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Physican documentation has evolved significantly over the past forty years. From Dr. Lawrence Weed's SOAP note approach, and the transformation from "source-oriented" to "problem-oriented", to modern EMR systems allowing an unpresidented amount of detail and tracking, at the cost of physician time and often patience.
Electronic Medical Records are often frustrating because of the level of automation driven by them. While previously notes would be primarily for other physicians, they are now utilized by a full medical team, including coders who may not understand the documenting physican's shorthand. The static, form-fill nature of EMRs also limits physician notes into a system which often was not created by a clinician. The tech-gap between clinicians and IT specialists also shows in customization of EMR for a given facility.
While this is certainly a problem, the number of accidental deaths prevented and improved patient care from EMR documentation has shown intense value. The push from Medicare to create better documentation for coding and quality scores means this will also need to remain. More about this struggle can be read from the original source here at RacMonitor.com.
As private insurance audits become more common, it's important to prepare and have a strategy. Here are a couple of tips from RACMonitor.com:
- Review any contract with the payer to see whether documents requested are covered. While you may wish to keep a good business relationship, it is important to know your options.
- If auditors are on-site, ensure their comfort with a nice location out of the way and offer basics of modern hospitality like coffee.
- Keep a physical copy of everything the auditors are using for internal records, even if its accessible electronically.
- NEVER let auditors leave with an original copy of medical documents.
- Ask if auditors would be open to an exit interview. Valuable insight into document management and auditor concerns can be found and applied to the next cycle of process improvement.
In a recent report by the Office of the Inspector General for the Health and Human Services Department (HHSD), the potential use of newly implemented EMR systems for fraud or upcoding was discussed.
While the overwhelming opinion is in favor for implementing the new solutions, the report criticizes the lack of controls for preventing double-billing, or even accidental user error. Copy-pasting records, where data is copied and pasted into the current field, is particularly error-fraught as it can lead to doublebilling. The ease with which false appointments and services can be created in the new systems has also raised concerns.
However, since other studies have found emergency room doctors have spent an average of 43% of their time entering data compared to 28% treating patients, administrators are worried about putting more steps into an already long process. With ACA starting to be implemented and ICD-10 coming soon, the process only looks to become more complex as the journey continues.
More about this story can be found in the New York Times article, available here.
According to contractor reports, some Mediare providers continuing to abuse the Medicare system, even after education measures have been taken with said providers. To quote:
"The behavior of these recalcitrant providers who refuse to comply with CMS requirements has resulted in their being placed on prepay medical review for long periods of time, requiring the extensive use of contractor resources... Accordingly, CMS is encouraging contractors to take advantage of current sanctions to address this problem of recalcitrant providers. The two authorities that may be appropriate to impose such a sanction are 1128A (a)(1)(E) of the Social Security Act (the Act), or 1128(b)(6) of the Actl which you can find at http://www.ssa.gov/OP_Home/ssact/title11/1128.htm on the internet. Both of these canctions are delegated to the Office of the Inspector General (OIG), who will work with CMS to pursue these cases."
Effective January 1, 2014, clinical trial claims submitted to Medicare contractors must report the clinical trial number on the claim. CMS will be using this number to better track Medicare payments, and ensure research focuses on pertinent issues to the Medicare community. More details about how an NLM code should be reported are available through the CMS article found here.
Many practices are finding it increasingly painful to find a good balance between investment in the new systems and processes needed for quality-of-care reimbursement and creating enough revenue while waiting for the new payment structure to be realized. This can be particularly difficult for oncology practices, as the administrative burden can be larger for billing. A similar pressure point is found with community practices, which often do not have the economies of scale to allow for an easier, more fluid transition. More about this can be found here, in the original article by Clinical Oncology News.
According to a recent post by RACMonitor.com, the Centers for Medicare & Medicaid Services will not be creating new recovery audits after May 31, 2013 until the end of the summer. This information was released in a stakeholder memo, and is currently unconfirmed by official PR channels. Read the original article here.
Clinical Documentation for Higher Reimbursements
By Karen Minich-Pourshadi, for HealthLeaders Media , October 29, 2012
As a healthcare organization moves from fee-for-service reimbursement to population health–based care, it must accurately define how sick its population is—not only to take good care of these individuals but also to be reimbursed correctly. If clinicians undervalue the population through the clinical documentation, then the government and payers will follow suit, and that can cost a hospital or health system millions.
