All Entries Tagged With: "Medicare"

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.

Are you paying attention to your case mix index?

What is Case Mix Index (CMI) and why, as a case manager, do I care what that is?  According to the Financial management for nurse managers and executives (3rd ed.), CMI is the measurement of the average severity of illness of patients treated by a healthcare institution.  Basically, CMI helps determine the dollar amount assigned to a diagnosis related group (DRG) for the Medicare population. Medicare assigns a dollar amount for every facility, which is partially determined by the CMI.

Hospitals use the CMI to determine the budget, and if the actual CMI is lower than the budgeted CMI, the incoming money for those DRGs will be less. This causes an imbalance in the hospital revenue. If the money isn’t coming in as planned, a financial fiasco can occur. Think of CMI as the yellow light that warns the hospital of any impending decrease in hospital income. The financial wizards and senior management monitor the CMI on a monthly basis.

Appropriate DRG assignment for each inpatient case impacts the CMI. This is another reason why complete and accurate documentation is important. Coders need thorough documentation to assign the appropriate DRG. Appropriate coding determines the DRG, and the average DRG weight determines the CMI. Case management and clinical documentation improvement specialists can help the coding team by ensuring documentation supports the appropriate diagnoses, which will lead to appropriate assignment of a DRG.

CMI is complex, but essential to the revenue survival of hospitals. CMI is used to adjust the hospital’s average cost per patient. CMS uses the annual CMI to determine the DRG amounts for the next year. CMI is a very complicated concept to grasp, but it is important to remember that CMI is a tool that is used to predict income, outlines patient types, and helps explain the cost of treating a hospital’s population. In the end it goes back to complete, accurate and timely documentation and appropriate coding practices.

Do you know what your institution’s budgeted CMI is and what your actual CMI is?

One year later: How are you handling HAC and POA

Last October, CMS began paying hospitals less for certain hospital-acquired conditions (HAC) that occur in specific situations and are not present on admission (POA). CMS designed the program to save money by ceasing to pay hospitals for conditions that could have been avoided. However, a new study published in the September 9 issue of Health Affairs, estimates that the program has saved $1.1 million to $2.7 million annually.

Before the HACs took effect, many experts warned that the HACs could affect the hospital’s bottom line, but this study suggests that may not be the case. Have they affected your hospital’s bottom line?

The following HAC conditions took effect October 1, 2008:

1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Stage III and IV Pressure Ulcers
5. Falls and Trauma

• Fractures
• Dislocations
• Intracranial Injuries
• Crushing Injuries
• Burns
• Electric Shock

6. Manifestations of Poor Glycemic Control

• Diabetic Ketoacidosis
• Nonketotic Hyperosmolar Coma
• Hypoglycemic Coma
• Secondary Diabetes with Ketoacidosis
• Secondary Diabetes with Hyperosmolarity

7. Catheter-Associated Urinary Tract Infection          (UTI)
8. Vascular Catheter-Associated Infection
9. Surgical Site Infection Following:

• Coronary Artery Bypass Graft (CABG) – Mediastinitis
• Bariatric Surgery
  • Laparoscopic Gastric Bypass
  • Gastroenterostomy
  • Laparoscopic Gastric Restrictive Surgery
• Orthopedic Procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow

10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

• Total Knee Replacement
• Hip Replacement

If you are finding HAC and POA is an issue at your facility, check out these tips. Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services at 3M Health Information Services in Atlanta, offered the following tips for keeping staff up to speed on HACs and POA in the September 2008 issue of Case Management Monthly:

• Educate case managers on what POA status is and partner with your health information management department to determine where POA codes apply.
• Be aware of new HACs when they’re announced by CMS. “This is just the beginning. It’s likely these conditions will continually evolve,” Garrison says.
• Look at your facility’s current documentation selection tools to see whether they lend themselves to capturing these data on admission. If they don’t, improve them.
• Do a self-audit. Randomly pull 30 charts to see whether they accurately note POA conditions. If you think there are gaps, chances are an auditor will as well.

“If you fail your own audit, you’re going to fail others, such as the recovery audit contractors’,” says Garrison, who describes case managers as “quality of care managers” and points to POA guidelines as “quality indicators.”

