently serving ACDIS advisory board members and their email addresses; they are happy to answer any questions you may have about the requirements, time commitment, and benefits of board service.

We look forward to your application! Please keep an eye out for the official opening of the application period on January 9.

News: Delayed implementation of the NOTICE act

Richard D. Pinson, MD, FACP, CCS

Richard D. Pinson, MD, FACP, CCS

by Richard D. Pinson, MD, FACP, CCS

With the release of the 2017 Inpatient Prospective Payment System final rule on August 2, 2016, CMS announced a delay in implementation of the NOTICE act.  CMS is submitting a revised version of the Medicare Outpatient Observation Notice (MOON) for a 30-day public comment period followed by final approval after review.  Implementation of the NOTICE act provisions for all Medicare beneficiaries using the MOON must take place within 90 days of final approval.

In response to public comment CMS reduced the number of required fields on the MOON including physician name and the date and time observation services began, and removed the field for the hospital name.  Hospitals will be permitted to pre-print the MOON to include their hospital name and logo at the top of it. CMS also removed the QIO contact section from the MOON over concerns it might unnecessarily prompt a flood of complaints about the nature and quality of care provided.

In response to public comment that the MOON language regarding coverage of post-hospital SNF care and Part B coverage should be more clearly stated and prominent, CMS has simplified it and moved it near the top of the notice. In addition, CMS has added a free text field where the specific reason for receiving observation services as an outpatient must be completed by the hospital

CMS noted that, while not required until 24 hours of observation have been provided, the NOTICE act does permit a hospital to voluntarily deliver notice sooner than 24 hours of observation services have been provided to ensure compliance. CMS does not recommend providing notice at the time of initiating observation services citing concerns that patients may be preoccupied with their healthcare needs and other paperwork.

Some States independently require notice of outpatient status for all outpatients, regardless of the payer and irrespective of whether the patient has received observation services, and some require notice within 24 hours. The MOON satisfies the written NOTICE Act requirements for a designated population of Medicare beneficiaries receiving observation services only. CMS notes that, in some cases, delivering the MOON may also fulfill State notice requirements for the Medicare population, but hospitals will need to make that determination on a state-by-state basis.

The revised MOON (Form CMS-10611) and notice instructions can be accessed at: https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10611.html.

Editor’s note: Richard Pinson, MD, FACP, CCS, principal of Pinson & Tang LLC, wrote this article. Contact him at info@pinsonandtang.com. Pinson has more than 12 years of experience improving coding and clinical documentation practices and educating thousands of coders, documentation specialists, and physicians. He is a recognized CDI authority who co-authored the CDI Pocket Guide published by ACDIS, co-developed ACDIS’ CDI for the Clinician eLearning program for hospitals, and has written the monthly Coding Corner of the ACP Hospitalist magazine for over four years.

Conference Special Update: Farewell from the ACDIS Director

Have a story about your trip home from ACDIS 2015? Share with us in the comments below!

Have a safe trip home, everyone!

The biggest and best CDI event of the year took place this week—the 9th annual ACDIS Conference in Atlanta. We had more than 1900 attendees, a figure that included CDI specialists, managers, revenue cycle directors, HIM/coding professionals, physicians and physician advisors to CDI, and exhibitors and sponsors. This was once again our biggest conference yet. Our team at our home base in Danvers, Massachusetts spent the past 14 months preparing for the conference, and the last few weeks have truly been “crunch time” with late nights and the usual anxieties that come with an event of this magnitude. But now that the conference has come to a close, I believe all the hard work was worth it. For those who attended the event, I hope you found it so.

This year we added some new wrinkles, including a 5th breakout and four panel sessions. At the end of day 1 we featured a panel of four physicians with the latest updates on the newly released definitions of sepsis and septic shock (Sepsis-3). We hosted two panels with the ACDIS advisory board, who gave a look inside what we’ve been working on at ACDIS, including our newly revised ACDIS Code of Ethics. I am very pleased that we had a presenter from CMS, Chief Medical Officer from the Atlanta Regional Office Dr. Richard Wild, who kicked off with a day 1 session on Value Based Purchasing and the Transformation of Healthcare. Healthcare is changing before our eyes and CDI professionals are perfectly positioned to lead the way through this change, positioned as they are at the intersection of clinical medicine and coded data. And we had a dynamite day 2 keynote speaker, Vicki Hess, who brought energy and passion and actionable change management strategies like you’ve never seen.

As great as our educational sessions were, I most looked forward to meeting old friends, making new ones, and learning from them all. Networking is at the heart of the ACDIS conference and I’ve never been ashamed to admit that our members learn as much or more from each other as we can bring them with our publications and leadership. With the return of our popular conference app, the networking began before we arrived in Atlanta in our busy activity feed. It was awesome to see! We were in a great spot and there was much fun to be had after hours with a nearby CNN tour, a world-class aquarium, terrific restaurants, and much more.

If you were one of the 1900 attendees, thank you for helping us create such a successful event. Though the conference has come to a close, please continue to let us know how ACDIS can best serve you. I’m here to listen and learn.

Safe travels home, everyone, and thank you for making the 9th annual ACDIS conference the most successful event yet!

