PYA Principal Denise Hall, along with King & Spalding’s Michael Paulhus, co-presented “Big Data: Implications of Data Mining for Employed Physician Compliance Management” at the Health Care Compliance Association’s (HCCA) 19th Annual Compliance Institute.
Big Data: Implications of Data Mining for Employed Physician Compliance Manag...PYA, P.C.
PYA Principal Denise Hall presented “Big Data: Implications of Data Mining for Employed Physician Compliance Management” at Becker’s Annual CEO & CIO Strategy Roundtables, November 18-19, 2015.
The presentation explored:
Data being aggregated by the government, as well as new approaches by regulators.
Public relations and litigation risk from the public dissemination of data by the government.
Big data connections to payment through quality metrics and the potential for new theories of False Claims Act (FCA) suits.
Internal use of broad spectrum analytics in employed physician compliance management.
Determination of risk tolerance and the customization of “outside the box” analytics.
Benchmarking, monitoring, and defining physician-focused risk area reviews.
What do big data and advanced analytics mean for healthcare? This question was answered during the Georgia Society of CPAs (GSCPA) 2015 Healthcare Conference, February 6, at the Cobb Galleria Centre in Atlanta, GA. PYA Principal Marty Brown and PYA Analytics President & CEO Brian Worley presented “Big Data Applications in Healthcare.”
Guarding Your Client's Valuation from Attack--Dos and Don'ts for Requesting, ...PYA, P.C.
During an AHLA webinar series roundtable discussion, “Guarding Your Client’s Valuation from Attack—Dos and Don’ts for Requesting, Reviewing, Using, and Discarding FMV Opinions,” PYA Principal Carol Carden joined other legal experts to explore the practical issues for counsel to consider when balancing the arguments for scrutinizing valuation reports with the arguments for ensuring valuator independence.
The Evolving Role of the Compliance Officer in the Age of Accountable CarePYA, P.C.
Much has been written about new competencies physicians must develop in the face of payment and delivery system reform. But providers are not the only ones seeing their roles change. Compliance officers, who serve as organizations’ internal police officers, will have many new challenges. PYA Principal Martie Ross presented a national Health Care Compliance Association (HCCA) webinar entitled “The Evolving Role of the Compliance Officer In the Age of Accountable Care.”
Exclusive Contracting and Incentivizing Quality in Your Hospitalist ProgramPYA, P.C.
PYA Principal Carol Carden co-presented a session along with Mark Easterly, Vice President of Legal Services for Houston Methodist, on “Exclusive Contracting and Incentivizing Quality in Your Hospitalist Program" at the AHLA Physicians and Hospitals Law Institute.
Healthcare Valuations in an Era of Reform and UncertaintyPYA, P.C.
PYA Principal Jim Lloyd's AICPA Health Care Industry Conference presentation explored reform and current environment highlights, healthcare transactions and affiliations, valuation considerations, and regulatory issues.
Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse...PYA, P.C.
PYA Senior Manager Chris Beckham co-presented “Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny” with Ross Burris of Polsinelli at the American Health Lawyer Association’s (AHLA) Physicians and Hospitals Law Institute, February 8-10, 2016.
Affiliation Strategies for At-Risk Community HospitalsPYA, P.C.
PYA Senior Healthcare Consulting Manager Michael Ramey presented “Affiliation Strategies for At-Risk Community Hospitals” with Jay Hardcastle, partner at Bradley Arant Boult Cummings at the AHLA Health Care Transactions Program. The presentation helped:
1. Identify factors affecting the continued financial viability of community hospitals.
2. Introduce the importance of board/management being proactive in evaluating potential affiliation alternatives before reaching a dire state.
3. Discuss the request-for-proposal process.
4. Explore legal structures to retain the best value for the community via appropriate models (i.e., management agreement, lease, acquisition, joint operating agreement, joint venture, affiliation).
5. Provide lessons learned from recent hospital transactions.
Big Data: Implications of Data Mining for Employed Physician Compliance Manag...PYA, P.C.
PYA Principal Denise Hall presented “Big Data: Implications of Data Mining for Employed Physician Compliance Management” at Becker’s Annual CEO & CIO Strategy Roundtables, November 18-19, 2015.
The presentation explored:
Data being aggregated by the government, as well as new approaches by regulators.
Public relations and litigation risk from the public dissemination of data by the government.
Big data connections to payment through quality metrics and the potential for new theories of False Claims Act (FCA) suits.
Internal use of broad spectrum analytics in employed physician compliance management.
Determination of risk tolerance and the customization of “outside the box” analytics.
Benchmarking, monitoring, and defining physician-focused risk area reviews.
What do big data and advanced analytics mean for healthcare? This question was answered during the Georgia Society of CPAs (GSCPA) 2015 Healthcare Conference, February 6, at the Cobb Galleria Centre in Atlanta, GA. PYA Principal Marty Brown and PYA Analytics President & CEO Brian Worley presented “Big Data Applications in Healthcare.”
Guarding Your Client's Valuation from Attack--Dos and Don'ts for Requesting, ...PYA, P.C.
During an AHLA webinar series roundtable discussion, “Guarding Your Client’s Valuation from Attack—Dos and Don’ts for Requesting, Reviewing, Using, and Discarding FMV Opinions,” PYA Principal Carol Carden joined other legal experts to explore the practical issues for counsel to consider when balancing the arguments for scrutinizing valuation reports with the arguments for ensuring valuator independence.
The Evolving Role of the Compliance Officer in the Age of Accountable CarePYA, P.C.
Much has been written about new competencies physicians must develop in the face of payment and delivery system reform. But providers are not the only ones seeing their roles change. Compliance officers, who serve as organizations’ internal police officers, will have many new challenges. PYA Principal Martie Ross presented a national Health Care Compliance Association (HCCA) webinar entitled “The Evolving Role of the Compliance Officer In the Age of Accountable Care.”
Exclusive Contracting and Incentivizing Quality in Your Hospitalist ProgramPYA, P.C.
PYA Principal Carol Carden co-presented a session along with Mark Easterly, Vice President of Legal Services for Houston Methodist, on “Exclusive Contracting and Incentivizing Quality in Your Hospitalist Program" at the AHLA Physicians and Hospitals Law Institute.
Healthcare Valuations in an Era of Reform and UncertaintyPYA, P.C.
PYA Principal Jim Lloyd's AICPA Health Care Industry Conference presentation explored reform and current environment highlights, healthcare transactions and affiliations, valuation considerations, and regulatory issues.
Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse...PYA, P.C.
PYA Senior Manager Chris Beckham co-presented “Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny” with Ross Burris of Polsinelli at the American Health Lawyer Association’s (AHLA) Physicians and Hospitals Law Institute, February 8-10, 2016.
Affiliation Strategies for At-Risk Community HospitalsPYA, P.C.
PYA Senior Healthcare Consulting Manager Michael Ramey presented “Affiliation Strategies for At-Risk Community Hospitals” with Jay Hardcastle, partner at Bradley Arant Boult Cummings at the AHLA Health Care Transactions Program. The presentation helped:
1. Identify factors affecting the continued financial viability of community hospitals.
2. Introduce the importance of board/management being proactive in evaluating potential affiliation alternatives before reaching a dire state.
3. Discuss the request-for-proposal process.
4. Explore legal structures to retain the best value for the community via appropriate models (i.e., management agreement, lease, acquisition, joint operating agreement, joint venture, affiliation).
5. Provide lessons learned from recent hospital transactions.
Don’t Stumble Coming Out of the Gate –Top Ten Issues to Address When Acquirin...PYA, P.C.
PYA Consulting Principal Carol Carden co-presented with Charlene McGinty of McKenna Long. They examined the top issues to address when acquiring a physician practice and some of the common and more complex issues hospitals face during the acquisition.
ICD-10 Is Really Here: What Does That Mean To Compliance Officers?PYA, P.C.
PYA Principal Denise Hall presented “ICD-10 Is REALLY Here: What Does that Mean to Compliance Officers?” at the THA 2015 Fall Compliance Conference. The presentation helps providers get “in tune” with the latest in ICD-10 compliance:
* A brief discussion of ICD-10 and its impact on healthcare.
* Compliance risks with the transition to the ICD-10 system.
* Mitigation of compliance risk and denial activities during and post-implementation.
* ICD-10’s impact on value-based purchasing and quality-based payment models.
How to Have a Successful Engagement and a Happily Ever After: “New Age” Nuanc...PYA, P.C.
PYA’s Tynan Olechny and Valerie Rock presented “How to Have a Successful Engagement and a Happily Ever After: ‘New Age’ Nuances to Physician Hospital Arrangements” with R. Ross Burris III of Polsinelli at the Health Care Compliance Association’s (HCCA) Regional Annual Conference.
Commercial Reasonableness in Hospital-Physician TransactionsPYA, P.C.
PYA Principals Lyle Oelrich and Darcy Devine presented “Commercial Reasonableness in Hospital-Physician Transactions” to the Health Care Fraud Working Group in Memphis, TN, April 10, 2013.
Presentation Explores Many Contexts of Community BenefitPYA, P.C.
PYA Principal David McMillan gets to the bottom of the definition of community benefit in “Community Benefit: One Term, Many Contexts,” a presentation given at the 2013 AICPA Healthcare Industry Conference.
Sustainable Growth Rate? Goodbye for Good!PYA, P.C.
PYA Staff Consultant Aaron Elias spoke to attendees of the Georgia Healthcare Financial Management Association’s (HFMA) Spring Institute May 6, 2015, on the implications of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Fair Market Value: What Rural Providers Need to Know PYA, P.C.
PYA Principal Tynan Olechny and Senior Manager Annapoorani Bhat provided important information for rural providers related to fair market value and commercial reasonableness considerations during a National Rural Health Association webinar, “Valuations: What Rural Providers Need to Know."
Alliances between AMCs and Community HospitalsPYA, P.C.
PYA Principal Jeff Ellis spoke on alliances between academic medical centers (AMCs) and community hospitals April 16, 2015, at a Greater Kansas City Society of Healthcare Attorneys luncheon meeting.
Big Data: Implications of Data Mining for Employed Physician Compliance Manag...PYA, P.C.
