NARHC Spring Institute

Transcription

1 NARHC Spring Institute Wednesday, March 21, 2018 San Antonio

2 Drawing for Prizes Must be present to win!

3 Develop Your Practice Management Toolbox Teresa Treiber Manager RHC & CAH Regional Practices Spectrum Health

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5 [ Develop your Practice Management Tool Box Survey Readiness and Maintaining Compliance Teresa Treiber March 21,

6 [ Objectives Learn how to develop an Evidence Binder Understand the importance of tracking and monitoring tools for compliance Learn the value of exam room standardization Understand the importance of Mock Surveys and how to develop a good Mock Survey tool Learn how to incorporate a quality chart review process 3

7 [ Evidence Binder Create a binder to house all of the documentation that will be requested by the surveyor at time of survey. Format and organize the binder in a manner that works best for you. Create sections that are labeled for quick reference. Review this binder at least quarterly to identify items that may be expiring or information that should be updated. Make sure that key staff know where to find your binder in case you are not there when a surveyor shows up for an unannounced survey. This binder will make your survey go much more smoothly and your surveyor will appreciate your organization and knowledge of what they will need. 4

8 Evidence Binder Suggested Evidence Binder contents make sure they are all current! 5 HPSA designation confirmation (printed from HRSA website) Copies of providers CV, state license, DEA, BLS and yearly training Copies of all staff job descriptions (including the Medical Director) Copy of clinic floor plan Yearly electrical inspection and bio-medical report Emergency drills documentation and staff sign-in sheets Current organization chart Most current yearly advisory meeting minutes All clinical staff BLS, certifications, licenses and yearly competency training Copy of CLIA (copy should also be posted in your lab area) Copy of DEQ license

9 Evidence Binder Suggested Evidence Binder contents cont. At least the last 2 completed chart review forms Roster of all current staff and physicians that also lists job title and FTE status Recommend creating additional binders for the following: Sample medication logs SDS information Various compliance monitoring and tracking logs (exam rooms, medication areas, housekeeping, lab area) Policy Manual 6

10 Evidence Binder 7

11 Compliance monitoring tools Utilizing various monitoring tools will: Keep your clinic RHC compliant Help hold staff accountable Provide your surveyor the proof that you continually maintain compliance and follow clinic policy. Monitoring tools can be utilized daily, weekly or monthly depending on your specific needs. 8

12 Compliance monitoring tools Examples of monitoring tools Exam room Supply room Medication storage rooms Cleaning logs Lab area review log AED log Eye-wash station Examples of these documents are provided in your conference material. 9

13 Exam Room Standardization Sometimes Less is more! 10

14 Exam Room Standardization Determine what supplies and the quantity that are used daily. Standardize the contents and quantity of supplies in each exam room to reflect what you use. Remove or limit supplies that are rarely used. Keep a master stocking list with expected daily quantities in each room. 11

15 Exam Room Standardization Standardization benefits: Reduces staff time spent during monthly review for expired medications. Reduces overstock and potential for waste of expired supplies. Reduces time spent by providers and staff searching for supplies during an exam or procedure. Reduces potential for theft. 12

16 Mock Surveys Are you performing mock surveys at your RHC? Mocks surveys should be performed at least annually. This will identify areas that are non-compliant. Mock surveys will also help to identify where additional staff education may be needed. Identify key staff to assist with surveys. This will prepare them to handle an official un-announced survey if you are not in the office. These surveys can also be reviewed at your program evaluation meeting and used as part of your quality assurance program. 13

17 Mock Surveys RHC deeming agencies can have additional quality and patient safety standards. It is important that you know these additional standards and incorporate them into your mock survey tool. Review your deeming agency standards annually. They may have changed or added new standards. 14

18 Mock Survey Complete document shown below can be found in your conference materials 15 RHC MONTHLY QUALITY, SAFETY and INFECTION PREVENTION ROUNDING TOOL * IF "NO" IS MARKED FOR ANY ANSWER, THE ACTION TAKEN AND OTHER COMMENTS MUST BE DOCUMENTED 2 Standard Is general appearance and are all surfaces clean, uncluttered, and intact? (This includes furniture, walls, flooring and high areas; look for tears in furniture, peeling floors, holes in walls/chipped paint, decals peeling, scuffs on floors/walls, peeling/chipped laminate) B Rationale Yes No* N/A Environment of Care TCT ADM 11.0; CFR 491.6(b)(3) 3 Housekeeping logs are being maintained. TCT ADM 11.0 CFR491.6(b)(1) Is lighting suitable for care, treatment, or services? (This includes emergency/exit lighting, includes shatterproof lightbulbs in gooseneck lamps or cover) Is there at least 36 inches of clear space (no obstruction) in front of all electrical panels? TCT REG 1.0 TCT EQP 1.0 Are tanks of compressed gasses (oxygen, etc.) properly labeled and secured in holders or chained to the wall? (labeled "full-ready for patient use" or TCT EQP 1.0; Adm 10.0 CFR "empty", storage clearly separated between full 491.9(c)(3) and empty, ambu-bag-valve-mask ventilation supplies attached to tank, any used tanks to be considered empty) Action Taken/Comments and Initials

