This document discusses strategies for home health care agencies to minimize risks from audits. It outlines the various entities that conduct audits, including RACs, MACs, and ZPICs. Key areas that auditors focus on include medical necessity, coding accuracy, documentation quality, and compliance with Medicare policies. The document provides guidance on ensuring documentation clearly supports the patient's homebound status, medical necessity of skilled services, and demonstrates progress towards goals. It emphasizes having objective data to justify findings and treatment plans.
This document provides an overview and introduction to palliative care. It discusses that palliative care focuses on relieving pain, symptoms and stress of serious illness to improve quality of life. Palliative care is delivered by an interdisciplinary team and can be provided at any stage of a serious illness alongside curative treatments. The document summarizes research finding that palliative care can reduce costs by lowering hospitalizations and emergency visits while improving quality outcomes like symptoms and satisfaction. It also outlines strategies some health payers and organizations are taking to integrate palliative care, like targeting high-risk patients, dedicating case management resources and reimbursing providers.
At the Heart of the Matter: Medical NecessityPYA, P.C.
PYA Principal Denise Hall and Michael Spake, Vice President of External Affairs and Chief Compliance & Integrity Officer at Lakeland Regional Health System, co-presented “At the Heart of the Matter: Medical Necessity,” at the AHLA Institute on Medicare and Medicaid Payment Issues. They discussed:
Recent cases and legal actions
Impact of medical necessity when interpreting the regulations and guidelines for:
-Stents
-Pacemakers
-Automatic Implantable Cardiac Defibrillators (AICD)
-Electrophysiology Studies (EPS) and Ablations
Common areas of risk in applying local coverage determination (LCD)/national coverage determination (NCD) guidance to cardiac procedures: how to identify your risks and avoid vulnerability
Best practices for ensuring compliance with regulations
Patient Resource: Medicare Observation Versus Admit DaysTerri Embry RN BS
This resource provides information a patient, their advocate or a health care professional can use to learn about this topic. Hyperlinks are embedded to allow for self guided research and is encouraged.
Presentation of intravalley health for patient experience & satisfaction surveysModupe Sarratt
Intravalley Health strives to provide quality care for patients but faces challenges in measuring patient experience and satisfaction. Regulations from CMS, HIPAA, and ACA dictate medical procedures and policies that can negatively impact the patient experience by being too rigid. For example, a patient was denied a prescription refill due to missing a follow-up appointment, though she felt no additional care was needed. To improve care, Intravalley Health must understand how regulations influence patient experiences and make policies more flexible to accommodate patient needs.
Patients and their loved ones often hold critical knowledge that informs diagnosis. This toolkit from the Institute of Medicine offers patients, families and clinicians guidance on how they can collaborate to improve diagnosis.
Disruptive Transformation and the Accountable Care OrganizationDarwin Health
Presentation by John Marchica (Darwin Health) and Bob Roth (Cypress HomeCare Solutions) at the Home Care Association of America Leadership Conference, Sep. 30, 2016.
The document discusses transitional care and efforts to reduce hospital readmissions. It provides background on the Hospital Readmission Penalty Program established by the Affordable Care Act and initiatives like Bundled Payments for Care Improvement (BPCI) that aim to improve care coordination. Popular tactics to reduce avoidable readmissions include patient education, risk assessment, care coordination between providers, and transitional care models.
Victim Compensation Without Litigation - the Lexington Experience Victim Co...MedicineAndHealth
The document discusses the victim compensation program implemented at the Lexington VA Medical Center since 1987. Under the program, when medical errors are identified that cause patient harm, the hospital fully discloses the facts to patients, accepts responsibility, and offers compensation through negotiated settlements. Over 13 years, the hospital settled over 170 cases through this approach, with an average settlement of $16,000, avoiding costly litigation. Studies found this approach improved patient satisfaction and reduced costs compared to traditional denial and litigation practices.
This document provides an overview and introduction to palliative care. It discusses that palliative care focuses on relieving pain, symptoms and stress of serious illness to improve quality of life. Palliative care is delivered by an interdisciplinary team and can be provided at any stage of a serious illness alongside curative treatments. The document summarizes research finding that palliative care can reduce costs by lowering hospitalizations and emergency visits while improving quality outcomes like symptoms and satisfaction. It also outlines strategies some health payers and organizations are taking to integrate palliative care, like targeting high-risk patients, dedicating case management resources and reimbursing providers.
At the Heart of the Matter: Medical NecessityPYA, P.C.
PYA Principal Denise Hall and Michael Spake, Vice President of External Affairs and Chief Compliance & Integrity Officer at Lakeland Regional Health System, co-presented “At the Heart of the Matter: Medical Necessity,” at the AHLA Institute on Medicare and Medicaid Payment Issues. They discussed:
Recent cases and legal actions
Impact of medical necessity when interpreting the regulations and guidelines for:
-Stents
-Pacemakers
-Automatic Implantable Cardiac Defibrillators (AICD)
-Electrophysiology Studies (EPS) and Ablations
Common areas of risk in applying local coverage determination (LCD)/national coverage determination (NCD) guidance to cardiac procedures: how to identify your risks and avoid vulnerability
Best practices for ensuring compliance with regulations
Patient Resource: Medicare Observation Versus Admit DaysTerri Embry RN BS
This resource provides information a patient, their advocate or a health care professional can use to learn about this topic. Hyperlinks are embedded to allow for self guided research and is encouraged.
Presentation of intravalley health for patient experience & satisfaction surveysModupe Sarratt
Intravalley Health strives to provide quality care for patients but faces challenges in measuring patient experience and satisfaction. Regulations from CMS, HIPAA, and ACA dictate medical procedures and policies that can negatively impact the patient experience by being too rigid. For example, a patient was denied a prescription refill due to missing a follow-up appointment, though she felt no additional care was needed. To improve care, Intravalley Health must understand how regulations influence patient experiences and make policies more flexible to accommodate patient needs.
Patients and their loved ones often hold critical knowledge that informs diagnosis. This toolkit from the Institute of Medicine offers patients, families and clinicians guidance on how they can collaborate to improve diagnosis.
Disruptive Transformation and the Accountable Care OrganizationDarwin Health
Presentation by John Marchica (Darwin Health) and Bob Roth (Cypress HomeCare Solutions) at the Home Care Association of America Leadership Conference, Sep. 30, 2016.
The document discusses transitional care and efforts to reduce hospital readmissions. It provides background on the Hospital Readmission Penalty Program established by the Affordable Care Act and initiatives like Bundled Payments for Care Improvement (BPCI) that aim to improve care coordination. Popular tactics to reduce avoidable readmissions include patient education, risk assessment, care coordination between providers, and transitional care models.
Victim Compensation Without Litigation - the Lexington Experience Victim Co...MedicineAndHealth
The document discusses the victim compensation program implemented at the Lexington VA Medical Center since 1987. Under the program, when medical errors are identified that cause patient harm, the hospital fully discloses the facts to patients, accepts responsibility, and offers compensation through negotiated settlements. Over 13 years, the hospital settled over 170 cases through this approach, with an average settlement of $16,000, avoiding costly litigation. Studies found this approach improved patient satisfaction and reduced costs compared to traditional denial and litigation practices.
Jama the role of physicians in controlling medical care costs and reducing wa...Carlo Favaretti
The document discusses the role of physicians in controlling rising healthcare costs in the United States. It outlines three scenarios: 1) physicians do nothing and costs continue to rise, 2) healthcare is rationed, and 3) physicians take the lead in identifying and eliminating waste. The author proposes a process to measure waste by reviewing medical records and classifying services as inappropriate, equivocal, appropriate, or necessary. Estimating waste in high performing hospitals could provide a rough measure of potential savings from eliminating wasteful services. Physicians must agree on the magnitude of clinical waste in order to influence the healthcare cost debate and identify strategies to reduce waste.
