Connecting the Revenue and Reimbursement Cycles Tuesday, August 19 th, 2014 Toni G. Cesta, Ph.D., RN, FAAN Consultant and Partner Case Management Concepts New York Office And Bev Cunningham, MS, RN Vice President Resource Management Medical City Dallas Hospital Partners and Consultant Case Management Concepts Dallas Office The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. Opinions, references and links provided by our speakers are provided for your convenience and do not represent our endorsement of such opinions, products or services.
FACULTY Toni G. Cesta, Ph.D., RN, FAAN is Partner and Healthcare Consultant in Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing and evaluating acute care and community case management models, new documentation systems, and other strategies for improving care and reducing cost. The author of eight books, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management. Dr. Cesta writes a monthly column called Case Management Insider in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management. Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York. Bev Cunningham, RN, MS is Vice President, Resource Management at Medical City Dallas Hospital. Her areas of responsibility include Case Management, Health Information Management, Clinical Documentation Integrity, Patient Access and Transplant Financial Services. Bev is a well-known speaker in the Case Management field. Involved in the development of case management for over twenty five years, her areas of expertise include denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process. She has served as a Commissioner on the Commission for Case Management Certification. Bev is also a partner and consultant in Case Management Concepts, a company that provides support to hospitals regarding effective Case Management model development and evaluation. Bev's publications include a chapter in CMSA's Core Curriculum for Case Management Certification and most recently, co-author of the 2 book, Core Skills for Hospital Case Management. She is also on the advisory board for Hospital Case Management.
OBJECTIVES 1. Review 3 strategies for coordinating the revenue and reimbursement cycles. 2. Identify the key loopholes for decreased reimbursement with value-based purchasing and healthcare reform. 3. Explain new and revised case management standards, regulations, and laws put forth by CMS, TJC and the federal government. 4. Evaluate case management protocols and penalties. 3
Revenue: Sum earned by the provider, measured in dollars Revenue Cycle: Series of activities connecting the services rendered by a healthcare provider with the methods by which the provider receives compensation for those services 4
YOUR HOSPITAL REIMBURSEMENT Diagnosis Related Groups (DRG): case rate Per diem: payment for each day in hospital Percent of charges Carve out services: based on contract; usually for high cost services, such as implants Pay for performance: reimbursement or reimbursement penalty based on clinical outcomes Global payment/bundled payment: reimbursement for both facility, all levels of care (both IP and OP) physician services most often seen in transplant in hospitals and the Accountable Care Organization (ACO) model Stop loss: increase in payment after charge threshold met Outlier : increase in payment after specific combination thresholds met, such as both LOS and charges 5
THE FOUR FUNCTIONS OF THE RN CASE MANAGER Utilization Management Care Coordination Discharge Planning Resource Management 6
AND THEN THERE CAME HEALTHCARE REFORM AND VALUE BASED PURCHASING METRIC REIMBURSEMENT 7
VALUE BASED PURCHASING DOMAINS AND MEASURES MEASURE 2014 2015 2016 2017 Clinical process of care 45% 20% 10% Clinical Care 35% Process 10% Outcome 25% 30% 40% Outcome 25% Patient Experience of Care 30% 30% 25% Patient and caregiver experience of care/care coordination 25% Efficiency NA 20% 25% Efficiency and cost reduction 25% Safety NA NA NA 15% At Risk: % of Your Medicare Reimbursement 1.25% 1.5% 1.75% 2% 8
TRANSITION OF MEASURES From 10 quality measures in 2004 (our starter set) to 57 measures for 2016 Chart abstracted core measures Claims based mortality and readmission measures Healthcare associated infection measures Survey measures (HCAHPS) Structural measures for us to assess capacity to improve quality of care 2017 will have a reduction of measures to 46 Removing 15 topped out chart abstracted measures Removing one structural measure topped out Adding one chart abstracted measure Adding 4 claims based measures Outcome and cost measures being considered to be added There will also be 16 voluntary electronically submitted measures 9
