FROM BILLING TO BEDSIDE Tim Rowan Editor Home Care Technology Report

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1 FROM BILLING TO BEDSIDE Tim Rowan Editor Home Care Technology Report Home Care Alliance of Massachusetts 2010 Spring Conference Connect Share Innovate HOME HEALTH AND HOSPICE ENVIRONMENT 2010 Is anything important going on this year? OASIS C Medicare pay rate cuts Rise of Private Duty organizations Bankrupt state Medicaid systems Medicare Advantage may end Nursing shortage QIC/PIC/ZPIC/ALJ/MAC/RAC stepping up payment denial activity HOME HEALTH AND HOSPICE ENVIRONMENT 2010 Leading edge of Baby Boomers turns? 1

2 HOME HEALTH AND HOSPICE ENVIRONMENT 2010 Anything else going on this year???? WHAT IS HOME CARE S CONCERN REGARDING THE NEW REFORM LAW? Pre-existing condition rules? Staying on parents policy until age 26? Insurance policy purchase exchanges? Medicare cuts Home Health PPS rate reductions Providing employee health insurance Waste & Fraud abatement efforts Payment Rates Payment Denials Payment Recoupments TO SURVIVE RATE CUTS, UNDERSTAND YOUR VALUE PROPOSITION 2

3 WHO ARE OUR PATIENTS? As you suspected, they really are arriving sicker: CMS contractor Abt Associates measured patient condition at the point of home care start of care. From 1999 to 2007, relative mortality risk did change. 1, % fewer arrive with Mortality Risk Level 1 (minor) 10.57% fewer arrive with Mortality Risk Level 2 (moderate) 14.09% more arrive with Mortality Risk Level 3 (major) 77.46% more arrive with Mortality Risk Level 4 (extreme) 1 Report Shows Patients Come to Home Care After Increasingly Shorter Hospital Stays 2 "Analysis of Home Health Case-mix Change WHERE DO OUR PATIENTS COME FROM? Comparing 2007 to 1999, Abt discovered that, in the 14 days prior to beginning a Medicare home health episode, beneficiaries spent, on average: 31% fewer days in acute care hospitals 6.19% more days in a Medicare Skilled Nursing facility 10.63% more days in a Long Term Care facility 28.43% fewer days in a Rehabilitation facility YOUR ONGOING VALUE TO PAYERS From 1999 through 2007: Average Medicare hospital expenditures for g p p beneficiaries who are discharged to home care decreased 18%, largely due to an average lengthof-stay decrease. PPS case mix creep caused an average expenditure increase of $200 per episode. 3

4 IN SUMMARY Patients arrive sooner and sicker to home care Case-Mix creep costs Medicare $200 In exchange, home care saves Medicare approximately $4,000 ARE YOU SELLING THE RIGHT BENEFIT? Average Percentage Cost Center Cost of Total Total Cost $ 22, % Direct Pt. Costs $ 9,268 42% Day One $ 1,246 6% Hospital Overhead $ 12,799 58% Day of Discharge $ 304 1% ARE YOU SELLING THE RIGHT BENEFIT Tell the hospital you can avoid one rehospitalization Cost Center Average Cost Percentage of Total Total Cost $ 22, % Direct Pt. Costs $ 9,268 42% Day One $ 1,246 6% Hospital Overhead $ 12,799 58% Day of Discharge $ 304 1% Tell the hospital you can shorten length of stay Does your referring hospital s payer need you to reduce lengths of stay? OR Does it need you to control RECIDIVISM 4

5 RECIDIVISM VS. LENGTH OF STAY What, therefore, is your message to hospitals and other referral sources? BECOMING A RECIDIVISM LEADER Data-rich intake Interdisciplinary patient care coordination Fall avoidance programs Remote patient monitoring But the #1, most important, do-or-die, can t-livewithout-it tool NO, IT S NOT TECHNOLOGY The highly-skilled, well-trained, well-equippedequipped nurse and therapist. 5

6 WITH GREAT POWER COMES GREAT RESPONSIBILITY CLINICIANS OWN?? % CONTROL OVER: Company revenue Compliance ADR rate Payment denials Overpayment recoupments MANAGEMENT RESPONSIBILITY: PROVIDE EMPOWERING TOOLS No matter how skilled, nurses and therapists need corporate support. At a minimum: 1. Computer-assisted clinical documentation 2. Quick, easy access to patient records 3. Online OASIS checking services 4. HIPAA protection technologies 5. Regular, high-quality training opportunities 6. Remote patient monitoring technologies CLINICAL TOOLS; Tool #3: ; MANAGEMENT TOOLS 6