Intravalley Health conducted patient experience and satisfaction surveys to improve their services. The document discusses two key findings:
1) Patient satisfaction is linked to medical procedures and healthcare services. Providers at Intravalley Health must understand the patient experience regarding the cause of medical care and the effect on patient satisfaction of health services.
2) The cause of negative patient experiences stems from strict regulations, policies, and procedures required to comply with laws like the Affordable Care Act. However, what patients consider to be quality care does not always align with metrics used to measure provider performance. Surveys may not fully capture the patient experience.
HCAD 660 individual project research paper for Intravalley HealthModupe Sarratt
Intravalley Health conducted patient experience and satisfaction surveys to improve their services. The document discusses two key findings:
1) Patient satisfaction is linked to medical procedures and healthcare services. Providers at Intravalley Health must understand the patient experience regarding the cause of medical care and the effect on patient satisfaction of health services.
2) The cause of negative patient experiences stems from strict regulations, policies, and procedures required to comply with laws like the Affordable Care Act. However, what patients consider quality care does not always align with metrics used to measure provider performance. Surveys cannot fully capture the patient experience of care received during medical procedures.
Transitional Care Management: Five Steps to Fewer Readmissions, Improved Qual...Health Catalyst
Reducing readmissions is an important metric for health systems, representing both quality of care across the continuum and cost management. Under the Affordable Care Act, organizations can be penalized for unreasonably high readmission rates, making initiatives to avoid re-hospitalization a quality and cost imperative. A transitional care management plan can help organizations avoid preventable readmissions by improving care through all levels in five steps:
Start discharge at the time of admission.
Ensure medication education, access, reconciliation, and adherence.
Arrange follow-up appointments.
Arrange home healthcare.
Have patients teach back the transitional care plan.
This standardized position description is for an Army Nurse (Clinical/Case Management) at grade GS-12. The nurse serves as a case manager on a multidisciplinary team, providing assessment, planning, implementation, coordination, evaluation and monitoring of patient care. Key responsibilities include developing plans of care for beneficiaries, facilitating communication between healthcare providers, and empowering patients to make informed healthcare decisions. The nurse also oversees nursing practice, develops clinical guidelines, and identifies strategies to improve access, quality and cost-effectiveness of care.
NCQA_Future Vision for Medicare Value-Based Payments FinalTony Fanelli
This document discusses principles for achieving an optimal future state of quality measurement to support performance-based clinician payment under MACRA. It outlines five principles: 1) Every Medicare enrollee needs a dedicated and well-organized primary care team; 2) Measurement must be specified appropriately for each different unit of accountability; 3) Measurement should support rapid improvement and clinical decision making; 4) A core set of measures will let all stakeholders make comparisons across programs; 5) Quality measure results should be easy for consumers and payers to get and use. The document emphasizes the importance of coordinated, team-based primary care and having measures tailored to different payment and delivery models.
This document discusses strategies that clinically integrated networks (CINs) can use to ensure patients stay within their network. It identifies five key areas of focus: 1) extending access beyond traditional models such as physician offices by partnering with urgent care and retail clinics, 2) managing patient migration outside the network through partnerships and narrow network contracts, 3) making it easy for patients to access care through optimized scheduling and expanded hours, 4) building engagement into clinical care through education and protocols, and 5) exploring innovative technologies like smartphone apps and social media to engage patients. The document emphasizes that keeping patients within the network is important for CINs to effectively manage patient care, costs, and outcomes under value-based payment models.
The document outlines an agenda for a presentation on new models for aligning value-based incentives with physicians, systems, and payers. The agenda includes discussions on Humana's commitment to population health, Transcend's partnership framework and value-based reimbursement models, a physician perspective from Chauhan Medical Center in Florida, and how Saint Luke's Health System in Kansas City is preparing for the transition from fee-for-service models. An interactive session will examine organizational readiness to transform from volume-based to value-based care through discussions on clinical integration, leadership capabilities, physician engagement, market strength, and relationships with business partners.
This document discusses a model for coordinating care for patients traveling long distances to an academic medical center. It proposes assigning each patient a "temporary medical home" based on their condition to coordinate all aspects of care during their episode of care. This includes assigning a dedicated nurse to coordinate appointments, financial clearance, and navigation through intake, treatment, discharge and follow up. The goals are to improve patient and provider experience, increase patient volumes and revenue, and support the institution's research mission.
Term Paper_BIG DATA AND ONTARIOS PRIMARY CARE SECTOR (00000003)Emmanuel Casalino
This document discusses the potential role of big data in primary care in Ontario. It outlines how big data could help support clinical decision making, enhance practice workflow, and improve continuity of care from the patient's perspective. Specifically, big data could help with preventative care, quality of care, patient co-management, decision support, and population health management. Currently, primary care relies heavily on paper records and data is fragmented across different systems. The province has invested in electronic health records but more can be done to leverage big data to transform primary care.
- Ascension Health, the largest nonprofit health system in the US, has two systems participating in the CMS Pioneer ACO program - Seton Health Alliance in Texas and Genesys Physician Hospital Organization (PHO) in Michigan.
- The goal is for these organizations to develop population health strategies and engage providers not employed by Ascension in financial risk-taking models.
- Seton Health Alliance and Genesys PHO chose different payment models from CMS - Genesys PHO selecting a fully population-based model in year 3 while Seton chose a model with no downside risk in the first year.
The document discusses how employer-sponsored on-site health clinics can help manage healthcare costs if run as patient-centered medical homes (PCMHs) using a team-based care and medical risk management approach, as done by WeCare TLC. It describes WeCare TLC's model of comprehensive primary care clinics that use data analytics to customize care and drive down costs. Research shows the PCMH model improves outcomes and satisfaction while reducing emergency visits, costs, and medical trend growth for employers who have their employees use the on-site clinic as their primary care provider. WeCare TLC clients have seen healthcare cost reductions of 15-25% within three years of implementing this approach.
WeCareTLC Risk Management White Paper 2015_1452008903358Kevin Cooksey
The document discusses how employer-sponsored on-site clinics can help manage healthcare costs if they implement a comprehensive medical risk management approach. It provides details on WeCare TLC, a company that operates on-site clinics using the patient-centered medical home model and analyzes data to identify savings opportunities and improve population health. WeCare TLC clinics have achieved high employee usage rates, reduced costs 15-25% for employers within 3 years, and improved health outcomes for conditions like diabetes and hypertension. Medical risk management is presented as the key to making on-site clinics successful in both improving health and reducing costs long-term.
The Evolution of Physician Group from Patient Centric Medical HomesVitreosHealth
A Quest to Achieve Higher Quality and Bend the Employers Health Care Cost Curves. Medical Clinic of North Texas (MCNT) enjoys a stellar FY 2010 performance with Total Medical Cost trend for their managed population 2.4% better than market. We tried to understand the journey and the drivers behind the success of Medical Clinic of North Texas from its early years and its future direction.
VBP, Delivery System Reform, and Health and Social ServicesAndré Thompson, MPA
This document discusses the transition from fee-for-service to value-based payment models in healthcare. It explains that fee-for-service results in poor outcomes and high costs. Value-based payment ties provider reimbursement to outcomes like quality and cost. The document outlines key components of value-based payment implementation including delivery system reform, payment reform, performance measurement, and population health management. It notes that social services organizations will need to demonstrate their value and be accountable for outcomes as the healthcare system shifts its focus to addressing social determinants of health.
Safety is Personal: Partnering with Patients and Families for the Safest CareEngagingPatients
The work of NPSF"s Lucian Leape Institute's Roundtable on Consumer Engagement, "Safety Is Personal: Partnering with Patients and Families for the Safest Care" is a call to action for health leaders, clinicians, and policy makers to take the necessary steps to ensure patient and family engagement at all levels of health care.The report identifies specific action items for health leaders, clinicians, and policy makers to pursue in making patient and family engagement a core value in the provision of health. care.
