Released: The Dartmouth Institute’s Report for Opportunities Related to Hospital Acquired Conditions and Readmission Rates

Unless hospitals curtail the trend of  “excessive numbers of patients returning shortly after they are discharged,” hospitals could face the Medicare penalties for high readmission rates that take effect in October 2012. (U.S. Hospitals, Facing New Medicare Penalties, Show Wide Room for Improvement at Reducing Readmission Rates, p. 1 (Sept. 28, 2011)). The Dartmouth Report analyzed all 10.7 million Medicare patient hospital discharges between July 2003 and June 2009, and found little variation.

While surgery patients were the least likely to be readmitted (12.7% re-hospitalized in 30-days), congestive heart failure, pneumonia, hip fractures and other conditions showed significant room for improvement. (Kevin O’Reilly, Hospitals Make Almost No Headway in Cutting Readmissions, amednews.com (Oct. 10, 2011)). Variations in re-admission rates were noted between regions. Following-up with a primary care physician, inadequate discharge planning and lack of care coordination were just a few of the causes sited.

Faced with the prospect of Medicare pay being cut up to 1% in 2012 for readmission rates for heart attack, heart failure or pneumonia that are higher-than-expected for the 30-day period, providers need to assess their clinical documentation and care plans now. Otherwise, the penalty will only increase in October 2014 to 3%. (Ibid.)

Posted on: 22 Oct, 2011          under: Uncategorized

Problems With Reducing Physician Medicare Payments

There has been a great deal of attention given to The Medicare Payment Advisory Commission’s (MedPAC) recommendation to be given to Congress at the end of October 2011 to repeal the sustainable growth rate formula (SGR). SGR establishes Medicare payments to physicians and if Congress does not adopt another payment plan or come up with an alternative before January 1, 2012, physicians face a 30% pay cut. (Healthcare Financial Management Association, MedPAC Votes to Repeal SGR Formula (Oct. 13, 2011)).

The congressional “super committee” challenged with reducing U.S. budget deficits, is considering a “doc fix” in its recommendations, which is due November 23^rd. A major item is that the 10-year cost of fixing the SGR is in excess of $300 billion. The short-term band-aid solutions that prevented the pay cut in recent years is also adding to the federal deficit. (Donna Smith, U.S. Deficit Panel Weighs Medicare Doctor Payments, Reuters (Oct. 12, 2011)).

In addition to determining how to solve the payment conundrum, the Health and Human Services Office of the Inspector General is reviewing the impact of physicians opting out of Medicare. Physician acceptance of Medicare patients decreased 2.6% between 2005 and 2008, but 61% indicated they would consider leaving Medicare if payments were significantly reduced from current levels. (Charles Fiegl, OIG to Study Physicians Who Leave Medicare, www.ama-assn.org (Oct. 13, 2011) citing the June 27, 2011 Archives of Internal Medicine, archinte.ama-assn.org/cgi/content/extract/171/12/1117).

Considering the financial impact on providers, accurate clinical documentation should be at the top of their list of concerns.

Posted on: 14 Oct, 2011          under: Uncategorized

HHS Secretary Submits Recovery Auditor Contractor Report to Congress

Per Section 6411(c) of the Affordable Care Act, “The Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall submit an annual report to Congress concerning the effectiveness of the Recovery Audit Contractor program under Medicaid and Medicare and shall include such reports recommendations for expanding or improving the program.”

The Report, Implementation of Recovery Auditing at the Centers for Medicare & Medicaid Service, FY 2010, highlighted that a majority of the year was spent on refining processes and that $92.3 million in overpayments and underpayments were identified. The auditors who participated in the Recovery Project (HDI (Region D) and Connolly, Inc. (Region C)) identified a greater number of improper payments. “To ensure claims are accurately reviewed, each Recovery Auditor is required to employ certified coders, nurses, and/or therapists. On a case-by-case basis, Recovery Auditors often consult with physician specialists for complex matters involving medical necessity determinations.” (CMS Report at p. 11).

A highly effective way to mitigate adverse medical necessity determinations is to utilize a peer-to-peer approach to clinical documentation compliance improvement.

