Cabral_Medicare Compliance Readiness_ACMA 2012
- 1. Medicare Compliance Readiness: Practical Strategies A story of inclusion, a nine month journey, and on-going optimization Lana Cabral, RN BSN MSM [email protected]
- 2. 2 Objectives • Describe an interdisciplinary approach to implement Medicare compliance practice standards in your health system or hospital • Clarify how Medicare compliance practices by the case manager impacts the hospital’s clinical and financial outcomes • Identify case management strategies to support a constant state of Medicare compliance readiness
- 3. 3 Lana Cabral, RN BSN MSM Director, Clinical Transformation Care Management/ MIDAS+ [email protected] Catholic Health East Newtown Sq, PA Laura H. Roberts Director, Corporate Compliance [email protected] Catholic Health East Newtown Square, PA CHE health system is located within 11 eastern states from Maine to Florida. CHE has 35+ hospitals (20 wholly owned), many long-term care facilities, assisted living and retirement communities. CHE is the largest not-for-profit provider of home health services in the nation. Catholic Health East
- 4. 4 Today’s Hospital Regulatory Environment • While compliance programs have been encouraged by the Health and Human Services Office of Inspector General since the mid to late 1990’s, with the passing of the Patient Protection and Affordable Care Act, these same programs are becoming required by law • The reimbursement landscape is changing in a way that reduces payment more often than it increases • Reimbursement will increasingly hinge on highly complex formulas and measurements • Case Management is the “bridge” between the clinical and reimbursement teams
- 5. 5 Areas of Focus • Short stay inpatient admissions • Readmissions • Outlier claims • High dollar/High frequency DRGs • Admissions where the payment exceeded charges • Discharges to Skilled Nursing Facilities • Discharges to Hospice Facilities $- $500,000,000.00 $1,000,000,000.00 $1,500,000,000.00 $2,000,000,000.00 $2,500,000,000.00 $3,000,000,000.00 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 HC Fraud Recoveries These are a few of the areas that have been the focus of Recovery Audit Contractors and the Office of Inspector General See Appendix A for one hospital’s story
- 6. 6 “Achieving Accurate Reimbursement & Compliance” A system-wide program
- 7. 7 System-Wide Initiative • Name drives expectation “Achieving Accurate Reimbursement & Compliance” • Executive Sponsorship: Case Management, Compliance, Revenue Cycle • Interdisciplinary group formed from across CHE (Catholic Health East) representing our core group of hospitals (n=20) • Key stakeholder groups solicited and updated regularly • Over 5 month period the task force and sub-task forces met frequently via conference calls
- 8. 8 Key Principles Addressed by Task Force 1. Hospital practices for utilization review and ‘status’ billing are in compliance with regulations; Compliance opportunities identified from reports such a PEPPER and Comparative Database Reports are evaluated and valid areas of opportunity are addressed 2. Inpatient medical necessity is based on the CMS definition of inpatient care; Hospitalized patients have their ‘status’ determined/ validated, preferably while they are hospitalized, otherwise, prior to billing 3. Hospitalized outpatients are proactively case managed and their transition to the appropriate level of care/setting is facilitated
- 9. 9 Key Principles Addressed by Task Force 4. There is consistent, accurate electronic communication to support accurate billing between Hospital Case Management (HCM), Patient Financial Services (PFS), and Patient Access; All required documentation is in the patient’s medical record, Health Information System, and/or the Case Management System as applicable to support coding for billing 5. Commercial/Managed Care payer determinations, which are managed by Utilization/Case Managers, are communicated electronically “by exception” to Patient Financial Services (PFS)
- 10. 10 The Output of the Task Force • Rapid self-assessment of current state: – Agreement that communication needed to be enhanced amongst all stakeholder parties – Agreement that processes/workflow needed to be more compliant, efficient, reliable, and auditable • Research on ideal future state: – Discussion on the gap – Future state process / workflows design discussions • Pilot by one large teaching hospital: – Progress and lessons learned incorporated • Developed 12 Standards of Practice (must dos) and 1 Leading Practice (highly recommended) effective Oct 1st 2010 – See Appendix B
- 11. 11 Impact from the Pilot - Implementation of Electronic workflow Between Case Management & Billing Pre-implementation: • DNFB (Days Not Final Billed) >60 days - Medicare Short Stay Accounts: – 40-116 (~$2M+) Post-Implementation: • DNFB (Days Not Final Billed) >60 days - Medicare Short Stay accounts: – Less than 5 “aged accounts” (<$500K) • DNFB threshold is a max of 15 accounts; Meet weekly to discuss the holds
- 12. 12 Enlisting Executive Support for System-wide Change • Key Stakeholder Groups: Hospital Case Management, Patient Financial Services, Patient Access, Compliance Officers, and Health Information Management/ Coding; Health System’s Hospital CFOs; CHE Senior’s Management Team and the Hospital CEOs • CEOs identified a Champion at each hospital • Hospitals given 3 months to form local task force and implement standards October 1st 2010