Borgess Health, a health system based in Kalamazoo, Mich., was able to uncover more than $6 million in reimbursement by getting physicians to improve their documentation. Chances are that for your organization, it's as simple—and complicated—as that.
Anthony Oliva, DO, CMO at Borgess Health, is no stranger to clinical documentation improvement. In 2004 he was vice president of medical affairs at Bayhealth Medical Center in Dover, Del., where the organization refocused its documentation process by taking a clinical perspective rather than concentrating on primary coding.
Bayhealth added a clinical documentation management program from J.A. Thomas to help get to the heart of assessing and reporting severity of illness (SOI) and expected versus observed mortality rates, to more accurately determine hospital and physician performance. So when Oliva arrived at Borgess Health, it was only natural that he looked at clinical documentation.
"Borgess Health was working to decrease observed mortality through quality care initiatives, but had overlooked another critical point: improving documentation to improve the SOI expected mortality part of the ratio," says Oliva, who adds that the healthcare industry has traditionally viewed mortality as a quality problem, largely ignoring the role documentation plays in outcome metrics.
Having gone through the process of assessing and correcting clinical documentation at Bayhealth, Oliva was intrigued at how changing Borgess Health's documentation approach might influence the organization's metrics. Borgess Health, part of the Ascension Health network, includes more than 120 care sites in 15 southern Michigan cities, as well as five owned or affiliated hospitals, a nursing home, ambulatory care facilities, home health care, physician practices, a cancer center, and an air ambulance service.
Implementing a new clinical documentation improvement program had to be done carefully to ensure that changes didn't negatively affect the system's overall quality of care. Once the J.A. Thomas clinical documentation program was in place, Oliva carefully monitored SOI and mortality for changes.
"If you're moving the severity number and increasing the expected level of severity of patients and your observation indicators, such as mortality, don't move, then you're not having an impact. But if it does move, then you know you're impacting your denominator and not doing anything to impact your quality," he explains. "The first measurements I took after J.A. Thomas was added, there was dramatic move in CC [complications or comorbidities] pairs, and our mortality dropped 30%. That told me the program was working."
To determine how large the opportunity was in the organization’s clinical documentation, Oliva needed to do a measurement gap analysis by comparing Borgess Health’s MS-DRG codes against a benchmark.
"I looked at a couple of different variables and measured the MS-DRG couplet and triplet percentage performance at Borgess Health based on high-to-low severity within 40 MS-DRG groups," he explains. He compared those numbers against his experience and data he'd seen while working at two previous organizations of similar size and make-up.
"That comparison showed me that there was a potential reimbursement increase of about $6 million if we took a more clinically focused documentation approach," he says.
But doing so required Oliva to get physicians to see where they were missing documentation and to work with documentation specialists and coders on accurately coding clinical work. No easy task, since it meant that physicians needed to spend extra time to do this, but it was the physicians’ outcomes that were the key to moving this program forward.
"With the data I'd gathered, I could show the physicians how putting their clinical documentation into a language that coders can understand would affect their outcomes," Oliva says. "With CMS and Healthgrades now tracking physicians' individual performance data, including individual physician mortality rates, seeing this information really hit a nerve."
Once Borgess Health physicians recognized they needed to document that their patients were sicker in order for severity adjustments to apply, it sunk in, Oliva says: "If you don't get the information into the documentation, it doesn't accurately reflect the patient that was treated. And if that physician is compared to another physician that is [documenting accurately], then that doctor's outcomes will look worse. Eventually we'll be paid for outcomes. So I tell them, 'Get the documentation right and you’ll get credit for what you're doing to care for your patients.'"
Physicians were not asked to memorize any codes, just to work more closely with the clinical documentation specialists when more information on the clinical notations was requested.
"We asked them to be part of the team that’s there to help them get their outcomes to where they should be. Over time, the physicians will learn where they need to put in more information to do a better job documenting," explains Oliva. "This is helping encourage a conversation between the coder and the physician."