19 Quality Chart Review RHC s are required to complete periodic reviews of patient medical records. There should also be documented reviews of mid-level patient charts by a physician. Both the mid-level and the physician must sign the review to validate that collaboration has taken place. The clinic can decide the frequency and number of charts that are reviewed. Surveyor will ask to see your policy and validate that you are completing them according to your policy. 16

20 Quality Chart Review Surveyors will also complete a chart review audit at time of survey to audit the requirements listed in CFR (3) For each patient receiving health care services, the clinic or center maintains a record that includes, as applicable: (i) Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; (ii) Reports of physical examinations, diagnostic and laboratory test results, and consultative findings; (iii) All physician's orders, reports of treatments and medications, and other pertinent information necessary to monitor the patient's progress; (iv) Signatures of the physician or other health care professional. 17

21 Quality Chart Review Spectrum Health grew from 8 provider-based RHC s in 2013 to 29 clinics by As we started through the survey process early on; we continually were cited for issues with chart completion regarding the documentation requirements in CFR Several issues were identified including issues with our EMR tools, process flows and additional education needs. 18

22 Quality Chart Review As a result, a new chart review tool was developed that would monitor these items quarterly to identify and resolve issues. We also added a second section to this chart review that captured the mid-level chart review process. Additionally, we enhanced the tool to include various quality and best practice metrics as well as PCMH initiatives. We also created a dashboard to monitor progress. This is reviewed at our annual program evaluation as part of the quality assurance program review. 19

23 Chart Review and Quality Tracking Tool Section 1 to be completed by office manager or designated staff for all providers (Physicians and APP's) Provider Name: Quarter of review: MRN Number Date of Service For each patient receiving health care services, the clinic maintains a record that includes, as applicable: Chief complaint or reason for the encounter P A P A P A P A P A Pertinent medical history and/or surgical history P A P A P A P A P A Known long-term medications, including current medications, over-thecounter drugs, and herbal preparations P A P A P A P A P A Social data (i.e.. marital status, habits, occupation, etc.) P A P A P A P A P A Smoking Status P NA A P NA A P NA A P NA A P NA A Family hx P A P A P A P A P A Known adverse and allergic drug reactions; P A P A P A P A P A Assessment of the health status, including complete vital signs on all patients every visit starting at age 2: Pain is assessed in all patients. (A comprehensive pain assessment is conducted as appropriate to the patient's condition and the scope of care, treatment, and services provided.) P NA A P NA A P NA A P NA A P NA A Height P A P A P A P A P A Weight P A P A P A P A P A BP (NA under age 3) P NA A P NA A P NA A P NA A P NA A BMI P A P A P A P A P A Report of physical examination P A P A P A P A P A Clinical impression or diagnosis; Brief summary of each episode P A P A P A P A P A Plan for care P A P A P A P A P A The problem list is initiated for the patient by the third visits and maintained thereafter. P NA A P NA A P NA A P NA A P NA A 20

24 Chart Review and Quality Tracking Tool Disposition P A P A P A P A P A Therapies administered and documented P NA A P NA A P NA A P NA A P NA A Orders - Lab reports, as appropriate, with a notation acknowledging results reviewed orders - X-ray and other diagnostic reports, with a notation acknowledging results reviewed P NA A P NA A P NA A P NA A P NA A P NA A P NA A P NA A P NA A P NA A All entries are dated and signed by the physician or other health care professional P NA A P NA A P NA A P NA A P NA A Consultation reports sent or received? P NA A P NA A P NA A P NA A P NA A Consent for procedure form if applicable P NA A P NA A P NA A P NA A P NA A Immunizations P A P A P A P A P A Mammogram every two years from age 40 to 69 P NA A P NA A P NA A P NA A P NA A Colonoscopy every ten years beginning at age 50 through age 75 P NA A P NA A P NA A P NA A P NA A Depression screening completed? P NA A P NA A P NA A P NA A P NA A Discharge instructions to the patient P A P A P A P A P A General Consent for treatment form (to be done yearly) done by front desk P A P A P A P A P A "People involved in pt care" form completed by front desk? P A P A P A P A P A Physical Exam Adequate Diagnosis supported by H & P Appropriate Us of Lab/Xray Plan/use of meds appropriate Plan of care appropriate Section 2 ( to be filled out by provider for APP charts only) Provider signature: APP signature: Date: Date: Comments: 21