1) A large study found that home-based physical therapy for stroke patients was just as effective as facility-based rehab, cost significantly less, and had better compliance rates.
2) Medicaid programs are now required to deny payments for costs associated with treating health conditions acquired in hospitals due to poor quality of care. Several private insurers have also adopted these policies.
3) An audit found hundreds of Medicaid caregivers to be unqualified due to deficiencies, putting $724 million in payments at risk of being recouped. Proper documentation of compliance is important for revenue protection.
Overview of Patient Experience Definitions and Measurement ToolsInnovations2Solutions
This publication will provide an overview of patient experience, how it is measured, and how to achieve it optimally within the healthcare setting. Sodexo’s definition of Patient Experience will also be explored.
The document discusses three ways to increase patient loyalty in healthcare: (1) provide quality service by listening to patient needs and being consistent, (2) personalize medical care through a team-based approach centered around the patient rather than symptoms, and (3) utilize effective medical teams where all members work together to focus on the patient through mutual monitoring and backup. The goal is to shift from reactive treatment to preventative care in order to strengthen long-term patient loyalty and relevance of healthcare groups.
QUESTIONAs an advanced practice nurse (APN), it is essential to.docxmakdul
QUESTION:
As an advanced practice nurse (APN), it is essential to understand your medicolegal responsibilities as they relate to coding the services you provide to patients. Improper coding, undercoding, or overcoding can have serious implications for patients, providers, and the provider’s care setting. For this Discussion, you examine potential coding issues in case studies and consider the medicolegal responsibilities of the advanced practice nurse.
To prepare:
· Select one of the provided case studies.
· Review the patient documentation given for the case. Think about medicolegal considerations and the responsibilities of the advanced practice nurse.
· Consider the medical codes selected by the advanced practice nurse. Reflect on how the selections might impact clinical practice and billing. Think about how the impact might differ from primary to acute care settings.
·
By Day 3
Post a brief description of the patient documentation given for the case study you selected. Explain any medicolegal considerations, including the role and responsibilities of the advanced practice nurse. Then, explain how medical coding might impact clinical practice and billing, as well as how implications might differ from primary to acute care settings.
Case Study 1:
Sally Jones, an acute care advanced practice nurse, is making hospital rounds on the same patients her colleague nurse practitioner saw yesterday. Sally had five history and physicals to complete on admissions that came in overnight. At the beginning of her shift, she had to complete two emergency admissions and was then called to intensive care, where she spent most of the afternoon. She had to leave work early because of her husband’s retirement party. Because she knew most of the patients on her rounding list, she decided to visit each patient’s room quickly for about 10 minutes. She coded all of the visits the same way she had done the day before, with codes 99231 and 99232.
ANSWER:
Introduction:
It is no secret that Evaluation and Management (E/M) miscoding and claims have been causing a major problems for the medical industry over the past several years. According to the Department of Health and Human services, there were about $6.7 billion inappropriately pain in 2010, that amounted to 21% of Medicare payments and a staggering 42% of incorrectly coded claims. Medical coding is the transformation of healthcare diagnosis, procedures, medical services and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician’s notes, laboratory, and radiologic results, etc. Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history. 99231 has a problem focused history, a problem focused exam and a straight forward MDM or Medical Decision Making (or of low complexity). 99231 requires documentation ...
Jama the role of physicians in controlling medical care costs and reducing wa...Carlo Favaretti
The document discusses the role of physicians in controlling rising healthcare costs in the United States. It outlines three scenarios: 1) physicians do nothing and costs continue to rise, 2) healthcare is rationed, and 3) physicians take the lead in identifying and eliminating waste. The author proposes a process to measure waste by reviewing medical records and classifying services as inappropriate, equivocal, appropriate, or necessary. Estimating waste in high performing hospitals could provide a rough measure of potential savings from eliminating wasteful services. Physicians must agree on the magnitude of clinical waste in order to influence the healthcare cost debate and identify strategies to reduce waste.
Intravalley Health conducted patient experience and satisfaction surveys to improve their services. The document discusses two key findings:
1) Patient satisfaction is linked to medical procedures and healthcare services. Providers at Intravalley Health must understand the patient experience regarding the cause of medical care and the effect on patient satisfaction of health services.
2) The cause of negative patient experiences stems from strict regulations, policies, and procedures required to comply with laws like the Affordable Care Act. However, what patients consider to be quality care does not always align with metrics used to measure provider performance. Surveys may not fully capture the patient experience.
HCAD 660 individual project research paper for Intravalley HealthModupe Sarratt
Intravalley Health conducted patient experience and satisfaction surveys to improve their services. The document discusses two key findings:
1) Patient satisfaction is linked to medical procedures and healthcare services. Providers at Intravalley Health must understand the patient experience regarding the cause of medical care and the effect on patient satisfaction of health services.
2) The cause of negative patient experiences stems from strict regulations, policies, and procedures required to comply with laws like the Affordable Care Act. However, what patients consider quality care does not always align with metrics used to measure provider performance. Surveys cannot fully capture the patient experience of care received during medical procedures.
Transitional Care Management: Five Steps to Fewer Readmissions, Improved Qual...Health Catalyst
Reducing readmissions is an important metric for health systems, representing both quality of care across the continuum and cost management. Under the Affordable Care Act, organizations can be penalized for unreasonably high readmission rates, making initiatives to avoid re-hospitalization a quality and cost imperative. A transitional care management plan can help organizations avoid preventable readmissions by improving care through all levels in five steps:
Start discharge at the time of admission.
Ensure medication education, access, reconciliation, and adherence.
Arrange follow-up appointments.
Arrange home healthcare.
Have patients teach back the transitional care plan.
This standardized position description is for an Army Nurse (Clinical/Case Management) at grade GS-12. The nurse serves as a case manager on a multidisciplinary team, providing assessment, planning, implementation, coordination, evaluation and monitoring of patient care. Key responsibilities include developing plans of care for beneficiaries, facilitating communication between healthcare providers, and empowering patients to make informed healthcare decisions. The nurse also oversees nursing practice, develops clinical guidelines, and identifies strategies to improve access, quality and cost-effectiveness of care.
NCQA_Future Vision for Medicare Value-Based Payments FinalTony Fanelli
This document discusses principles for achieving an optimal future state of quality measurement to support performance-based clinician payment under MACRA. It outlines five principles: 1) Every Medicare enrollee needs a dedicated and well-organized primary care team; 2) Measurement must be specified appropriately for each different unit of accountability; 3) Measurement should support rapid improvement and clinical decision making; 4) A core set of measures will let all stakeholders make comparisons across programs; 5) Quality measure results should be easy for consumers and payers to get and use. The document emphasizes the importance of coordinated, team-based primary care and having measures tailored to different payment and delivery models.
This document discusses strategies that clinically integrated networks (CINs) can use to ensure patients stay within their network. It identifies five key areas of focus: 1) extending access beyond traditional models such as physician offices by partnering with urgent care and retail clinics, 2) managing patient migration outside the network through partnerships and narrow network contracts, 3) making it easy for patients to access care through optimized scheduling and expanded hours, 4) building engagement into clinical care through education and protocols, and 5) exploring innovative technologies like smartphone apps and social media to engage patients. The document emphasizes that keeping patients within the network is important for CINs to effectively manage patient care, costs, and outcomes under value-based payment models.
The document outlines an agenda for a presentation on new models for aligning value-based incentives with physicians, systems, and payers. The agenda includes discussions on Humana's commitment to population health, Transcend's partnership framework and value-based reimbursement models, a physician perspective from Chauhan Medical Center in Florida, and how Saint Luke's Health System in Kansas City is preparing for the transition from fee-for-service models. An interactive session will examine organizational readiness to transform from volume-based to value-based care through discussions on clinical integration, leadership capabilities, physician engagement, market strength, and relationships with business partners.