PYA Consulting Manager Kristen Lilly presented “Big Data: Implications of Data Mining for Employed Physician Compliance Management” during a webinar for the Georgia chapter of the Healthcare Financial Management Association (Georgia HFMA), March 31, 2016.
The presentation explored:
Public relations and litigation risk from the public dissemination of data by the government.
Internal use of broad spectrum analytics in employed physician compliance management.
Determination of risk tolerance and the customization of “outside the box” analytics.
Benchmarking, monitoring, and defining physician-focused risk area reviews.
PYA Presents Intro to Healthcare Valuation PYA, P.C.
PYA Principal Jim Lloyd, along with other presenters, provided a “Healthcare Valuation 101” during a pre-conference workshop at the 2013 AICPA Healthcare Industry Conference.
As healthcare is a language “all its own,” PYA Principal David McMillan presented “Learning the New Language of Healthcare" at the Georgia Society of CPAs' 2014 Healthcare Conference.
Forensic and Valuation Issues in HealthcarePYA, P.C.
PYA Principal Carol Carden co-presented “Forensic and Valuation Issues in Healthcare” at the AICPA Forensic & Valuation Services Conference in New Orleans, LA, November 10, 2014.
PYA Highlights Next Steps of Meaningful UsePYA, P.C.
At the 2013 AICPA Healthcare Industry Conference, PYA Principal David McMillan and Senior Manager Chris Wilson recently explored the “new normal” of meaningful use as compliance and strategic standards in new care/reimbursement-model development.
Demystifying Commercial Reasonableness in Physician/Hospital TransactionsPYA, P.C.
PYA Principal Lyle Oelrich presented “Demystifying Commercial Reasonableness in Physician/Hospital Transactions” at the Georgia Society of Certified Public Accountants’ (GSCPA) 2016 Healthcare Conference, February 11, 2016, in Atlanta, Georgia.
Three Key Strategies for Healthcare Financial TransformationHealth Catalyst
To succeed in today’s rapidly evolving business environment, healthcare organizations must have accurate financial data. Approximately 50 percent of CMS payments are now tied to a value component; hospital operating margins are at an all-time low; and consumer demands are rising with their costs. In order to meet these new challenges, health systems must shift their strategy or risk being left behind. This article details the operational, organizational, and financial strategies that drive financial transformation, as well as examples of how to obtain and utilize financial data, find waste reduction opportunities, and much more.
ICD-10 Transition: What Health Lawyers Need to KnowPYA, P.C.
PYA Principal Denise Hall, along with Senior Corporate Counsel Julie Chicoine of Ohio State University Wexner Medical Center, presented “ICD-10 Transition: What Health Lawyers Need to Know” at the AHLA 2015 Institute on Medicare and Medicaid Payment Issues.
PYA Senior Consultant Kathryn Culver presented "Fundamentals of Healthcare Valuation" before the Tennessee Society of Certified Public Accountants (TSCPA). The presentation:
Provided a healthcare valuation overview.
Discussed healthcare valuation approaches.
Covered healthcare valuation considerations and trends.
Don’t Stumble Coming Out of the Gate –Top Ten Issues to Address When Acquirin...PYA, P.C.
PYA Consulting Principal Carol Carden co-presented with Charlene McGinty of McKenna Long. They examined the top issues to address when acquiring a physician practice and some of the common and more complex issues hospitals face during the acquisition.
ICD-10 Is Really Here: What Does That Mean To Compliance Officers?PYA, P.C.
PYA Principal Denise Hall presented “ICD-10 Is REALLY Here: What Does that Mean to Compliance Officers?” at the THA 2015 Fall Compliance Conference. The presentation helps providers get “in tune” with the latest in ICD-10 compliance:
* A brief discussion of ICD-10 and its impact on healthcare.
* Compliance risks with the transition to the ICD-10 system.
* Mitigation of compliance risk and denial activities during and post-implementation.
* ICD-10’s impact on value-based purchasing and quality-based payment models.
How to Have a Successful Engagement and a Happily Ever After: “New Age” Nuanc...PYA, P.C.
PYA’s Tynan Olechny and Valerie Rock presented “How to Have a Successful Engagement and a Happily Ever After: ‘New Age’ Nuances to Physician Hospital Arrangements” with R. Ross Burris III of Polsinelli at the Health Care Compliance Association’s (HCCA) Regional Annual Conference.
Commercial Reasonableness in Hospital-Physician TransactionsPYA, P.C.
PYA Principals Lyle Oelrich and Darcy Devine presented “Commercial Reasonableness in Hospital-Physician Transactions” to the Health Care Fraud Working Group in Memphis, TN, April 10, 2013.
Presentation Explores Many Contexts of Community BenefitPYA, P.C.
PYA Principal David McMillan gets to the bottom of the definition of community benefit in “Community Benefit: One Term, Many Contexts,” a presentation given at the 2013 AICPA Healthcare Industry Conference.
Sustainable Growth Rate? Goodbye for Good!PYA, P.C.
PYA Staff Consultant Aaron Elias spoke to attendees of the Georgia Healthcare Financial Management Association’s (HFMA) Spring Institute May 6, 2015, on the implications of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Fair Market Value: What Rural Providers Need to Know PYA, P.C.
PYA Principal Tynan Olechny and Senior Manager Annapoorani Bhat provided important information for rural providers related to fair market value and commercial reasonableness considerations during a National Rural Health Association webinar, “Valuations: What Rural Providers Need to Know."
Alliances between AMCs and Community HospitalsPYA, P.C.
PYA Principal Jeff Ellis spoke on alliances between academic medical centers (AMCs) and community hospitals April 16, 2015, at a Greater Kansas City Society of Healthcare Attorneys luncheon meeting.
Big Data: Implications of Data Mining for Employed Physician Compliance Manag...PYA, P.C.
PYA Consulting Manager Kristen Lilly presented “Big Data: Implications of Data Mining for Employed Physician Compliance Management” during a webinar for the Georgia chapter of the Healthcare Financial Management Association (Georgia HFMA), March 31, 2016.
The presentation explored:
Public relations and litigation risk from the public dissemination of data by the government.
Internal use of broad spectrum analytics in employed physician compliance management.
Determination of risk tolerance and the customization of “outside the box” analytics.
Benchmarking, monitoring, and defining physician-focused risk area reviews.
PYA Presents Intro to Healthcare Valuation PYA, P.C.
PYA Principal Jim Lloyd, along with other presenters, provided a “Healthcare Valuation 101” during a pre-conference workshop at the 2013 AICPA Healthcare Industry Conference.
As healthcare is a language “all its own,” PYA Principal David McMillan presented “Learning the New Language of Healthcare" at the Georgia Society of CPAs' 2014 Healthcare Conference.
Forensic and Valuation Issues in HealthcarePYA, P.C.
PYA Principal Carol Carden co-presented “Forensic and Valuation Issues in Healthcare” at the AICPA Forensic & Valuation Services Conference in New Orleans, LA, November 10, 2014.
PYA Highlights Next Steps of Meaningful UsePYA, P.C.
At the 2013 AICPA Healthcare Industry Conference, PYA Principal David McMillan and Senior Manager Chris Wilson recently explored the “new normal” of meaningful use as compliance and strategic standards in new care/reimbursement-model development.
Demystifying Commercial Reasonableness in Physician/Hospital TransactionsPYA, P.C.
PYA Principal Lyle Oelrich presented “Demystifying Commercial Reasonableness in Physician/Hospital Transactions” at the Georgia Society of Certified Public Accountants’ (GSCPA) 2016 Healthcare Conference, February 11, 2016, in Atlanta, Georgia.
Three Key Strategies for Healthcare Financial TransformationHealth Catalyst
To succeed in today’s rapidly evolving business environment, healthcare organizations must have accurate financial data. Approximately 50 percent of CMS payments are now tied to a value component; hospital operating margins are at an all-time low; and consumer demands are rising with their costs. In order to meet these new challenges, health systems must shift their strategy or risk being left behind. This article details the operational, organizational, and financial strategies that drive financial transformation, as well as examples of how to obtain and utilize financial data, find waste reduction opportunities, and much more.
ICD-10 Transition: What Health Lawyers Need to KnowPYA, P.C.
PYA Principal Denise Hall, along with Senior Corporate Counsel Julie Chicoine of Ohio State University Wexner Medical Center, presented “ICD-10 Transition: What Health Lawyers Need to Know” at the AHLA 2015 Institute on Medicare and Medicaid Payment Issues.
PYA Senior Consultant Kathryn Culver presented "Fundamentals of Healthcare Valuation" before the Tennessee Society of Certified Public Accountants (TSCPA). The presentation:
Provided a healthcare valuation overview.
Discussed healthcare valuation approaches.
Covered healthcare valuation considerations and trends.
Canada's healthcare claims management market is likely to grow at a CAGR of 23.4% from a market size of $2.13 Bn in 2022 to $11.48 Bn in 2030. The rise in research and development expenditure in healthcare along with the new technological advancements and the increasing trend of automation in healthcare acts as a growth factor for the market. To get a detailed report, contact us at - info@insights10.com
With the patient at the true center of next generation care, it is critical to stay on the cutting edge of what is required for compliance monitoring, particularly for specialty products. With a focus on patient interactions and associated programs, this Helio presentation highlights how the automation of a company's compliance monitoring and implementation of an analytics engine can produce real-time results and identify best practices to be applied to business intelligence for future activities.
Compliance Design in a World of New Models PYA, P.C.
This presentation discusses mitigating compliance risks presented by new payment models, creating a compliance culture through human resources, leveraging new regulations to increase access to care and reduce costs, and how to educate start-ups and nontraditional facilities about integrity principles within compliance programs.
SROA Presentation - Clinical Results of a Medical Error Reduction/Compliance ...edbkline
Clinical results from application of paper-based medical error reduction/compliance program vs software-based MERP program implenented at 30 free-standing radiation oncology centers.
“CARES Act Provider Relief Fund: Opportunities, Compliance, and Reporting”PYA, P.C.
PYA Principal Martie Ross spoke at the virtual North Carolina Healthcare Association Critical Access Hospital Statewide Meeting. The two-day event, “Quality Focus is a Finance Focus,” provided critical access hospital leaders with the opportunity to network and review data-informed strategies as well as updates to the Medicare Flexibility Program Project. It also provided guidance on federal compliance and tracking of Provider Relief Funds.