Coders and clinical documentation specialists were also put through two weeks of clinical documentation training to grow their knowledge and improve the relationship between these two departments. "You have to build a team between the CD specialists and coders and the physicians so they don’t see their worlds as separate," says Oliva. "This is all really basic stuff, but it's effective."
The financial and clinical results speak for themselves: Since the implementation of the program in August 2011, Borgess Health has picked up over $6 million in reimbursements, and with a 25% improvement in severity-adjusted mortality, which has placed the organization in the top 10% performance category of the Premier, Inc., outcome database.
"In healthcare, it's a positive to identify patients on a more granular level," Oliva says. "We need accurate information if we are to manage populations in the future."
The decision prevents physicians from fighting recovery audit contractors over the reopening of old Medicare claims.
By Alicia Gallegos, amednews staff. Posted Sept. 10, 2012.
Health professionals cannot challenge auditors’ decisions to review Medicare claims that are more than a year old, the 9th U.S. Circuit Court of Appeals has ruled. Federal rules do not allow an administrative or judicial remedy through which doctors can fight the reopening of such cases, the court said.
The ruling is harmful to physicians, who must accept audits without being afforded the opportunity to question the reasoning behind reopening old claims, said Long X. Do, legal counsel for the California Medical Assn. The CMA joined a friend-of-the-court brief in support of Palomar Medical Center, the plaintiff in the case.
Case at a glance
“Any audit is going to be very disruptive to a physician’s practice,” Do said. “The longer the audit goes back, the more burdensome it is on physicians. … The court has upheld the ability of the auditor to [reopen claims] without being subject to physicians’ challenges.”
The case involves a 2009 lawsuit brought by Escondido, Calif.-based Palomar Medical Center against the Dept. of Health and Human Services. Palomar challenged auditors’ reopening of a claim 20 months after initial payment. After a review, recovery audit contractors determined Palomar was overpaid for the claim because the medical services were determined to be “not reasonable and necessary,” according to court documents.
Palomar went through several rounds of administrative appeals to fight the determination and to argue that auditors never had the right to reopen the claim. Under Medicare regulations, recovery audit contractors can review a claim for any reason if it is less than a year old. If the claim is more than a year old and less than four years old, the auditors must have good cause to reopen the claim. After four years, there must be clear evidence of fraud to revisit the claim.
An administrative law judge found that Palomar was overpaid for the medical services, but the judge said the RAC had not demonstrated good cause to examine the claim. However, HHS argued the reopening of a claim deemed to have good cause was not subject to appeal. The administrative law decision was overturned by a Centers for Medicare & Medicaid Services administrator. CMS said Medicare regulations prevent medical professionals from challenging an audit’s good-cause determination.
Palomar appealed, saying health professionals should be able to fight the reopening of a claim either by administrative action or in court. A district court ruled for HHS in 2010, and Palomar again appealed.
The Litigation Center of the American Medical Association and the State Medical Societies, along with the CMA and eight other state medical societies, issued two briefs in support of Palomar. Physicians should be protected from arbitrary and unreasonable efforts to recover payments for services provided long before initiation of the recovery action, the briefs said. The AMA and others have criticized the actions of RACs hired by Medicare to find past overpayments, saying the auditors act as “bounty hunters” that cause administrative headaches for practices even if the reviews don’t uncover any evidence of overpayment.
In its Aug. 22 decision, the appeals court said the issue was difficult to resolve because of competing principles. On the one hand, Congress sought to establish an effective recovery audit program to reduce Medicare overpayments, the court said. On the other hand, medical professionals have a legitimate interest in the finality of claim determinations.
“However, in view of the goals of the RAC program, and the secretary’s regulations stating that decisions to reopen are ‘final’ and ‘not appealable,’ we hold that the issue of good cause for reopening cannot be raised after an audit’s conclusion and the revision of a paid claim for medical services,” the judges said.
At this article’s deadline, Palomar had not made a decision about whether to appeal the ruling to the U.S. Supreme Court.
Doctors may need Congress to step in
The appeals decision is the latest in an ongoing battle between physicians and CMS over determining reasonable standards for Medicare audits. The AMA and other physician organizations recently voiced opposition to new requirements on doctors related to potential Medicare overpayments. According to the rules, physicians would be required to retain up to 10 years of medical records to review if they determine at a later date that they had received excess pay. Practices also would be required to return any identified overpayments within 60 days of discovery.
