Automated Guidelines Healthcare Reimbursement Series Reducing friction in the reimbursement process is an important challenge faced by healthcare organizations today. Many of them are looking for technology to reduce inefficiencies and cut costs while improving the visibility of integrated patient and clinical data. Trisotech addresses the issue with an easy to use business modeling and automation platform. Business modeling and automation is a mature technology based on open standards that has proven its value in a wide range of industries. In healthcare, it enables clinical, business and IT personnel to collaborate in a visual environment to document, communicate and automate healthcare guidelines. The technology can be integrated with hospital information systems using FHIR and CDS Hooks. Automating these complex workflows can improve efficiency, allowing resources to be allocated to more challenging problems. Issues can be identified and resolved in real-time with the logic underlying all decisions transparently available to the organization. To illustrate the capabilities of business modeling and automation for healthcare reimbursement, we will demonstrate how it can be used by payors and providers alike in a series of three webinars. Documentation of Medical Necessity for CMS Home Services Audits for medical necessity can be a headache and a financial burden to providers. Problems are often traced to issues such as incomplete documentation and incorrect coding. In this third webinar, we will demonstrate how business models can be used to meet Centers for Medicare and Medicaid Services (CMS) rules for home health care. These models can serve as documentation, especially when supported by decision models for disease severity and therapeutic decision-making. In addition, the models can schedule renewals when needed, reducing interruptions in patient care.

1. Automated Guidelines
for Healthcare
Reimbursement Series
Three FREE Online Presentations/Micro-Events
Dr. John Svirbely, MD
Chief Medical Informatics Officer (CMIO),
jsvirbely@Trisotech.com
Denis Gagne
Chief Executive Officer (CEO),
dgagne@Trisotech.com

2. Automated Healthcare Reimbursement
Guidelines Series
1. Orthopedic Surgery Preauthorization
2. Preauthorization for Targeted Drug Therapy and
Streamlining of the Appeals Process
3. Documentation of Medical Necessity for CMS Home Services

3. Some logistics
1. Recording and slides will be
made available to all
attendees
2. Q&A – Send your questions in

4. Abstract
Automated Guidelines Healthcare Reimbursement Series
Reducing friction in the reimbursement process is an important challenge faced by healthcare organizations today. Many of them are looking
for technology to reduce inefficiencies and cut costs while improving the visibility of integrated patient and clinical data. Trisotech addresses
the issue with an easy to use business modeling and automation platform.
Business modeling and automation is a mature technology based on open standards that has proven its value in a wide range of industries. In
healthcare, it enables clinical, business and IT personnel to collaborate in a visual environment to document, communicate and automate
healthcare guidelines. The technology can be integrated with hospital information systems using FHIR and CDS Hooks. Automating these
complex workflows can improve efficiency, allowing resources to be allocated to more challenging problems. Issues can be identified and
resolved in real-time with the logic underlying all decisions transparently available to the organization.
To illustrate the capabilities of business modeling and automation for healthcare reimbursement, we will demonstrate how it can be used by
payors and providers alike in a series of three webinars.
Documentation of Medical Necessity for CMS Home Services
Audits for medical necessity can be a headache and a financial burden to providers. Problems are often traced to issues such as incomplete
documentation and incorrect coding. In this third webinar, we will demonstrate how business models can be used to meet Centers for
Medicare and Medicaid Services (CMS) rules for home health care. These models can serve as documentation, especially when supported by
decision models for disease severity and therapeutic decision-making. In addition, the models can schedule renewals when needed, reducing
interruptions in patient care.

5. Automatable
Guidelines
An Automatable Guideline is a visual decision
model that is both human readable and machine
automatable.
Such a standardized workflow can improve the
efficiency and quality of healthcare processes.