In “CARES Act Provider Relief Fund: Opportunities, Compliance, and Reporting,” Martie gave an overview of the history of distribution of those funds as well as regulations and guidelines including:
Statutory Language
Reporting Requirements
Use of Funds Calculation
Expenses
Risk Management
Martie presented Thursday, March 4, 2021.
If you would like guidance related to Provider Relief Fund regulations, or for assistance with any matter related to strategy and integration, compliance, or valuation, contact one of our PYA executives at (800) 270-9629.
Short essay" Final "
Chapter 7
• Categories Of Investment Decisions in Health Care:
1- Strategic Decisions
2- Expansion Decisions
3- Replacement Decisions
The Objectives of The Capital Investment Decision المال رأس استثمار قرار أهداف
1- Financial Return
2- Future funding
3- Nonfinancial Benefits
Strengths and weaknesses of Payback method
Strengths: • Simple to calculate • Easy to understand •
Weaknesses: • Answers in years not dollars • Disregards cash flows after payback • Does not account for the time value of money
NPV (net present value)
Internal Rate of Return
Chapter 8
Financing Debt of Financing
• Maturity: • Term Loans- paid off within 10 years
• • Bonds- maturity in 20-35 years
Type of Interest Loan
• Fixed Interest rate debt
• Variable rate demand bonds
• Auction rate securities
• Interest rate swap
• Direct tax-exempt loan bond purchase by a bank Advantages:
• Direct debt purchase is less time consuming and cheaper to issue
• Loan does not require a credit rating by a rating agency
• Loan avoids remarketing
• If a loan qualifies as bank qualified, the bank can deduct 80% of its interest costs which results in lower interest
Chapter 9
FIXED COSTS Costs that stay the same in total over the relevant range but change inversely on a per unit basis as activity changes.
VARIABLE COSTS Costs that stay the same per unit but change directly in total with a change in activity over the relevant range: Total Variable Cost = Variable Cost per Unit x Number of Units of Activity.
Break even formula can be used to:
1) Find Price
2) Find quantity
3) Find Fixed cost
4) Find Variable cost per unit
There are four methods to apply economy of scale principles to affect health care:
1) Scale up volume.
2) Reduce costs.
3) Alter fixed and variable cost structure.
4) Innovate business model.
direct costs: are those that an organization can measure or trace to a particular patient or service (e.g., the time a nurse or nursing assistant spends with a client)
Indirect costs: are those that the organization is not able to associate with a particular patient or service (e.g., the cost of the billing clerk or computer system).
Chapter 10
• What is the purpose of planning?
To identify: • Goals • Objectives • Tasks • Activities • Resources needed
• Name the key budgeting dimensions?
participation
Budget models
Budget detail
Budget forecast
Budget Modifications
• What are the components of budgeting?
Four major components: 1. Strategic Planning 2. Planning 3. Implementation 4. Controlling
• Difference between static and flexible budget
Static Budgets: forecast revenues and expenses for a single level of activity.
Flexible Budgets: forecast revenues and expenses for various levels of activities.
• Difference between participatory and authoritarian approach of budgeting.
Authoritarian Approach Budgeting and decision making done by relatively few people concentrated in the highest level of the organizational structure, (opposite of the participatory approach
The
Short essay" Final "
Chapter 7
• Categories Of Investment Decisions in Health Care:
1- Strategic Decisions
2- Expansion Decisions
3- Replacement Decisions
The Objectives of The Capital Investment Decision المال رأس استثمار قرار أهداف
1- Financial Return
2- Future funding
3- Nonfinancial Benefits
Strengths and weaknesses of Payback method
Strengths: • Simple to calculate • Easy to understand •
Weaknesses: • Answers in years not dollars • Disregards cash flows after payback • Does not account for the time value of money
NPV (net present value)
Internal Rate of Return
Chapter 8
Financing Debt of Financing
• Maturity: • Term Loans- paid off within 10 years
• • Bonds- maturity in 20-35 years
Type of Interest Loan
• Fixed Interest rate debt
• Variable rate demand bonds
• Auction rate securities
• Interest rate swap
• Direct tax-exempt loan bond purchase by a bank Advantages:
• Direct debt purchase is less time consuming and cheaper to issue
• Loan does not require a credit rating by a rating agency
• Loan avoids remarketing
• If a loan qualifies as bank qualified, the bank can deduct 80% of its interest costs which results in lower interest
Chapter 9
FIXED COSTS Costs that stay the same in total over the relevant range but change inversely on a per unit basis as activity changes.
VARIABLE COSTS Costs that stay the same per unit but change directly in total with a change in activity over the relevant range: Total Variable Cost = Variable Cost per Unit x Number of Units of Activity.
Break even formula can be used to:
1) Find Price
2) Find quantity
3) Find Fixed cost
4) Find Variable cost per unit
There are four methods to apply economy of scale principles to affect health care:
1) Scale up volume.
2) Reduce costs.
3) Alter fixed and variable cost structure.
4) Innovate business model.
direct costs: are those that an organization can measure or trace to a particular patient or service (e.g., the time a nurse or nursing assistant spends with a client)
Indirect costs: are those that the organization is not able to associate with a particular patient or service (e.g., the cost of the billing clerk or computer system).
Chapter 10
• What is the purpose of planning?
To identify: • Goals • Objectives • Tasks • Activities • Resources needed
• Name the key budgeting dimensions?
participation
Budget models
Budget detail
Budget forecast
Budget Modifications
• What are the components of budgeting?
Four major components: 1. Strategic Planning 2. Planning 3. Implementation 4. Controlling
• Difference between static and flexible budget
Static Budgets: forecast revenues and expenses for a single level of activity.
Flexible Budgets: forecast revenues and expenses for various levels of activities.
• Difference between participatory and authoritarian approach of budgeting.
Authoritarian Approach Budgeting and decision making done by relatively few people concentrated in the highest level of the organizational structure, (opposite of the participatory approach
The
Short essay" Final "
Chapter 7
• Categories Of Investment Decisions in Health Care:
1- Strategic Decisions
2- Expansion Decisions
3- Replacement Decisions
The Objectives of The Capital Investment Decision المال رأس استثمار قرار أهداف
1- Financial Return
2- Future funding
3- Nonfinancial Benefits
Strengths and weaknesses of Payback method
Strengths: • Simple to calculate • Easy to understand •
Weaknesses: • Answers in years not dollars • Disregards cash flows after payback • Does not account for the time value of money
NPV (net present value)
Internal Rate of Return
Chapter 8
Financing Debt of Financing
• Maturity: • Term Loans- paid off within 10 years
• • Bonds- maturity in 20-35 years
Type of Interest Loan
• Fixed Interest rate debt
• Variable rate demand bonds
• Auction rate securities
• Interest rate swap
• Direct tax-exempt loan bond purchase by a bank Advantages:
• Direct debt purchase is less time consuming and cheaper to issue
• Loan does not require a credit rating by a rating agency
• Loan avoids remarketing
• If a loan qualifies as bank qualified, the bank can deduct 80% of its interest costs which results in lower interest
Chapter 9
FIXED COSTS Costs that stay the same in total over the relevant range but change inversely on a per unit basis as activity changes.
VARIABLE COSTS Costs that stay the same per unit but change directly in total with a change in activity over the relevant range: Total Variable Cost = Variable Cost per Unit x Number of Units of Activity.
Break even formula can be used to:
1) Find Price
2) Find quantity
3) Find Fixed cost
4) Find Variable cost per unit
There are four methods to apply economy of scale principles to affect health care:
1) Scale up volume.
2) Reduce costs.
3) Alter fixed and variable cost structure.
4) Innovate business model.
direct costs: are those that an organization can measure or trace to a particular patient or service (e.g., the time a nurse or nursing assistant spends with a client)
Indirect costs: are those that the organization is not able to associate with a particular patient or service (e.g., the cost of the billing clerk or computer system).
Chapter 10
• What is the purpose of planning?
To identify: • Goals • Objectives • Tasks • Activities • Resources needed
• Name the key budgeting dimensions?
participation
Budget models
Budget detail
Budget forecast
Budget Modifications
• What are the components of budgeting?
Four major components: 1. Strategic Planning 2. Planning 3. Implementation 4. Controlling
• Difference between static and flexible budget
Static Budgets: forecast revenues and expenses for a single level of activity.
Flexible Budgets: forecast revenues and expenses for various levels of activities.
• Difference between participatory and authoritarian approach of budgeting.
Authoritarian Approach Budgeting and decision making done by relatively few people concentrated in the highest level of the organizational structure, (opposite of the participatory approach
The
• Categories Of Investment Decisions in Health Care:
1- Strategic Decisions
2- Expansion Decisions
3- Replacement Decisions
The Objectives of The Capital Investment Decision أهداف قرار استثمار رأس المال
1- Financial Return
2- Future funding
3- Nonfinancial Benefits
Strengths and weaknesses of Payback method
Strengths: • Simple to calculate • Easy to understand •
Weaknesses: • Answers in years not dollars • Disregards cash flows after pay
• Categories Of Investment Decisions in Health Care:
1- Strategic Decisions
2- Expansion Decisions
3- Replacement Decisions
The Objectives of The Capital Investment Decision أهداف قرار استثمار رأس المال
1- Financial Return
2- Future funding
3- Nonfinancial Benefits
Strengths and weaknesses of Payback method
Strengths: • Simple to calculate • Easy to understand •
Weaknesses: • Answers in years not dollars • Disregards cash flows after pay
• Categories Of Investment Decisions in Health Care:
1- Strategic Decisions
2- Expansion Decisions
3- Replacement Decisions
The Objectives of The Capital Investment Decision أهداف قرار استثمار رأس المال
1- Financial Return
2- Future funding
3- Nonfinancial Benefits
Strengths and weaknesses of Payback method
Strengths: • Simple to calculate • Easy to understand •
Weaknesses: • Answers in years not dollars • Disregards cash flows after pay
• Categories Of Investment Decisions in Health Care:
1- Strategic Decisions
2- Expansion Decisions
3- Replacement Decisions
The Objectives of The Capital Investment Decision أهداف قرار استثمار رأس المال
1- Financial Return
2- Future funding
3- Nonfinancial Benefits
Strengths and weaknesses of Payback method
Strengths: • Simple to calculate • Easy to understand •
Weaknesses: • Answers in years not dollars • Disregards cash flows after pay
• Categories Of Investment Decisions in Health Care:
1- Strategic Decisions
2- Expansion Decisions
3- Replacement Decisions
The Objectives of The Capital Investment Decision أهداف قرار استثمار رأس المال
1- Financial Return
2- Future funding
3- Nonfinancial Benefits
Strengths and weaknesses of Payback method
Strengths: • Simple to calculate • Easy to understand •
Weaknesses: • Answers in years not dollars • Disregards cash flows after pay
• Categories Of Investment Decisions in Health Care:
1- Strategic Decisions
2- Expansion Decisions
3- Replacement Decisions
The Objectives of The Capital Investment Decision أهداف قرار استثمار رأس المال
1- Financial Return
2- Future funding
3- Nonfinancial Benefits
Strengths and weaknesses of Payback method
Strengths: • Simple to calculate • Easy to understand •
Weaknesses: • Answers in years not dollars • Disregards cash flows after pay
• Categories Of Investment Decisions in Health Care:
1- Strategic Decisions
2- Expansion Decisions
3- Replacement Decisions
The Objectives of The Capital Investment Decision أهداف قرار استثمار رأس المال
1- Financial Return
2- Future funding
3- Nonfinancial Benefits
Strengths and weaknesses of Payback method
Strengths: • Simple to calculate • Easy
Lowering Costs
o Patient Protection and Affordable Care Act (ACA) o CMS trying to control rising costs
o Value Based Purchasing (VBP)
• Goals of the Health Care System o Access
o Cost
o Quality
• Changing Methods Of Health Care Financing and Delivery
o Requirement that almost all individuals have insurance coverage.