25 Tips to help you be successful Involve your staff! They have the best ideas. Ask for their input or to help make modifications to fit your needs. Identify key staff that can help perform monthly reviews. Get staff on board! Approach this as not only RHC compliance but also patient and staff safety. Discuss findings of reviews during staff meetings. 22

26 23 Questions

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28 Audit Your Practice Like a CPA Jeff Bramschreiber CPA, Partner Wipfli LLP

29 National Association of Rural Health Clinics Audit Your Practice Like a CPA Jeff Bramschreiber, CPA Health Care Partner March 21, 2018 Wipfli LLP 1

30 Audit Overview Do-It-Yourself Audit Approach Conclusion/Take-Aways Wipfli LLP 2

31 Wipfli LLP 3

32 What Is an Audit? An audit is the examination of an entity's accounting records, as well as the physical inspection of its assets. If performed by a certified public accountant (CPA), the CPA can express an opinion on the fairness of the entity's financial statements. This opinion is then issued along with the financial statements to the investment community, owners, and other stakeholders. Wipfli LLP 4

33 Audit Cost vs. Benefit Benefits Reassurance to investors/lenders Internal control/safeguarding of assets Educational to physician/owners Performance measurement for employees Possible support in the event of an investigation (attorney client privilege must be considered) Costs Significant professional fees Ongoing time/cost performing testing and maintaining records of results Wipfli LLP 5

34 When Does An External Audit Make Sense? When it is required by law (e.g. publicly traded). When it is required by a lender (e.g. bank) or grantor (e.g. HRSA). When attempting to attract investors or donors. When there are absentee owners. When seeking outsiders perspective on financial operations and results. Wipfli LLP 6

35 The Auditing Process Understand the Client and Environment Perform Risk Assessment Test Controls Substantiate Account Balances Issue Audit Report Wipfli LLP 7

36 Wipfli LLP 8

37 DIY Audit Approach Six Potential Risk Areas for Rural Health Clinics: 1. Internal Controls and Accounting System Design. 2. Rural Health Clinic Conditions of Certification. 3. Provider-Based Qualifications. 4. Billing and Coding. 5. Medicare/Medicaid Cost Reporting and Settlements. 6. Accounts Receivable Valuation. Wipfli LLP 9

38 DIY Audit Approach 1. Internal Controls and Accounting System Design. Resources for auditing Internal Controls and Accounting System Design: Job Descriptions and Accounting Procedures. Segregation of Duties; Checks and Balances. Evidence of Oversight by Owners/Directors. Financial Reporting and Reviews. Budgets and Budget-to-Actual Analysis. Wipfli LLP 10

39 DIY Audit Approach 2. Rural Health Clinic Conditions of Certification ( CofC ). Resources for auditing compliance with CofC : Form CMS 30. State Operations Manual (SOM) Appendix G. AAAASF or The Compliance Team survey checklists. RHC Policy and Procedure Manual. Wipfli LLP 11

40 DIY Audit Approach 3. Provider-Based Qualifications. Resources for auditing compliance with provider-based qualifications: CMS Transmittal A (April 18, 2003). Medicare Administrative Contractor sample attestation statement. CMS Provider-Based Designation Checklist (updated October 27, 2017). Provider-Based Attestation Statements filed by the facility. Wipfli LLP 12

41 DIY Audit Approach 4. Billing and Coding. Resources for auditing billing and coding compliance: Billing guidance in RHC Technical Assistance webinar (February 2, 2018). Chart reviews conducted for annual RHC Program Evaluation. Third party payer denial reports. Office of Inspector General (OIG) Compliance Program. Practitioner code frequency statistical analysis. Wipfli LLP 13

42 DIY Audit Approach 4. Billing and Coding (continued). Sample practitioner code frequency statistical analysis. Wipfli LLP 14

43 DIY Audit Approach 5. Medicare/Medicaid Cost Reporting and Settlements. Resources for auditing cost reporting: Audited/finalized cost reports with adjustments. Filed but not audited cost reports. Medicare Provider Reimbursement Manual, Cost Reporting Forms and Instructions. State Medicaid Program, Cost Reporting Instructions (varies by state). NARHC Rural Health Clinic Benchmark Report. Wipfli LLP 15

44 DIY Audit Approach RHC Benchmark Report A NARHC Member Benefit Compare your RHC productivity and costs with providerbased RHCs in your state, region, and nationally. Wipfli LLP 16