This document discusses a model for coordinating care for patients traveling long distances to an academic medical center. It proposes assigning each patient a "temporary medical home" based on their condition to coordinate all aspects of care during their episode of care. This includes assigning a dedicated nurse to coordinate appointments, financial clearance, and navigation through intake, treatment, discharge and follow up. The goals are to improve patient and provider experience, increase patient volumes and revenue, and support the institution's research mission.
Term Paper_BIG DATA AND ONTARIOS PRIMARY CARE SECTOR (00000003)Emmanuel Casalino
This document discusses the potential role of big data in primary care in Ontario. It outlines how big data could help support clinical decision making, enhance practice workflow, and improve continuity of care from the patient's perspective. Specifically, big data could help with preventative care, quality of care, patient co-management, decision support, and population health management. Currently, primary care relies heavily on paper records and data is fragmented across different systems. The province has invested in electronic health records but more can be done to leverage big data to transform primary care.
- Ascension Health, the largest nonprofit health system in the US, has two systems participating in the CMS Pioneer ACO program - Seton Health Alliance in Texas and Genesys Physician Hospital Organization (PHO) in Michigan.
- The goal is for these organizations to develop population health strategies and engage providers not employed by Ascension in financial risk-taking models.
- Seton Health Alliance and Genesys PHO chose different payment models from CMS - Genesys PHO selecting a fully population-based model in year 3 while Seton chose a model with no downside risk in the first year.
The document discusses how employer-sponsored on-site health clinics can help manage healthcare costs if run as patient-centered medical homes (PCMHs) using a team-based care and medical risk management approach, as done by WeCare TLC. It describes WeCare TLC's model of comprehensive primary care clinics that use data analytics to customize care and drive down costs. Research shows the PCMH model improves outcomes and satisfaction while reducing emergency visits, costs, and medical trend growth for employers who have their employees use the on-site clinic as their primary care provider. WeCare TLC clients have seen healthcare cost reductions of 15-25% within three years of implementing this approach.
WeCareTLC Risk Management White Paper 2015_1452008903358Kevin Cooksey
The document discusses how employer-sponsored on-site clinics can help manage healthcare costs if they implement a comprehensive medical risk management approach. It provides details on WeCare TLC, a company that operates on-site clinics using the patient-centered medical home model and analyzes data to identify savings opportunities and improve population health. WeCare TLC clinics have achieved high employee usage rates, reduced costs 15-25% for employers within 3 years, and improved health outcomes for conditions like diabetes and hypertension. Medical risk management is presented as the key to making on-site clinics successful in both improving health and reducing costs long-term.
The Evolution of Physician Group from Patient Centric Medical HomesVitreosHealth
A Quest to Achieve Higher Quality and Bend the Employers Health Care Cost Curves. Medical Clinic of North Texas (MCNT) enjoys a stellar FY 2010 performance with Total Medical Cost trend for their managed population 2.4% better than market. We tried to understand the journey and the drivers behind the success of Medical Clinic of North Texas from its early years and its future direction.
VBP, Delivery System Reform, and Health and Social ServicesAndré Thompson, MPA
This document discusses the transition from fee-for-service to value-based payment models in healthcare. It explains that fee-for-service results in poor outcomes and high costs. Value-based payment ties provider reimbursement to outcomes like quality and cost. The document outlines key components of value-based payment implementation including delivery system reform, payment reform, performance measurement, and population health management. It notes that social services organizations will need to demonstrate their value and be accountable for outcomes as the healthcare system shifts its focus to addressing social determinants of health.
Safety is Personal: Partnering with Patients and Families for the Safest CareEngagingPatients
The work of NPSF"s Lucian Leape Institute's Roundtable on Consumer Engagement, "Safety Is Personal: Partnering with Patients and Families for the Safest Care" is a call to action for health leaders, clinicians, and policy makers to take the necessary steps to ensure patient and family engagement at all levels of health care.The report identifies specific action items for health leaders, clinicians, and policy makers to pursue in making patient and family engagement a core value in the provision of health. care.
1) A large study found that home-based physical therapy for stroke patients was just as effective as facility-based rehab, cost significantly less, and had better compliance rates.
2) Medicaid programs are now required to deny payments for costs associated with treating health conditions acquired in hospitals due to poor quality of care. Several private insurers have also adopted these policies.
3) An audit found hundreds of Medicaid caregivers to be unqualified due to deficiencies, putting $724 million in payments at risk of being recouped. Proper documentation of compliance is important for revenue protection.
Overview of Patient Experience Definitions and Measurement ToolsInnovations2Solutions
This publication will provide an overview of patient experience, how it is measured, and how to achieve it optimally within the healthcare setting. Sodexo’s definition of Patient Experience will also be explored.
The document discusses three ways to increase patient loyalty in healthcare: (1) provide quality service by listening to patient needs and being consistent, (2) personalize medical care through a team-based approach centered around the patient rather than symptoms, and (3) utilize effective medical teams where all members work together to focus on the patient through mutual monitoring and backup. The goal is to shift from reactive treatment to preventative care in order to strengthen long-term patient loyalty and relevance of healthcare groups.
QUESTIONAs an advanced practice nurse (APN), it is essential to.docxmakdul
QUESTION:
As an advanced practice nurse (APN), it is essential to understand your medicolegal responsibilities as they relate to coding the services you provide to patients. Improper coding, undercoding, or overcoding can have serious implications for patients, providers, and the provider’s care setting. For this Discussion, you examine potential coding issues in case studies and consider the medicolegal responsibilities of the advanced practice nurse.
To prepare:
· Select one of the provided case studies.
· Review the patient documentation given for the case. Think about medicolegal considerations and the responsibilities of the advanced practice nurse.
· Consider the medical codes selected by the advanced practice nurse. Reflect on how the selections might impact clinical practice and billing. Think about how the impact might differ from primary to acute care settings.
·
By Day 3
Post a brief description of the patient documentation given for the case study you selected. Explain any medicolegal considerations, including the role and responsibilities of the advanced practice nurse. Then, explain how medical coding might impact clinical practice and billing, as well as how implications might differ from primary to acute care settings.
Case Study 1:
Sally Jones, an acute care advanced practice nurse, is making hospital rounds on the same patients her colleague nurse practitioner saw yesterday. Sally had five history and physicals to complete on admissions that came in overnight. At the beginning of her shift, she had to complete two emergency admissions and was then called to intensive care, where she spent most of the afternoon. She had to leave work early because of her husband’s retirement party. Because she knew most of the patients on her rounding list, she decided to visit each patient’s room quickly for about 10 minutes. She coded all of the visits the same way she had done the day before, with codes 99231 and 99232.
ANSWER:
Introduction:
It is no secret that Evaluation and Management (E/M) miscoding and claims have been causing a major problems for the medical industry over the past several years. According to the Department of Health and Human services, there were about $6.7 billion inappropriately pain in 2010, that amounted to 21% of Medicare payments and a staggering 42% of incorrectly coded claims. Medical coding is the transformation of healthcare diagnosis, procedures, medical services and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician’s notes, laboratory, and radiologic results, etc. Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history. 99231 has a problem focused history, a problem focused exam and a straight forward MDM or Medical Decision Making (or of low complexity). 99231 requires documentation ...
Medicare and Medicaid In-Patient service' s provided within Nursing Homes for the Mental disabled. These service;s are avaliable through out the United States in every State.Contact us for more information?
Innovation in Care Delivery: The Patient JourneyJane Chiang
The document describes innovations in care delivery at Massachusetts General Hospital aimed at improving the patient experience. It discusses the implementation of innovation units to test changes to care delivery and identifies three key areas of focus: implementing relationship-based care, enhancing the role of the attending nurse, and standardizing processes. The goals are to improve patient and staff satisfaction, clinical quality, and reduce costs.