o Requirement that states create insurance exchanges.
o Provisions for expansion of Medicaid (is a social health care program for families and individuals with low income and
resources).
o Provisions for medical loss ratio and premium rate reviews. o Bundled payments and VBP.
o Accountable Care Organizations.
• List any four factors contributing to decrease the cost of healthcare? o Value-based purchasing (VBP)
o Management of physician preferences in medical devices
o Generic drugs coming onto the market
o Lean/six sigma initiatives 5-Informed consumers responsible for more of the cost of care o Workplace wellness and employer programs
o More robust use of health IT to manage populations and prevent medical errors
• Factors Contributing to Increases in Costs of Care? o Emerging medical technology.
o chronic diseases.
o Aging population.
o professional liability and malpractice costs.
o Influx of participants into the market due to extended coverage and insurance mandate
❖ Easy question:
• Statements used in Not-for-Profit Health Care Entities OR list the financial Statements used in Not-for-Profit Health Care Entities
o Balance sheet
o Statement of Operations
o Statement of Changes in Net Assets o Statement of Cash Flows
• Current assets may include :
o cash, investments, limited or restricted as to use current position, patient accounts receivable, estimated
receivables from 3
• Non-current assets may include:
o self insurance, benefit plans, capital equipment (includes long-lasting goods acquired and owned by a company or
organization that are not consumed in the normal course of business—goods such as machinery, trucks, large computers, and office furniture), held by the board under bond indenture agreements, property and equipment, goodwill, net of accumulated amortization.
• Current Liabilities could include:
o accounts payable, accrued expenses (expenses are recognized when incurred), salaries & wages, estimated
payables to third parties, short term borrowings, commercial paper
• Noncurrent Liabilities could include:
o long term debt, self-insurance reserves, accrued pension and retiree health costs
• Operating Activities
o Inflows : Receipts from customers • Cash dividends received • Interest from borrowers • Other
o Outflows :Salaries and wages • Payments to suppliers • Taxes and fines • Interest paid to lenders • Other
• Investing Activities
o Inflows: • Selling long-term productive assets • Selling equity investments • Collecting principal on loans • Other o Outflows :• Purchasing long-term productive assets • Purchasing equity investments • Purchasing debt
investments • Other
• Financing Activities
o Inflows: • Issuing
Similar to Big Data: Implications of Data Mining for Employed Physician Compliance Management (20)
PYA Presented on 2021 E/M Changes and a CARES Act Update During GHA Complianc...PYA, P.C.
The Georgia Hospital Association (GHA) Compliance Officers Roundtable, an active GHA group that meets quarterly and includes educational sessions featuring government representatives, industry experts, and other thought leaders speaking about compliance-related issues, conducted their latest meeting virtually. PYA Principals Lori Foley, Tynan Kugler, and Valerie Rock were among the presenters at this quarter’s event. In their session, they:
Described key elements associated with 2021 E/M changes, and strategies for preparation and implementation.
Explained the impact of 2021 E/M changes on physician compensation and contracting, including potential mitigation approaches.
Presented key components of Stark Law and Anti-Kickback Statute final rules.
Provided an update on the CARES Act.
The Compliance Certification Board offered CEUs for this event, which took place on Friday, December 4, 2020.
Webinar: “Trick or Treat? October 22nd Revisions to Provider Relief Fund Repo...PYA, P.C.
On October 22nd, the Department of Health and Human Services released revised Provider Relief Fund (PRF) reporting requirements. Under HHS’ September 19 directive, “lost revenue” was defined narrowly as a negative change in year-over-year patient care operating net income. Now, HHS will permit providers to use PRF funds to cover the difference between their 2019 and 2020 actual patient care revenue with some adjustments for COVID-related expenses. The October 22nd notice is available here.
PYA Principals Martie Ross and Michael Ramey hosted a complimentary 30-minute webinar, “Trick or Treat? October 22nd Revisions to Provider Relief Fund Reporting Requirements” on Thursday, October 29th.
“Regulatory Compliance Enforcement Update: Getting Results from the Guidance” PYA, P.C.
PYA Principal and Chief Compliance Officer Shannon Sumner and Consulting Senior Manager Susan Thomas presented “Regulatory Compliance Enforcement Update: Getting Results from the Guidance” at the virtual 2020 Montana Healthcare Conference. They reviewed the sources of regulatory enforcement and investigation information—guidelines, statutory updates, best practices, settlements, case studies, etc.—available to healthcare organizations. They will also discuss how to interpret and implement the guidance in order to strengthen the compliance function and protect the organization. The presentation covered:
Compliance regulatory requirements for healthcare organizations.
Guidance available for consideration in organizational compliance programs.
Internal and external reporting to ensure regulatory requirements are met.
Best practices for implementation of guidance.
Case studies for illustration of guidance implementation.
“Federal Legislative and Regulatory Update,” Webinar at DFWHCPYA, P.C.
The Dallas Fort Worth Hospital Council (DFWHC) and PYA co-hosted an exclusive complimentary webinar, “Federal Legislative and Regulatory Update,” on Wednesday, September 23.
DFWHC President/CEO Stephen Love hosted a discussion with PYA Senior Manager Kathy Reep about concerns that have dropped from the radar during the last four months of COVID-19, addressing issues for which hospitals must prepare in approaching 2021. This session focused on these key areas:
Appropriate use criteria
Transparency
Site neutral payments
The future of the Medicare Trust Fund
The federal budget
Key provisions of the final rule for the inpatient prospective payment system for FY2021 and the proposed outpatient rule for CY2021
On-Demand Webinar: Compliance With New Provider Relief Funds Reporting Requir...PYA, P.C.
On September 19, the Department of Health and Human Services (HHS) published its Post-Payment Notice of Reporting Requirements. The Notice details the reporting requirements for all Provider Relief Fund (PRF) recipients that have received $10,000 or more in aggregate payments.
Under the PRF Terms and Conditions, a recipient may use the funds only for healthcare-related expenses and lost revenue attributable to coronavirus. The Notice provides the clearest direction to date regarding permissible uses of PRF funds.
PYA offered a 45-minute complimentary webinar that explained the new reporting requirements and delved into permissible uses. While many questions remain, we provided practical advice on the next steps in the reporting process.
The webinar took place Monday, October 5 at 11 a.m. EDT.
Webinar: “While You Were Sleeping…Proposed Rule Positioned to Significantly I...PYA, P.C.
You likely know from the headlines that the 2021 Medicare Physician Fee Schedule (MPFS) Proposed Rule slashes payments for surgical specialists. But the impact of the Proposed Rule is far broader, reflecting a fundamental realignment driven by the transition to value-based payments. In our webinar, “While You Were Sleeping…Proposed Rule Positioned to Significantly Impact Physician Compensation,” PYA experts addressed these proposals, helping you understand and prepare for the changes ahead.
Following this presentation, attendees were able to:
Understand how a handful of wRVU changes would alter Medicare reimbursement for nearly all physicians.
Appreciate the operational impact of these changes.
Recognize the challenges to existing physician compensation models.
Identify strategies and tactics to prepare for and manage these impacts.
Presenters include PYA Principals Angie Caldwell, Martie Ross, and Valerie Rock. The webinar took place Thursday, September 10 and was hosted in conjunction with the Florida Hospital Association.
If you have additional questions about the MPFS Proposed Rule and its impact on physician compensation or need assistance with any matter involving physician compensation, valuation, strategy and integration, or compliance, contact a PYA executive below at (800) 270-9629.
Webinar: “Cybersecurity During COVID-19: A Look Behind the ScenesPYA, P.C.
Cybersecurity breaches have been in the news almost daily for some time now. COVID-19 has amplified the problem, as “bad actors” seize upon the opportunity to take advantage of hospitals at their most vulnerable time. Given this climate and an aging HIPAA rule, it is difficult to anticipate and prepare for the future.
PYA Principal Barry Mathis presented “Cybersecurity During COVID-19: A Look Behind the Scenes,” on Wednesday, August 12, 2020. This one-hour, complimentary webinar was hosted by PYA in conjunction with the Montana Hospital Association as Part 2 of the Frontier States Town Hall Meeting.
Barry covered information related to HIPAA, cybersecurity, and a special behind-the-scenes view into the tradecraft of bad actors. This unique presentation included:
Recent enforcement trends by the Office for Civil Rights.
The current environment for ransomware.
An opportunity to watch as Barry logs onto the Dark Web and shows you first-hand how bad actors operate.
Ideas for managing cybersecurity threats.