For more information on HACs, visit www.cms.hhs.gov

To listen to the HCPro, Inc., audio conference “POA Reporting for Hospital Acquired Conditions: Strategies to Obtain Complete Documentation,” visit www.hcmarketplace.com.

To read the complete article ” Don’t let HACs cut into your bottom line“, visit the ACDIS Web site’s Helpful Resources section.

Condition code 44 – The continuing saga

On August 28, CMS issued Medicare Claims Processing Manual (MCPM) transmittal 1803, which is the October 2009 update to the Outpatient Prospective Payment System (OPPS). CMS included minor revisions to those sections of Chapter 1 of the MCPM that relate to condition code 44.

As you will recall, condition code 44 is used when a patient’s initial inpatient status is successfully changed to outpatient for purposes of billing and payment. This generally occurs when case management and other utilization review personnel were not available (weekends and holidays) at the time that the admission decision was made, and it is later determined that the patient does not meet Medicare’s inpatient guidelines. Condition code 44 is reported on the subsequent outpatient (013X) type of bill that is submitted to recover for the services provided in the inpatient setting.

Those inpatient services are covered and reimbursed on the same terms and conditions as if they actually had been provided in the outpatient setting, so long as all of the following criteria are met:

• The decision to change status must be made by the hospital’s “utilization review committee” (UR committee). One “member” of the UR committee can make the decision, with the attending physician’s agreement; in all other cases, the decision must be made by at least two “members.” The change in status must be made prior to discharge or release of the patient and before the hospital has submitted a claim for the inpatient admission;
• A physician must concur with the decision;
• The physician’s concurrence must be documented in the patient’s medical record; and
• The UR committee must provide written notice to the hospital, the patient and the patient’s physician within two days (but not later than the patient’s discharge or release from the hospital) of the change and its impact on the patient, including financial liability for applicable deductible and coinsurance amounts.

In the transmittal issued on August 28, CMS stated that although one physician member of the UR committee is empowered to make the decision to change status, the physician member who makes the decision must be different from the concurring physician, who is the physician responsible for the care of the patient. Based upon this most recent statement, it is not clear what the effect would be if the physician responsible for the care of the patient did not concur with the change in status.

The regulations that set out the hospital’s conditions of participation (CoP), which call for the establishment of a UR committee, along with the scope of its responsibility and authority (including change of status), indicate that, in all other circumstances, the change in status decision must be made by two members of the UR committee. Presumably, this is the procedure that a hospital should follow if it were unable to obtain the agreement of the patient’s physician to change the status of care from inpatient to outpatient.

Hospitals are encouraged to have at least two signatures on the documentation for the change in status: (1) when the attending physician concurs, signatures of both the attending physician and the physician member of the UR committee who made the change in status decision; or (2) when the attending physician does not concur, signatures of the two physician members of the UR committee who made the decision to change status.

Hospitals are also encouraged to confirm with their FI/MAC that the process as outlined above, particularly when the patient’s physician does not concur, meets the requirements of a condition code 44 change in status.

Editor’s note: This article was written by Judith Kares, an, instructor for HCPro’s Medicare Boot Camp – Hospital Version. It was originally published on the MedicareMentor blog. Read the original post here.

HIPAA clarifications of importance to case managers

CMS Medicare Learning Network has posted a revision of a special edition (SE) posting that clarifies several privacy points of HIPAA that are important to case managers, particularly those who are working with patients, families and post-acute providers during the discharge planning process.

The title of the article is:

Clarification about the Medical Privacy of Protected Health Information

Note: This article was first published in 2007 and was revised on May 11, 2009, to reflect updated Web addresses for several products (resources) referenced in the article and to clarify those ‘sticky’ points of whether what case managers do is or is not HIPAA compliant.

You can access the article here.

The purpose of the article is to review:

• The Privacy Rule’s protections for personal health information held by providers and the rights given to patients, who may be assisted by their caregivers and others, and
• That providers are permitted to disclose personal health information needed for patient care and other important purposes.