6. Our Objective
Promote the modeling of Automatable
Guidelines using open standards to:
• Disambiguate Guidelines creation and
interpretation
• Inform care coordination workflows
so that:
• Clinical Knowledge is delivered at the point of
care
• A single visual Knowledge Artefact is created for
clinicians and for automation

7. Marrying two sets of standards
www.OMG.org www.HL7.org

8. Established to foster the sharing and
promulgation of best-practices
around modeling and sharing:
• clinical pathways,
• clinical guidelines, and
• other healthcare knowledge
A robust and thriving community-
of-practice of healthcare
institutions, professional societies,
and vendors
www.BPM-plus.org

9. Overview

10. Healthcare Reimbursement
Medical Necessity is a key concept in
reimbursement
A medically necessary service is one that is required
to help a patient survive or to get better
In our previous webinars we discussed
preauthorization, which involves determination of
medical necessity prior to a service being provided
Today we will discuss determination of medical
necessity after a service has been provided, usually
through the use of audits

11. Benefits of Automating Healthcare
Reimbursement
Payer
•Effectiveness: Complete and correct information at submission
•Efficiency : Increased decisions throughput
•ROI: Reallocation of resources
Patient
Necessary care with minimum delay
Reduced stress and anxiety
No incurred financial surprises
Provider
Real time adjudication
Clear understanding of the acceptance criteria
Lower administrative burden

12. Home Oxygen Therapy
…over 1 million Medicare
recipients are prescribed long-
term oxygen therapy at an
annual cost of $2 billion.
“ Stop Prescribing Nocturnal Oxygen to Patients With COPD - Medscape - Nov 06, 2020.

13. Written Guidance

14. Home Oxygen

15. What can go wrong and how
Process Automation can help
To address some common
problems in documentation
found during chart audits
To avoid errors that can
impact patient outcomes
To demonstrate how
automation can provide
insights into the quality-of-
care delivery

16. CMS Audits for
Medical Necessity
CMS confirms the
medical necessity
of a service often
using audits
performed weeks
or months after an
encounter
The auditor
typically will screen
a number of
patient charts for
compliance with
the requirements
The auditors check
for a number of
factors such
severity of illness
and therapeutic
decisions relative to
cheaper
alternatives
Performance on
these charts is then
extrapolated to all
patients

17. Common Problems in Documenting
Medical Necessity
POOR
DOCUMENTATION
INCORRECT CODING MISSING OR UNSIGNED
ORDERS
INCORRECT OR
MISSING DATES OF
SERVICE

18. Consequences of errors for the provider
THE PROVIDER WILL NEED TO RETURN MONEY IF A
SERVICE IS JUDGED TO NOT SHOW MEDICAL
NECESSITY
THE PROVIDER IS AT JEOPARDY OF CRIMINAL
CHARGES IF THERE IS A REPEATED PATTERN OF
INAPPROPRIATE CHARGES
THESE CONSEQUENCES MEANS THAT A PROVIDER MUST DIVERT RESOURCES
TO PERFORM SELF-AUDITS TO PRE-EMPTIVELY DETECT PROBLEMS

19. Ensuring Proper Coding

20. A Patient Receiving Home Care
• Has one or more chronic
comorbid conditions that may
require therapy for years
• May deteriorate if therapy is
interrupted
• Is often vulnerable
This Photo by Unknown Author is licensed under CC BY-ND

21. Errors in the delivery of a
necessary service:
May cause an unnecessary interruption in care if there
has been a failure to recertify a patient or reschedule a
therapy as specified in the regulations
May cause unnecessary economic burdens
May cause delays in being referred for appropriate
services such as to palliative care

22. Recertification Demo

23. Quality
CMS is always seeking better information on Quality-of-care
• Some associated goals:
• Make care safer by reducing harm caused while care’s delivered.
• Improve support for a culture of safety.
• Reduce inappropriate and unnecessary care.
• Prevent or minimize harm in all settings.
• Help patients and their families be involved as partners in their care.
• Promote effective communication and coordination of care.
• Promote effective prevention and treatment of chronic disease.
• Work with communities to help people live healthily.
• Make care affordable.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/CMS-Quality-Strategy

24. CQL: Clinical Quality Language
A standard from HL7
https://HL7.org

25. Addressing Quality-of-care Reporting

26. Conclusions
Benefits of Process Automation
Complete and accurate documentation at or near the time of
service
Fewer errors impacting patient care
Improved insights into the quality-of-care

27. Any questions?
THANKS!