Archive for the ‘ACO’ Category

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The Role of Compliance : Home Health and Hospital Readmissions

Tuesday, January 8th, 2013

This is THE topic one sees everywhere; trade journals, conferences, CMS, MLN, State Alerts, Home Health Associations. This topic is no longer just an operational and financial issue. Boards of Directors are looking to the Corporate Compliance Department and stating hospital readmissions should be part of the Corporate Compliance Plan.

More and more, leaders are demanding that the Corporate Compliance Officer be involved in evaluating the underlying causes for readmission and discerning the readmission issues.

Hospitals have put in place operational and financial impact reviews of readmissions into their facility within 30 days of discharge. The Affordable Care Act has required a number of measures be instituted to reduce hospital readmissions. Among these measures is the Hospital Readmission Reductions Program (HRRP) that regulates adjustment for payment to facilities with excess readmissions within 30 days of discharge.

Hospitals recognize that evaluation of the issue requires review of three phases of operation; admission/inpatient care, discharge/transition planning, and post-discharge care. The hospital compliance officer is beginning to look at each phase of care. They are beginning to have active involvement on the “Safety and Quality of Post Acute Care” Committees. These committees are looking at which agencies have the most readmissions and which physicians are involved. What diagnoses are seen most frequently and which medications are seen most frequently? Which agencies have overall compliance issues?

Smart Home Health Providers are viewing this as an opportunity. Not only can the agencies market their hospital readmission prevention programs; i.e. falls risk, heart failure, and medication reconciliation, but now is the time to market the home health agency corporate compliance program and theirleaders involvement in this program.

Hospitals usually do not envision compliance programs in home health agencies, even though they are strongly encouraged, they are not mandated by the OIG as

they are in the acute care setting. Positioning the home health agency as compliant, meeting the OIG required elements and also focusing on HIPAA, strongly states the agency parallels the hospital’s focus on compliance. It also non -verbally speaks to the agency’s root cause analysis approach to seeking solutions to problems. Since audit and prevention are required elements of a compliance program, the home health compliance officer can relay the home health agency’s approach to reduce hospital readmissions and discuss data infomatics leading to present programs and review of hospital readmission.

It is this type of collaboration that positions a home health agency as a future partner in new programs; i.e. ACOs, Patient Centered Medical Homes, and other Transitional Care Initiatives.

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Posted in ACO, Affordable Care Act (ACA), CMS, Compliance, Corporate Compliance, HIPAA, Home Health, Hospital Readmission Reductions Program (HRRP), Hospitals, MLN, Patient Centered Medical Homes, Transitional Care Initiatives | No Comments »

Some Important Sites for Providers of Home Health Services

Friday, September 21st, 2012

In this day when the only constant is change, here are a few important sites to add to your list.

MLN Matters Articles Index thru August 2012

An excellent site housing national articles designed to inform providers about the latest changes in the industry.

It includes links to MLN related information and over 50 products relating to DME, EHR, Education and Management, Medicare Payment Policy, Provider Compliance, and Provider Specific Information.

www.CMS.gov/outreachandeducation

Patient Centered Medical Home Model

CMS is still testing the patient centered medical home model in the multi-player Advanced Primary Care Practice Demonstration and the Federally Qualified Health Centers Advanced Primary Care Practice Demonstration.

CMS continues to test the PCMH model under the Innovation Center created by Section 3021 of the Affordable Care Act allowing CMS the opportunity to test a variety of models and expand implementation throughout the country.

http://innovations.cms.gov/

The Innovation Center

The Center was created by Section 3021 of the Affordable Care Act allowing the opportunity to test a variety of models and expand implementation throughout the country, the goal is to increase quality and reduce health care expenditures through innovation.

http://innovations.cms.gov/

Survey Guidelines

www.cms/surveycertificationinfo.gov/downloads

Preventing Billing Errors

To increase Understanding of billing requirements and to avoid common billing errors, visit

www.cms.gov/outreachandeducation

Claims Processing

To review expectations for proper claims processing, go to

www.cms/outreachandeducation

The Official Medicare Claims Processing Manual Chapter 22- Remittance Advice

http://www.cms.gov/manuals/downloadsclm104c22.pdf

Understanding the Remittance Advice:

A Guide for Medicare Providers, Physicians, Suppliers, and Billers

http://www.cms.gov/inproductsdownloads/RA_Guide_Full_2_22_06.pdf

Therapy Claims-Based Data Collection Strategy

Proposed rule CMS 1590-P was released as a proposal to collect more date on patient function as it relates to Speech/ language, occupational, and physical therapy services delivered. The Middle Class Tax Relief and Jobs creation Act (MCTRJCA) requires CMS to begin this data collection January 1, 2013.