Lists of topics included.  Numbers 1 and 2 of particular importance for case managers:

1. HIPAA does not require patients to sign consent forms before doctors, hospitals, or ambulances can share information for treatment purposes;
2. HIPAA does not require providers to eliminate all incidental disclosures;
3. HIPAA does not cut off all communications between providers and the families and friends of patients;
4. HIPAA does not stop calls or visits to hospitals by family, friends, clergy or anyone else;
5. HIPAA does not prevent child abuse reporting;

For each of the above listed topics, there are links that will take you deeper into the topic and allow you to fully understand that HIPAA was not, and is not, intended to interrupt the work you do with patients.  Case managers need to communicate across the continuum and thus are in a unique position when it comes to protecting information while promoting continuity of care.

As a case manager, this is essential reading. Share this with your compliance officer pointing out what efforts you are taking to comply and yet provide a safe transition of care.

Let us know how you apply this info to your policies and procedures in your organization.

Inpatient or observation, now that is the question

Just as you get your processes and procedures in place and staff trained on what is Observation and what is Inpatient, along comes Medicare! For acute care hospitals, how do we know if a patient should be Inpatient or Observation? First, and most importantly, you must have consistent processes and criteria to appropriately and proactively establish the appropriate placement of patient.
Here are a few questions to ask when determining the Medical necessity and appropriate status placement:

Dealing with Medicare and commercial observation cases

As we see more and more uninsured and underinsured patients entering the ED, we’re seeing more and more patients languishing in Observation Status. What are your challenges with Observation Cases? At Scottsdale Healthcare System, we have both Medicare and commercial observation cases; both have their own sets of challenges. [more]

CMW News: The RAC is back on track

The Centers for Medicare & Medicaid Services announced on February 6 that the contract protests over the Recovery Audit Contractors (RAC) have been settled and the implementation of the RAC program will now be continued.

The RAC jurisdictions are as follows:

Region A:  Diversified Collection Services (DCS)
Region B:  CGI Technologies and Solutions, Inc.
Region C:  Connolly Consulting, Inc.
Region D:  HealthDataInsights, Inc. [more]

CMW Sneak Peek: Mastering Medicare’s Important Message

Although many facilities struggle with delivering the Important Message (IM) from Medicare as part of the admitting and discharging process, some have it down to a science. Learning from such facilities may help your organization educate patients and increase compliance.

Timing is critical when it comes to delivering the IM. CMS’ guidelines state that the first IM must be delivered at or near admission but no later than two days following the date of admission. [more]

CMW Tip of the Week: How to handle Advance Beneficiary Notices of Noncoverage

This week’s tip comes from Jackie Birmingham, RN, BSN, MS, CMAC.

A Medicare beneficiary (or authorized representative) who has been given an Advance Beneficiary Notice of Noncoverage (ABN) may elect to receive the item or service anyway. In this case, the beneficiary should indicate that he or she is willing to be personally and fully responsible for payment by marking options 1 or 2 in box G on the ABN form. This new version of the ABN is used before services are rendered (as the name implies) and it may be given by outpatient department staff.  

Here are some more tips regarding filling out the ABN:

• Option 1 indicates the beneficiary or representative will pay for the service out of pocket, but the hospital will also bill Medicare to see whether Medicare will pay for the item or service. If Medicare does not pay, the patient has the opportunity to appeal, but there is no guarantee Medicare will pay for the item or service.
• Option 2 indicates the individual accepts full financial responsibility for the item or service. Medicare will not be billed, and the beneficiary cannot appeal. This option requires that the patient be informed of the cost of the service prior to receiving the service.
• When a beneficiary decides to decline an item or service, he or she should indicate this by marking option 3 in box G on the ABN form. Counseling the patient on this decision and documenting the discussion is important. The service has been ordered based on the patient’s physician’s advice, and if the patient declines the item or service, it is important to be sure that he or she is fully informed of the consequences of the decision.  
• The beneficiary cannot refuse to sign the ABN and still demand the item or service.
• If a beneficiary refuses to sign a properly executed ABN, the notifier should consider not furnishing the item or service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such that this is not an option.
• Additionally, the notifier may annotate the ABN, and have the annotation witnessed, indicating the circumstances and persons involved.

For additional information, the CMS Web site contains notices, manuals, and instructions on how to use the ABN.