- 13. 13 Expected Outcomes - Benefits Clinical: • Earlier case management of all Medicare patients promotes earlier treatment plan assessment and intervention; earlier patient and family engagement; earlier transition planning Financial & Compliance: • Timely and accurate billing • Workflow efficiency/ Productivity • Medicare compliance • Data reliability and accuracy • Throughput/ LOS/ Capacity
- 14. 14 Practical Strategies Medicare Compliance Readiness:
- 15. 15 Practical Strategies • Establish Clear Expectations of Case Management, Patient Access, Billing & Coders with a Solid Infrastructure: – Standards/P & P; Education; Monitoring; and Tools • Engage Physician Advisor(s) and Utilization Review Committee (URC) : – ‘Market’ throughout your hospital/health system the growing importance of the roles of PA and URC – Inpatient Medical Necessity: Know and use the CMS definition of Inpatient Care, Invasive Procedure Criteria, and Practice Guidelines that are evidence-based and well accepted by the medical community – Make the most of your URC: Use the interdisciplinary membership as an advisory board/decision making body; Bring completed data analyses with recommendations
- 16. 16 Practical Strategies • Tighten the Front-end; Insert ‘Checks & Balances’ in the Front–end: – Institute a 3 Point Match (Order, Medical Necessity, HIS System) • Incorrect status in HIS increases the potential for billing errors – Check status at the time of referral to Patient Access/ Logistics Center (direct admits, transports in) • Conduct Status Checks (again) Prior to Surgery: – Check order for status again prior to surgery/procedure: • Confirm status as IP prior to incision (when on the IP only List) or risk denial from the RAC • Check the CMS Lists: – Use Addendum E – IP Only List – USE Addendum B – Quarterly Updates (all Pdx)
- 17. 17 Practical Strategies • Address Failure Points in the Process Flow: – ‘Decision to admit’ without CM input ‘Point of Entry’ UM • Be concurrent in case management practice and prospective whenever possible, with case management in the ED, Logistics center, PAT/OR – Incorrect status in HIS (Health Information System) increases the potential for billing errors • Be clear about Status clerical corrections vs. notification of a Status change • Conduct Status Checks Prior to Billing : – Review/confirm status within the period before the bill drops – If necessary, (for the short term): Hold bills (≤ 3 LOS); release once confirmed • Move Process and Communication to Electronic: – Efficient, measurable and auditable – Agreement on which system you will find which data
- 18. 18 Practical Strategies • Stress Proper Patient Notification - CMS Beneficiary Notices: – Provide written and verbal information regarding status: • CMS: “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” – Clearly identify the responsible party(s) to deliver, in a timely fashion, Status Change Notification letters to the patient, physician, and hospital – Establish a comfort level with HINN and Discharge Appeal Notice delivery; consider having staff from both Case Management and Patient Financial Services deliver the notice to the patient • Address Actionable Data (e.g. PEPPER); Understand Where the Hospital is an Outlier for Certain Risk Areas: – Utilize an interdisciplinary process to analyze data and develop action plans; Keep the URC informed
- 19. 19 Tools • Standards Manual (34 pages): Clearly states the must-dos, rationale, and citations • Concurrent and Retrospective Status Change Worfklows • Quick-Reference Guides • Case Management Information System supports: worklist rules, new dictionary terms, documents, reports, e-mail notifications • Training and support • Subject of the system-wide 2011 External Audit
- 20. 20 External Compliance Audit • Audit design based on the standards in the manual; core hospitals audited in 2011 • Lessons Learned from the findings: – Hospitals which specifically followed the manual were found to have Medicare complaint practices – Hospitals which asked for and had individual education were found to have complaint practices – Hospitals with competing priorities which impacted Patient Financial Services or Case Management did not perform well on the audit
- 21. 21 Appendix A: One Hospitals Experience “Achieving Accurate Reimbursement & Compliance”
- 22. 22 One Hospital’s Experience • In December 2007, Saint Joseph’s Hospital in Atlanta, Georgia entered into a 5 year Corporate Integrity Agreement as a result of an audit focused primarily on Short Stay admissions • This case resulted from a qui tam action; Many corrective actions, including close collaboration between Case Management and Compliance, were implemented prior to the Corporate Integrity Agreement was signed • Saint Joseph’s was the first hospital in the country to implement a “Case Management Assessment Protocol” as a requirement of a Corporate Integrity Agreement
- 23. 23 History of the Case • The Department of Justice focused their investigation on the following areas: – Zero-day stays – Inpatient admissions where the admission date and the discharge date were the same – One-day stays – Inpatient admissions where the admission date and the discharge date were one day apart. The investigation focused primarily on: • Chest pain admissions • Admissions made from the Emergency Department and Direct Admissions • Medically Unbelievable admissions – the Length of Stay and the patients discharge were significantly shorter than the statistical average • End Stage Renal Disease – Specifically dialysis services provided to inpatients for which there was not an associated inpatient diagnosis – For patients discharged to Nursing Homes who possibly did not have a medically necessary inpatient admission of 3 days prior to discharge.