Update on ACOs

We have written several blogs and ezines regarding the new Chronic Care Management Models, including Accountable Care Organizations. Health and Human Services Secretary announced that as of mid summer there are 89 new ACOs in 40 states serving 1.2 million people. As we have discussed in prior ezinesin both 2011 and 2012. ACOs may be formed by health care groups (not home health agencies) such as hospitals and physician groups. New applications continue to be accepted and there is expectation of the formation of many more of the alternative

care models. Go to:

http://www.hhs.gov/news

Remember, the CMS website has had new updates re Open Door Forum Discussions and MLN educational updates as well as content re ICD-10. Visit often as regulations are changing and being updated routinely.

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Posted in ACO, Affordable Care Act (ACA), Billing, CMS, ICD-10-CM Coding, Medicare, Surveys, Therapy | No Comments »

Home Health Agencies: Start Preparing to Work with the Patient- Centered Medical Model

Thursday, September 6th, 2012

There is a fundamental need for health care reform in the US states. CMS, under the Affordable Care Act (ACA) plans to expand patient access to care while reengineering the delivery system to provide lower cost higher quality care. For years, there has been growing evidence of fragmented care, and lack of coordination in both primary and preventive care with rising costs.

CMS, through MLN, has offered numerous articles regarding innovative programs and practices for health care providers. Dollars have been made available to provide care under programs considered innovative, offering coordinated care no matter the level of care. Besides the Accountable Care Organization(ACO),  the Patient-Centered Medical Model (PCMM) has received endorsement snd support by a broad coalition of health care providers, including major health care plans, Fortune 500 companies, the AMA, and numerous specialty societies. Currently, there are over 25 multi-health plan/societal provider pilots underway in a dozen states. CMS is pushing for over 500 physician practices to practice PCMM and there are over 20 bills in 20 states promoting PCMM.

History of the PCMM

1. Since 2000, CMS has been monitoring several quality indicators and seen that states with higher spending per Medicare beneficiary tended to have lower ranking on 22 quality of care indicators.

2. The US population is projected to be 349M by 2035

902 million visits were made to physician offices in the US in 2007. 2/3 of the visits were in primary care, Peds, and Family Practice. The expected rise in care needed will be unsustainable unless new ways of delivering care are found.

3. In 2011, 10,000 individuals per day became eligible for Medicare with a dwindling supportive working population.

23% of all Medicare beneficiaries have 5 or more chronic conditions. The dollars spent account for ¾ of all Medicare spending which is for beneficiaries visiting 14 different physicians for 40 office visits annually. (Source: American College of Physicians 2007).

What is the Patient Centered Medical Model aka Patient Care Medical Home? 

The Patient Centered Medical Model is a care delivery model whereby patient treatment  is coordinated through the primary care physician and a guided care practitioner (an RN specially trained in this model by the John Hopkins certified program). The objective is to establish a centralized setting that will oversee office personnel that may include nutritionists and educators and encourages partnerships between physicians and their patients and families. This model monitors care delivered by Home health agencies, registries, inpatient and outpatient facilities, using information technology, health information sharing, and other means that allow a fully coordinated plan of care for the patient overseen by one notone, but numerous disjointed teams; primary care physician and the guided care practitioner, and other office personnel transforming patient care delivery. This model will no doubt be a part of local ACOs. This model requires certification and approval by CMS. Before long, it is expected state licensure will ensue.

This team may use traditional resources as well as performing a PCMM assessment, a care Gap analysis using education, collaborative meetings and retreats to design an over arching plan of care thatmonitors the diagnoses, care, progress and outcomes. This PCMM will coordinate participants in the plan of care seeking innovative proven programs delivered by quality proven health care organizations.

They will seek agencies with strong EMRs that will “speak” with their EMRs. They will seek efficiencies and innovations such as patient portals. Validated tools and evidenced-based processes will be required. Agencies should have successful validated programs available on line with the capability to have personal patient portals for messaging, lab values, communicating with the PCMM team and education modules.

The PCMM is based on four cornerstones: Provide primary care, is patient-centered, is a new model practice, and is a part of payment reform. This practice is based on 20 years of research demonstrating far better patient outcomes than traditional care.

 It is truly patient centered having a primary overseer of care to eliminate the multiple physician fragmented care model. Engagement of consumers at all levels of care is expected. The PCMM is expected to find innovative methods to achieve the communication goals.

This model is endorsed by the American Academy of Palliative Care, the American Academy of Neurology , the American Academy of Cardiology, the American College of Client Physicians, the American College of Osteopathic Family Physicians, the American Geriatrics Society, the AMA, the American Society of Addictive Medicine, the Infectious Disease Society of America, the Association of program Directors of Internal Medicine, andthe Society of Critical Care Medicine. Agencies should be certain that programs developed meet the appropriate society protocols or they will not be accepted by ACOs or the PCMMs.