On Friday, August 21, 2020, a webinar co-hosted by PYA prepared hospitals for a new rule taking effect on January 1, 2021, to address price transparency in healthcare. The Centers for Medicare & Medicaid Services published a rule in November 2019 requiring hospitals to establish, update, and make public a list of their standard charges for items and services they provide. In addition to the current requirement to post standard charges on their websites, the Final Rule requires hospitals to publish online, in a machine-readable format, their payer-specific negotiated rates for 300 “shoppable” services and their standard charges for all items and services provided, defined as the gross charge, payer-specific negotiated charges, discounted cash price, and the de-identified minimum and maximum charges.
As we approach January 2021, it is vital that hospitals understand the requirements of the pricing transparency rule and options for compliance. It is unlikely that this rule will “go away”–court decisions are always subject to appeal, and there is even concern that Congress is considering action that would transform these requirements from regulation to legislation.
During the complimentary webinar, PYA Senior Manager Kathy Reep discussed hospital requirements related to pricing transparency, and Chris Kenny, Partner in the Washington, D.C., office of King & Spalding, addressed concerns related to compliance and the legal challenges associated with the final transparency rule.
This webinar was presented in conjunction with:
Dallas-Fort Worth Hospital Council
Florida Hospital Association
Georgia Hospital Association
Kansas Hospital Association
Louisiana Hospital Association
Montana Hospital Association
Not a surprise to most — healthcare is making headlines on an international level. Though not front and center, still of importance to the hospital community are issues working their way through government agencies and the legislature.
As one of the keynote speakers of this year’s virtual Florida Institute of CPAs Health Care Industry Conference, PYA Senior Manager Kathy Reep presented a “Federal Legislative and Regulatory Update.” She covered a number of current issues affecting healthcare providers, including:
Price transparency.
Congressional action on surprise billing.
The Administration’s budget for 2021.
Medicare proposed rules related to hospital inpatient payments and post-acute care for FY2021.
The virtual event took place June 23-24, 2020.
Webinar: Post-Pandemic Provider Realignment — Navigating An Uncertain MarketPYA, P.C.
The COVID-19 pandemic will materially affect U.S. provider industry structure, as financial weaknesses are exposed, risk tolerances are tested, and uncertainties persist. As a result, provider mergers-and-acquisitions (M&A) activities across industry sectors will likely spike in the short- to medium-term future. Providers of all types need to be aware of, and prepared for, the changes they will face.
In this 45-minute joint webinar, PYA Principal Brian Fuller and Juniper Advisory Managing Director Jordan Shields provided a real-time assessment of the COVID-19 pandemic, as well as shared predictions for what the extending crisis means in coming years for M&A activity in the provider space.
The webinar took place Thursday, August 6, 2020, at 11 a.m. EDT.
Since March, PYA experts have closely tracked and carefully evaluated the pandemic’s impact on employed physician compensation. During this complimentary one-hour webinar, PYA Principals Angie Caldwell and Martie Ross highlighted five immediate considerations for hospitals and health systems to manage the storm. They also explored five longer-term considerations impacting future planning.
This webinar took place Friday, July 24, 2020, at 11 a.m. EDT, and was held in conjunction with:
Dallas-Fort Worth Hospital Council
Florida Hospital Association
Kansas Hospital Association
Montana Hospital Association
The COVID-19 pandemic has exposed organizational and industry weaknesses. To build a more resilient delivery system, leaders now must engage their governing boards in re-calibrating strategic plans, re-evaluating investments, and re-imagining hospitals’ and health systems’ roles in their communities.
In this 45-minute webinar, PYA Principals Martie Ross and Brian Fuller provided a framework for these critical discussions including root-cause analysis, market assessment, new realities, guiding principles, and strategic and operational priorities.
This webinar originally took place on Wednesday, June 24, 2020.
Webinar: Free Money with Strings Attached – Cares Act Considerations for Fron...PYA, P.C.
PYA, in conjunction with the Montana Hospital Association, recently co-hosted a Frontier States Town Hall Meeting webinar, “Free Money With Strings Attached: CARES Act Considerations for Frontier States’ Healthcare Provider Organizations.” Principals Lori Foley, Martie Ross, and David McMillan introduced the CARES Act Provider Relief Fund including distribution formulas, the attestation process, the verification and application process, and ongoing recordkeeping requirement. They also answered attendees’ numerous questions regarding these matters.
Webinar: “Got a Payroll? Don’t Leave Money on the Table”PYA, P.C.
Under the CARES Act, every employer with a payroll has an opportunity to retain cash–whether they have a PPP loan or not. What employers need to know right now.
The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) along with the Payroll Protection Program (PPP) offer all business owners relief, but the details can be confusing or overlooked.
Perhaps you don’t fully understand how the deferral of the employer’s share of Social Security taxes works. Maybe you wonder if the deferral even applies to you—good news, it does if you have a payroll!
Failure to fully understand your options could cost you money, at a time when “cash is king.”
As part of PYA’s ongoing commitment to sharing helpful guidance, Tax Principals Debbie Ernsberger and Mark Brumbelow outlined issues and opportunities within the CARES Act, and answered questions during a one-hour webinar that originally aired on Wednesday, May 20, 2020.
Webinar: So You Have a PPP Loan. Now What?PYA, P.C.
The CARES Act provides relief to small businesses through Paycheck Protection Program (PPP) loans, but receiving the loan is only the first part of the equation. PYA discussed what businesses need to know and do next.
Failure to fully understand the requirements for PPP loan forgiveness could cost employers money, at a time when every penny counts. Employers need to stay up-to-date on recent activities regarding the PPP loan forgiveness application, necessary documentation, and other best practices to ensure they are well-prepared for the next steps under the PPP.
As part of PYA’s ongoing commitment to sharing helpful guidance, Tax Principals Debbie Ernsberger and Mark Brumbelow outlined PPP loan forgiveness requirements and answered questions during a one-hour webinar on Wednesday, June 3, 2020.
Webinar: “Making It Work—Physician Compensation During the COVID-19 Pandemic”PYA, P.C.
What to do with your physician compensation plan in the face of the COVID-19 pandemic? It’s a question that leaves administrators searching for answers.
PYA Principal Angie Caldwell and Senior Manager Katie Culver introduced several key considerations for provider compensation during and after the COVID-19 pandemic. In PYA’s complimentary webinar, they:
Summarized the current environment impacting physician compensation associated with the pandemic.
Provided an overview of the Stark Blanket Waivers and opportunities created for physician compensation.
Described restoration and recovery strategies for physician resources.
PYA hosted this one-hour webinar Tuesday, April 28, 2020, at 11 a.m. EDT in conjunction with the Florida Hospital Association.
Webinar: “Provider Relief Fund Payments – What We Know, What We Don’t Know, W...PYA, P.C.
The federal government is now making CARES Act Relief Fund payments to Medicare providers. These payments are not loans—they do not have to be repaid or forgiven. However, this money comes with strings attached.
During PYA’s 30-minute webinar, Provider Relief Fund Payments—What We Know, What We Don’t Know, What To Do Now, PYA Principals Martie Ross and Lori Foley discussed:
The source of the funds.
The required attestation process.
Compliance, tax, and audit concerns.
The webinar took place Friday April 17, 2020.
Webinar: “Hospitals, Capital, and Cashflow Under COVID-19”PYA, P.C.
Hospitals and providers need to think creatively, strategically, and long-term about capital and cashflow under the pressures of the COVID-19 pandemic. A one-hour webinar hosted by PYA discussed the current state of capital markets for non-profit healthcare systems, and considerations for capital management, including the role of real estate assets.
PYA Principal Michael Ramey joined Realty Trust Group Senior Vice-President Michael Honeycutt and Ponder & Company Managing Director Jeffrey B. Sahrbeck to present “Hospitals, Capital, and Cashflow, Under COVID-19” In this webinar, they covered:
Hospital industry capital market updates and trends, including how the capital markets are responding to the crisis.
Access to capital under recent regulations.
Cash preservation techniques for hospitals considering real estate operations and assets.
The webinar took place Thursday, April 9, 2020, at 11 a.m. EDT.
PYA Webinar: “Additional Expansion of Medicare Telehealth Coverage During COV...PYA, P.C.
Late on March 30, CMS released an interim rule which, among other things, significantly expands Medicare telehealth coverage, even beyond the initial Section 1135 waivers. PYA’s complimentary one-hour webinar explained these changes and how they make telehealth an even more attractive option in response to the COVID-19 pandemic.
PYA Principals Martie Ross and Valerie Rock addressed the latest developments, including:
New reimbursement for telephone-only services.
Broader coverage for remote patient monitoring.
New payments for rural health clinics and federally qualified health centers.
Use of telehealth to meet supervision requirements.
New rules regarding coding and billing as well as the changed payment rates for telehealth services.
The webinar took place Friday April 3, 2020, at 11 a.m. EDT.
Webinar: “Getting Online with Telehealth: Practical Guidance for Physician Pr...PYA, P.C.
Medicare’s decision to reimburse for telehealth services, concerns for patient and staff safety, and the loss of revenue from canceled elective procedures are leading many physician practices to consider providing or expanding telehealth services.
During this webinar, PYA’s panel of heavy-hitting experts provided guidance physician practices can use to rollout, or further tap into, the telehealth opportunity. The presenters discussed:
Technology options and speed-to-implementation.
Solutions to internal process challenges.
Patient engagement in telehealth.
PYA hosted this one-hour webinar Thursday, March 26, 2020, at 4 p.m. EDT.
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Dr. David Greene, founder and CEO of R3 Stem Cell, is at the forefront of groundbreaking research in the field of cardiology, focusing on the transformative potential of stem cell therapy. His latest work emphasizes innovative approaches to treating heart disease, aiming to repair damaged heart tissue and improve heart function through the use of advanced stem cell techniques. This research promises not only to enhance the quality of life for patients with chronic heart conditions but also to pave the way for new, more effective treatments. Dr. Greene's work is notable for its focus on safety, efficacy, and the potential to significantly reduce the need for invasive surgeries and long-term medication, positioning stem cell therapy as a key player in the future of cardiac care.
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Big Data: Implications of Data Mining for Employed Physician Compliance Management
1. Page 0
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Big Data: Implications of Data
Mining for Employed Physician
Compliance Management
HCCA’s 19th Annual Compliance Institute
April 22, 2015
2. Page 1
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Big Data
“Big-data initiatives have the potential to transform
healthcare, as they have revolutionized other
industries. In addition to reducing costs, they could
save millions of lives and improve patient outcomes.
