Author Archive for PARC Editor

Have a RAC question? CMS has some answers

Although none of the newest Recovery Audit Contractor FAQs released by CMS—it published 15 in the last two weeks—is particularly surprising, they are perhaps a sign that CMS is continuing to make every effort to share RAC information providers need to know, through as many channels as possible.

It may be sharing the same information during RAC outreach sessions or during Open Door Forum calls, but now the information is also readily available to those who wish to learn about RACs in a Q&A format.

Read the full report by Andrea Kraynak for HealthLeaders Media.

From HFMA: Five ways leaders fail

Editor’s note: The following is a passage on www.healthleadersmedia.com from Philip Betbeze, who attended the Healthcare Financial Management Association’s annual conference last week in Seattle.

Keynote speaker, Patrick Lencioni, kicked off the opening weekday, speaking about Leadership.

Lencioni often works with hospitals to adopt ideas around teamwork. Now, it's more important than ever in these difficult economic times, when everyone is expected to do more with less. He gave us five ways leaders often mess up their teams. Pay attention. I've definitely been on some bad teams and some good ones, and this guy has it right:

1. The absence of trust: Most think about predictive trust, which means we have known each other long enough I can predict your behavior. But that's not what makes a team great. The team we need is based on vulnerability. Vulnerability-based trust happens when human beings on team say things like "I don't know the answer," or, "I think I need help; I think I screwed this up," or even "I'm sorry." When you have that dynamic on team it creates powerful competitive advantage. Vulnerability can never be faked.

2. Fear of conflict: Why don't people like to engage in conflict? They say they don't want to hurt people's feelings. Organizations that think conflict is bad crush people because it ends up as a conflict of people and not issues.

3. Lack of commitment: When we can't get people to debate, people won't commit. If people don't weigh in on a decision they won't buy in on a decision. Truth is if we want to get people to commit we need to make sure we are hearing people and their opinions. My job as leader is to make sure I know what everyone thinks, and if that takes time then so be it and if there is not consensus then it is my job to break the tie. When you can do that, hear everyone, and factor in their input, 99 times out of 100 they will support the decision even if they disagree.

4. Avoidance of accountability: This is the most common and most dangerous of all the dysfunctions. When you walk out of meeting and know that person next to you didn't commit, how much courage will you have to hold them accountable? The thought of letting down a trusted colleague is the biggest motivator. They love their teammates. You find it in firefighters and police. The best teams play for one another.

5. Results: Pay attention to results of team rather than individual needs. You have to make sure you do the best for the hospital, not the department. When there are silos at the top of the organization, they suffer the most. The most important priority is the collective results of the organization.

Read Betbeze’s full report on HealthLeaders Media’s Web site.

Patient access teams get financially smart in a tight economy

Hospitals can't escape layoffs these days, and they're not adding many jobs any time soon.

Bureau of Labor Statistics data released Friday say hospitals added only 300 payroll jobs across the entire nation, compared to 16,800 jobs in May 2008, and 8,700 jobs in May 2007.

So what are hospitals doing about it, especially on the front end where accurate registrations and upfront collections can mean the difference between a denial and a full return on a patient bill?

They are getting smarter, more technologically savvy, and analyzing their payer mix and what each entity requires.

Read the full story by HealthLeaders Media's Dom Nicastro.

Take our survey; Be part of a comprehensive look at national RAC preparedness

We invite you to take our comprehensive survey on what your facility is doing to prepare for the permanent RAC program. It should take approximately 10 minutes to complete.

We value your input and appreciate your time and effort in completing this anonymous survey. As a thank you, we will be happy to send you our completed benchmarking report detailing the results of the survey. To receive your free copy of the benchmarking report, you will have the opportunity to separately request one upon completion of the survey. Thank you for your time and consideration.

To participate in the survey, click here.

CMS updates RAC audit timeline: complex reviews still months away

CMS anticipates Recovery Audit Contractor (RAC) automated reviews will begin in late June and July, according to Marie Casey, deputy director of the Division of Recovery Audit Operations at CMS. However, this is not set in stone, she says, noting, "there is some leeway."

But complex reviews won't begin until later, says Casey. CMS is aiming to begin certain types of complex reviews (e.g., coding and DRG validation) this fall. However, medical necessity complex reviews won't begin until early 2010.

The nature of automated reviews is simpler on the whole, she says, making them an easier choice to roll out first. "The automated reviews are less burdensome on the provider, because there's no request for medical records," says Casey, adding that automated reviews are also easier on the RACs themselves to manage.

Read the full story by Andrea Kraynak of HealthLeaders Media.

Proposal would require health plans, doctors to cut appointment wait times

California soon may become the first state in the nation to set a maximum number of hours a health plan enrollee may wait before getting in to see a doctor.

Under the proposed regulations that are six years in the making, a patient needing an "urgent" appointment for a service not requiring prior authorization must be seen within 48 hours. For urgent appointments requiring prior authorization, they must be seen within 96 hours.

Patients would be allowed to speak with a doctor on the phone or receive a "triage" call back from a health professional–not answering service personnel–within 10 minutes, no matter what time of the day or night they call.

Read the full story by HealthLeaders Media’s Cheryl Clark.

Is healthcare better without doctors?

In all the talk about creating a medical home for every American, it's important to realize that increasingly, consumers are getting their healthcare outside of the traditional physician-based healthcare system. And that may very well be a good thing.

"Access to healthcare does not necessarily mean going to the doctor anymore," says health consultant Mary Kate Scott of Scott & Co. In her report for the California HealthCare Foundation released last week, Scott points to the rapid expansion of drugs and devices to test, monitor, and treat medical conditions without the physician office visit that defined access to healthcare a decade or two ago. In fact, a physician isn't required in the process at all.

"We're going to see an explosion in medical devices, and over-the counter drugs," as well as telemedicine applications for their use, Scott says.

"Consumers can purchase more than 700 over-the-counter medications whose ingredients and dosages were once available only by prescription," she writes in her report. "And in the last 15 years, numerous over-the-counter devices have become available" enabling oneself, or a non-physician to diagnose, monitor and treat a medical condition.

And that is the wave of the future, she predicts. "It's not like consumers love going to the doctor. They actually don't."

Read the full story by HealthLeaders Media’s Cheryl Clark.

Processing your MSP claims

CMS released a transmittal describing the formula it uses to determine its liability on claims when Medicare is the secondary payer. It is important practitioners accurately convey the primary payer’s group codes, claim adjustment reason codes, and associated adjustment amounts when sending claims to the Medicare contractor.

Effective date: July 1, 2009
Implementation date: July 6, 2009

View the transmittal
View the MLN Matters article
View the Job Aid article

Centralized scheduling/online fax orders

I would like to network with hospitals that have Centralized Scheduling and Online Fax orders.

Sabine McNair
Director of Patient Financial Services
Hopkins County Memorial Hospital

National Appeal Process denial

Does anyone have a success story on getting a denial overturned by using the National Appeal Process after all levels of appeals for the insurance company have failed? Also, can someone provide that address?

Rosemary R. McLain, RN
Clinical Nurse Auditor
Providence Hospital