More than 100 organizations, including the AMA, sent an April 16 letter to acting CMS Administrator Marilyn Tavenner, calling on the agency to make necessary changes before that proposal is finalized. The letter called the proposed requirements “impossible, unworkable and unattainable.”
Dick Semerdjian, an attorney for Palomar, said the 9th Circuit ruling is a disappointing development for all health professionals who provide Medicare services.
“Medical providers are in a tough position because now they lack the ability to appeal the reopening” of a claim, he said. “That’s going to affect not just medical centers, but all medical providers.”
At this article’s deadline, CMS and HHS had not returned messages seeking comment on the ruling.
Semerdjian said a possible next step is asking lawmakers to amend the rules on Medicare claims audits. “It’s time to go to Congress and see if the law can be modified, wherein there would be a due process provision to allow a medical provider to appeal and contest the reopening” of a claim, he said.
Expertise on call
Annual outsourcing report shows providers of all sizes continue to pursue arrangements that offer savings for their revenue-strapped operations
By Beth Kutscher (Modern Health Care)
Whether it's called outsourcing, partnering or another term, hospitals and health systems continue to use that approach as they realize that much of the expertise and resources they need, especially in the new era of value-based care, aren't available in-house.
Driven by the near-desperate need to reduce operating costs to cope with lower reimbursement rates, they're increasingly turning to outside contractors for services such as construction, medical staffing, food services and information technology to bridge the gap in a more cost-effective manner. In turn, the companies providing the services are reporting double-digit growth in their clients.
Modern Healthcare's annual Outsourcing Survey found that the top 20 outsourcing firms, based on the number of national healthcare clients, reported 13.1% growth between 2010 and 2011. As a group, the top 20 contractors served a total of 16,463 healthcare clients in 2011, up from 14,556 the previous year. This year's survey includes responses from 34 vendors.
Stephen Mooney, president of Conifer Health Solutions, Frisco, Texas, which provides revenue-cycle management services, notes that independent and smaller hospitals used to be the primary clients for outsourcing firms. But its customers are now getting larger. Hospitals big and small are “having trouble keeping up with curve,” he says.
For the first time, this year's survey results were also supplemented by data from a random sample of 75 not-for-profit hospitals and health systems in 37 states. The supplemental healthcare provider data was culled from not-for-profit financial database Guidestar, and represents information that was reported to the Internal Revenue Service on Form 990s for tax year 2009, which was often the most recent year available.
The hospitals and systems included in the supplemental data had median annual revenue of $528 million and median total annual expenses of $518.6 million. The median amount spent on contracted services—based on the five highest-compensated independent contractors cited by each provider—was $16.9 million, or roughly 3.3% of annual expenses.
Looking for partners
However, some hospitals and health systems relied on outsourcing more heavily than others. At the top of the list, Tri-County Memorial Hospital, Whitehall, Wis., reported that 23% of its 2009 expenses went toward its top five independent contractors. Those payments represented about $3.5 million of its roughly $14.9 million in expenses.
Its top two independent contractors, according to its Form 990, were Gundersen Lutheran Administrative Services, La Crosse, Wis., and Computerized Medical Imaging, Eau Claire, Wis., which provides diagnostic imaging services. Tri-County is part of Gundersen Lutheran Health System.
“I prefer to look at it as partnering,” says Brian Theiler, CEO at Tri-County Memorial. “The outsourcing is really more technology and expertise. We have not lost jobs; we have actually expanded jobs.”
Outside technology firms, for instance, have helped the facility implement an electronic health-record system from vendor Epic Systems, Verona, Wis. “We would never be able to put Epic in our system without partnering,” he says, adding that its partnership needs are “consistently growing.”
Just as many independent hospitals have turned to mergers and clinical affiliations with larger systems to expand their services, others have called in vendors to provide that additional expertise.
“With small facilities, you're not going to be in existence if you don't find a partner,” Theiler says.
Yet small medical facilities are not alone. Eight of the top 10 largest spenders on outsourcing services, in terms of percentage of total expenses, had at least 395 beds.