Healthcare stakeholders that take the lead in investing
in innovative data capabilities and promoting data
transparency will not only gain a competitive
advantage, but will lead the industry to a new
era.”(McKinsey)
3. Page 2
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Agenda
• Public relations and litigation risk from the public
dissemination of data being harvested and aggregated by
the government (e.g. Physician payment data, Sunshine Act
regulations, discharge data)
• Internal use of Broad Spectrum Analytics in Employed
Physician Compliance Management
• Determination of Risk Tolerance and Customizing Analytics
that are “Outside the Box”
• Benchmarking, Monitoring, and Defining Physician/Focused
Risk Area Reviews
4. Page 3
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Big Data Trends
• Trends in the use and public dissemination of
healthcare financial, claims, and quality data
– Publicly available & Third-party data
• Federal Charge Data
• State-Level Charge Data
• Physician and Other Supplier Public Use File
• Broad Disclosure of Physician Payment Information under
Sunshine Act
• Public Use Files of Part C and D Reporting Requirements
Data
• Other Public or For Purchase Data Sources
5. Page 4
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Federal Charge Data
• CMS has released hospital-specific data from
2011 comparing the charges for the 100 most
common inpatient services and 30 common
outpatient services
• Inpatient DRG examples:
– Heart Failure & Shock w cc
– G.I. Obstruction w cc
– Transient Ischemia
4
6. Page 5
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Federal Charge Data (cont’d)
• Outpatient examples:
– Level III Endoscopy Upper Airway
– Level I Nerve Injections
– Level 1 Hospital Clinic Visits
See http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/Medicare-Provider-Charge-Data/index.html
5
7. Page 6
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
• Numerous states also provide
state-level charge data
• The information and format varies
• Examples:
– Wisconsin, X Facility,
Cesarean Delivery: $12,881
– Tennessee, All Facilities, Rotator Cuff Repair,
Average Charge without another procedure: $23,483
– Oregon, X Facility, Esophagitis, gastroent & misc digest
disorders w/o MCC, Average Charge: $8,546
State-Level Charge Data
6
8. Page 7
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Physician and Other
Supplier Public Use File
• Physician and Other Supplier Public Use File
released for the first time in April 2014
• Contains 100% of final-action
physician/supplier Part B non-institutional line
items for the Medicare fee-for-service
population for CY2012 paid through June 30,
2013
7
9. Page 8
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Physician and Other
Supplier Public Use File (cont’d)
• Contains information on services and
procedures provided to Medicare
beneficiaries by physicians and other
healthcare professionals, including:
– Utilization
– Submitted charges
– Payment (allowed amount and Medicare
payment)
See http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html
8
10. Page 9
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Broad Disclosure of Physician
Payment Info under Sunshine Act
• Manufacturers of drugs, devices, biologicals, and medical
supplies, and some group purchasing organizations (GPOs),
must report payments and other transfers of value to
“covered recipients” which are defined as:
– Teaching hospitals
– Physicians (except physicians who are employees of the applicable
manufacturer)
• CMS must make information submitted
in transparency reports and physician
ownership reports publicly available
on a searchable website
9
11. Page 10
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Public Use Files of Part C and D
Reporting Requirements Data
• Federal regulations require Medicare Advantage (MA) plans
and Part D sponsors to report to CMS information on (among
other things):
– Enrollment and Disenrollment (Part C and Part D)
– Grievances (Part C and Part D)
– Special Needs Plans Care Management (Part C)
– Organization Determinations/Reconsiderations (Part C)
– Coverage Determinations and Exceptions (Part D)
– Long-Term Care Utilization (Part D)
– Medication Therapy Management Programs (Part D)
– Redeterminations (Part D)
10
12. Page 11
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Big Data Trends
• Other Government Data Sources
– Medicare Fraud Strike Force Team
– Data-Driven Quality Initiatives
– Other Non-Public Government Data Sources
• Government Uses of Data for Compliance
and Enforcement
13. Page 12
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
What Providers and
Payers Can Expect
• Scenario 1: Increased Media Exposure
• Scenario 2: Linking Manufacturer Payments
Data to Anti-Kickback Allegations
• Scenario 3: Quality of Care FCA Litigation
14. Page 13
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Scenario 1:
Increased Media Exposure
See http://time.com/#198/bitter-pill-why-medical-bills-are-killing-us/
13
15. Page 14
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Scenario 2: Linking Manufacturer
Payments Data to AK Allegations
• Expect qui tam relators to
attempt to bolster complaints
by “linking” physician payments
to “increased” drug or device
utilization in order to allege
an Anti-Kickback Statute (AKS)
violation
14
16. Page 15
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
FRCP 9(b) & Big Data
• Interplay of Rule 9(b) Motions to Dismiss
and Big Data
Scenario 2: Linking Manufacturer
Payments Data to AK Allegations
15
17. Page 16
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Scenario 2: Linking Manufacturer
Payments Data to AK Allegations
Rule 9(b) Relator’s Counsel “In Their Own Words”
“Sunshine data instantly provides qui tam attorneys a
host of information that would have been impossible
or very difficult to find before the Act. [One relator’s
counsel] believes the information would, right off the
bat, add credibility to a relator's allegations. Attorneys
will be able to corroborate their client's allegations or
confirm suspicions of widespread conduct by running
a simply search.”
16
18. Page 17
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Scenario 2: Linking Manufacturer
Payments Data to AK Allegations
“At the very least, Sunshine data will provide facts to
beef up a plaintiff's complaint. Rule 9(b) of the Federal
Rules of Civil Procedure requires that for ‘alleging
fraud or mistake, a party must state with particularity
the circumstances constituting fraud or mistake.’ [One
relator’s counsel] notes that the exact dates of
transactions and the precise amounts of payments will
add that required specificity.”
See http://www.policymed.com/2014/02/physician-payment-sunshine-act-will-sunshine-data-
help-qui-tam-whistleblowers-and-their-attorneys.html
17
19. Page 18
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Scenario 3: Quality of
Care FCA Litigation
Linked To Data
• Expect qui tam relators and/or government to
contend payment structures and reporting
measures set forth in various new quality
programs materially affect payment and are
thereby conditions of payment—and that
violations triggers False Claims Act (FCA)
liability
18
20. Page 19
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Scenario 3: Quality of
Care FCA Litigation
Data-Driven Quality Initiatives
• Programs resulting from the Patient Protection and
Affordable Care Act (PPACA), the American Recovery and
Reinvestment Act (ARRA) as well as those initiated by OIG
and CMS reflect an increased focus on quality
• Health Information Technology for Economic and Clinical
Health (HITECH) Act established the Electronic Health
Record (EHR) Meaningful Use Program to provide financial
incentives to providers to promote the adoption and
meaningful use of certified EHR technology to improve
patient care (ARRA, Public Law 111-5, Division A, Title XIII
and Division B, Title IV)
19
21. Page 20
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Scenario 3: Quality of
Care FCA Litigation
Data-Driven Quality Initiatives (cont’d)
• PPACA establishes numerous quality-related programs,
potentially exposing providers to increased liability for quality
shortfalls; these include, among others:
– Medicare Physician Quality Reporting Improvements: financial
incentives and penalties for reporting or failure to report Physician
Quality Reporting Initiative (PQRI) measures (PPACA §§ 3002,
3007)
– Value-Based Purchasing Program: pays hospitals based upon how
well they perform on specific quality measures (Id. § 3007)
20
22. Page 21
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Potential Review Results
PQRS/QUALITY REPORTING DETAILED RESULTS
PQRS Results Family Practice Internal Medicine
Other
Specialties
Met 757 247 103
Not Met 545 145 68
PQRS code and/or ICD-9 code not documented 144 56 50
Supporting ICD-9 or additional PQRS code should be reported 99 26 6
A different PQRS code was documented 107 29 7
No documentation received 0 2 4
Corresponding CPT code not supported 195 32 1
Modifier deficiency1 6 0 0
1 Of note, Not Met is counted per transaction or claim line versus the deficiencies listed which include transaction-level
and component-level errors. Modifier deficiency is a component-level error; meaning that the error count in some
instances may also be captured in one of the other categories.
23. Page 22
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Real World Examples of
Physician Compliance Risk
1. Overuse of -25 modifier
2. Overuse/exclusive use of high level E/M
codes
3. Extremely high levels of production
4. Psychiatry time-based codes and use of E/M
codes with same
5. High utilization of specialty-related services
(Oncology, Cardiac)
24. Page 23
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
How Can We Mitigate Risk?
Think like a reporter, a qui tam relator, a MAC,
MIC, ZPIC, RAC, DOJ, and the OIG, etc.
25. Page 24
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Key Questions
• Are you incorporating data sets in your compliance
and internal audit activities?
• Is data analytics a key part of your monitoring and
auditing plan?
• Are you assessing data analytics capabilities (or lack
thereof) as part of your annual risk assessment?
• Are you evaluating where you are amongst your
peers?
• If you are an outlier, is there a legitimate reason why,
or do you need to mitigate an issue through corrective
action?
26. Page 25
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Resources to Identify Most
Significant Areas of Potential Risk
• OIG Work Plan
• OIG Semi-Annual Report to Congress
• OIG Special Fraud Alerts
• OIG and DOJ Announcements
• Corporate Integrity and Deferred Prosecution Agreements
• RAC Audits
• RADV Audits
• Complaints, Investigations, and Audits
• . . . Your Gut!
27. Page 26
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Using Data Effectively
• Considerations when designing an effective data
analytics function:
– Availability of data
– Accessibility to the data
– Timeliness to gain access to the data
– Quality of the data
– Expertise of those using the data
– Corporate support for the program
– Privacy and Privilege considerations
28. Page 27
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Physician Compliance Monitoring
Making the information come to you…
29. Page 28
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Making Physician Compliance
Manageable AND Meaningful
Targeted
Physician Probes
Effective use of physician analytics
allows a physician compliance
program to be extremely detailed
while remaining efficient and
cost-effective.