PCMM Major Domains and Standards

Access and Communication

  1. Patient Tracking Capability
  2. Intense Case Management
  3. Patient Self-Management Support
  4. Electronic Prescribing and Pharmacologic Review
  5. Test Tracking
  6. Referral Tracking
  7. Performance Reporting and Improvement
  8. Advanced Electronic Communication

Each standard contains sub elements, 10 of which are considered a “must pass”

Initial Level 1 is least complex care, which has 49 points for sub elements

Level 2 is Moderate care with 50-74 points. 10/10 of the appropriate sub elements must be passed.

Level 3 is Complex care with 75 points and 10/10 appropriate elements that must be provided successfully.

This is a new day for home care when present care delivery methods are rapidly changing. Your home health agency should start researching now, seeking evidenced base processes with agency research practices established, having a robust EMR and communication system. Time is of the essence. Where will your agency be in 2-6 years from now?

 

 

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ICD-10: An Overview Are You Prepared? Part 1

Thursday, August 16th, 2012

The implementation date for ICD-10-CM has been pushed back one year to October 1, 2014, but it doesn’t mean you have a lot of time. If you have not assessed, through a Gap Analysis, the impact of ICD-10 on your organization, you should be planning that event…soon. There is a lot to do.

 Consider organizing an ICD-10 Transition Team. That team should have a project leader.

One of the first tasks of the team is to conduct an overview of ICD-10, identify the differences between ICD-9 and ICD-10, as well as the changes soon to come.

 The ICD-10-CM Manual is available in both a print and an electronic version. It will provide the classification system that identifies diagnoses and injuries. Acute care procedures are not included in ICD-10-CM as they have been provided in a separate classification system called ICD-10 PC, so they are not a focus of home care.

 The Transition Team needs to understand that all entities covered by HIPAA, per the American Recovery and Reinvestment Act (ARRA) who conduct healthcare transactions must comply with ICD- 10 requirements.

 Per CMS, every day it pays 4.4 million claims totaling  $1.5 B. Each month, Medicare receives 19,000 provider enrollment applications. Each year, Medicare pays over $430 B for 45 million beneficiaries. Each year, Medicaid nationally pays 2.5 billion claims for 54 million beneficiaries in 56 states and territories. ICD-10 is expected to assist in cost savings as well impacting fraud and abuse. Because of the specificity of ICD-10, more sophisticated algorithms are designed to hone in on questionable combinations of codes coupled with OASIS answers to spot potential fraud.

 What is the rationale for ICD-10?

 - ICD- 9 is 30 years old and no longer has code space for new diagnoses or new conditions and treatments.

 - ICD-9 is not always precise or unambiguous.

 - US mortality data is being reported in ICD-10

thus making international comparison of mortality and morbidity difficult.

 We need more coding specificity!

- Accountable Care Organizations, Patient Centered Medical Models, Guided Coaches, etc will require more discreet data.

- Benchmarking and quality measurement require more detailed codes

- Reimbursement will require detailed documentation reflected by codes that portray accurate patient conditions

- Increased specificity in data means more robust design of algorithms to predict outcomes and care

- Increased coding detail offers the capability to find previously unrecognized relationships in  

  disease as well as variables

- Increased capability to measure healthcare quality, safety, and efficiency

- Space to accommodate future advances and expansion

- Improved capability to determine disease severity for audit risk and adjustment

 The primary physician or specialist must establish a patient’s diagnosis. A nurse or therapist will document all pertinent diagnoses on the OASIS-C and the Home Health Certification and Plan of Care (Form CMS-485). New or additional diagnoses that the clinician identifies at the assessment must be verified by the physician before the diagnoses may be added to the patient’s medical record. For ICD-10, nothing changes other than greater detail availability via codes.

 At first glance, trying to use the ICD-10-CM Manual may seem overwhelming. In ICD-9-CM, there were approximately 14,000 choices for codes. In ICD-10-CM, there are  approximately 68,000 choices. Codes exist for so many injuries, including W61.11XA biting by a macaw, initial encounter or W61.11XD biting, subsequent encounter or codes for bites by a parrot, a goose, a turkey, or a chicken. All in all nine codes for each animal and there are a total of 312 animals. There are even separate codes for a turtle as one may be “bit by a turtle” or “struck by a turtle.” Humor aside, there are now the precise combination codes to more clearly depict the true presenting picture of the patient and their needs.

 ICD-10 CM may now have 68,000 codes but acute care procedure codes, ICD-10 PC, have increased from 3,000 to 87,000 codes. That is a phenomenal increase, but necessary, given the medical advances these past 30 years. There are expected organizational benefits from ICD-10 including administrative efficiencies, cost containment, capability for more accurate trend and cost analysis, along with improved coding accuracy and productivity.