45 DIY Audit Approach 5. Medicare/Medicaid Cost Reporting and Settlements (cont). RHC Benchmark Report RHC MI Mean Midwest Mean Nation Mean Number of Facilities ,094 Encounters per FTE: Physicians 8,500 3,688 3,857 4,274 Physician Assistants 2,398 3,200 3,171 3,145 Nurse Practitioners 0 3,071 2,722 2,884 Visiting Nurses Midlevel Staffing Ratio 90% 49% 51% 53% Midlevel Visit Ratio 72% 45% 44% 44% Cost per Encounter: Physician Physician Assistant Nurse Practitioner Visiting Nurse Clinical Psychologist/Social Worker Total Health Care Staff Cost Cost per FTE: Physician 2,263, , , ,802 Physician Asstistant 0 129, , ,904 Nurse Practitioner 0 110, , ,413 Total Healthcare Staff Costs per Provider FTE 129,642 86,509 96,463 93,011 Wipfli LLP 17

46 DIY Audit Approach 6. Accounts Receivable Valuation. Resources for auditing accounts receivable: Subsequent receipts. Credit balance report. Historical reimbursement by payer. Written financial/collection policies and procedures. Accounts receivable ratio. Accounts receivable aging report. Wipfli LLP 18

47 DIY Audit Approach 6. Accounts Receivable Valuation (continued) AR Ratio CY2015 CY2016 April 2017 Benchmark Wipfli LLP 19

48 DIY Audit Approach 6. Accounts Receivable Valuation (continued). April 30, 2017 Actual Data MGMA Benchmark 121+ Days 15% 121+ Days 40% Current 42% Days 6% Days 8% Current 59% Days Days 4% Days 9% 5% Days 12% Current Days Days Days 121+ Days Current Days Days Days 121+ Days Wipfli LLP 20

49 Wipfli LLP 21

50 Conclusion Session takeaways (examples): Wipfli LLP 22

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52 Wipfli LLP 24

53 Today s Presenter: Jeff Bramschreiber, CPA Partner, Health Care Practice jbramschreiber@wipfli.com wipfli.com/healthcare Wipfli LLP 25

54 wipfli.com/healthcare Wipfli LLP 26

55 Network Break (15 min. only) Refreshments in Regency Foyer The Texas Session: New Telemedicine Rules follows. But if you are leaving early

56 The Texas Session: New Telemedicine Rules for Texas Nora Belcher Executive Director Texas e-health Alliance

57 TEXAS SESSION: NEW TELEMEDICINE RULES FOR TEXAS Presentation to the National Association of Rural Health Clinics Nora Belcher, Executive Director Texas e-health Alliance March 21 st, 2018

58 Background- Nora Belcher 20+ years in public policy with an emphasis on health care technology Senior leadership roles in Texas Medicaid and the Governor s Office Involved in starting the SXSW Health and MedTech Expo Won computer programming contest in the 1980s and still has the trophies

59 Background What is the Texas e-health Alliance? State s leading advocate, from local communities to the national level, for the use of health information technology to improve the health system for patients 501(c)6 non-profit started in 2009 and serves as a trade association for HIT companies As such, cannot recommend or endorse specific products Slide 3

60 Role of the Patient is Changing Health information technology landscape is generally thought of as lagging behind the Internet in terms of maturity Image Credit: Jeran_Renz licensed under CC0

61 70 60 Internet use exploded once content became accessible and useful. Internet Revolution: Value to Users % U.S. Households Using the Internet at Home Computer developed - IBM 0 TCP/IP Standard ARPANET First e- mail sent Mosaic Web Browser Prodigy WWW HTML HIT Today Today, health care information technology (HIT) is at the 2000 of the Internet age Source: U.S. Census Bureau, Population Division, Education & Social Stratification Branch, Reported Internet Usage for Households, by Selected Householder Characteristics,:2007 ; Texas ehealth Alliance: Nora Belcher

62 Understanding Telemedicine Telemedicine has three major components by which it succeeds or fails in any state, country or program: -Reimbursement -Regulation -Rhetoric 2/28/2018 6

63 A study conducted by IHS predicted that by 2018, the use of telehealth technology will be more than 10 times that of the 2012 rate. Global Forecast of Telehealth Patients and Device and Service Revenue Source: IHS Technology, January 2014.