Analytics Suite
on All Employed Physicians
Focused
Physician
Reviews
30. Page 29
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Typical Areas of Focus
“REV $”“PHYS ALIGN”“CODING”
•Area/Metric
•Area/Metric
•Area/Metric
•Area/Metric
•Area/Metric
•Area/Metric
•Area/Metric
•Area/Metric
•Area/Metric
Develop unique areas of focus, metrics to measure, and thresholds to assess
compliance and risk. This is an active, fluid initiative.
31. Page 30
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Other Customized Analytics:
Getting “Outside of the Box”
In addition to a number of analytics to evaluate certain “expected” areas
of physician utilization (e.g., E/M bell curves), consider other topical ways
to assess physicians based upon a customized list of targeted service
areas to determine if “outlier” patterns exist. Some example focus areas
include:
CODING
PHYS
ALIGN
REV $
• Critical Care Service Utilization
• 25-Modified E/M Services
• Preventative Medicine Services (e.g., ratio of G-code to 9-code use)
• Extended Discharge Day Management Services
• Incident-To/Split Shared Services
• Time Studies/Work RVU Analysis
• EP Study Utilization
• Long-term Drug Use ICD-9 Code Utilization
32. Page 31
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Physician Analytics Suite
Examples
33. Page 32
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
E/M Distribution
(“Bell Curve”) Analysis
CODING
PHYS
ALIGN
REV $
34. Page 33
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Benchmark Specialty
Procedural Service Mix Analysis
CODING
PHYS
ALIGN
REV $
Physician
Rank
Percent
CPT/HCPCS
Codes
Appended CPT/HCPCS Brief Description
Neurosurgery
Benchmark
Rank
Neurosurgery
Benchmark
Rank
Percent
of Total
Benchmark
Units CPT/HCPCS Brief Description
Physician
Rank
1 23% 99232 Subsequent hospital care 8 1 14% 99213 Office/outpatient visit est 63
2 15% 99222 Initial hospital care 16 2 7% 99214 Office/outpatient visit est 55
3 14% 99231 Subsequent hospital care 7 3 6% 99212 Office/outpatient visit est -
4 7% 99223 Initial hospital care 13 4 5% 99204 Office/outpatient visit new -
5 5% 63047 Removal of spinal lamina 28 5 5% 99203 Office/outpatient visit new -
6 3% 99233 Subsequent hospital care 21 6 4% J2323 Natalizumab injection -
7 2% 63048 Remove spinal lamina add-on 12 7 3% 99231 Subsequent hospital care 3
8 2% 22851 Apply spine prosth device 14 8 3% 99232 Subsequent hospital care 1
9 2% 22551 Neck spine fuse&remov bel c2 37 9 3% J0585 Injection,onabotulinumtoxinA -
10 2% 99221 Initial hospital care 24 10 2% G8447 Pt vis doc use EHR cer ATCB -
11 2% 61781 Scan proc cranial intra - 11 2% 99205 Office/outpatient visit new -
12 1% 22614 Spine fusion extra segment 17 12 2% 63048 Remove spinal lamina add-on 7
13 1% 22552 Addl neck spine fusion 46 13 2% 99223 Initial hospital care 4
14 1% 61312 Open skull for drainage - 14 2% 22851 Apply spine prosth device 8
15 1% 22845 Insert spine fixation device 33 15 2% 99215 Office/outpatient visit est -
Specialty Benchmark Comparison
PHYSICIAN
Specialty Benchmark Comparison
NEUROSURGERY
35. Page 34
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Targeted Physician Probes
Special Data Analytics for High-Risk Concerns
36. Page 35
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
New vs. Established
Patient E/M Services
CODING
REV $
Physician
Ratio
Est Patient E/M
to
New Patient E/M
PHYSICIAN
Ratio
Est Patient E/M
to
New Patient E/M
BENCHMARK
Percent
Variance
Dashboard
>=50%
>=35%
>=20%
Physician A 1.3 3.6 177%
Physician E 0.9 2.4 176%
Physician I 1.7 3.6 112%
Physician C 1.2 2.4 100%
Physician B 3.2 4.0 25%
37. Page 36
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Focused Benchmark Analysis:
Modifier Use
Physician
Modifier Use
> 30%
Above Benchmark
Modifier Use
> 25%
Above Benchmark
Modifier Use
> 20%
Above Benchmark
Physician A 25, 80 59
Physician B 51 22
Physician C 51 51
Physician D 80 59 51
Physician E 25 22
Physician F 22 25
Physician G 25
Physician H 59 25 80
Physician I 80 59
25 Significant separately identifiable E/M service
59 Distinct procedural service
80 Surgical assistant
22 Increased procedural service
CODING
PHYS
ALIGN
REV $
38. Page 37
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Physician Productivity Analysis:
Addressing Work Relative Value
CODING
PHYS
ALIGN
REV $
Physician Specialty Work RVUs
Weighted
Average Work
RVU per Unit
90th
Percentile
Work RVUs per
MGMA
Work RVUs
as a % of
90th
Percentile
Dashboard
>200%
>150%
>100%
Physician A Geriatrics 20,658 1.43 6,194 334%
Physician B Hospitalist 21,666 1.03 6,901 314%
Physician C Endocrinology 16,232 0.94 6,801 239%
Physician D Geriatrics 14,163 1.58 6,194 229%
Physician E General Surgery 18,179 2.63 10,730 169%
Physician F Gynecology/Oncology 16,233 1.24 10,775 151%
Physician G OB/GYN 16,022 1.88 10,432 154%
Physician H Gastroenterology 15,609 1.75 12,604 124%
Physician I Hospitalist 9,244 1.80 6,901 134%
Physician J Family Medicine 7,790 0.35 7,082 110%
Physician K Plastic/Reconstructive Surgery 6,551 1.87 11,411 57%
Physician L Psychiatry 3,819 1.34 6,189 62%
39. Page 38
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Physician Productivity Analysis:
Work RVUs
CODING
PHYS
ALIGN
REV $
40. Page 39
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Place Of Service Impact Analysis
The Office of Inspector General reports the following in its HHS OIG
Work Plan for Fiscal Year 2014:
“Federal regulations provide for different levels of payments to physicians
depending on where services are performed (42 CFR §414.32). Medicare
pays a physician a higher amount when a service is performed in a non-
facility setting, such as a physician’s office, than it does when the service is
performed in a hospital outpatient department…”
CODING
REV $
Physician
SORTED BY
CLIENT Billed in
Non-Facility ($$) Setting
Benchmark Billed in
Facility ($) Setting
CLIENT | Benchmark
Place of Service
Match
Dashboard Reimbursement
Higher Based upon CLIENT
Compared to Benchmark
Place of Service
Physician D 70% 30%
Physician A 61% 39%
Physician G 1% 76%
Physician C 0% 100%
Physician O 0% 77%
Physician K 0% 51%
41. Page 40
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Non-Physician Practitioner (NPP)
Collaboration “Probe” Analysis
Define physicians who may collaborate with NPPs to perform
incident-to, split/shared E/M visit and post-operative follow-up
services.
CODING
PHYS
ALIGN
REV $
Physician
SORTED BY
Percent
Billing Provider = MD
and
Rendering Provider = MLP
Dashboard
>=50%
>=35%
>=20%
Physician B 55%
Physician A 47%
Physician C 35%
Physician D 33%
Physician G 20%
Physician K 15%
Physician O 0%
42. Page 41
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Benchmark Physician
Time Study Analysis
Physicians with “higher than expected” FTE-equivalent levels often
collaborate with NPPs, nursing and other ancillary staff to engage in the
work flow/practice patterns necessary to support high utilization levels.
CODING
PHYS
ALIGN
REV $
Physician
Total
Professional
Service Time
(in Hours)
FTE-Equivalent
(Based upon 2,000
Annual Hours)
Dashboard
>=3.0
>=2.5
>=2.0
<2
Physician B 9,702 4.85
Physician A 9,616 4.81
Physician C 6,803 3.40
Physician D 4,995 2.50
Physician G 4,306 2.15
Physician K 4,211 2.11
Physician N 2,683 1.34
Physician O 2,386 1.19
Best calculated using the current Medicare Physician Time Study and 2,000
total annual hours per full-time equivalent.
43. Page 42
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
PHYS
ALIGN
Gross And Net Revenue
“Pulse Check” Analysis
Use data to gain a high-level understanding of any potential areas of
revenue “vulnerability.”
REV $
44. Page 43
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Outcome:
“At A Glance” Reporting
CODING
PHYS
ALIGN
REV $
Specialty Physician
Total Work
RVU
Benchmark
Comparison
Total Work
RVUs by
Service Type
Weighted
Average Work
RVU per Unit
by Service
Type
Productivity
Stability Probe
E/M Services
Total Days
Worked by Day
of the Week
Average Daily
Billed Service
Hours by Day
of the Week
Benchmark
Physician
Time Study
Analytics
Physician A
Physician B
Physician C
Physician D
Physician E
Physician F
Physician G
Physician H
Physician I
Physician J
Physician K
Physician L
Physician M
Physician N
Physician O
Physician P
Physician Q
Physician R
Electrophysiology
Interventional Cardiology
45. Page 44
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Next Steps:
Focused Physician Reviews
No more annual 10 chart provider review
compliance plan commitments!!!
Grading or Compliance Rate Considerations
Feedback During Review Process
Trending
Corrective Action Plans
46. Page 45
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Coding and Documentation Review
Guidelines
• CPT
• ICD-9-CM
• ICD-10-CM
• HCPCS
• 1995/1997 Documentation
Guidelines for E/M Services
• Medicare/Medicaid/Other Gov’t
• State and Federal
Documentation
• Explanation of Benefits
• CMS 1500
• Medical Record
VS.