The passing of an industry great

Dr. Robert S. Gold

Dr. Robert S. Gold

Robert S. Gold, 1942-2016 

If you’ve ever read an issue of HCPro’s flagship newsletter Medical Records Briefing … if you’ve ever picked up an issue of Briefings on Coding Compliance Strategies and turned to the column “Clinically Speaking”… if you’ve been a regular listener of HCPro’s HIM or CDI audio conferences or webinars… if you’re a member of the Association of Clinical Documentation Improvement Specialists (ACDIS) and subscribe to the CDI Talk newsgroup or listened to an ACDIS quarterly conference call, chances are you’ve encountered the phenomenon known as Robert Gold, MD.

For the better part of 20 years Dr. Gold has been a fixture in the HCPro and the ACDIS community, authoring countless articles, several handbooks, and speaking on numerous webcasts and audio conferences. He served two terms on the ACDIS advisory board, helping ACDIS get off the ground by serving as an inaugural board member from 2007-2010.

Last week his one of a kind voice was silenced. Dr. Gold lost a battle with cancer that began last year, passing away at the age of 74. We’re all saddened by his loss, and the coding and CDI communities are greatly diminished by it.

A graduate of Hahnemann Medical College, Dr. Gold trained in general surgery in the U.S. Navy where he spent his professional career as a practicing surgeon. After leaving the service, he worked as a consultant in the fields of managed care medicine, locum tenens, home health, hospital accreditation and licensure. Later Dr. Gold co-founded DCBA, Inc. (short for Documentation Coding and Billing Accuracy). There he quickly gained a reputation as a consultant who married clinical knowledge with coding expertise. His clinical acumen, knowledge of medical coding and billing, and easy, engaging manner allowed him to bridge the gap between healthcare delivery and the business of medicine. And he did it with his own unique, caring, personal, and inimitable style.

I had a chance to watch Dr. Gold at work a couple years ago. He was in town near our home office on assignment at Beverly Hospital and invited me to pay him a visit. There I got to see him work with a small CDI team as they reviewed patient charts together on the floor. He was a patient, engaging teacher, asking questions of the CDI nurses about the nature of the patients they were seeing and encouraging them to use their critical thinking skills through a series of probing questions.

I learned a lot that day about what CDI specialists do and the difficult detective work it takes to ferret out diagnoses and comorbidities, drawing inferences from physicians’ clinical decision making and often from incomplete and imprecise documentation.  But I also learned a lot about Dr. Gold.

With the news of his passing several tributes and remembrances made their way into our inboxes. Here is just a sampling:

Dr. Gold challenged us to look through another lens, and with that, he helped us grow. He will forever be remembered. 

Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP, Director of Education, MedPartners

Certainly a legacy! A man that has challenged, inspired, and directed CDI to capturing the nature of clinical care. Always motivating change! He will be missed, but remembered.

–James Fee, MD, CCS, CCDS, Vice President, Enjoin

Dr. Gold was excellent with people. He never talked down to anyone. He helped doctors think outside the box.

–Lamar Blount, President, American Benefit Advisors (ABA) & Health Law Network (HLN)

Dr. Gold has been a ‘legend’ in the industry, always deeply concerned about ‘getting the correct diagnosis’ reported, and calling it like he saw it. I did not always agree with his final views, but I always knew where he stood, and for that, I admired his convictions, dedication and passion. Few were as passionate or dedicated as he…several times he called me in order to discuss various issues. I have to say I was impressed that he would care so much to reach out to a me, a person he did not really know. May he rest in peace.

–Paul Evans, RHIA, CCS, CCS-P, CCDS, Manager, Regional Clinical Documentation, Sutter West Bay

 

Robert Gold

Robert Gold

Right up to the end Dr. Gold was deeply involved in the healthcare industry. He was due to present at the ACDIS conference next week. At the time of his passing he had been working with the ICD-10 Coordination and Maintenance Committee to fix some ongoing cardiology issues in ICD-10, including proposals he had put forth to break down heart failure into right, left and biventricular, add HFrEF and HFpEF as alternate phrases for systolic and diastolic (now passed), stratify New York Heart Association heart failure classes, add end stage heart failure, and reclassify atrial fibrillation. He had irons in the fire at AHA Coding Clinic, seeking clarification on what he saw as imperfections in the marriage of medical codes with clinical practice. He was writing to me, and to current ACDIS Advisory Board members, regarding suggestions for reconciling current ICD-10 limitations with the newly released definitions of sepsis and septic shock.

For those that got to know Dr. Gold he revealed himself as a caring, compassionate, big-hearted man underneath his occasionally gruff exterior. On a couple occasions he invited our CDI boot camp instructors out to his home in Atlanta to see his gardens and his extensive baseball card collection. He loved Halloween and each year decorated his home with an awesome, sprawling display of ghosts, goblins, and ghouls, delighting thousands of neighborhood children.

Dr. Gold cared about the clinical truth. He cared about medical codes and the powerful truths they can convey when reported with accuracy. But most of all he cared about people. And for that, we’ll miss him.

Farewell Dr. G.

Brian Murphy
Director, ACDIS
bmurphy@acdis.org

Read Dr. Gold’s obituary online: http://www.legacy.com/obituaries/atlanta/obituary.aspx?n=robert-stanley-gold&pid=179995223&fhid=4904 . Per the obituary, In lieu of flowers, contributions to the Winship Cancer Foundation at Emory or planting trees in Israel in his memory are fitting honors.