Posted on: 8 Oct, 2011          under: Uncategorized

Compliance and the Role of Clinical Documentation

Generally, “compliance is a state of being in accordance with established guidelines, specifications, or legislation or the process of becoming so.” (PPMpractitioner, Regulatory Compliance Programmes (Dec. 19, 2010)).  One area that falls under the umbrella of compliance is clinical documentation. The importance of clinical documentation has been set forth in the 1997 Documentation Guidelines for Evaluation and Management Services and indicate, “The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.” (page 3).

So, what is clinical documentation and why is it important?

“Medical record documentation is required to record pertinent facts, findings and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates: (1) the ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her health care over time; (2) communication and continuity of care among physicians and other health care professionals involved in the patient’s care; (3) accurate and timely claims review and payment; (4) appropriate utilization review and quality of care evaluations; and (5) collection of data that may be useful for research and education.” (University of North Texas Regulatory Compliance Office, Clinical Documentation & Compliance Manual: A Guide to Documentation, Coding and Billing of Medical Services for Compliance (Apr. 27, 2004) citing the 1997 Documentation Guidelines for Evaluation and Management Services).

With ICD-10 implementation, increases in government audits from Recovery Audit Contracts (RAC) and other auditors, and Centers for Medicare and Medicaid (CMS) initiatives such as Hospital Acquired Conditions and Value-based Purchasing that rely on medical record content, it is imperative that providers are as accurate as possible. Furthermore, it may end up serving as a legal document to verify the care provided in a number of circumstances.

Posted on: 1 Oct, 2011          under: Uncategorized

The Difference Between Medical Necessity and Meaningful Use

There has been a great deal of focus by the Centers for Medicare and Medicaid (CMS) surrounding medical necessity and meaningful use. (https://www.cms.gov). Both are important for providers to know from a compliance standpoint. In order to assist providers, these are the nuances of the respective terms.

Medical Necessity – The Social Security Act states, “no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” The problem arises in trying to define what “reasonable and necessary” means. In order to assist with this ambiguity, CMS set for National Coverage Determinations (NCDs). (www.cms.hhs.gov/mcd.search.asp). For physicians, who provide services based on their clinical judgment, just because a course of treatment falls within professional standards, does not mean it will be covered. Furthermore, physicians and hospitals will need to substantiate a claim by providing an accurate and comprehensive medical record.

Meaningful Use – The American Recovery and Reinvestment Act of 2009 expressed three main components: (1) the use of a certified EHR in a meaningful manner; (2) the use of certified EHR technology for electronic exchange of health information to improve quality of health care; and (3) the use of certified EHR technology to submit clinical quality and other measures. “Simply put, “meaningful use” means providers need to show they’re using certified EHR technology in ways that can be measured significantly in quality and in quantity.” (See CMS EHR Meaningful Use Overview). Eligible hospitals, including critical access hospitals, must report on all 15 of their clinical quality measures in order to demonstrate meaningful use.

In either instance, it is imperative that the medical record is complete and comprehensive.

Posted on: 25 Sep, 2011          under: Uncategorized

Recovery Audit Contractors Role Expands to Include Medicaid

Beginning January 2, 2012, states will be required to create and sustain a relationship with a “Recovery Audit Contractor” (RAC) to identify improper payments and fraud within state administered Medicaid programs.  Section 6411 of the Patient Protection Affordable Care Act was implemented on September 14, 2011, when The Department of Health and Human Services released a final rule. (42 CFR Part 455).

The Medicaid RAC program’s final regulations include:

• Payment system between states and Medicaid RACs;
• State discretion in determining whether or not to exclude Medicaid managed care claims from Medicaid RAC review;
• Coordination between RAC and other audit entities;
• States establish limits on the number and frequency of medical records to be reviewed by Medicaid RACs, but RACs may request exceptions;
• Three-year look back period on reviewing claims UNLESS the state approves; and
• States need to establish an adequate appeal process for providers to dispute adverse determinations. (Rani Singh, HHS Releases Final Medicaid Recovery Audit Contractor Rule (Sept. 16, 2011).

The expected recovery estimated by HHS is $2.1 billion over five years. A significant portion is projected to be returned to the states.

In light of this new rule, it is important for providers to assess their current clinical documentation improvement and compliance programs.

Posted on: 18 Sep, 2011          under: Uncategorized