Original publication date of the article was June 2013

A Q&A with Donald M. Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and keynote speaker at the upcoming 2013 HFMA National Institute, recently caught my attention. As hospitals look for new approaches to ensuring quality patient care and the financial integrity of their institutions, they’re increasingly becoming focused on creating healthcare systems that embody the attributes that Berwick points to in this piece: “seamless, coordinated, patient-centered, (and) free of waste.”

In order to make the massive changes involved in the transition to value-based healthcare, providers must look for new ways to balance patient care and the business of healthcare appropriately. One way providers are doing just that is by looking for incremental ways to improve care coordination while also increasing margins beyond the atypical “full-bed” scenario that Berwick also points to in his piece.

A simple way to embrace this emerging approach to care involves changing to a concurrent format for the discharge summary. Who wants to wait for a discharge summary that is often not ready at the time of coding, missing needed documentation, or failing to support inpatient diagnoses? Often, hospitals will choose to code the encounter prior to receiving the complete medical record. However, hospitals do so at their own risk. Recovery Auditors (RACs) review the entire medical record when performing diagnosis-related group (DRG) validation. If a hospital codes without the full discharge summary, this may increase their chance of error, and RACs will not take this into consideration. Furthermore, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires that discharge information be documented or dictated and authenticated within 30 days post-discharge, and such information must be compiled on patients with lengths of stay greater than 48 hours.

Original publication date of the article was October 2013

Now that we are one year out from the ICD-10 implementation deadline, we have to consider that this transition is about something much larger than a change in the way we code.

ICD-10 highlights the need for us to change our perspectives on how we think about the quality of our clinical documentation. In the same way focus is shifting away from volume-based reimbursement and toward value-based reimbursement, clinical documentation and coding efforts must reflect the severity of illness and quality of care. ICD-10 makes up only one part of the movement toward quality documentation. We also must consider the importance of accurately capturing hospital-acquired infections (HAIs), patient safety indicators, core measures, and physician and hospital profiling – just to name a few factors.

If your organization does not have a clinical documentation improvement (CDI) program currently in place, you already are beginning to fall behind as it pertains to efforts to drive quality data, capture accurate patient severity, and secure the appropriate reimbursement for the services your clinical teams are delivering. For those organizations that already have a CDI program in place, now is a great time to evaluate and assess your program according to best-practice benchmarks and recommended critical success factors.

Original publication date of the article was November 2014

As you may be aware, the 2015 U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan was released on Oct. 31, 2014. This should be considered mandatory reading for all healthcare providers looking to avoid fraud charges.

From an institutional perspective, a very effective method to probe for compliance issues at your organization is to compare the projects listed in the 2015 Work Plan to your organization’s current practices. As the OIG does periodically update the document, plan on revisiting the website regularly to stay current throughout the year as part of your ongoing compliance activities. For instance, with the Ebola situation in the U.S., we suspect an update related to infectious disease control may be in the works.

Staying current on OIG and Centers for Medicare & Medicaid Services (CMS) rules is not only important for compliance reasons, but due to serious financial implications for providers as well. This new OIG Work Plan reports expected 2014 recoveries of over $4.9 billion, including nearly $834.7 million in audit receivables and about $4.1 billion in investigative receivables. The investigative receivables encompass about $1.1 billion in non-HHS investigations in areas such as the states’ shares of Medicaid restitution and $15.7 million in savings from OIG recommendations.

Original publication date of the article was December 2014

Risk adjustment is an actuarial tool used to predict healthcare costs and adjust payments to healthcare plans to cover expected relative costs for providing coverage to enrollees. Risk adjustment ensures that health insurance plans have adequate funding to provide care to people who are likely to have high healthcare costs while at the same time preventing overcompensation for healthy patients. Insurance plans compete on the basis of quality and service, which are the foundation of value-based purchasing (VBP) and healthcare reform.

Why is Risk Adjustment so Important?

Risk adjustment promotes fair payments to health insurance plans by rewarding efficiency and encouraging the provision of high-quality care for the chronically ill. For example, risk scores can be used to identify those patients who may benefit from disease management intervention to prevent costly emergency department visits or inpatient admissions. In addition, it has been determined that risk scores help predict post-discharge costs more effectively than inpatient costs. This is because patients with higher risk scores have a greater number of medical complications and therefore have significantly higher post-discharge costs. Risk scores then may be used to design post-discharge care plans to flag these patients for more intense follow-up.

Wednesday, 04 March 2015 17:24

Quality in IRFs Key Focus in Final Rule

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Original publication date of the article was September 2014

The Inpatient Rehabilitation Facility (IRF) Prospective Payment System Final Rule for the 2015 fiscal year was published on Aug. 6, 2014. The final published rule:

  • Updates the federal prospective payment rates for the 2015 fiscal year
  • Finalizes a policy to collect data on dollar amounts and modes of therapy provided in the IRF setting
  • Revises the list of diagnosis and impairment group codes that presumptively meet the “60-percent rule”
  • Updates the IRF-PAI to provide the IRF a way to indicate whether the prior treatment and severity requirements have been met for arthritis cases to presumptively meet the “60-percent rule”
  • Revises and updates quality measures and reporting requirementsDelays the effective date for the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the 60-percent rule that were finalized during the 2014 fiscal year
  • Addresses the implementation of ICD-10-CM for IRFs

This article will address several key components of the final rule.

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