This document discusses improving the customer experience in healthcare. It outlines the key stakeholders in healthcare delivery (patients, providers, payors) and describes two common types of patient journeys (routine/preventative care and acute/emergency care). These journeys involve coordination between many different groups. The document examines areas like task routing, resource management, facilities management, revenue cycle management, and compliance that are important to consider when improving the customer experience across the healthcare system.
The document discusses the nursing process and documentation. It describes the 5 steps of the nursing process as assessment, diagnosis, planning, implementation, and evaluation. It then explains each step in detail including types of assessments, sources of data, nursing diagnoses, care planning, interventions, and evaluation. The document also discusses principles of documentation, various documentation systems, and specific documentation tools like progress notes and discharge summaries.
US Health Care System Week 5 For this assignment, you wishandicollingwood
US Health Care System:
Week 5
For this assignment, you will generate, designate, Organize, investigate and, present a Manage Care Control Cost Plan: Under traditional indemnity insurance, the money follows the patient. Patients select health care providers and visit them as they choose. Providers then bill the private insurer or public payer and are reimbursed on a fee-for-service or per case basis
Manage Care Control Cost Plan: Chapters 9 & 10
Objective
:
Managed health care as it has developed in the USA, and the current backlash against it, must be viewed in the context of the traditional US health care system.
This system of employer-based, indemnity insurance and fee-for-service health care conditioned both providers ‘and patients ‘expectations of unlimited resources and unrestrained choice.
Not surprisingly, the constraints and controls imposed by managed care have resulted in outrage by doctors and their patients (and by doctors through their patients).
ASSIGNMENT GUIDELINES (10%):
For this assignment, you will generate, designate, Organize, investigate and, present a Manage Care Control Cost Plan: Under traditional indemnity insurance, the money follows the patient. Patients select health care providers and visit them as they choose. Providers then bill the private insurer or public payer and are reimbursed on a fee-for-service or per case basis.
Most indemnity plans attempt to limit demand through financial barriers to the patient, such as deductibles and co-insurance, rather than constraints on the provider. Many also require the patient to pay the provider directly and seek reimbursement from the insurer, often with payments less than charges.
Due to growing popular discontent with managed care organizations, many critics believe that the system will not continue in its current state. No one, however, expects managed care to disappear completely and indemnity plans to rise to their former prominence. Changes are expected to occur as managed care programs begin competing among themselves. Cost and efficiency will no longer be the main selling point; quality of services will take precedence. One researcher has suggested that along with new systems of managed care and continuing systems of indemnity plans, health care providers may even organize and offer services directly to employers, thus eliminating the middlemen. This development would be beneficial to all involved: employers would pay less; providers would be better compensated; and clients would receive better care
The paper will be 4-5 pages long. More information and due date will provide in the Fifth Week assignments link.
EACH PAPER SHOULD INCLUDE THE FOLLOWING:
1.
Introduction (30%)
Provide a short-lived outline of the meaning (not a description) of Chapter 9 and 10 and articles you read, in your own words. Types and classifications of managed care models.
2.
Manage Care Control Cost Plan:
(50%)
a.
Cost savings
‘‘Structural changes centere ...
Read the scenario that you will use for the Individual Projects in ea.pdfashokarians
Read the scenario that you will use for the Individual Projects in each week of the course. The
Centers for Medicare and Medicaid Services (CMS) has taken on a more visible role in health
care delivery. Many changes have transpired to improve patient safety along with the
implementation of additional quality metrics, and these changes impact reimbursement rates
Likewise, the Patient Protection and Affordable Care Act has changed the reimbursement fee
structure of Medicare and Medicaid reimbursement for health care services. Other legislation
including the HITECH Act and the Medicare Authorization and CHIP Reactivation Act of 2015
(MACRA) all impact how healthcare organizations receive reimbursement and demonstrate use
of data to improve quality and delivery of patient care Mr. Magone, CEO of Healing Hands
Hospital, has asked you to join the \"Future of Healing Hands Task Force, and your first
assignment is to work with the Hospital Chief Financial Officer, Mr. Johnson, and provide a
summary of the current regulations regarding Medicare reimbursement including how MACR
impact reimbursement if/when Healing Hands coordinates delivery of services by affiliating with
physician practices For this assignment, write a 2-3 page report that you will deliver to Mr.
Magone on how the new CMS initiatives and regulations impact the organization\'s revenue
structure. In your presentation, address the following questions: Why did CMS become more
involved in the reimbursement component of health care? How does CMS\'s involvement impact
the reimbursement model for Healing Hands Hospital and other health care organizations If
CMS reimbursement regulations for Medicare and Medicaid change, does it follow that other
insurance providers change heir policies on reimbursement? What tools can be implemented to
ensure organizations such as Healing Hands Hospital and physician practices are meeting the
policies and procedures set forth by CMS? Identify 3 tools from the CMS Web site that are
helpful in meeting the requirements for Medicare reimbursement set forth by CMS
Solution
Part-a & part-b:
The physician’s work, practice expense, and malpractice, RVU values, CMS (centers for
Medicare and Medicaid services) is required to control overall expenditures in health care
organization. Therefore, CMS become highly involved in the reimbursement component of
health care to patients as per their \"insurance packages\". The CMS\' involvement in “budget
Neutrality” & the reimbursement model at Healing Hand hospital & other health care
organizations is mainly for physician RVU based payments from Medicare & Medicare that can
control its physician costs by adjusting physician payment rates based on “previous periods in a
calendar year” as per federal acts and regulations. The Medicare is going to control physicians
costs according to “medical procedures and medical visits of their record” in a Jan- 1 ending Dec
31. Conversion Factor is main basis to control the physician costs ac.
The document discusses various perspectives on quality healthcare including those of the government, patients, and healthcare providers. It outlines the government's national strategy for quality improvement and focuses on better care, healthy communities, and affordable costs. The patient perspective values compassionate care, time with physicians, timely appointments, and preventative programs. Providers value proven outcomes and reduced errors. The document also discusses opportunities to lower costs through standardized care and reducing unnecessary variations in treatment and costs. It provides examples of accountable care organizations and bundled payments that aim to improve care coordination and reduce costs.
To support your work, use scholarly sources and also use outside s.docxedwardmarivel
This document discusses regulations related to long-term care. It notes that there are many federal and state regulations imposed on long-term care facilities to ensure quality of care and protect consumers. Quality of care is measured through factors like resident outcomes, pain levels, restraint use, and functional status. The Centers for Medicare and Medicaid Services implements national standards to evaluate nursing home quality. Both public agencies and private organizations work to regulate various aspects of long-term care, including quality of services and costs.
Georgia-based medical groups can effectively manage denial claims by identifying the root causes, prioritizing high-impact areas, and improving processes. They should analyze denial data to determine where errors most commonly occur, such as registration, eligibility verification, authorization, and claims submission. Groups can reduce denials by 10% by enhancing registration accuracy, eligibility verification training, pre-authorization checks, and customizing claims edits to payer requirements. Outsourcing denial management to experts can not only provide insights but implement tools and services to eliminate future denials.
The document discusses the importance of evaluating mental health professionals through regular professional evaluations. These evaluations help identify areas for improvement, discuss difficult practices, and establish support to prevent burnout. Clinical supervisors are responsible for assessing supervisees to identify issues that need attention in order to further develop their quality of care.
I need the follwoing assignmentThe project is the creation of a w.docxnatishahaen
I need the follwoing assignment:
The project is the creation of a white paper.
