Archive for August, 2009

Reduce Readmissions: Strategies to Improve Transitions of Care

As the population ages and more people develop chronic illnesses, healthcare professionals are challenged to balance patient needs and the bottom line with the government’s goals to reduce readmissions and improve quality.

Medication errors, missing or incomplete medical record documentation, and human errors that occur when patients fail to understand care requirements are just a few of the problems that can cause unnecessary readmissions. But by educating patients on their conditions prior to discharge—whether to home, a skilled nursing or other facility—and by taking simple steps post-discharge, providers can mitigate the problem.

To that end, HCPro will be hosting a live audio conference, “Reduce Readmissions: Strategies to Improve Transitions of Care,” on September 23.

This program taps the expertise of staff members Karen Mauro, LMSW, ACM, and Christina Pavetto Bond, MS, FACHE, of the Crouse Hospital of Syracuse, NY, who grew their comprehensive program in a nationally recognized model of care coordination.  They will show you how to audit and analyze your readmission data, provide tools to help you develop processes to reduce readmissions, and explain ways to reduce the likelihood of readmissions through pre- and post-discharge education. You’ll also learn valuable tips for effective communication with other providers and levels of care (e.g., primary care physicians, SNFs, and home health).

For more information on how you can reduce readmissions at your facility, visit HCMarketplace.com.

Providing care to undocumented immigrants

Without question, providing care to undocumented immigrants is a problem that leaves hospitals with few options. Because patients typically do not qualify for government assistance and cannot afford care, hospitals typically foot the bill for these patients, and sometimes the price can be in the millions.

A recent Healthleaders Media article, by John Commins, reported on one such a case. A partially paralyzed illegal immigrant was treated at a Martin Memorial Medical Center for three years before being transferred to his native Guatemala to continue his care. The hospital estimated the cost of treating the man to be around $1.5 million.

The patient’s family sued the hospital claiming that Martin Memorial illegally repatriated the man to Guatamala—a case they ultimately lost. To read more about the case visit the Healthleaders Media Web site.

In the same article, Mark E. Robitaille, CEO at Martin Memorial, said the issue of providing healthcare to undocumented immigrants remains unresolved on a state and national level, and he’s not optimistic that the issue of providing care to undocumented immigrants will be addressed soon.

“This is an opportunity for leaders at the state and federal levels to find a solution, rather than relying on individual healthcare providers to develop solutions on a case-by-case basis,” he says. “Unfortunately, none of the proposed national healthcare reform bills currently being debated in Washington address the issue of how to adequately provide healthcare for undocumented immigrants in a way that is fair and equitable to everyone involved.”

How does your facility handle undocumented immigrants? What resources are available to help your facility collect payment for these scenarios?

Need more info? Check out Caring for Uninsured and Undocumented Patients (Audio Conference).

Here they come: Two RACs post issues eligible for review

Editor’s note:  My colleague, Andrea Kraynak, does a great job staying on top of all the RAC news over at the Revenue Cycle Institute blog. The following is round-up of some of the news she has covered recently in regards to issues eligible for RAC review.

Two of the four RACs have posted issues eligible for RAC review on their Web sites, meaning that RACs can begin auditing in those areas at any time.

Connolly, the RAC for region C, has posted the approved issues for South Carolina and Florida. No word yet on the other states and territories that Connolly covers. However, many experts are advising providers to pay attention to these issues, regardless of whether they are within the Connolly’s jurisdiction.

Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc., says providers outside Connolly’s jurisdiction may want to review the issues as a clue to what RACs might audit in their area. However, she notes that providers should anticipate that RACs will audit for different issues for different jurisdictions although there certainly could be some overlap.

Connolly will focus on the following six issues for both states: [more]

The FY 2010 IPPS changes impacting case managers

On July 31, the Centers for Medicare and Medicaid Services (CMS) released the FY 2010 Inpatient Prospective Payment System (IPPS) Final Rule. Hospital payment rates will increase by an average of 2.1%, as opposed to the 0.2% proposed earlier in the year. CMS elected not to implement a 1.9% reduction, referred to as the coding and documentation adjustment. This coding and documentation adjustment accounts for changes in clinical documentation and coding patterns—not real changes in patient acuity.

Implications for case managers

The start of the Medicare Fiscal Year IPPS, which begins each October 1, brings a host of new coding, payment, and other regulatory changes including updated relative weights for the 745 MS-DRGs. Some MS-DRG relative weights increase—others decrease. Relative weights are a proxy for patient acuity. Higher relative weights signify higher acuity, providing for a higher level of reimbursement, while lower relative weights translate into lower acuity with less reimbursement.