Stanford Hospital and Clinics, Palo Alto, Calif., ranked second on the overall list, spending 22%, or $432.6 million, of its $1.95 billion in expenses on independent contractors. Yet its largest contract—at $288 million—was with its parent, Stanford University, according to its 990 tax form.
“Those payments are compensation for clinical services provided by Stanford School of Medicine faculty,” a spokeswoman wrote in an e-mail. “Because most nonacademic medical centers don't report physician payments as contractor expenses, it is difficult to make a direct comparison (to other hospitals.)”
The other four largest contractors hired by the medical center included Blue Cross of California, Thousand Oaks; DPR Construction, Redwood City, Calif.; Perot Systems, Plano, Texas; and Accenture, Chicago. (Perot Systems became part of Dell in 2009.)
Continuing to build
Despite the challenging economic environment, hospitals continued to invest in facility upgrades, with the 75 hospitals and health systems included in the analysis spending a total of $458.3 million on independent construction firms in 2009, again based on aggregate spending from each organization's top five contractors.
In addition, three of the top 10 contractors, based on total payments received, in the supplemental analysis were construction firms: DE Harvey Builders, Houston, which earned $66.8 million in payments from the organizations; Hensel Phelps Construction, Greeley, Colo., with $65.6 million; and Turner Construction Co., New York, with $57.6 million.
At 909-bed Methodist Hospital System in Houston, all five of its largest independent contractors were related to construction. The system spent $173.8 million, representing 14% of its total expenses, on four construction companies and an architecture firm.
“Houston's still a growing market and still a strong economy,” says Mick Cantu, the system's executive vice president, who notes that its expansion projects have included a large outpatient facility, research labs and a 200-bed replacement hospital on the west side of the city.
Still, he says that the system does only limited outsourcing of other functions, with one exception being installing new technology and teaching staff how to use it. “I don't really see us doing very much from an outsourcing perspective,” he says. “Our preference is to do it ourselves versus having someone else do it.”
Local presence, national model
Outsourcing firms have taken note of hospitals' reluctance to use contractors and have tried to build offerings that pair local talent with outside experts.
Radisphere, a Beachwood, Ohio-based radiology outsourcing firm, says its niche is having local radiologists work alongside a network of offsite subspecialists who can offer around-the-clock consultations. Dr. Frank Seidelmann, the company's chief medical officer, notes that radiology has become increasingly subspecialized, posing a challenge to smaller hospitals.
“Hospitals are looking for the full array of subspecialty care,” he says. “Our people are onsite, we're local, but being supported by a model that has national expertise.”
Hank Schlissberg, the company's chief strategy and business development officer, notes that about 98% of hospitals outsource radiology services—significantly more than any other field—but most rely only on local practice groups.
Outsourcing firms in Modern Healthcare's survey reported a 12% decline in the number of contracts they had last year for radiology services, the largest among medical specialties. Observers say reimbursement concerns as well as acquisitions and consolidation in the industry often drive growth or contraction of services in each specialty.
Yet Charlie Rhoades, assistant administrator of general services at El Centro (Calif.) Regional Medical Center, notes that by using an outside radiology firm, scans that used to take up to 24 hours to read can now be done in an average of 25 minutes. “One of the big benefits that we've seen for our system is turnaround time,” he says.
The 165-bed hospital also works with a number of other medical services companies including TeamHealth for emergency medicine staffing, Quantum for hospitalists and Specialists on Call for neurology telemedicine.
Medical services as a whole represented the second-largest category for outsourcing expenditures, following closely behind construction. The 75 hospitals and systems included in the analysis spent a total of $456.8 million to hire companies that provide medical staffing services and other clinical functions.
Yet providers differed in which medical services they outsourced. Contractors that provide medical services reported in Modern Healthcare's survey that requests for nursing staff saw the largest fall-off, with a 22% decline in hospital clients using that service.
Psychiatric services similarly saw a decline of 4.3%, but contracts for anesthesiology and emergency department services increased 21.4% and 10.1%, respectively, among the outsourcing firms that responded to the survey.
EmCare, Dallas, which provides outsourced physician management services in five specialties and witnessed a 16.1% increase in healthcare clients between 2010 and 2011, reports that it has seen the greatest amount of growth in its integrated service lines, such as staffing hospitals with both emergency medical specialists and hospitalists.