- 24. 24 One Day Admissions and PEPPER- Example 1DS Chest Pain 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% Q1 FY 2006 Q2 FY 2006 Q3 FY 2006 Q4 FY 2006 Q1 FY 2007 Q2 FY 2007 Q3 FY 2007 Q4 FY 2007 Q1 FY 2008 Q2 FY 2008 Q3 FY 2008 Q4 FY 2008 HospitalPercentage Hospital Statewide:90thPercentile Statewide:75thPercentile Statewide:Median Statewide:10thPercentile Statewide 90th Percentile Hospital Statewide Median
- 25. 25 Case Management Assessment Protocol • The Florida QIO developed this type of protocol and worked with CMS to implement a demonstration project for hospitals in Florida • With the investigation focusing on the appropriate admission status, it seemed prudent to Saint Joseph’s to implement a similar protocol • As seen on the previous slide, the impact was dramatic following the implementation of the case management assessment protocol in FY Q2 2008 (January-March 2008)
- 26. 26 Appendix B: CHE Hospital Standards of Practice Manual “Achieving Accurate Reimbursement & Compliance”
- 27. 27 A Note About Standard Language Working with multiple hospitals from Maine to Florida required agreement on and the use of a standard language for use in the “Achieving Accurate Reimbursement & Compliance” Manual Hospitalized Patient: Generic term for an outpatient or inpatient in a bed Status/ Status Management: A patient’s hospital “status” is either “Inpatient” or “Outpatient” Service Level: o Inpatient: e.g. Critical Care, Intermediate Care, Acute Care o Outpatient: e.g. Observation, Outpatient in a Bed, Ambulatory Surgery “Initial Review”: Formerly known as the “Admission Review” Patient Financial Services (PFS): Hospitals use a variety of names such as Central Business Office, Billing Patient Access: Hospitals use a variety of names such as Admitting
- 28. 1. Hospital Utilization Determinations (e.g. Status Management) Must be Made By a Physician Member of the Utilization Review Committee 2. Inpatient medical necessity is based on the CMS definition of inpatient care as determined by the Physician Member of the Utilization Review Committee 28 A patient’s hospital “status” is either “Inpatient” or “Outpatient.” o Observation is an outpatient service Only a physician member of the Utilization Review Committee (URC) can make a status change determination. o The CMS definition of inpatient care is utilized by the Utilization Review Committee Physician when making a status determination. The hospital’s designated Case Management Physician Advisor (PA) is an active member of the Utilization Review Committee; this includes a vendor Physician Advisor and their inclusion as a physician member of the URC is documented in the hospital’s UR Plan. Inpatient Care Definition o Medicare Benefit Policy Manual: Chapter 1, §10: Inpatient Hospital Services Covered Under Part A Inpatient-only Procedures Outpatient in a Bed Outpatient Observation Services Standards Review
- 29. 3. All Medicare Patients Will have Their Status Confirmed Prior to Billing; Billing Guidelines Are Adhered To 4. Use of the Case Management Information System Is Required By All parties in the Status Management Workflow 29 The Status Confirmation and Status Change Workflows require the use of case management information system by Hospital Case Managers, Hospital-based Physician Advisors, Patient Financial Services, and Patient Access Medical Necessity Review consists of the Initial Review (formerly known as the “Admission Review”) of a hospitalized patient to determine appropriate status and hospital level of care o 1st Level Review – Case Manager; 2nd Level Review – UR Committee Physician Advisor Concurrent and Retrospective Reviews (Patient Status flows: “CHE Hospital Standards of Practice Manual”) o Concurrent Review occurs while patient is still hospitalized – IP to OP Status Changes: Condition Code 44 o Retrospective Review occurs post-discharge – Provider Liable Claim (12X Bill) Standards Review
- 30. 5. Status Management is a Daily Activity; Prospective and Concurrent 30 Hospitals are expected to manage the status confirmation process 7 days per week o Status confirmation is conducted whenever possible concurrently, or prospectively, and in the event status confirmation is conducted after the patient’s discharge, the CHE Standard Retrospective Workflow is followed. The need for hospitals to correct inappropriate admissions (Status Changes IP OP) should be a rare circumstance o All efforts should be placed on conducting Medical Necessity Reviews prospectively as applicable, otherwise concurrently at the points of entry and on the patient care units Utilization Review Process o Prospective o Concurrent – Medicare Emergency Department Case Management o Retrospective Standards Review