Much of what happens in healthcare is about understanding the expectations of the many departments and personnel within the organization. Reimbursement drives the financial operations of healthcare organizations; each department affects the reimbursement process regarding timelines and the amount of money put into and taken out of the system. However, if departments do not follow the guidelines put into place or do not capture the necessary information, it can be detrimental to the reimbursement system.
An important role for patient financial services (PFS) personnel is to monitor the reimbursement process, analyze the reimbursement process, and suggest changes to help maximize the reimbursement. One way to make this process more efficient is by ensuring that the various departments and personnel are exposed to the necessary knowledge.
For your final project, you will assume the role of a supervisor within a PFS department and develop a white paper in which the necessary healthcare reimbursement knowledge is outlined.
The project is divided into three milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules One, Three, and Five.
In this assignment, you will demonstrate your mastery of the following course outcomes:
†
Analyze the impacts of various healthcare departments and their interrelationships on the revenue cycle
†
Compare third-party payer policies through analysis of reimbursement guidelines for achieving timely and maximum reimbursements
†
Analyze organizational strategies for negotiating healthcare contracts with managed care organizations
†
Critique legal and ethical standards and policies in healthcare coding and billing for ensuring compliance with rules and regulations
†
Evaluate the use of reimbursement data for its purpose in case and utilization management and healthcare quality improvement as well as its impact on
pay for performance incentives
Prompt
You are now a supervisor within the patient financial services (PFS) department of a healthcare system. It has been assigned to you to write a white paper to educate other department managers about reimbursement. This includes how each specific department impacts reimbursement for services, which in turn impacts the healthcare organization as a whole. The healthcare system may include hospitals, clinics, long-term care facilities, and more. For now, your boss has asked you to develop a draft of this paper for the hospital personnel only; in the future, there may be the potential to expand this for other facilities.
In order to complete the white paper, you will need to choose a hospital. You can choose one that you are familiar with or create an imaginary one. Hospitals vary in size, location, and focus.
Becker’s Hospital Review
has an excellent .
This document discusses several topics related to healthcare finance and quality reporting systems:
1) It summarizes the goals of the Physician Quality Reporting System (PQRS) and Value-Based Purchasing System (VBPS), including improving quality of care and tying reimbursement to quality metrics.
2) It outlines the roles of Health Information Management professionals in supporting these programs through data analytics and quality reporting.
3) It describes the roles of Quality Improvement Organizations in ensuring accurate medical coding and documentation for reimbursement.
4) It provides an overview of several laws and acts aimed at reducing healthcare fraud, including the Anti-Kickback statute and their effects on providers.
This e-book focuses on Health Management Solutions the value it adds alongside other systems that are already in place throughout the care lifecycle...
The Entity chosen was Baptist Healthcare South Florida for years 201.docxtodd701
The document outlines a course project that requires students to analyze the financial operations of a healthcare organization using three years of financial statements and metrics. It provides details on the expected case study format, including sections on background, issues identified, analysis using ratios, recommendations, implementation plan, monitoring methodology, and references. It also includes a sample analysis of Baptist Health South Florida that was done as part of the project, focusing on its statement of operations, balance sheet, statement of cash flows, and key financial ratios for 2017-2019.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
How to Make a Field Mandatory in Odoo 17Celine George
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
2. Define Roles and Focus of Audit Groups
Identify key areas of Medicare Policy Benefit
Manual, Chapter 7 essential to the home health
clinician
Identify specific strategies to promote best
practices and minimize interaction potential
with RACs, Macs, and ZPics
3. 4.5 million claims per work day
574,000 claims per hour
9,579 claims per minute
Is it any wonder there is concern regarding
fraud and abuse?
4. “Accuracy of coding and claims for Medicare HHRGs:
We will review Medicare claims submitted by HHAs to
determine the extent in which the HHRG billing codes
that are used in determining payments of home health
agencies are accurate and supported by documentation in
the medical record. The Social Security Act 1895, governs
the payment basis and reimbursement for claims submitted
by HHAs including a case-mix adjustment using HHRGs.
Medicare pays for home health episodes based on a PPS that
categorizes beneficiaries into groups, referred to as HHRGs.
Each HHRG has an assigned weight that affects the payment
rate. We will assess the accuracy of HHRG assignment
and identify patterns of coding by HHAs.
Remember that HHAs refers to home health agencies
7. Medicare Prescription Drug, Improvement, and
Modernization Act (MMA)
Tax Relief and Health Care Act of 2006 (TRHCA)
TRHCA section 306 gave CMS authority to make
recovery audit contractors (RACs) a permanent
nationwide program and the establishment of the
nationwide Program Safeguard Contractors (PSCs)
to fight fraud with data analysis
8. Focus on Hospitals and Physician Practices
In only six states, recovered over $1.6 Billion
Incorrectly coded: 35%
Medically unnecessary: 40%
Insufficient documentation: 10%
9. Per FI NGS, “The RACs detect and correct past
improper payments so that CMS and carriers, fiscal
intermediaries (FIs) and Medicare Administrative
Contractors (MACs) can implement actions that will
prevent future improper payments”
RACs can only review discharged records
Cannot review records already reviewed by other
entities
Home Health, Hospice, and DME now have a RAC
exclusive for them!
10. RACs are paid contingency fees from 9.9%-12%
Can reopen claims up to three years from date claim
was paid
Required to follow all CMS payment policies
Required to have a medical director on staff with
audits teams to include RNs, therapists, and coders
Annual accuracy rates are to be publically stated
11. Region A:
Connecticut, Delaware, Maine, Maryland, Massachusetts, New York, New Jersey,
Pennsylvania, Rhode Island, and New York
Region B:
Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin
Region C:
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North
Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia
Region D:
Alaska, Arizona, California, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska,
Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming
12. Services are medically unnecessary or there is delayed
implementation (Focus: Therapy)
Patients are not Homebound
Services are incorrectly coded and sequenced
Failure to provide claim supportive
documentation
Duplicate claims submitted
Medicare secondary pay or improper payments
Lack of order centricity
13. Medicare Benefit Policy Manual- Home bound status
Homebound status may be an issue with certain records. CMS defines
homebound status as:
Confined to the home – Describe why the patient is homebound. An
individual is considered “confined to the home” if both of the following two
criteria are met:
Criteria 1--The patient must either:
Because of illness or injury, need supportive devices such as crutches, canes,
wheelchairs, and walkers; special transportation; or another person’s help to
leave his or her residence, OR
Have a condition such that leaving his or her home is medically
contraindicated
Criteria 2--There must exist:
A normal inability to leave home; AND
Exertion of a considerable and taxing effort needed to
leave the home.
(Medicare Benefits Policy Manual Chapter 7 Home Health Services, MBPM
Chapter 7
14. Skilled Services-
Per CMS Medicare Benefit Policy Manual, Chapter 7:
“A service that is ordinarily considered nonskilled could be
considered a skilled therapy service in cases in which there is clear
documentation that, because of special medical complications,
skilled rehabilitation personnel are required to perform the
service. However, the importance of a particular service to a
patient or the frequency with which it must be performed does
not, by itself, make a nonskilled service into a skilled service.”
If a chronic diagnosis is the primary reason for ongoing care, the
skilled nurse or therapist should be VERY clear as to why (s)he is
still making visits.
If visit notes do not EACH stand alone and justify care, the nurses
or therapist’s visits are at risk.
15. Teaching-
MBPM Chapter 7 states:
Teaching & Training activities that require skilled nursing personnel
to teach a patient, the patient’s family, or caregivers how to manage
the treatment regimen would constitute skilled nursing services.
Where the teaching or training is reasonable and necessary to the
treatment of the illness or injury, skilled nursing visits for teaching
would be covered.
When is teaching & training no longer covered?
Where it becomes apparent after a reasonable period of time that the
patient, family, or caregiver will not or is not able to be trained, then
further teaching and training would cease to be reasonable and
necessary.
The reason why the training was unsuccessful should be documented
in the record.
