Showing posts tagged with: Select Data

What is Select Connects with Clinicians?

JP Boranprasit
Clinical Practices, Coding, Compliance, OASIS, Training

Select Connects With Clinicians

Free 30-minute trainings to help clinicians improve OASIS assessment accuracy.


You're Invited to attend

"Select Connects With Clinicians"

What is Select Connect with Clinicians?

Every other month Select Data sponsors a 30 minute training free of charge for clinicians and support staff working in Home Health. This is an effort to support OASIS accuracy and compliance and to promote better outcomes for patients. For more information please send an email to or call 866-538-CODE (2633). For assistance with PDGM, Coding, and OASIS & documentation review, contact SELECT DATA at 1.800.332.0555.

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New Bundled Payment Projects

Legislation, Payment Updates


New Bundled Payment Projects: Get Prepared Now or Risk being Passed Over by the Hospitals

Agencies should prepare NOW developing Cardiac and/or Orthopedic Best Practice programs if they are not already present. Conduct statistical analysis reflecting outcomes. Demonstrate your agency’s value and strengths to that acute care hospital. If you already have a program, run the analytics. Show the value of your Agency’s specific care.


On July 25, 2016, CMS released the proposed rule stating they intend to test new bundled payments to Hospitals for the following diagnoses: Myocardial Infarcts (MIs), Coronary Artery Bypasses (CABGs), and Surgical Hip/Femur fractures. This proposal is similar to the Comprehensive Care for Joint Replacement (CJR) model that began the Spring of 2016. That proposal made hospitals responsible for the first 90 days of cost following hospital discharge for that condition. CMS has been pleased with the results thus far.

The new models would run from July, 2017- 2021 and like the CJR model, the hospital providing the procedure would be held accountable for costs and quality of care from surgery through 90 days post acute care. Of course, the hospital will be able to choose the post acute providers.

Agencies should prepare NOW developing Cardiac and/or Orthopedic Best Practice programs if they are not already present. Conduct statistical analysis reflecting outcomes. Demonstrate your agency’s value and strengths to that acute care hospital. If you already have a program, run the analytics. Show the value of your Agency’s specific care.

How to Show YOUR AGENCY’s Value

Gather emergent and rehospitalization data such as number of patients cared for and the resulting rehospitalization admission rate. Be prepared to discuss what makes your Cardiac program successful and why your agency will be an excellent partner.

CMS will choose 98 markets by random selection. Those hospitals working with post acute care providers including physicians are expected, by CMS, to deliver care that is at a “quality adjusted target price, while meeting or exceeding quality standards, and would be paid the savings achieved.”

For the Surgical Hip/Femur Fracture Treatment, that model will be placed in 67 areas where the CJR is ongoing. This looks to be an add-on to the present project. This diagnosis is the eighth most common discharge diagnosis for Medicare fee for service patients in a hospital. CMS has noted that mortality rates associated with this diagnosis is 5%- 10% after 1 month and approximately 33% at a year.


Centers for Medicare & Medicaid (2016). Bundled Payments for Care Improvement (BPCI) Initiative: General Information. Retrieved from:
For clinical record document review and coding services that can assist you with these models and more, CONTACT SELECT DATA at 1.800.332.0555

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The Surveillance and Utilization Review Subsystem (SURS)


Predictive Analytics or Provider Profiling? Call it what you want, is your agency being monitored by CMS and/or state Medicaid etal? And, have you directly triggered an alert? Or, are physicians that sign orders for your agency patients being investigated? Should you be aware that your agency could trigger a PPS RAC, MAC, or Z-PIC audit and that a related party or a referral source under review could trigger an audit of your agency? Yes, that could be a reality. CMS and related agencies are using predictive analytics to identify aberrant care delivery and utilization patterns for PPS. At the time the claim is dropped, an assessment of multiple patient factors is conducted. These factors may include diagnoses, frequency, and disciplines involved in care. Your agency practice patterns are now being compared to peer groups and may include a comparison to validated benchmarks. Physicians who refer to your agency may be having their practice patterns monitored also, especially if the payor source is Medicaid. The Surveillance and Utilization Review Subsystem (SURS) is responsible for monitoring claims process for Medicaid, seeking indicators of fraud.  They look for duplicate, inconsistent, or excessive visits in relation to diagnoses and visits provided in State systems. Section 456.25 of Title 42, Code of Federal Regulations writes that "States are required to have a post-payment review process that allows State personnel to develop and review: (1) recipient utilization profiles, (2) provider service profiles, (3) exception criteria; and (4) identifies exceptions so that the agency can correct misutilization practices of recipients and providers." No two state Medicaid systems are the same, thus, there are a variety of post- payment review SUR systems. Some state systems are routinely using tools that can statistically use random sampling with extrapolation for provider reviews. This allows the auditor to identify a current trend and apply the findings retrospectively for a specific past time point. Recoupment dollars can add up quickly using this methodology. The SURS are also using tools that flag inconsistencies and over-utilization of visits in relation to care delivered at those visits. At times, they may be focusing on specific discipline practices. States have different practices.  Personnel in the New Hampshire Surveillance and Utilization Review Subsystem (SURS) monitor financial claims for the NH Medicaid plan. SURS review provider claims for fraud, waste or abuse and may refer cases under suspicion to the Medicaid Fraud Unit of the State Attorney General. The unit also recovers overpayments by using predictive analysis algorithms that search its data warehouse for aberrant claim information. "In addition, SURS in New Hampshire also conducts reviews to determine if recipients are inappropriately using certain types of medications." This can trigger other areas of investigative need. Some states are querying relational databases which provide flexible and easy access to years of paid claims and the ability to query real time data along with trending patterns and profiles. The SURS also use exception profiling as a starting point for case development. Ranked reports can quickly identify outliers. A sample profile might include the following elements: -Average patients per agency -Average reimbursement per agency -Average disciplines per patient -Average diagnoses per patient -Average number of patients with labs -Average number of patients with injections -Evidence of upcoding -Evidence of downcoding Medicaid is monitoring payment for care and now closely monitoring physician practices. Agencies need to be certain that they strictly adhere to the regulations for care provision. A physician who is being monitored now can bring review and audits to those for whom he or she may provide referrals. Compliance risks have always existed. But now, agencies need to expand those risk mitigation practices to their referral sources as well as their marketing departments. Be certain you and your referral source philosophies are similar. Quality oriented physicians are also seeking agencies with like philosophies. They too want to improve the patient transition of care.  The bad press regarding 78 Texas home health agencies and the linked Texas physician has raised some physicians concerns nationally re this industry. Showcase your agency quality programs and excellent outcomes.

  • Work to improve bi-directional communication flow.
  • Establish points of accountability for sending and receiving patient information.
  • Increase the use of case management and professional care coordination.
  • Develop performance measures that encourage better transitions of care that are well documented.
  • Let it be known that your agency supports a strong regulatory culture that offers accountability and effort toward solid patient outcomes.
That well-stated philosophy and agency culture exhibited through employee conversation, patient care, and marketing materials tells all stakeholders involved that your agency strives to be a quality-oriented care delivery provider.

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