All Entries Tagged With: "government policy"

Promoting efficient use of resources and appropriate hospitalization length of stay to physicians, a different approach

Physicians sometimes acquiesce to family wishes and desires and admit a patient for “social” reasons. On the other hand, a physician may keep a patient in the hospital an extra day because the patient expresses a desire to stay just “one more day.” These unnecessary, avoidable hospital days have a material effect on potential revenue loss for the hospital through denied days or denied hospital stays by third party payers.

A major challenge in motivating physicians to move the patient along the continuum is the disconnect between prudent hospital fiscal management and the practice patterns of physicians. The physician generally receives payment for his evaluation and management services regardless of whether the hospital is paid or denied for the patient care.

However, change is on the horizon. Medicare is currently considering provisions that will promote efficiency in the practice of medicine. Medicare and other third party payers are also committed to transitioning from physician payment based strictly on volume to payment based upon the relationship between quality, costs, and outcome. The efficiency and effectiveness of a physician’s practice of medicine will determine the physician’s financial welfare and business success.

Evidence of this impending change in reimbursement can be found in the General Accountability Office’s (GAO) report entitled “Per Capita Method Can Be Used to Profile Physicians and Provide Feedback on Resource Use.”  This report is a must read. In essence the report concluded that it is feasible to use Medicare claims data to profile physicians on resource use, taking into account patient acuity through risk adjustment methodologies.

The report examined the following:

• The extent to which physicians in selected specialties show stable practice patterns and how beneficiary utilization of services varies by physician resource use level
• The factors to consider in developing feedback reports on physicians’ performance, including per capita resource use
• The extent to which feedback reports may influence physician behavior

The GAO focused on four medical specialties (cardiology, diagnostic radiology, internal medicine, and orthopedic surgery) and chose four metropolitan areas (Miami, Phoenix, Pittsburgh, and Sacramento).

Take this oppurtunity to educate physicians about the possible changes in the reimbursement model

The message is out!

Now is the time for case managers to become familiar with these eventual changes to the healthcare reimbursement model from a physician and a hospital perspective. This reimbursement model transition will not only drive out waste in the practice of medicine. It will also drive and promote a collaborative approach to healthcare delivery by using financial incentives.

Case managers should educate physicians on the need to collaborate with case management to move the patient along the continuum efficiently because physicians will receive reduced reimbursement for excessive resources.

Let the education begin.

House approves healthcare reform bill

The House passed its version of the bill, can the Senate do the same?

The U.S. House of Representatives recently passed the healthcare reform bill (HR 3962) by a narrow margin (220–215). The bill’s estimated cost is more than $1 trillion over the next 10 years.

The Senate is working on its own version of the bill. If that version passes, then a congressional conference committee will meet to compromise on the two versions. If the committee reaches a compromise, it will send that bill would to both the House and Senate for another vote. If it passes both houses, the next step is President Obama’s desk for his signature.

Preliminary drafts of the Senate bill differ from the House version with respect to funding. how many individuals will be covered, and the availability of a public option.

Source: CNN

The ZPICs have begun in zone 4

Health Integrity LLC, the zone four (Colorado, New Mexico, Oklahoma, and Texas) Zone Program Integrity Contractor (ZPIC), has begun requesting medical records for review.

The ZPICs are Medicare audit contractors that specifically identify cases of fraud and abuse. According to the CMS Program Integrity Manual, ZPICs may “take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped.”

During HCPro’s November 3 audio conference, “Zone Program Integrity Contractors Learn Who They Are, What They Want, and How to Respond to a Review”, a caller from Oklahoma shared that a Health Integrity representative visited the facility recently and stayed for a two-day, on-site audit. During the visit, the auditor reviewed more than 40 medical records related to one-day stays dating back as far as 2007.

This information came as a mild surprise to Robert Wade, partner at Baker and Daniels, LLP, in South Bend, IN. Wade said ZPICs have the authority to start reviews as soon as they are awarded the contract, and Health Integrity was awarded the zone four contract in February.

Facilities should be aware that ZPICs could notify the facility via fax a mere hour before the visit. This can leave little time for the facility to prepare. Wade said in situations where ZPICs give short notice, facilities are within their rights to supplement any requested records with supporting documentation even after the visit is complete.

So far CMS has awarded only three of the seven ZPIC contracts:

• Zone 4: Colorado, New Mexico, Oklahoma, and Texas—Health Integrity LLC
• Zone 5: Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia—Advance Med
• Zone 7: Florida, Puerto Rico, and Virgin Islands—SafeGuard Services LLC

So what does this information mean for providers that are within one of these zones?