16. There are essentially three types of teaching:
Initial Teaching of a patient requires instruction on a new
order, new medication, new diagnosis. The specifics should
be clearly stated,, if a med change or new med, what
specifically was taught as to the administration of the med
and how it impacts upon the disease process.
Reinforced Teaching requires teaching/instruction on
something the patient and/or caregiver may be
knowledgeable of, but needs additional teaching.
Re-teaching involves evaluation and reinstruction on a
medication, diagnosis, treatment, etc that the patient or
caregiver has had prior instruction.
What was to be taught, how it would be taught, how the
clinician knew there was learning does not appear to be
clearly delineated within several of the records.
17. Congruency Congruency Congruency
Therapists use many tests to measure baseline and
progress. Be certain the same test is used to
demonstrate progress or regression.
Objective data/documentation supports findings
throughout the episode.
Protect your dollars…have objective supportive data
for findings.
Five denied visits out of 24 billed can mean a loss of
approximately $1200.00
18. Prior to 2008, the more than 50% of high therapy
cases ended with 10-13 visits
With the move to the tier model in 2010, this group
has declined and significant growth has occurred in:
6-9 visits
14-19 visits
20+ visits
19. Full or partial denial because the clinical
documentation:
Did not support the medical necessity of the skilled
services billed
Did not demonstrate a reasonable potential for
change (improvement) in the medical condition or
Sufficient time had been allowed for teaching or
observation of response to treatment in prior
episodes of care.
20. How many therapy visits are you averaging per
episode? Percentage of patients receiving therapy?
Of the patients who receive therapy, what is the
distribution (%) across the ranges?
How does your agency compare with your peers
regionally or nationally?
Do response levels on functional M items correlate
with therapy referrals? High-Low levels of
impairment?
21. Do therapy treatment plans and progress notes have:
Clear functional goal statements?
Document progress toward goals objectively?
How is care coordinated among therapists? Among all
disciplines?
How can you support “reasonableness and medical
necessity?”
What is the patient treatment: diagnoses? Restoration/maintenance of
function affected by illness? Frequency and duration of services
consistent with home care client’s: medical history, disease, prior to end
of episode level of function, and risk identification.
22. Is therapy consistent with the nature and severity
of the condition?
Therapy services must be provided, expecting that
the condition of the patient will improve in a
reasonable period of time.
Documentation of medical necessity should be
documented through evaluation, treatment plan, and
progress notes.
Has your agency identified high risk diagnosis,
number of visits, or number of episodes?
23. RACS are paid on a contingency fee basis
Focus: High dollar improper payments with highest return
for RACS (for dollars invested)
Belief is that Coding, Homebound status, Therapy use,
Wound Care, Co-Morbidities, and Medical necessity will
be scrutinized
RACS must pay back contingency fees if they lose appeals
RAC program to cost .22 cents for each dollar returned
to the trust funds (Based on RAC performance with
Hospitals)
25. Medicare Administrative Contractors have replaced fiscal
intermediaries.
January, 2009 CMS announced the awarding of the final
MAC contracts to a total of 15 companies. Each now has a
jurisdiction.
California is in district 1 and New York is in jurisdiction 13.
MACs have been transitioning in and replacing the Regional
Home Health Intermediaries (RHHIs) They can act with
RACs.
Of the 15 MACS, 4 will service only DME claims
CMS has assigned agencies that provide Home Health AND
Hospice to four “specialty” MACs (regions 1, 6,11,14,15)
Auditing claims and making coverage determinations more
quickly is the ultimate goal and remains same in 2014
26. Full or partial denial because the clinical
documentation:
Did not support the medical necessity of the skilled
services billed
Did not demonstrate a reasonable potential for
change (improvement) in the medical condition or
Sufficient time had been allowed for teaching or
observation of response to treatment in prior
episodes of care.
27. While agencies worry about RACs, Remember,
a MAC can place an agency on focused review
for a year, if it identifies potential cause.
Answer ADRs promptly!
29. MICs Medicaid Integrity Contractors
MICs are expected to complete four program
integrity activities:
1. Review provider actions
2. Audit claims
3. Identify overpayments
4. Educate providers, managed care providers,
beneficiaries, and others with respect to payment
integrity and quality of care
30. Program Integrity efforts target Medicare and
Medicaid Individually as well as Medi-Medi
MICs have been labeled as the “RACs for
Medicaid”
MICs are not paid by contingency fee but fee for
service
Renewal of MIC contract is based on successful
performance
Dollars identified or recovered are not tied to
compensation of the MICs
MICs must comply with state-imposed
requirements
32. ZPICs will perform Medicare Program integrity
functions for CMS
Each MAC will interact with one ZPIC to handle
fraud and abuse issues within their jurisdictions
ZPICs are seen to consolidate work of present CMS
Program Safeguard Contractors (PSCs) and
Medicare Drug Integrity Contractors (MEDICs)
ZPICs are divided into 7 zones.
33. Bill Dombi, Chief Legal Representative for NAHC
stated (4/20/2010), “If an agency receives a Z-PIC
letter, they should just call their legal counsel”
The RACs act with the Department of Justice and
FBI as the investigators when fraud is very strongly
thought to have been found. When the ZPICs notify
an agency, they have already discerned an issue.
35. The more aggressive investigator of essentially
DME and HH
Expansion of DOJ/CMS/HHS Inspector General
Medical Strike forces to Baton Rouge, Brooklyn,
Detroit, Houston, LA, Miami-Dade, McAllen, TX,
and Tampa Bay
Using state of the art technology to expand the
CMS Medicaid and Medicare provider audit
program
This program leadership has meetings with top
anti-fraud leaders in Congress/Law
enforcement/Private sector
36. “Providing additional resources to our civil
enforcement efforts under the False Claims Act
to increase dollars recovered; data sharing,
including access to real time data; detect
patterns of fraud through technology;
strengthening partnerships among Federal
agencies between public and private sectors.”
CMS
38. Readying for P4P
Looking at patient /beneficiary outcomes
Assessing beneficiary satisfaction
39. Why has CMS moved to CAHPS?
Measure patient perception of care- Are
consumers happy with the home care they
received?
Component of Home Health Quality Initiative
(HHQI)
Place in public domain for beneficiary informed
decision
Possible component of P4P
40. Similar in that they will rate providers
CAHPS asks patients to report experiences
Focus: Aspects of care patients find important
Aspects of care patients can report on
CAHPS reports are specific, actionable, objective
36 questions re patient experience and characteristics
of care
41. Everything starts with a solid assessment,
congruent OASIS,
an individualized clinical careplan,
coding to the highest level of specificity,
and correct sequencing to drive the Plan of
Care:
the result is Proper payment
43. Agencies must support services and care (NAHC,
2009, 2012)
This starts with the correct tools
This starts with excellent assessments and care
plans
This starts with expert ICD-9-CM Coding…more
than just a coder…..a process…a process designed to
target weaknesses and build on strength
44. With RACs, MACs, and ZPICs, increased scrutiny
abounds.
Be certain visit documentation links to a documented
diagnosis.
Are the OASIS answers congruent? How are you
verifying congruency of answers?
Be certain there is coordination among the team.
Therapy and Nursing activity must be connected to
specific functions, tests, and goals.
Patient responses to treatments and interventions should
be clearly stated.
Measurements of progress toward goals should be
clearly documented throughout the episode.
45. NEW NUMBERING
SYSTEM NUMBERING BY SYSTEM
Tracking Items M0010-
M0150
Clinical Record Items M0080-
M0110
Patient HX and Diagnoses
M1000s
Living Arrangements M1100
Sensory Status M1200s
Integumentary Status
M1300s
Respiratory Status M1400s
Cardiac Status M1500s
Elimination Status M1600s
Neuro/Emotional/
Behaviorial Status M1700s
ADLs/IADLs M1800s/M1900s
Medications M2000s
Care Management M2100s
Therapy Need/POC M2200
Emergent Care M2300
Data collected at
Transfer/DC M2400s
M0903 and M0906
46. Is your billing process/system order centric?
Be certain documentation is prompt, clear, concise
based upon realistic goals within realistic
timeframes…on each visit:
Does each note specifically identify wound care, IV
administration, and flushes?