47. Page 46
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Coding and Documentation Review
• Chief Complaint
• History of Present Illness
• History Level
• Review of Systems
• Examination
• Past, Family, and/or Social
History
• Medical Decision-Making Level
• Modifier Usage
• CPT Selection
• Modifier Usage
• ICD-9 Selection
• Signature Compliance
• Time-Based Code Support
• NPP/Midlevel Provider Compliance
• NCCI/Bundling Compliance
• Other Agreed-Upon Regulatory or
Facility-Specific Areas of Interest
• ICD-10 Documentation Readiness
E/M Compliance Elements General Compliance Elements
48. Page 47
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00%
All Internal Medicine
Physician A
Physician B
Physician C
Physician D
Physician E
Physician F
Physician G
Physician H
Physician I
Physician J
Physician K
Physician L
Physician M
Physician N
Physician O
Physician P
Physician Q
Physician R
Physician S
Physician T
Physician U
Compliance
Missing Provider Signature
Not Documented
Missed Opportunity to Bill
Bundled
Insufficient Documentation to Bill
Overcoded
Undercoded
Inaccurate CPT/HCPCS Assigned
Potential Review Results
INTERNAL MEDICINE SNAPSHOT – PHYSICIAN CODING DEFICIENCY FINDINGS
(In Compliance Rate Order)
49. Page 48
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Potential Review Results
Family Practice Internal Medicine Other Specialties
Provider Compliance
Dashboard
<60%
61-89%
90-100% Provider Compliance
Dashboard
<60%
61-89%
90-100% Provider Compliance
Dashboard
<60%
61-89%
90-100%
Physician A 90% Physician A 83% Physician A 85%
Physician B 89% Physician B 80% Physician B 75%
Physician C 88% Physician C 79% Physician C 71%
Physician D 86% Physician D 75% Physician D 68%
Physician E 76% Physician E 75% Physician E 66%
Physician F 75% Physician F 75% Physician F 65%
Physician G 75% Physician G 75% Physician G 63%
Physician H 74% Physician H 72% Physician H 60%
Physician I 74% Physician I 68% Physician I 60%
Physician J 73% Physician J 67% Physician J 58%
Physician K 71% Physician K 65% Physician K 53%
Physician L 71% Physician L 62% Physician L 52%
Physician M 69% Physician M 61% Physician M 50%
Physician N 69% Physician N 53% Physician N 50%
Physician O 68% Physician O 45% Physician O 40%
Physician P 65% Physician P 43% Physician P 36%
Physician Q 65% Physician Q 40% Physician Q 30%
Physician R 65% Physician R 40% Physician R 27%
Physician S 64% Physician S 37% Physician S 24%
Physician T 63% Physician T 36% Physician T 18%
Physician U 62% Physician U 20% Physician U 7%
Physician V 61% Physician V 5%
Physician W 59%
Physician X 59%
Physician Y 58%
Physician Z 58%
Physician AA 58%
Physician AB 57%
Physician AC 57%
Physician AD 57%
Physician AE 55%
Physician AF 54%
Physician AG 54%
Physician AH 53%
Physician AI 52%
Physician AJ 52%
Physician AK 48%
Physician AL 47%
Physician AM 45%
Physician AN 43%
Physician AO 40%
Physician AP 38%
Physician AQ 37%
Physician AR 35%
Physician AS 34%
Physician AT 33%
Physician AU 31%
Physician AV 24%
COMPLIANCE RATES PER PROVIDER
50. Page 49
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Potential Review Results
TOTAL AND SPECIALTY GROUPING ERROR COUNTS
51. Page 50
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Potential Review Results
E/M CODING DETAILED RESULTS
Met 267 55% Met 127 61% Met 70 39%
Not Met 217 45% Not Met 81 39% Not Met 111 61%
Undercoded 95 20% Inaccurate CPT/HCPCS Assigned 2 1% Inaccurate CPT/HCPCS Assigned 9 5%
Insufficient Documentation to Bill 74 15% Insufficient Documentation to Bill 13 6% Insufficient Documentation to Bill 9 5%
Overcoded 35 7% Missing Provider Signature 1 0.5% Missing Provider Signature 6 3%
Not Documented 6 1% Not Documented 17 8% Not Documented 28 15%
Bundled 4 1% Overcoded 39 19% Overcoded 52 29%
Inaccurate CPT/HCPCS Assigned 2 0.4% Undercoded 9 4% Undercoded 7 4%
Missing Provider Signature 1 0.2%
Family Practice
E/M Coding Detailed Results
Internal Medicine
E/M Coding Detailed Results
Other Specialties
E/M Coding Detailed Results
52. Page 51
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Potential Review Results
PROCEDURAL CODING DETAILED RESULTS
53. Page 52
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Identifying Overpayments
54. Page 53
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Medicare Parts A & B:
Identifying Overpayments
Medicare Parts A & B
• 60‐Day Overpayment Proposed Rule
– 10-year look‐back period
– Duty to take affirmative investigative action related to
potential overpayments
53
55. Page 54
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Medicare Parts C & D:
Identifying Overpayments
Medicare Parts C & D
• 60-Day Overpayment Final Rule
– Six-year look-back period
– “[I]f an MA organization or Part D sponsor has received
information that an overpayment may exist, the
organization must exercise reasonable diligence to
determine the accuracy of this information, that is, to
determine if there is an identified overpayment ... ‘‘day
one’’ of the 60-day period is the day after the date on
which organization has determined that it has identified
the existence of an overpayment.”
54
56. Page 55
April 22, 2015
Prepared for
HCCA’s 19th Annual
Compliance Institute
Thank You!
Denise Hall, RN, BSN
Principal, Healthcare Consulting
PYA
(404) 266-9876
dhall@pyapc.com
Mike Paulhus, J.D.
Partner
King & Spalding
(404) 572-2860
mpaulhus@kslaw.com
Wisconsin
www.wipricepoint.org.
Montana
www.montanapricepoint.org
Virginia
http://www.vapricepoint.org
New Jersey
http://www.njhospitalpricecompare.com/topdrg.aspx
Iowa
www.iowahospitalcharges.com
Texas
http://www.txpricepoint.org/
Ohio
http://publicapps.odh.ohio.gov/facilityinformation/
Tennessee
http://www.tnhospitalsinform.com/outpatient.aspx
Minnesota
http://www.mnhospitalpricecheck.org/reports.aspx
Oregon
http://www4.cbs.state.or.us/ex/ins/hit/ ; http://www.orpricepoint.org/
Wisconsin
www.wipricepoint.org.
Montana
www.montanapricepoint.org
Virginia
http://www.vapricepoint.org
New Jersey
http://www.njhospitalpricecompare.com/topdrg.aspx
Iowa
www.iowahospitalcharges.com
Texas
http://www.txpricepoint.org/
Ohio
http://publicapps.odh.ohio.gov/facilityinformation/
Tennessee
http://www.tnhospitalsinform.com/outpatient.aspx
Minnesota
http://www.mnhospitalpricecheck.org/reports.aspx
Oregon
http://www4.cbs.state.or.us/ex/ins/hit/ ; http://www.orpricepoint.org/
Wisconsin
www.wipricepoint.org.
Montana
www.montanapricepoint.org
Virginia
http://www.vapricepoint.org
New Jersey
http://www.njhospitalpricecompare.com/topdrg.aspx
Iowa
www.iowahospitalcharges.com
Texas
http://www.txpricepoint.org/
Ohio
http://publicapps.odh.ohio.gov/facilityinformation/
Tennessee
http://www.tnhospitalsinform.com/outpatient.aspx
Minnesota
http://www.mnhospitalpricecheck.org/reports.aspx
Oregon
http://www4.cbs.state.or.us/ex/ins/hit/ ; http://www.orpricepoint.org/
Generally, anything of value furnished to a covered recipient is reportable, unless expressly excluded by the law.
Information to be reported:
Name of the covered recipient
Business address of the covered recipient
National Provider Identifier and specialty of the covered recipient, if the covered recipient is a physician
Amount of the payment or transfer of value
Dates of the payments or transfers of value
Name of any specific product to which the payment or transfer of value relates
Description of the form and nature of payment or transfer of value
Express exclusions include:
Product samples intended for patient use
Educational materials that directly benefit patients or are intended for patient use
Payments made indirectly through a 3rd party where the manufacturer does not know the identity of the covered recipient
Discounts and rebates
In-kind items used in the provision of charity care
Dividends and investment interests in a publicly traded security or mutual fund
Loans of a medical device for a short-term period, not to exceed 90 days, for device evaluation purposes
Certain items or services provided under a contractual warranty
Payments for provision of health care to employees under a manufacturer’s self-insured plan
Transfers of value less than $10, subject to an aggregate cap of $100 (with inflation factors for future years)
[OTHER EXAMPLES?]
[OTHER EXAMPLES?]
[OTHER EXAMPLES?]
[OTHER EXAMPLES?]
For example, if a facility were to report inaccurate quality data to CMS, and government payment is somehow linked to scores derived from the data, one can envision arguments that the inaccurate quality data submissions constitute false claims or false statements material to false claims
PPACA § 10104(j)(2), 124 Stat. at 901.
The law on quality of care liability is in flux. On the one hand, penalties imposed by the government can be severe, ranging from injunctive relief to the imposition of Corporate Integrity Agreements (CIAs) and exclusion, along with large civil and criminal monetary payments. On the other hand, a shift by regulators to pursuing smaller providers on quality of care theories with the looming threat of massive penalties and exclusion may, paradoxically, set up situations in which providers have nothing to lose in taking cases to trial and challenging these aggressive quality theories. This has the potential to clarify the law in a more efficient way than has often been the case in high stakes FCA cases.
The government and relators likely will contend payment structures and reporting measures set forth in various new quality programs materially affect payment and are thereby conditions of payment—and that violations triggers the FCA liability.
Given this, providers are well-advised to place a strong emphasis on internal quality programs and standards as ways to mitigate risk.
The government and relators likely will contend payment structures and reporting measures set forth in various new quality programs materially affect payment and are thereby conditions of payment—and that violations triggers the FCA liability.
Given this, providers are well-advised to place a strong emphasis on internal quality programs and standards as ways to mitigate risk.
Additional potential review results later in presentation. –esg, 3/9, 12p
BioMed equipment CDM capture
-GA modifier use to then check for ABN on file
Ability to assess service utilization specific to the facility setting
Ability to isolate services rendered in the facility setting (IP/OP/Bedside)
A detailed review will be performed on each encounter relative to CPT/HCPCS code and modifier assignment, documentation adherence to the 1995 and/or 1997 Documentation Guidelines for Evaluation and Management Services and compliance with relevant payer requirements. For example, each E/M encounter will be reviewed for the requisite components for code assignment, as follows:
In addition, where applicable, each encounter will be reviewed for compliance with the regulations surrounding time-based billing, the use of mid-level providers and any other agreed-upon regulatory or facility-specific areas of interest.