In reviewing the Healthcare Financial Management Association’s (HFMA) recent overview of the Final 2010 IPPS Rule, an interesting point was made that certainly impacts hospitals and case managers. [more]

Have you mastered the HINN?

Last week, during the HCPro’s Master the HINN: Integrate Policies and Procedures into Hospital Operations audioconference, a poll question revealed that 87% of the facilities on the call designate case managers as the ones responsible for providing HINNs. Does this statistic ring true in your facility?

If so, please share your challenges, comments, and best practices when it comes to delivering HINNs properly and effectively. For example, how do you and your team identify cases where a HINN is necessary? How to you ensure the patient is notified of his or her liability in a timely manner? How do you educate your staff about which HINN is appropriate for a situation?

Documentation requirements for critcal care services

Editor’s Note: This blog was originally posted by Melissa Varnavas, CPC, the associate director of the Association for Clinical Documentation Improvement Specialists, for the ACDIS Blog. Read the original post here.

In the July 23 issue of CDI Strategies, Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, offered a tip to help CDI specialists gain physician support for improved documentation in the medical record regarding critical care. In a subsequent e-mail, Gold added comments from his “guru” on physician professional billing, Paul Dickson, MD.

Here is the amended information:

Critical care does not include ongoing monitoring of a patient who has stabilized, regardless of how many organs have failed in the past, but have now stabilized, how many lines and tubes were inserted, or how many devices were instituted. When the patient is stable, it is not critical care.

Too many physicians, however, do not realize that we can bill:

• Critical care delivery by time increments for the first encounter
• Additional critical care when the patient crashes again
• A level three subsequent visit for noncritical care in addition to the critical care delivery on the same day

Any usual evaluation and management (E/M) service appropriate for services and documentation provided may be billed prior to a critical episode, but not vice versa. Consider the following case study.

A patient presents to the cardiac care unit after a coronary artery bypass graft. The patient is intubated with a left ventricular assist device still in place but is not active and receives low-dose dopamine for renal perfusion. The patient’s vital signs are stable with a little hypotension due to lack of vascular tone due to residual effects of anesthesia, however, it is easily controlled. The external pacer is in place, chest tubes are in place to underwater seal, and diluted urine is flowing through the Foley. A physician accepts the patient onto the intensive care unit (ICU) and performs an evaluation. The patient is not critically ill. However, the patient is on a respirator, and the physician manages that respirator. This may be ventilator management 94002-3 alone, and no E /M service may be billed with these codes.

In this case, the patient does not have acute respiratory failure. Writing the words “acute respiratory failure,” means a condition exists that involves the respiratory tree due to a disease process. If, indeed, the patient does have acute respiratory failure due to a disease process when he underwent the surgery, then it is appropriate to document that, if it still exists. If this is not the case, then the presence of the words “acute respiratory failure” will give the heart surgeon a black mark since the condition would be considered a complication of the surgery. [more]

Guidance to ‘the most appropriate level of care’

Case managers serve as the patient’s advocate to promote safe, quality care during the patient’s stay in the hospital and after discharge. Sounds like the ideal job, right? For nurses who “live” the role, rather than “do” the job, it truly is. Grace’s story is one that conveys how complex, yet fulfilling living the role can be.

Grace read the physician’s orders for Diane to begin outpatient dialysis upon her return to her nursing home. Grace began looking for a dialysis center that would be close to Diane’s nursing home and had chairs available. However, the center that would accept Diane was quite a distance from the nursing home. If Grace were to receive treatment at the facility, she would need to be transported via ambulance three times each week for treatment. Unfortunately, this circumstance was not unusual, so Grace proceeded with making tentative arrangements.

When Grace entered Diane’s room to discuss her treatment, she saw Diane lying on her side. She was thin, drawn, and severely contracted with tunneling decubiti throughout her body. With the slightest movement, she cried out in pain. However she was alert, oriented and communicative. Throughout Grace’s long career as a case manager, she had symbolically seen Diane far too many times.

Grace approached Diane with a warm smile and a trusting, caring tone of voice. After explaining her reason for being there, Grace began to question Diane in order to determine her mental competency and ability to make decisions. After all, Grace was there to determine what Diane needed and wanted, not just to tell her to do what the physician had ordered. Grace sought Diane’s consent for the treatment plan. She explained the risks, benefits and alternatives of her plan for continuing dialysis as an outpatient. [more]

Do you use Milliman?

