Becoming a Champion of Physician and Hospital Alignment: Focusing on Length of Stay, Discipline and Standards of Care Marc Tucker, DO Senior Director Audit, Compliance & Education AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product. 1
Agenda IP vs. OBS What are the shared risks and potential solutions? Dealing with the uncooperative physician Review of UR review and regulations Compliance and documentation Managing LOS 2
Importance of Utilization Review Providers will be judged by their Utilization Review Process UM Committee is the only committee required by Medicare in the Conditions of Participation Medicare does not say ALL cases have to be reviewed but Medicare does say ALL billing claims have to be accurate The best way to ensure accurate billing is by having a consistent and compliant UR process that ensures appropriate review and documentation to support the claim 3
What is the Role of the Physician Advisor in Physician Alignment? Physician Education What is a UR committee? What is a UR plan? What is the proper process for UR review? Helping them understand that the UR process and CM function needs their cooperation What skin do they have in the game? Case Management Education What is the role of the CM in the UR review process? What are their limitations? What is a second-level review? Where can the PA intervene between the physician and the CM? IS IT REALLY MORE THAN JUST THIS??? 4
What are the Shared Risks? AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product. 5
What are the Shared Risks? MAC Pre-payment reviews o FCSO, Novitas, Trailblazer, others will follow Place of Service Billing Concordance OIG 2012 Work Plan Documentation Documentation must support the level of care ordered E&M billing codes Not just Medicare but all payors Total Joint audits Managing LOS 6
2012 OIG Work Plan for Professional Services Claims for incident-to services that exceed 24 hours in a given day Do not appear in claims data and can be identified only by reviewing the medical record Expose Medicare beneficiaries to care that does not meet professional standards of quality High cumulative Medicare Part B payments to practitioners Unusually high Medicare payments may indicate incorrect billing, fraud, or abuse Look at specific areas of the country to see if they are experiencing a higher number of physicians opting out of the Medicare program and assess the potential impact on beneficiaries Wants to know if opt-out physicians have been submitting claims to Medicare 7
2012 OIG Work Plan for Professional Services E/M services to ensure that the submitted codes accurately reflect the services provided E/M services provided during the post-op period of a global surgery will be of particular interest Trends in coding of claims from 2000-2009 Place-of-Service Errors Services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service 8
Will Physicians Be Audited? Answer: Most definitely OIG Workplan RAC Final SOW FAQs Why? Billions of Medicare $ in incorrect physician payments Likely basis for audit: Lack of claim agreement between the hospital and physician 3M has created edits for the MACs to identify the disagreement between hospital and physician claims Physicians are exposed from at least the 3-year look back of the RAC s and perhaps earlier for others! 9
Concordance: How are Hospitals and Doctors Affected? The components of concordance: 1. The hospital UR decision 2. The treating physician order 3. The hospital claim (Part A services) 4. The physician claim (Part B services) 10
Getting Your Medical Staff On Board Physician Error?... Hospital UR Determination Physician Order Hospital Claim (Part A) Physician Claim (Part B) Physician Impact OBS IP None IP VERY BAD 11
Most physicians: Why Should The Physician Care About Change in Medicare Claim Status? Have no idea what observation means Medicare vs. Managed Care vs. Medicaid! Very liberal use of Observation Status Aren t usually concerned about or don t understand the impact on the hospital Are concerned that it means different care for their patients Are concerned that it may affect their reimbursement and/or compliance exposure 12
Why is Getting Patient Status Correct Such an Important Issue? Overuse of Inpatient Focus of Recovery Audit Contractors Potential False Claims issue if no compliant process is in place Eventual loss of revenue on audit and loss of opportunity for appropriate OBS APC and ancillary charge payment Overuse of Observation Revenue integrity issue for hospitals and physicians Length of stay artificially elevated Mortality data artificially elevated Market share data artificially lowered Cost of IP care data artificially elevated Transfer DRG payment impact Qualified stay impact on patient s skilled care benefit Unexpected patient financial responsibility (self administered medication charges, inflated copayments) It s about getting it right! 13
How Does One Deal with the Uncooperative Physician? AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product. 14
Tell Me Exactly How to Get My Docs to Change When the student is ready The teacher will appear 15
Dealing with the Uncooperative Physician Make sure it is clear who is doing the teaching! The role of physician advisor means being an expert in multiple areas, as well as, a resource to other physicians in these areas. Know your stuff! 16
Dealing with the Uncooperative Physician The Same approach will not work on all physicians all physicians are unique just ask them! Evaluate the physician and situation: Is this an isolated incident or is it a common occurrence? Is the physician responsive to case management? Is the physician responsive to you? Most resistance comes from a lack of understanding.. of the purpose of the UR process and the UR team 17
Dealing with the Uncooperative Physician Methods of Coaching: Gentle Approach CM initially trying to coach/provide education to the physician o One-on-one conversation o Discussing concordance o Coaching the physician in the medical necessity and regulatory audit consequences PA providing one-on-one education: Understand the difference between IP and OBS What is Medical Necessity Documentation education (think in ink) Admission review best practices CC44 and how it plays a role Help physician understand this is not to tell them how to treat their patients Review rules and regulations 18