“Traditionally there's been a bit of friction between those service lines,” says Todd Zimmerman, EmCare's president. “What it allows us to do is provide more coordinated care.”
Its services, he notes, can improve patient flow and reduce the number of emergency room patients who leave without treatment—both of which can have an impact on revenue as well as patient satisfaction in an age of value-based purchasing and patient-centered medicine.
“The focus on the patient experience is heightened right now,” Zimmerman says.
According to the survey, food service contractors saw the largest percentage increase, 55%, in the number of facilities served. Healthcare providers included in the supplemental data spent a total of $52 million in 2009 on food service contractors, making it the eighth-largest category for expenditures.
“The demand for the services has always been strong,” says Theodore Wahl, president and chief operating officer at Healthcare Services Group, Bensalem, Pa., which specializes in housekeeping, laundry, environmental services, and dining and nutrition.
The publicly traded company grew its healthcare client list 26.8% between 2010 and 2011 to 3,733, according to the survey. Its food services business grew 62%. It also reported in an earnings release that revenue increased 15% to $889 million and net income increased 11% to $38 million.
Wahl attributes the growth to a maturing middle management team that has been able to take on new clients.
Yet he notes that cost pressures have created new opportunities for all outsourcing firms—adding that his company has a diverse list of clients that range from large national chains to small independent hospitals.
Focus on the revenue cycle
A tighter reimbursement environment has also spurred interest in technology that helps providers extract the most money for the care they deliver.
Richard Close, senior research analyst at Avondale Partners who covers healthcare technology, says he's seeing outsourcing growth primarily in revenue-cycle management, particularly as providers seek help in getting paid on managed-care contracts and containing bad debt.
That sector also has been boosted by high-profile account wins and partnerships. In May, Conifer, a subsidiary of for-profit hospital chain Tenet Healthcare Corp., Dallas, announced that it forged a 10-year deal to provide revenue-cycle services to 56 hospitals that are part of Catholic Health Initiatives, Englewood, Colo. As part of the deal, CHI took a minority stake in Conifer.
Revenue-cycle management represents the largest piece of Conifer's business, and also contributed to the company's 41.4% growth in clients between 2010 and 2011, according to Mooney. At the end of last year, it counted 270 national healthcare clients and expects this year's number to be even larger owing to deals such as the one with CHI. “You're seeing an uptick in the level of service,” he says.
But Mooney notes that going forward it expects its capitation management business—which focuses on accountable care organizations and other risk-based payment models—to be an increasingly important part of its bottom line.
“There's a lot of discussion about population management,” Mooney says, adding that some providers are taking baby steps and others are going full-steam ahead toward implementing the new risk-based payment models.
Other contractors similarly expect to see the most growth in areas that relate to healthcare reform, such as setting up ACOs.
“The key is very accurately being able to measure performance,” says Tom Vorpahl, COO at TriMedx, which specializes in healthcare technology management.
The company, which saw a 32% jump in healthcare clients from 2010 to 2011, helps to “bridge the gap between the CIO and COO,” he says. “What we end up doing is becoming chief technology officer to take care of their supply chain.”
Information technology as a whole ranked seventh in terms of the amount of money spent by the 75 hospitals and systems represented in the supplemental data. Those providers spent a total of $63.2 million on information technology services, based on their 2009 tax forms.
Vorpahl notes that TriMedx brings in the tools and infrastructure but still works with the hospital's employees. “Our model is not an outsource model; it's an in-source model,” he says. “They can literally take care of all their (needs) with in-house talent. Our role going forward is more of a consulting role.”
Outsourcing, according to Avondale's Close, generally has been seen as a taboo for healthcare providers. “A lot of these hospitals might be the largest employers in town,” he says. “They're viewed as one of the stable cornerstones of the community. Sometimes there's a negative connotation.”
But financial considerations have made it the new reality. “They need to cut significant costs out of their operations,” Close says.
TAKEAWAY: Noting some providers' reluctance to use outsourcing, vendors are touting partnership roles to help hospitals and health systems cope in tough economic times.
Electronic Medical Records, Health, Medical Oncology, Medicare & Private Insurance, Radiation Oncology