- 31. 6. Case Manager Confirms the Patient’s Status “Matches” on 3 Points 31 Standards Review Pt Status = SI/IS Status in Health Info System Physician Order Accurate Billing to Payer and Patient Case Management’s Three Point Match + + = Match
- 32. 7. All Hospitalized Outpatients Are ‘Case Managed’ Concurrently 8. Avoid the Use of “Outpatients In A Bed” (OIB,) such as “Extended Recovery” For Patients 32 Hospitalized Outpatients: o All hospitalized outpatients are case managed concurrently based on their clinical condition to affect a rapid transition to an alternate care setting or inpatient status at the point of their earliest qualification. Outpatients In A Bed: o The assignment of an ambulatory surgery outpatient released from Post-Anesthesia Care Unit to a patient care unit bed should not be considered unless their condition warrants a change in their service to OBS or their status to Inpatient which will require a physician order. Hospitals are to have a process in place to comply with any inpatient notification requirements for the circumstance of a Hospitalized Outpatient changing status to that of an Inpatient. Standards Review
- 33. 9. The hospital’s Utilization Review Committee (URC) is a Required and Valuable Committee to the Hospital 33 The hospital’s Utilization Review Committee carries out the duties required by the Hospital Conditions of Participation for Utilization Review and fulfills any state UR requirements The URC is data-driven, outcomes-focused, and action oriented Standards Review
- 34. 10. Distribution of CMS Beneficiary Notices and Hospital Discharge Appeal Notices Are an Interdisciplinary Task 34 CMS Beneficiary Notices and Hospital Discharge Appeal Notices will be distributed in accordance with CMS guidelines. o Advanced Beneficiary Notice (ABN) o Hospital-Issued Notice of Non-Coverage (HINN) o Hospital Discharge Appeal Notices Every effort should be made for a notice to be delivered to the patient jointly by a Case Management staff member and a representative of Patient Access/Financial Counseling; both the clinical and financial implications are reviewed with the patient. Standards Review
- 35. 11. HCM Communicates Commercial and Managed Care Payer Exceptions to Patient Financial Services (PFS) 35 Payer Determinations as a result of the ‘external’ review process with payers (Commercial, Managed Care, TriCare, Some State Medicaid) are communicated to Patient Financial Services by exception Case Management Information System use is required by all parties in the payer determination communication process Standards Review
- 36. 12. Valid Areas of Opportunity Identified Through Key Reports Require Action 36 Keys Reports that Potentially Generate Actionable Data o Program for Evaluating Payment Patterns Electronic Report (PEPPER) o Information system reports, such as comparative database reporting Process: o Establish a monitoring team o Identify Reports o Conduct routine meetings o Conduct action item follow up o Perform on-going monitoring, trending data over time o Report findings o Maintain documentation Standards Review
- 37. Leading Practice*Not required, however, the adoption of this practice is encouraged • Claim Concordance of the Hospital Bill and the Physician Bill is Important o The hospital has a role in supporting Claim Concordance of the hospital bill and the physician bill due to an increasing emphasis and level of scrutiny on billing accuracy o Physician coders and billing personnel collaborate to match the physician claim with the dates of service that is in the hospital system 37 Hospital: Admission date is Day Three Previous observation charges combined into inpatient stay Example: Day One: Patient placed in observation status Day Two: Patient observed overnight Day Three: Patient advanced to inpatient status Day Four: Patient maintained in inpatient status Etc…. Physician: Day One: Initial observation code Day Two: Office visit code Day Three: Initial inpatient code Day Four: Follow up inpatient code