Alabama Audit Summit Embassy Suites Birmingham - Hoover April 10, Alabama Hospital Association

Transcription

1 Alabama Audit Summit Embassy Suites Birmingham - Hoover April 10, 2018 Alabama Hospital Association

2 Agenda ALABAMA AUDIT SUMMIT April 10, :00 8:30 Registration 8:30 Welcome 8:30-9:45 OIG/DOJ Update Gregg B. Everett, Esq. and John W. Weiss, Esq. Gilpin Givhan, P.C. 9:45-10:45 CMS Rules and Regulations Relative to Patient Status, Medical Necessity, and the Two Midnight Rule Joan Ragsdale, Med Management Dr. Andres (Andy) Exposito, Medical Director of Physician Advisor Services 10:45-11:00 Break 11:00-12:00 MACRA The Path Forward Deborah Holzmark, Chief Nursing Officer Dixon Hughes Goodman LLP 12:00-12:30 Lunch 12:30-1:30 CMS Alternative Payment Models / Hospital Panel Lauren Leach, Associate Vice President of Planning & Population Health UAB Health System Daniel Conville, Alternative Payment Models Project Manager - DCH Health System 1:30 2:30 Jurisdiction J Palmetto GBA New MAC Rules Karen Northcutt, Executive VP Medical Management Plus, Inc. 2:30 3:30 State of the Alabama Hospital Industry Dr. Don Williamson, President/CEO - Alabama Hospital Association 3:30 Closing/Wrap up

3 Session Objectives and Speaker Bios 8:30-9:45 OIG/DOJ Update Objective: This session will review recent enforcement activity by the HHS Office of Inspector General (OIG) and the Department of Justice (DOJ) and the most recent updates to the OIG work plan. OIG/DOJ continue to aggressively pursue enforcement actions against hospitals, physicians, laboratories, and other providers, and recoveries continue to be significant. Participants will hear updates on these important areas of compliance. Gregg Brantley Everett, Esq. Gilpin Givhan, PC Gregg Everett served as General Counsel and Senior Vice President for the Alabama Hospital Association (AlaHA) Through his years at AlaHA, he worked extensively on Medicare and Medicaid matters, health insurance issues, Joint Commission compliance, quality assurance, physician recruitment and retention, and risk management issues. In addition, he dealt with regulatory compliance matters under EMTALA, the Stark law, and other issues affecting both non-profit and forprofit healthcare entities. Mr. Everett also dealt with legislative issues for hospitals across the state. For eleven years before joining the Alabama Hospital Association, he was the General Counsel for a large hospital where he participated in forging positive relationships between hospitals and physicians as well as developing successful partnerships with administrators and medical staff. Mr. Everett is a member of the Gilpin Givhan, PC Health Care practice group and a frequent lecturer (locally, statewide, and nationally) on a wide array of health care issues. He is an Adjunct Professor in the Graduate School at Auburn University Montgomery, and has served as Special Counsel to the Alabama Legislature. Mr. Everett is on the Boards of the Gift of Life Foundation and the Alabama Board of Specialization of the Alabama State Bar. He was selected as one of the top lawyers in Alabama in John Ward Weiss, Esq. Gilpin Givhan, PC Mr. Weiss is a shareholder in the firm of Gilpin Givhan, PC and practices in the areas of health care, taxation, and business organizations. With over thirty years experience in health law, he represents hospitals, physicians and other health care providers in various arrangements while blending an operational understanding of the health care industry with the technical elements of health law practice. John regularly advises clients with regard to business organizations and structures, contractual arrangements, health care and tax compliance matters, joint ventures, recruiting, acquisitions and operations, and is a frequent lecturer on various compliance matters. He earned his undergraduate degree from Presbyterian College, law degree from the University of Alabama and Master of Laws in Taxation from New York University. He is a member of the Health Law and Taxation Sections of the American Bar Association, the American Health Lawyers Association, the National Association of Bond Lawyers, and the Taxation and Health Law Sections of the Alabama Bar Association. 9:45 10:45 CMS Rules and Regulations Relative to Patient Status, Medical Necessity, and the Two Midnight Rule The challenge continues Objective: It is critically important for compliance and for sound fiscal management for health care professionals to understand the current rules and regulations and corresponding audit and denial activity. This session will provide an overview of the current activity and provide practical approaches for maintaining compliance with billing regulations in an attempt to preemptively avert the need for denial response, as well as providing a discussion on how to approach denials. Joan Ragsdale, J.D. Chief Executive Officer MedManagement LLC Joan serves as Chief Executive Officer for MedManagement, LLC, a company she cofounded in 1995 and renamed as EdiPhy Advisors in She is a Phi Beta Kappa graduate of the University of Alabama where she received her Bachelor of Arts degree, magna cum laude. She also received her law degree from the University of Alabama where she was an editor of the Alabama Law Review and was on the National Moot Court team. Prior to founding MedManagement, Joan practiced law in