7 UNLESS YOUR SOFTWARE VENDOR ALREADY PROVIDES THESE FEATURES CMS risk-adjusted benchmarking OASIS completeness checking OASIS internal logic check OASIS to 485 logic comparison Detailed reporting with drill-down to individual clinician level YOU NEED ASSISTANCE FROM ONE OF THESE SERVICES Acucare Health Strategies Healthcare Systems Solutions (The Analyzer) Home Health Gold Outcome Concept Systems (OCS) PPS Plus Strategic Healthcare Programs (SHP) REMOTE WOUND CARE EXPERTISE ClickCare WOCN Connect 7

8 Tool #4: SAFE DATA, SAFE WORK ENVIRONMENT LOOSE LAPTOPS CAUSE HIPAA HEADACHES MISSING LAPTOP COSTS What does a breach of Protected Health Information cost a HIPAA Covered Entity? Cash You must notify every potentially affected patient Cost of mailing alone can be astronomical Reputation It will hit the newspapers Referrals will be impacted 8

9 TWO TYPES OF TOOLS As in personal health maintenance, approach security breaches in two ways: 1. Prevention 2. Cure PREVENTION Audience question: What are your agency s written policies regarding employee responsibility for company-owned equipment? CURE Absolute Software CompuTrace Software kernel hidden in BIOS GPS Auto-erase programs and data Reveal user IP address Versions for laptops, PDAs, smart phones 9

10 Clinician Support Tool #5 HIGH-QUALITY, ONGOING EDUCATION PATIENT OUTCOMES THERE ARE TWO 1. The one in the patient s body 2. The one on your documentation THEY SHOULD BE THE SAME! WHY CMS LIKES YOU Since : Average 10%-15% discount per episode Data from SHP, OCS, HH Gold and PPS Plus indicate 80%-90% of OASIS corrections increase payment You routinely under-code, under-assess why? Clinical documentation quality, as a whole, is: Excellent Acceptable Sloppy at best Desperately in need of improvement 10

11 UNDERMINING YOUR ABILITY TO SHOW A PROFIT The Medicare Discount Because some of the OASIS questions are HHRG drivers, and most of the inaccuracy in poor assessments is in the form of under-assessing the severity of patient problems, poor assessments undercut your payment. It has been well-researched by Jeff Lewis and others since 2002 that providers continue to give Medicare a 10%-15% discount through improperly under-assessing patients. 31 WHY ELSE DOES TRAINING MATTER? A WORD ABOUT MEDICARE S DISTRACTION For the next year, you have more imminent threats to worry about: Payment denials from RHHI, ZPIC, QIC, MAC, etc. are happening NOW. Primary denial reason: lack of demonstrated medical necessity Medical necessity is demonstrated in clinical documentation 11

12 A BRIEF WORD ABOUT MEDICARE S DISTRACTION Payment denials are happening NOW. RHHI, ZPIC, QIC, MAC, etc. Primary denial reason is lack of demonstrated medical necessity Medical necessity is demonstrated where? SAME ADVICE: PROTECT YOURSELF WITH PREVENTION AND CURE Clinical documentation File timely appeals (Learn Section 935) Don t go in there alone While you are distracted about remotely possible, future overpayment recoupments, there are entities taking your money today: Fiscal Intermediary Program Safeguard Contractor (PSC) Zone Program Integrity Contractor Medicare Program Integrity Medicaid Integrity Program State-based False Claims Act (14 states so far) 12

13 DURING THE DEMONSTRATION PROJECT $1.03 billion in payment corrections. 96% of those were overpayments ($988 million recouped) 4% were underpayments ($40 million repaid) HOWEVER DURING THE SAME 24 MONTHS Fiscal Intermediaries in only three states California Florida New York prevented $1.8 billion in improper payments by denying claims before they were paid. 1 Source: CMS, The Medicare Recovery Audit Contractor Program: An Evaluation of the 3-year Demonstration June 2008 CMS RULE Contractors may only investigate issues that were investigated during the demonstration Contractors may not investigate issues that were not part of the demonstration Contractors may petition CMS to approve new issues not investigated during demonstration How MANY home health care and hospice issues were investigated during the demonstration? 13

14 HOW MANY HOME HEALTH CARE AND HOSPICE ISSUES HAVE BEEN APPROVED BY CMS? HOW MANY HOME HEALTH CARE AND HOSPICE ISSUES HAVE BEEN REQUESTED BY CONTRACTORS AND ARE AWAITING CMS APPROVAL? NOW THAT WE HAVE THAT ISSUE OUT OF THE WAY What would be a reasonable response? Identify the RAC for your region Bookmark k that t contractor s t web site Check periodically to see if they have applied for CMS approval of an issue that might affect you Go do something important 14