“They can come knocking at any time,” Wade said.

Consequences of a ZPIC review include payment denials, recoupment of overpayments, and referral to other law enforcement agencies. Because ZPICs can refer cases to the Department of Justice, Office of Inspector General, or other law enforcement agencies, a ZPIC review may only be the first step in a long legal battle.

Have you heard about the ZPICs starting in any other zones?

Possible MIC audit issues that involve case management

Editor’s Note: This post was excerpted an article on the Revenue Cycle Institute Web site.

There’s no question that audit activity is escalating.

It’s no longer just RAC, MAC, CERT, and ZPIC audits looking to ensure the accuracy of Medicare payments. Providers are also subject to increased scrutiny on the Medicaid side, as states are working with the federal government to help reduce payment error rates and recoup overpayments.

The scrutiny comes in the form of Medicaid Integrity Contractors (MICs), who will begin auditing providers in all states by the end of 2009.

What will MICs be auditing? It will vary from state to state, of course. But James G. Sheehan, the Medicaid Inspector General for New York, listed several issues he expects the MICs will audit during the October 15 HCPro audio conference, “Medicaid Integrity Contractor Audits: Know What to Expect and How to Prepare.”

The following are some of the potential MIC audit issues Sheehan listed that case management staff members should be aware of:

• Heart failure and shock. For this issue, MICs will look for failure to meet InterQual criteria for inpatient care.
• Ambulatory surgery with no complications to justify inpatient stay. “Commonwealth Fund just came out with a ranking of the states on this issue, and some states are better than others. It may not be a bad idea to find out where your state stands and whether this will be an issue,” Sheehan says.
• Observation beds. This is always a popular issue because Medicaid rules differ by state and also differ from Medicare in most states, explains Sheehan.

Editor’s note: Sheehan and Sarah Kay Wheeler, partner at King & Spaulding LLP in Atlanta spoke during the October 15 HCPro audio conference, “Medicaid Integrity Contractor Audits: Know What to Expect and How to Prepare.”

For additional background information view the April 22, 2009 GAO report “Improper Payments: Progress Made but Challenges Remain in Estimating and Reducing Improper Payments,” visit the GAO Web site.

Speak up: CMSA urges case managers to contact local legislators

You may have heard, but Congress is attempting to enact some type of healthcare reform in the near future. Although the extent of that reform is still up for debate, the conversation about how to improve the current healthcare model is not going away.

What better way to celebrate National Case Management Week than to contact your local legislator and tell him or her about how case managers can improve the healthcare system?

Healthcare reform will have a huge impact on the way you do your job, which is why The CSMA Public Policy Committee is encouraging case managers to speak up and share their experiences.

“We want case managers to share their stories with their local legislators,” said Carol A. Gleason, MM, RN, CRRN, CCM, LRC, BCPC Chair of the CMSA Public Policy Committee.

Gleason says she and the committee are not asking people to talk politics, but rather share what works with the current model and what needs improvement. The idea is that if case managers and other healthcare professionals share their wealth of knowledge with lawmakers, who have likely never worked in a hospital, than our government will be better equipped to create reform that works.

You can also think of it as another form of patient advocacy. Case mangers know how the system affects certain populations because they deal with difficult case everyday. This is a chance to tell the story about the time it broke your heart to tell someone, “I’m sorry but that’s just how the system works.”

The Case Management Model Act

The public policy committee has also created a Case Management Model Act which defines the case management role and explains how the case management principles can be the building blocks for successful healthcare reform. You can download a copy of the Model Act at the CSMA Web site. While you are there, check out the sample letter you can send to your representative and the list of talking points you can use to call him or her directly.

CMW News: Massachusetts seniors waitlisted for homecare

Because of state budget cuts in Massachusetts, many seniors find themselves on a waiting list of more than 300 names to receive the help of a homecare aid—a waiting list that didn’t exist two months ago.

Homecare aids help seniors avoid costly nursing homes by giving them assistance in their homes with basic tasks such as bathing and grocery shopping. However, state budget cuts took away about $4 million—or 3.6%—of the funding for the program.

Homecare representatives say the cuts are ironic because keeping seniors out of nursing homes saves the state money. Since the homecare program began in 2001, the number of patient days in nursing homes has decreased approximately 21%, according to The Boston Globe. The state pays about $158 per patient per day in a nursing home and only about $8.76 per day for each resident enrolled in the homecare program.

Sources: HealthLeaders Media, The Boston Globe