We are looking for case management departments that use Milliman Care Guidelines for a future project. If your facility uses Milliman, please get in touch with me.

Ben Amirault
bamirault@hcpro.com
781-639-1872 x3934

Surprise! Voluntary refunds don’t protect against RACs

For many providers, self-auditing has become an important RAC preparation tool. Certainly, internal audit results can show where additional education is necessary to ensure appropriate coding, billing, and documentation practices. And this will result in fewer RAC denials, because if practices are correct, the RACs will find fewer errors to deny.

But many providers also assume that reporting errors (and refunding identified overpayments) discovered while self-auditing will protect those claims from RAC review.

Not so, says CMS.

In a recently released FAQ on the CMS Web site, CMS clarified that only one type of self-audit will ensure RACs may not later review the claims, and it probably isn’t the kind of self-auditing that most providers are doing, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

The FAQ states:

There are two types of self audits. One is commonly called a voluntary refund and is claim based. If the required claim information is included along with the amount of the improper payment, the claim will be adjusted by the claim processing contractor. The RAC will be aware of the adjustment, but the refund does not preclude future review. The second type of self audit may involve the use of extrapolation. If extrapolation is used the claim processing contractor will review the case file to determine if it is acceptable. The claim processing contractor will accept or deny the extrapolation for the issue identified by the provider. If the claim processing contractor accepts the extrapolation, those claims in the universe will be excluded from RAC review.

In other words, if a provider uses an extrapolation that its MAC or FI accepts, the claims are off-limits for RACs. Otherwise, individual claims corrected after a self-audit are fair game.

“This will come as a surprise to a lot of providers,” says Mackaman. “Providers assume if they do a self-audit and correct and report errors, that [the claims] are excluded from future RAC audits. But they’re not.”

Those providers who review claims individually may feel a little less incentive to report errors and refunds they discover since the claims aren’t protected from RACs, but not doing so is a compliance problem. Ignoring a false claim is never a good idea, says Mackaman.

Nor should this news discourage providers from self-auditing in the first place. Providers can use audit results to better understand their risks, to change internal processes regarding areas of concern and to appropriately return reimbursements for claims paid in error, according to Mackaman.

ER case managers must have special skills

A nurse case manager is a definite asset in the emergency room (ER).  An ER case manager benefits the patients, the staff, and the hospital.  The role is multi-faceted and requires superior skills in:

• Quality
• Education
• Communication
• Customer service
• Negotiation
• Creativity
• Risk management
• Knowledge and understanding of insurance requirements and regulatory mandates

It also requires an ability to interact with patients, families, insurance representatives, and caregivers both in the ER and those who are treating the patients in the out-patient arena.

Visits to the ER may have one of several outcomes. Usually, the patient is treated and discharged home with a plan or the patient is admitted to the hospital. It is here that the ER case manager can be most effective to improve the quality of care and prevent readmissions to the ER.

An ER case manager can ensure that each patient who is discharged from the ER has an appropriate discharge plan that is viable and appropriate to assist the patient in recovering and maintaining their health.  A case manager is an expert in confirming the patient can afford any prescriptions provided , is able to be compliant with recommended follow-up visits with  specialists and can assist the patient in connecting with a primary care physician. The nurse case manager can be instrumental in  working with the patient  and their support system to make sure that they understand and have the interest and ability to be compliant with the discharge instructions.

The case manager can enhance the care provided by a busy ER nurse and physician  by assessing situations and family dynamics, listening to the patient and helping them understand the rationale for various tests and the time needed to interpret results. The case manager can assist the ER nurse with patient education and  providing information necessary to maximize  the patient’s health status.

The case manager can also benefit the hospital by working with both ER physicians and admitting physicians to ensure that all acute care admissions meet medical necessity and are admitted to the appropriate level of care.  The case manager can assist with transfers to alternative levels of care such as skilled nursing or rehab when patients do not meet criteria for acute care but are unsafe to return home.  The case manager can arrange home healthcare, physical  and occupational therapy or other appropriate services to help a patient maintain their independence in the home.

Case managers are an integral part of the ER team to improve the quality of care and help maintain fiscal responsibility for resources both in the ER and on the hospital admitting units. Case managers coordinate care and provide patients will all the tools necessary to improve their quality of life and feel their best within any limits of their illness or disability.