 CMS believes that the impact on reimbursement expected, includes increased accuracy, fairer reimbursement, improved justification for medical necessity, fewer errors and rejected claims (after the initial learning curve), and reduced opportunities for fraud.

 ICD-10-CM codes may have up to 7 digits and digits 2 and 3 are numeric, digits 4-7 are alpha or numerical. The greater the specificity, the greater the number of characters required.

 A Bit of Humor

 There are so many codes including injuries incurred while sewing, ironing, playing a brass instrument, even while crocheting. There is even a code, V91.07XA, for burns due to water skis on fire. Really, quite the vision and subsequent to…what, one might ask.

 Because of the precise specificity, ICD-10 requires expertise in anatomy and physiology, pathophysiology, and diagnostics. The specificity is far greater than ICD-9 and the need to better understand finite A&P as well as diagnostics is vital. Injuries are grouped by anatomical site rather than type of injury. Another change includes sequelae instead of after effects.

 CMS plans to have a draft grouper ready by April, 2013.

 New features in ICD-10 include combination codes for a large variety of conditions, commonly seen symptoms, and manifestations. An example of a combination code includes:

E13.331 Diabetic Retinopathy with Macular Edema- other specified diabetes Mellitus with moderate non-proliferative diabetic retinopathy with macular edema.

  There are a number of expanded codes for diseases and conditions, such as diabetes, substance abuse, and injuries. Codes for post operative complications have also been expanded with a distinction between intraoperative complications and post procedural disorders.

 There will be an impact on many home health departments. In our next article, let’s discuss what preparation will be needed and the specifics needed for the Gap Analysis.

 Next article: What do we do to prepare for ICD-10: Developing the Gap Analysis

 

 

 

 

 

 

 

 

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Home Health Providers Should be Aware of New Updates

Monday, July 30th, 2012

New Shared Saving Program FAQs Posted to the CMS Website

CMS has posted new Medicare Shared Savings Program Frequently Asked Questions (FAQs) to the CMS Shared Savings Program website. Answers to questions from industry stakeholders have necessitated that the FAQs be updated to provide additional guidance to all Medicare Shared Savings Program applicants under 42 CFR part 425 related to mergers and acquisitions. The new FAQs also cover the following topic categories:  Accountable Care Organization (ACO) Participant List, Form CMS-588 Electronic Funds Transfer, and Governing Body. To learn more about the Shared Saving Program, please visit www.cms.hhs.gov/SharedSavingsProgram

Healthcare can only achieve long-term success through strategic alignment between hospitals and their physicians.

CMS and Industry Conferences everywhere are talking ACOs and Care Transition Models.  Explore new hospital and physician integration models online at the CMS website. Learn all you can about ACOs, Guided Care Models, Patient Centered Medical Models, and Care Transitions as home health is changing and you may need to change also.

HHS Announces 89 New Accountable Care Organizations

Just a month ago the numbers were 31 ACOs and 1.1M  beneficiaries. Now CMS reports 2.4 million people with Medicare are to receive better, more coordinated care through 89 new ACOs.

On July 9, HHS Secretary Kathleen Sebelius announced that as of July 1, 2012 there were 89 new Accountable Care Organizations (ACOs) serving 1.2 million people with Medicare in 40 states and Washington, D.C. ACOs are organizations formed by groups of doctors and other health care providers that formally agree to work together to coordinate care for people in need covered by Medicare.

The Medicare Shared Savings Program (MSSP), and other initiatives related to ACOs, is made possible by the Affordable Care Act (ACA).  The 89 ACOs announced on July 9 bring the total number of organizations participating in Medicare shared savings initiatives to 54. In all, as of July 1, more than 2.4 million beneficiaries are receiving care from providers participating in Medicare shared savings initiatives.

To ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely, an ACO must meet quality standards. (See June/July Select Data ezines as to ACO requirements). For 2012, CMS has established 33 quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and patient and caregiver experience of care.

 

Beginning this year, new ACO applications will be accepted annually. The application period for organizations that wish to participate in the MSSP beginning in January 2013 is from August 1 through September 6, 2012.

 

More Than 16 Million People With Medicare Get Free Preventive Services in 2012

Attributed to the Affordable Care Act, additional preventive services at no cost to beneficiaries.

Prior to 2011, people with Medicare faced cost-sharing for many preventive benefits such as cancer screenings. Through the Affordable Care Act, many preventive benefits are offered free of charge to beneficiaries, with no deductible or co-pay, because, it is believed, cost has been a factor. Now offered at no cost for seniors are several prevention screenings.

The law also added an important new service for people with Medicare — an Annual Wellness Visit with the doctor of their choice— at no cost to beneficiaries.

For more information on Medicare-covered preventive services, visit Healthcare.gov.

The healthcare industry is rapidly changing. Agencies must be ready to change. Are you?

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