Dealing with the Uncooperative Physician Provide opportunities for voluntary education Lunch with the UR Team Provide examples of higher acuity cases that do not meet first level review What is first level review? Can CMs use clinical judgement? Can CMs give the final determination for Claim Status? Differences in Payor contracts We are not looking over your shoulder We are watching your back! 19
Dealing with the Uncooperative Physician Methods of Coaching: Aggressive Approach Generally reserved for a repeat or frequent offenders How aggressive are you willing to get? o Department Head/Chairman/PA one on one discussion o Make this physician take an active role on the UR Committee o Escalate to CMO, VPMA o Use as a metric for re-credentialing, physician report card o Escalate to Medical Executive Committee o Consider removing from staff Generally in this situation there are other issues such as quality issues 20
Dealing with the Uncooperative Physician Consequences of not addressing this issue: Compliance risks Revenue integrity risks Physician self-risks - concordance Is this worth the Investment of time? How far is your executive level willing to back you? o We do not want this doc to take his/her patients elsewhere Do you really want a physician like this on your staff? o Disruptive behavior 21
Coaching for Beneficiary Responsibility AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product. 22
Patient Deductible and Copays Inpatient (Part A) 2012: Day 1-60: $1156 inpatient deductible Day 61-90: $289 / day Day 91-151: $578 / day Outpatient (Part B): $140 per year deductible 20% coinsurance for all covered outpatient services 100% of non covered outpatient services Coinsurance amounts for Part B covered services vary depending upon the nature of the services and the payment methodology that applies. Deductibles and/or coinsurance may be waived altogether for certain Part B services, including screenings and other preventive services. 23
Observation Care Documentation must support Order of observation prior to placing the patient in observation status Initiation of observation status Supervision of the care plan for observation Clinical course in the unit Performance of periodic reassessments Medical decision-making (i.e., diagnosis, etc.) Final examination Discharge, or admit, plans made 24
Observation Tips Be sure to include: Timed order to place in observation status Provisional diagnosis Assessment notes throughout observation encounter Final diagnosis Timed discharge order Disposition Most important, who is managing the observation encounter?! (e.g., EDMD, PMD, RN, etc.) 25
Coaching for Documentation AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product. 26
Simple Equation for Compliance and Documentation The ORDER Co-Morbidities What was done Supported by Documentation Predictable Risk Intent for Treatment Matches the CLAIM Submitted Intent for Overnight Stay 27 27
Physician Perceived Lack of Understanding Supported by Documentation I don t know how to take what I know clinically and transition it into an order for LEVEL OF CARE! 28
Said Simply What can go wrong with my patient based on HOW they present and the CONDITION in which they present Is this not how physicians think? Think in INK! 29
Key Words: Give Them Some Guidelines SUSPICIONS what do you suspect is going on? i.e. What is your impression? CONCERNS what are your concerns of the situation? High or low? PREDICTABLE RISK given the patient s history and current presentation what kind of adverse outcomes are likely and what are the chances? 30
Coaching for the Process of UR Review AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product. 31
Physician Alignment In order to deal with physicians and behavior one must have a detailed understanding of The Conditions of Participation (CoP) 42CFR482.30* *This is the basis of Medicare Admission Review 32
Managing Length of Stay AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product. 33
Background Began with Medicare and DRG reimbursement Coding initiatives designed to optimize revenue Took into account LOS along with resource use Goal was to minimize variation among physicians Managed Care capitalized on this concept Resulted in significant cost savings for them Hurt hospitals as costs were fixed but lead to some degree of excess capacity 34
Basic Goals of LOS Management Opportunity to affect revenue and manage costs Reduce physician variation while standardizing care Enhance quality and improve margins 35
Role of Physician Advisor Identify opportunities to decrease LOS Multifactorial approach What is the effect on revenue and quality? Gain the cooperation of: Executive level Senior Management Physicians Work with physicians for better documentation to justify IP days Documentation accuracy and details must be the same for the first day and every day 36
Role of Physician Advisor Utilize physician profiling Establish a dashboard for the UR Committee to monitor Research and provide benchmarks Provide ongoing performance targets Ensure that quality is not sacrificed with better throughput Look what has happened in ER s with better throughput Ongoing, frequent, and timely reporting of process improvement and successes 37
Monitoring LOS Key drivers of LOS Your physicians o This is why profiling helps o Cost and LOS per diagnosis per physician Can be a quality issue also The diagnosis o There are benchmarks for LOS for DRG s The patient themselves o What is the acuity of the patient? Resources that MUST be utilized Communicating with known abusers daily Discharge planning starts on day one o Why 7 day/week coverage is critical Same tactics the first day and every day 38
Conclusion Physician alignment is a complicated issue but it is possible to achieve success The Physician Advisor role is critical to success Consistent process must be paired with diligent oversight and data review 39
Questions? Marc Tucker, DO Senior Director Audit, Compliance & Education drtucker@ehrdocs.com 40
Copyright 2012 Executive Health Resources, Inc. All rights reserved. No part of this presentation may be reproduced or distributed. Permission to reproduce or transmit in any form or by any means electronic or mechanical, including presenting, photocopying, recording and broadcasting, or by any information storage and retrieval system must be obtained in writing from Executive Health Resources. Requests for permission should be directed to INFO@EHRDOCS.COM. 41