64 Reimbursement Landscape Medicaid has shifted in terms of policy and now views telemedicine/telehealth as an essential tool Medicare telehealth limitations still highly restrictive Commercial insurers are aggressively pursuing virtual care models Scope of practice was the battleground issuenow it s reimbursement

65 SB 1107 Developed through a working group led by Texas e-health Alliance, Texas Medical Association and Texas Academy of Family Physicians Authored by Sen. Charles Schwertner, MD, sponsored in the House by Representative Four Price Passed with overwhelming bipartisan votes in both chambers and signed by the Governor Page 9

66 SB 1107 Makes a major change in the way the Texas Medical Board will be regulating telemedicine services that result in a prescription. A practitioner-patient relationship, which is needed for a valid prescription, can now be established using either audio-visual interaction or store and forward technology. The standard of care must still be met, and the practitioner must use clinical information relevant to the encounter. Page 10

67 Texas Medical Board Rulemaking Rules were complete in November 2017 Mental health services were exempt (per SB 1107) Providers must still provide a notice of privacy practices and the TMB complaint process Fraud and abuse prevention protocols are still required Limitations on chronic pain treatment based on existing state and federal law (Ryan Haight Act) Page 11

68 SB 1107 Makes a major change in the way the Texas Medical Board will be regulating telemedicine services that result in a prescription. Joint rulemaking will be done between the Medical Board, Nursing Board, Physician Assistant Board and Pharmacy Board All health professional boards must review their rules to ensure they are not a higher standard of care than the rules adopted by TMB Page 12

69 SB 1107 Modifies the Insurance Code related to telemedicine, which impacts fully insured plans in Texas Requires fully insured plans to publish their policies and payment practices for telemedicine and telehealth on their websites. Clarifies that insurers to not have to pay for textonly s, phone calls or faxes as part of the telemedicine benefit Page 13

70 SB 1107 Modifies the Insurance Code related to telemedicine, which impacts fully insured plans in Texas Clarifies that if a physician who chooses to use telemedicine for a contracted service to a contracted patient, a fully insured plan cannot deny the claim just because telemedicine was used instead of a face to face visit. These changes become effective January 1, 2018 Page 14

71 SB 1107 Removes language from the HHSC statues that govern the Medicaid telemedicine benefit: a requirement that providers go through an approval process before being permitted to provide telemedicine services a requirement for a telepresenter to be involved in Medicaid telemedicine services, and a rulemaking provision that charged TMB with adopting rules governing those situations where a face to face visit would be required before a telemedicine service Page 15

72 Next Steps Medicaid is moving into rulemaking mode Amend HHSC s telemedicine rules in 1 Texas Administrative Code Sec and Amend Medicaid Telemedicine Services Medical Policy. State Plan Amendment to update the definition of telemedicine services. Minor amendments to the STAR Kids and STAR Health contracts to remove reference to televideo services. Page 16

73 Medicaid Benefit Updates Next Steps Remove patient site presenter requirements. Exception for school-based telemedicine services. Remove requirements for initial in-person, faceto-face visit between the physician and patient prior to telemedicine service. Distinguish between fee for service and managed care requirements concerning telemedicine service delivery modalities. Optional reimbursement by MCOs of services provided through audio or text modalities. Page 17

74 Medicaid Reimbursement Changes Next Steps There are no anticipated changes to reimbursable provider types or procedure codes as a result of the S.B implementation activities. There are no anticipated changes to the fee schedules available through the Texas Medicaid & Healthcare Partnership (TMHP) as a result of the S.B implementation activities. Page 18

75 Other Tele Bills HB 1697 by Representative Four Price establishes a grant program through HHSC to assist rural hospitals in purchasing telenicu and tele-icu equipment. HHSC has established a workgroup to work on: Technical specifications for pilots that use open standards to ensure connectivity Leveraging resources available through UTMB to potentially provide equipment for pilot sites Using data to identify pilot sites Page 19

76 Other Tele Bills SB 922 by Senator Dawn Buckingham, MD, requires HHSC to ensure that Medicaid reimbursement is provided for telehealth services provided through a school district or charter school by a health professional, even if the health professional is not the patient's primary care provider. Page 20

77 Other Tele Bills SB 1633 by Senator Charles Perry allows pharmacies to establish remote dispensing sites, defined as a location licensed as a telepharmacy that is authorized by a Class A provider pharmacy through a telepharmacy system to store and dispense prescription drugs and devices. The remote dispensing sites cannot dispense controlled substances and may not be located within 25 miles by road of an existing Class A pharmacy. Page 21

78 So What? Less Regulatory Uncertainty More Clarity on Reimbursement Page 22

79 Questions? Nora Belcher Executive Director Texas e-health Alliance (512) Page 23

80 Thank you for a great conference! Hope to see you at a future conference Fall 2018 in Lake Tahoe Spring 2019 in San Antonio Safe Travels!