4 Birmingham. She was a partner with Sirote & Permutt and later, Bradley, Arant, Rose & White where she served as Chair of the Healthcare Group. She is a past-president of the Health Law Section of the Alabama Bar, was previously selected for inclusion in the Best Lawyers in America, was chosen as one of the Birmingham Business Journal s Top Ten Business Women in Birmingham and was identified as a Birmingham Health Care Hero. In April 2016, she was featured as one of The Birmingham 205 Influential Execs by BhmBiz magazine. Joan is Chair of the UAB Callahan Eye Foundation, Inc. Board, a Board member of the Jefferson County Medical Foundation Trust, and a member of the University of Alabama at Birmingham Medical Leadership Committee. Dr. Andres (Andy) Exposito Medical Director Physician Advisor Services Dr. Exposito is Board Certified by the American Board of Emergency Medicine. He has been a licensed physician in the state of North Carolina for 18 years. Dr. Exposito earned his Doctor of Medicine degree from The University of North Carolina Chapel Hill after completing a Bachelor of Arts Degree at Duke University. He completed his Residency in Emergency Medicine at The University of Massachusetts. Dr. Exposito has served as a Physician Advisor with MedManagement for over six years. Having demonstrated his skill in not only conducting medical necessity reviews, but training and leading others to do the same, he now serves as the Medical Director of Physician Advisor Services for EdiPhy Advisors and MedManagement. Dr. Exposito has served as Attending Emergency Physician at the Camp LeJeune Naval Hospital, a hospital that serves approximately 45,000 patients each year. He also served as an attending Physician at Onslow Memorial Hospital. He currently serves as a staff physician at Lower Cape Fear Hospice providing care for patients in the hospice care center as well as guidance to the home care team. His service on the NC State Medical Assistance Team II included deployment for disaster relief following Hurricane Katrina. With a passion for the health and well-being of children, Dr. Exposito serves as guardian ad litem in the 5th Judicial District of NC, a volunteer child advocate and court-appointed representative of children who are in the Department of Social Services custody. 10:45 11:00 Break 11:00 12:00 MACRA The Path Forward Objective: In this session we will discuss the future of MACRA and how providers can move forward in participation in MIPS and Advanced APMs. We will discuss the interactions between components of MACRA and the various mandatory and voluntary payment models in existence and how you can work with providers to pool and focus resources to gain improvements in multiple programs. Deborah Holzmark, RN, MBA, CPHQ, LBBP Chief Nursing Officer Dixon Hughes Goodman LLP Deborah Holzmark serves as the Chief Nursing Office with DHG Healthcare based out of Ashville, North Carolina. She is a proficient healthcare leader with deep clinical, financial and performance improvement experience with hospitals and healthcare providers, focusing on improving patient care, understanding and guiding performance improvement and meeting organizational goals related to the Triple Aim. She has worked with hospitals on improving care, throughput and operations to increase efficiency and quality. Additional areas of focus in consulting include payment reform measures such as lowering hospital acquired conditions, decreasing readmissions and focusing on improvement in value based purchasing metrics and bundled payment initiatives. Deborah also has extensive experience in physician practice management including throughput, revenue cycle, operations and quality improvement. Deborah received her Bachelors of Nursing and Masters in Business Administration from the University of Texas at Dallas. 12:00 12:30 Lunch