CLINICAL PROCESSES OF CARE AMI-7a Fibrinolytic therapy IMM-2 Influenza PN-6 ABX selection for immunocompetent SCIP-Inf-2 Prophylactic abx selection SCIP-Inf-3 Abx DC d within 24 hours postop (prophylactic) SCIP-Inf-9 Foley removed postop day 1 or 2 SCIP-Card-2 Beta-blocker during op period if on betablocker SCIP-VTE-2 VTE prophylaxis within 24 hours prior--to 24 hours after or 10
PATIENT EXPERIENCE OF CARE Communication with nurses Communication with doctors Responsiveness of hospital staff Pain management Communication about medicines Cleanliness and quietness of hospital environment Discharge information Overall rating of hospital 11
OUTCOME Mortality within 30 days of admission PSI-90 Composite CLABSI CAUTI Healthcare associated infection measures: SSI (FY 2017) Abdominal hysterectomy Colon surgery 12
PSI-90 COMPOSITE PSI-03: Pressure ulcer rate PSI-06: Iatrogenic pneumothorax rate PSI-07: Central venous catheter related bloodstream infection rate PSI-08: Postoperative hip fracture rate PSI-12: Postoperative PE or DVT rate PSI-13: Postoperative sepsis rate PSI-14: Postoperative wound dehiscence rate PSI-15: Accidental puncture or laceration rate 13
MEDICARE SPENDING PER BENEFICIARY: EFFICIENCY INCLUDES PART A AND PART B SPENDING Hospital admission 30 days post discharge 3 days prior Transfers and readmissions included 14
BASELINE AND PERFORMANCE PERIODS FY 2016 DOMAIN BASELINE PERFORMANCE Clinical process of care 1/1/12-12/31/12 1/1/14-12/31/14 Patient experience of care 1/1/12-12/31/12 1/1/14-12/31/14 Outcome: Mortality 10/1/10-6/30/11 10/1/12-6/30/14 Outcome: PSI 10/1/10-6/30/11 10/1/12-6/30/14 Outcome: CAUTI/CLABSI/SSI 1/1/12-12/31/12 1/1/14-12/31/14 Efficiency 1/1/12-12/31/12 1/1/14-12/31/14 15
HOSPITAL-ACQUIRED CONDITION REDUCTION PROGRAM Beginning FY 2015 hospitals in top quartile for rate of HACs (those with lowest rate of performance) will have Medicare payments reduced by 1% 16
HOSPITAL READMISSIONS REDUCTION PROGRAM 3% penalty for poor performers in FY 2015 (discharges within 30 days after hospital discharge) 17
ALTERNATE PAYMENT APPROACH FOR SHORT STAY CMS solicited public input on alternate payment for short hospital stays in 2015 IPPS proposed rule (May 2014) Requesting input on definition of short stays and appropriate payment 2015 IPPS final rule states CMS will consider comments submitted after proposed rule was posted (August 2015) 18
CHANGE IN USE OF ICD-9 CODES UB UB UB CODES FOR REIMBURSEMENT CODES FOR REIMBURSEMENT AND FOR QUALITY TRANSITION TO ICD-10 (SCHEDULED FOR OCTOBER 2015) 19
THE TRANSITION TO ICD-10CODES Increased specificity Identify specific disease processes Identify interaction between symptoms and definitive diagnoses ICD-9 ICD-10 Characters 3-5 3-7 Diagnosis codes 14,315 69,101 Adding new codes Limited space Flexible space Digits 3-4 7 Procedure codes 3,838 71,957 20
HFMA SAYS THAT 60% OF ALL MONEY IS IN THE REVENUE CYCLE 21
BUT HOW MUCH MONEY CAN BE LOST IN THE REVENUE QUALITY CYCLE AND THE REVENUE EFFICIENCY CYCLE? 22
Patient admitted REVENUE CYCLE Verification & notification Clinicals called in: Patient Care delivered and care documented Patient discharged Bill dropped: Coding from documentation 23
WHERE CAN ERRORS OCCUR? Patient admitted REVENUE CYCLE Before pt adm: Elective, HMO auths, OON, Uncovered benefits Verification & notification Clinicals called in Patient discharged Bill dropped At time of adm: Notification, Level of care, Med necessity Incomplete information Lack of medical necessity Notification of change in level of care Incomplete information Inaccurate coding Incorrect billing, Late billing Never event or hospital acquired condition, resulting in payment penalty Payer pays partial payment 24
WHERE CAN ERRORS OCCUR? REIMBURSEMENT CYCLE Patient admitted Verification & notification Clinicals called in Patient discharged Bill dropped Indentify present on admission issues Document appropriate reason for admission Readmission? Understand why Payer not notified Patient does not give correct information or gives late information Manage LOS Manage core measures Manage hospital acquired admissions Appropriate physician documentation to support coding Appropriate discharge management to decrease readmissions Appropriate coding based on physician documentation 25