15 MEET DIVERSIFIED COLLECTION SERVICES, INC., A PERFORMANT COMPANY In 2008, DCS became one of four vendors on the CMS Recovery Audit Contract (RAC) with a proven track record of quick and thorough recovery efforts. Under the RAC contract, DCS will assist providers in reducing Medicare improper payments, and help cut down on waste and abuse within the Medicare program. CMS APPROVED AUDIT ISSUES: From the DCS Healthcare Services web site: Inpatient hospital 10 DME Suppliers 10 Ambulance Providers 1 CSW Providers

16 WHEN DCS SAYS HOME CARE They mean: Multiple DME Rentals within a Month Oxygen Rentals Solid Seat Inserts and Headrests for Power Wheelchairs with a Captain s Chair Seat Prosthesis Billing Issues Pharmacy Supply and Dispensing Fees Urological Bundling STEPS TO TAKE NOW Perform Self-Audit Outside consultant Random charts Limited date range Current staff Be strict, even harsh on yourself In-service on the results Learn the Medicare appeals process It will be the same for RAC as it is now for RHHI/QIC/ZPIC/ALJ Use attorney or specialized consultant Read RHHI and CMS guidance materials Study Section IF RACS ARE IGNORING US, WHY WORRY? When they do finally turn their attention to home health care, even if it is two years down the road, they will be looking back in time to the charts you are writing today. 16

17 IF RACS ARE IGNORING US, WHY WORRY? It is strongly suspected and widely believed that CMS has imposed payment denial quotas on each RHHI, QIC, MAC and ZPIC. They either crack down on you or lose their contract. REMEMBER HER? WITH GREAT POWER COMES GREAT RESPONSIBILITY CLINICIANS OWN 100% CONTROL OVER: Company revenue Compliance ADR rate Payment denials Overpayment recoupments TRAINING RECOMMENDATIONS CHEX (The Corridor Group) The Hospice Education Network (Weatherbee Resources) Med-Pass Silverchair Learning Systems RBC Limited Healthcare Provider Solutions Carosh Media & Marketing State Associations Live workshops (Decision Health et al) Hire trainer to conduct seminar at your site 17

18 NURSES ARE HUMAN: TRAINING FADES OVER TIME With or without point-of-care software that guides clinical decisions and practice, your #1 patient outcomes improvement derives from clinician skills: Patient care skills Documentation skills Clinician-to-Clinician consistency NURSES ARE HUMAN: TRAINING FADES OVER TIME 1. New information must be renewed every 3 months 2. Training is not to be rolled out only when rules occasionally change 3. It must be consistent, universally available and ongoing Clinician Support Tool #6 REMOTE ELECTRONIC PATIENT MONITORING 18

19 HOME TELEHEALTH 1. Because clinicians cannot be everywhere at once and there are not enough of them. 2. Because it works To improve patient care To reduce agency costs To reduce payer costs HOME TELEHEALTH VENDORS American Medical Alert American Telecare Cardiocom Health Hero Network (Bosch) Homecare Interactive Honeywell HomMed Ideal Life Intel Digital Health Meditech (PtCT) Noninvasive Medical Technology Pharos Innovations Philips Healthcare Phytel Touch Point Care Viterion ViTel Net (Bosch) HOME TELEHEALTH Recent research studies: Robert E. Litan study of October h t h t / ti h VNA of Greater Philadelphia case study by Karen Alston Department of Veterans Affairs demonstration project by Darkins, et al 19

20 VHA CCHT STUDY Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions REDUCTION IN UTILIZATION BY CONDITION MONITORED (SINGLE AND MULTIPLE DIAGNOSES) CONDITION NUMBER OF PATIENTS % UTILIZATION DECREASE Diabetes 8, Hypertension 7, CHF 4, COPD 1, PTSD Depression Other mental health condition Single condition 10, Multiple conditions 6, IMPACT ON COSTS The cost of CCHT was $1, per patient per annum. This compares very favourably to the direct cost of VHA s home-based primary care services of $13, per annum and market nursing home care rates that average $77, per patient per annum. CCHT is therefore a flexible and cost-effective adjunct to VHA s existing NIC services. 20

21 WHEN A REFERRAL SOURCE SAYS, THAT S FINE FOR THE VHA, BUT The processes that support CCHT in VHA are not unique to the organization and it should be possible to implement CCHT or a variant of CCHT in other healthcare systems. WHEN A NURSE SAYS, A MACHINE CANNOT DO WHAT I DO. CCHT does not replace the need for nursing home care or for traditional non-institutional care programs. It does, however, enhance the ability for self-management of chronic disease as well as delaying institutionalization. TECHNOLOGY AND TRAINING: SELF-SUPPORTING CYCLE Ongoing Clinical Training Capital Available for Further Technology Investment Improved Clinical Documentation Increased Revenue Fewer Payment Denials 21

22 FROM BILLING TO BEDSIDE Home Care Alliance of Massachusetts 2010 Spring Conference Tim Rowan Editor Home Care Technology Report 22