5 12:30 1:30 CMS Alternative Payment Models / Hospital Panel Objective: Over the past five years we have witnessed the proliferation of bundled payments from small pilot experiments to scaled payment programs across multiple conditions. Medicare now has four active programs including the large-scale Bundled Payments for Care Improvement Initiative (BPCI), the Comprehensive Care for Joint Replacement Program (CJR), the Episode Payment Models (EPM/Cardiac Bundles) and the Oncology Care Model (OCM). Similar to the fed s move to value-based payment models such as bundled payments, statewide programs involving Medicaid and public employee health benefit plans are also moving large volumes of healthcare dollars away from fee-for-service. This session will focus on some of these bundled payment models that our Alabama hospitals and physician practices are currently participating in and how your organization should be preparing for this shift in payment reform. Lauren Leach Associate Vice President, Planning and Population Health UAB Health System Lauren Leach received her MBA from the University of Alabama Manderson Graduate School Of Business. She now serves as Associate Vice President, Planning and Population Health for UAB Health System. Lauren manages the BPCI participation for UAB Medicine as well as UAB s Population Health strategy implementation. Daniel Conville, MHA, CPM Corporate Director, Physician Services DCH Health System Daniel Conville joined DCH Health System in 2016, serving as the project manager for bundled payment programs. In this role, he is responsible for leading the implementation of clinical and business practices to enable DCH to thrive in this new financial environment. Mr. Conville has over 17 years of experience in strategic planning and operations of health systems including planning in both the private and public health care sectors. Mr. Conville earned his Bachelor s degree in Healthcare Management from the University of Alabama, and a Master s in Healthcare Administration from the University of Cincinnati. In addition, he is a Federal Certified Project Manager and is an active member in the American College of Healthcare Executives and the Healthcare Financial Management Association. 1:30 2:30 Jurisdiction J Palmetto GBA New MAC Rules Objective: Mrs. Northcutt will present an overview of Jurisdiction J Palmetto GBA (MAC) current medical reviews and results. Additionally, Palmetto GBA local coverage determinations (LCDs) will be discussed to point out nuances/differences from the old MAC Cahaba GBA LCDs. She will provide a Jurisdiction J risk assessment for identified services based on RealTime Medicare Data for hospitals to target their own risk areas for internal review and proactive steps to prevent medical necessity denials. She will explain how to identify high-risk areas, assess your facility s risk, audit for compliance, and develop corrective actions if needed. From this session you will: Know Palmetto GBA Jurisdiction J high-risk review areas by being able to identify current reviews and coverage policies. Determine which Palmetto local coverage determination (LCD) policies would apply to their facility. Gain knowledge of impact of risks identified by RealTime Medicare Data in Jurisdiction J and how these rates could impact their facility. Understand where to find Palmetto GBA covered indications and documentation requirements for procedures and services. Be able to develop an internal risk assessment and plan of action to ensure coverage indications are met. Be able to develop processes to ensure clinical documentation supports the medical necessity of the services provided. Ms. Karen M. Northcutt, BS RN, COC Executive Vice President Medical Management Plus, Inc. (MMP, Inc.)

6 Karen M. Northcutt, BSRN, COC is the co-founder and Executive Vice President of Medical Management Plus, Inc. ( MMP, Inc. ), Birmingham, Alabama. MMP, Inc. has been in business since 1989 providing healthcare consulting services. Prior to co-founding MMP, Inc., she was a registered nurse with experience in medical/surgical and urgent care nursing. Karen earned her bachelor s degree in Nursing at the University of Alabama at Birmingham (UAB) in Ms. Northcutt directs all revenue integrity services including medical necessity risk assessments, clinical composition audits, HCPCS/CPT/ICD-10 coding, charge description master reviews, medical record documentation audits, UB04 audits and Corporate Compliance consulting projects. Ms. Northcutt has worked primarily with acute care facilities throughout the Southeast ranging in size from 35 to 902 staffed beds and representing not-for-profit, for-profit corporations, major teaching, general and tertiary provider status. Ms. Northcutt assisted the Alabama Hospital Association in establishing and facilitating the Revenue Integrity Committee (RIC) in In this capacity Ms. Northcutt assists the Alabama Hospital Association statewide Revenue Integrity Committee in identifying common reimbursement issues and clarification of billing/documentation guidelines with Alabama s MAC, Medicaid of Alabama and Blue Cross Blue Shield of Alabama. As a provider representative, Karen presents issues and facilitates discussion and promotes resolution with representatives of the major payers in the state of Alabama. 2:30 3:30 State of the Alabama Hospital Industry Objective: Attendees will understand the following: Financial condition of Alabama hospitals Prominent payment sources and the challenges associated with these sources Instability of Alabama healthcare market Donald E. Williamson, M.D. President/CEO Alabama Hospital Association Donald Williamson, MD, president/ceo of the Alabama Hospital Association, has almost 35 years of health care experience. Before joining AlaHA, Dr. Williamson served as state health officer for 23 years. He has been the recipient of a number of awards including recognitions by the Medical Association of the State of Alabama, the Association of State and Territorial Health Officials, the Alabama Hospital Association, the Public Health Foundation and the American Academy of Pediatrics. Dr. Williamson has served in numerous leadership positions with other national and state organizations, including serving as president of the Association of State and Territorial Health Officials and as a member of the board of directors of the Public Health Foundation and the steering committee on Access for the Uninsured of the National Academy for State Health Policy. He received his medical degree from the University Of Mississippi School Of Medicine and completed a residency in internal medicine at the University of Virginia. 3:30 Closing/Wrap up