WHY IS CASE MANAGEMENT USED IN HOSPITALS? To promote quality, safe and cost-effective care To promote utilization of available resources to achieve clinical and financial outcomes To ensure appropriate access to care To work collaboratively with patient / family, physician, providers, payers and others to develop and implement a plan that meets the individual s needs and goals To interject objectivity, healthcare choices and promotion of self-care where it is lacking To assure compliance to rules and regulations, both government and commercial payer 26
HEALTHCARE REFORM STRATEGY: STRONG CASE MANAGEMENT OVERSIGHT Right model Right roles, with the right functions Align relationships Education of current staff Effective orientation of new staff Accurate competencies Hardwired departmental processes Knowledge of who does what Integrate staff into hospital processes Physician relationships Collaboration in both the revenue cycle and the reimbursement cycle 27
HEALTHCARE REFORM STRATEGY: HARD WIRED PROCESSES Interventions/strategies for each of the publicly reported measures In-depth understanding of what drives each measure (coding, which codes and documentation) Develop mechanism for collecting abstracted data concurrently Admission and discharge time outs 28
HEALTHCARE REFORM STRATEGY: HARD WIRED PROCESSES Daily rounds Engage physicians Process consistency among key staff and physicians 29
HEALTHCARE REFORM DEMANDS A CHANGE IN YOUR REVENUE STAKEHOLDERS PATIENT ACCESS RAC NCD/LCD COORDININATOR ANCILLARY TEAM FINANCE CASE MANAGEMENT PHYSICIAN HIM NURSING QUALITY REVENUE CYCLE STAKEHOLDERS CDI 30
NEXT STEPS Find your results for VBP, readmissions and Spending per Medicare Beneficiary Measure Determine how you benchmark against others Assure an effective audit program to identify documentation and coding errors Watch out for those other payers they often mimic CMS Know your role in the revenue and reimbursement cycles 31
LEARNING FROM OTHERS OTHER COUNTRIES ARE ALSO FOCUSED ON QUALITY AND VALUE UNITED KINGDOM S INSTITUTE FOR INNOVATION AND IMPROVEMENT HAS A FOCUS ON HIGH VOLUME CARE 32
HIGH VOLUME CARE Healthcare resource groups (HRG) Groups of clinically similar activities for which a similar quantity of resources is needed Also the bases for the United Kingdom s National Health System Payment by Results system 50 HRGs account for about 50% of all bed days Acute admissions in adult mental health Acute stroke Caesarean section Fractured neck of femur Cholecystectomy Short stay emergency care (LOS of 2 days or less) UTIs in frail older patients Primary hip and knee replacement Outcomes for these HRGs are published in Delivering Quality and Value documents to improve the quality and value of care 33
HIGH VOLUME CARE STRATEGIES Effective, integrated system-wide communication Robust clinical leadership Alternatives to admission used when possible Proactive discharge plans Overcome barriers when admission necessary Effective multidisciplinary working and training Continuous and seamless service Services focused on users and caregivers Care is high quality and effective and includes psychological interventions Balanced approach to risk taking supported from the top of the organization 34
BACK TO THE BEGINNING: JUST BECAUSE YOU HAVE AN AUTH 35
WHAT IS YOUR CASE MANAGEMENT ROLE? KNOWLEDGE RESPONSIBILITY COLLABORATION HANDS OFF Clinical processes of care X X Patient experience of care X X X Outcome: Mortality X X Outcome: PSI-90 Composite X X Outcome: CLABSI, CAUTI, SSI X X Efficiency X X X Case Manager Role: Utilization Management Case Manager Role: Discharge Planning Case Manager Role: Care Coordination Case Manager Role: Resource Management X X X X X X X X X X X X 36
This presentation is intended solely to provide general information and does not constitute legal advice. Attendance at the presentation or later review of these printed materials does not create an attorney-client relationship with the presenter(s). You should not take any action based upon any information in this presentation without first consulting legal counsel familiar with your particular circumstances. 37
THANKS FOR JOINING US! IT S TIME FOR QUESTIONS! bevcmc@hotmail.com cestacon@aol.com 38