Are education and patient teaching sessions clear
with patient responses and documentation of
progress or reevaluation need or completion?
47. Starts with a great tool, an experienced
well educated clinician and knowledge of
basics like…..
48. CMS is promoting evidence-based care practices
The conditions targeted by the new OASIS-C
process measures: diabetes, heart failure, pressure
ulcers
Prevention oriented situations: falls and depression
49. Implementation of best practices:
diabetic foot care
pain management
influenza and pneumococcal vaccinations
risk assessments for pressure ulcers
risk assessments for depression
risk assessments for falls
50. Care Processes mean the use of assessment tools
(included in a comprehensive assessment) or the
planning and delivery of specific clinical
interventions
Several evidenced-based screening tools can be
considered “best practices” in home health. OASIS-C
includes data items to measure these processes.
52. Measuring how customers (patients) view their
experience
Inpatient and emergent care home health
assessments
Functional status improvement
Clinical symptoms assessment and change
Pain assessment and intervention
Education of patients and caregivers
Patient care quality
53. 25 Process Measures in Total
Represent 7 Domains: Timeliness of Care
Assessment
Care Planning
Care Coordination
Care Plan Implementation
Education
Prevention
54. 1.Timely
Care
2. Assessment
3. Care Planning
4. Care
Coordination
6. Education
7. Prevention
5. Care Plan
Implementation
55. Date of referral and physician-ordered start of care (timeliness)
Patient-specific parameters for physician notification (care coordination)
see M0102 and M104 below
(NQF endorsed – will appear on Home Health Compare and
CASPER/OBQI)
56. Physician Notification Guidelines Established
Percentage of home health episodes of care in which the
physician ordered plan of care establishes limits for
notifying the physician of changes in patient status.
Looking at how many episodes of care had a specific
date and how many started within 2 days of the referral
date.
See the SOC/ROC M2250 Patient-specific parameters
for notifying physician plan of care
Not NQF endorsed but will appear on CASPER
Reporting/OBQI
57. Four Assessment measures
All NQF endorsed and will appear on Home
Health Compare:
Depression Assessment
Multifactor Fall Risk Assessment
Pain Assessment
Pressure Ulcer Risk Assessment
60. If the answer is a 2 or a 3 or a 4?
Do you have an algorithm?
Do you have a psych nurse?
Having a current prescription for a hypnotic
increases suicide risk by four times…..ABQAURP,
2012
61. CMS is looking at the percentage of home
health episodes of care when patients were
screened by a standardized depression tool at
the SOC.
62. So you have a psych team?
Does your psych team include an OT?
Occupational Therapy is becoming a key
member on the team
So much of therapy for depression requires healthy
displace of hostility.
The RN therapist frequently uses words and
counseling.
The Occupational therapist frequently uses
activities.
63. “sedative treatment was associated with nearly
fourteen-fold increase of suicide risk…”
www.biomedcentral.com/1471-2318/9/20
64. OTs can assist with Stress Management and
Self Awareness
Anger and Conflict Management
Self Esteem Building
Basic Living Skills
Relaxation Techniques
Grief Counseling
The OT can assist, using various tools and activities
The trained OT can use the Mini Mental status exam and the
Geriatric Mood Assessment
65. Is the Geriatric Mood Assessment Tool one of
your approved tools?
What other tools are you using or considering?
Must all tools used be approved by agency
leadership?
Even therapy tools?
69. M1910- Multi-Factor Fall Risk Assessment
Falls history, multiple medications, mental impairment,
toileting frequency, general mobility/transferring
impairment, environmental hazards.
A good assessment is necessary as M2250 asks whether the
physician-ordered POC includes fall prevention
interventions. M2400 asks whether interventions to
prevent falls were ordered in the plan of care and
implemented.
Falls Risk assessment, planning and interventions
(safety)
So, after the assessment, what is the algorithm?
74. Domain:
Formal pain assessment, pain interventions, and
pain management steps (effectiveness of care)
Look at your agency SOC/ROC M01240 and M1242
and note how integrated assessment information is
sought.
What information is collected ?
75.
76. Measuring pain using a standardized tool
Measuring the patient’s acceptable pain level
Let’s discuss the advantages of having an
acceptable pain level measurement.
79. M1300, M1302 risk of developing pressure ulcers
The clinician/agency will determine if a risk assessment was
performed and the patient has a risk
M1300 asks if the patient was assessed for risk of developing
pressure ulcer. If the answer is “yes” then the clinician is asked
if the assessment was based on an evaluation of mobility,
incontinence, and nutrition or using a standardized tool.
Many agencies use the standardized Braden or Norton Scale.
Remember, the answer “yes” can only be chosen when the
clinician completing the OASIS C assessment is also the
person completing the pressure ulcer assessment. OASIS Contractor,
NAHC Conference, 10/2011
M1302 asks what was concluded about the patient’s pressure ulcer
risk,
80. Influenza and pneumococcal vaccines (population health
and prevention) is only collected at transfer RFA 6/7 but,
should this information be collected at the SOC/ROC RFA1/3
or on the Agency Referral form so it is readily available?
The agency (You) will need a process to keep current on this
item. Perhaps, when recertifications are sent to the
physician, this question can be asked/clarified/verified?
81. Two items focused on medication safety:
M2002 Potential Medication Issues identified and
Timely Physician contact at SOC
M2004 Potential Medication issues identified and
timely physician contact during the episode
85. Besides the present demographic and statistical data
collected: Name, address, phone, next of kin, DOB,
payor, recent hospitalizations, and medications…
Now, collect M0102 Date of Physician Order
M0104 Date of Referral
Status of Immunization
Previous Diagnoses and manifestations such as neuropathy,
CKD/ESRD, PVD, Peripheral circulatory, and
opthalmic conditions.
Procedure Codes
History of Pressure Ulcers
86. In OASIS-C, CMS wants to include a way to measure an agency’s
use of evidence-based best practices…give good care after strong
assessment, screening, and care planning for predictable outcomes.
Research shows that best practices assist to prevent exacerbation
of serious conditions. Agencies that do not invest in an education
EBP thinking may have significant difficulty with CMS and its
many audit arms.
It is expected that processes of care implemented according to
evidence-based guidelines will ultimately lead to better clinical
outcomes.
87. What will be your process following the
assessment?
Will the clinician alone determine the CP and
POC?
Do you have algorithms in place?
When will you audit the care?
How will you look at clinician productivity?
Individually? As part of a team?
Do you have a billing audit tool in place?
Do you have a RAC audit tool? Is there a
difference?
88. Evidenced-Based decision making is based not
only on available evidence but also on patient
characteristics, situations, and preferences.
Buyssess and Wesley have identified that
Evidenced Based Practices may be defined as
“treatment choices based not only on outcome
research but also on practice wisdom (the
experience of the clinician) and on family
values (the preference and assumptions of a
client and his or her family or subculture).
89. We cannot lose site of the fact that good clinicians
want to care for their patients as they attain,
maintain, or recover optimal health.
Assisting the clinician with tools to bridge the
span from assessment and SOC to Discharge and
planned outcomes becomes the daunting task.
Quality care delivery and improvement
processes are co-existent with a solid bottom
line. It is establishing the proper process, for
each domain, that is the leader’s challenge. But
then, you are up to the task!
90. Contact Susan Carmichael at:
susanc@selectdata.com
or call: Select Data
714.524.2500 x235