PFS Program Presentation - AAHAM Western Reserve Chapter

Transcription

This Is My World.
Welcome To It!
Patient Financial Services Program
Akron General Health and Wellness Center
Friday, February 18, 2011
February 18,2011
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Opening Remarks & Introductions
Program Committee Chairs
8:00‐8:15
OHA Updates
Charles Cataline
8:15‐9:00
“The RAC”:
Past, Present, and Future
Don Paulson
Lyman Sornberger
Charity Care: From Vague Law to Concrete Practice
Don Paulson
Matt Sheldon
ICD‐10 Transition Perspectives
Christine MacKay‐Michels
Karen Melton
1:15‐2:30
Accountable Care Organizations: No Turning Back
Charles Vignos
2:45‐4:15
February 18,2011
9:00‐10:30
10:45‐12:15
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NEO HFMA PFS Committee:
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Don Paulson (Co‐Chair)
Holly Pelaia (Co‐Chair)
Chuck Backus
Cindy Hoyt
Grace Jen
Jim McCauley
Joe Gabriel
Joe Harrison
Rhonda Ridenour
Lyman Sornberger
Matt Sheldon
Sandra Wolfskill
AAHAM Western Reserve Board:
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Sue Bertram Dilys Krueger
Toni Shamblin
Steve Rybka
Casey Williams
Pam McFarland
Sue Bertram
Cindy Anderson
Diana Choate
Nanette Woldin
James Monroe
Cindy Hoyt
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Charles Cataline – Senior Director of Health Policy, Ohio Hospital Association
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Don Paulson – VP Finance Revenue Cycle Management, University Hospitals
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Lyman Sornberger – Executive Director Revenue Cycle Management, Cleveland Clinic Health System
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Mary Legerski – Chief Compliance Officer/Associate General Counsel, MetroHealth System
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Matt Sheldon – Revenue Cycle Director, Lake Health
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Christine MacKay‐Michels – Senior Director Revenue Cycle, Akron General Health System
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Karen Melton – Product Manager, Siemens Healthcare
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Charles Vignos – President, Summa Health Network; COO – Summa Accountable Care Organization; VP of Managed Care – Summa Health System
February 18,2011
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Charles Cataline is the senior director of health policy for the Ohio Hospital Association in Columbus, where, he manages many of the association’s finance and patient financial services activities. Charles also acts as a liaison for Ohio hospitals to the Centers for Medicare and Medicaid Services’ (CMS), the Ohio Department of Job and Family Services and the Bureau of Workers’ Compensation on Medicare, Medicaid and BWC policy interpretation and payment initiatives. A 1974 graduate of the Ohio State University, Charles has been in the health care industry since 1975 and with OHA for over 30 years. Charles staffs the OHA Finance and Admitting, Billing and Collection Committees. He has also served on a number of state and national boards and committees, including the CMS Outpatient Medicare Technical Advisory Group, the 2005 chair of the Allied Association of Hospital Accountants and Financial Specialists, 15 years with the National Uniform Billing Committee, and six years with the American Hospital Association’s (AHA) Model Practices Group and the Editorial Advisory Board of AHA’s Coding Clinic for HCPCS. February 18,2011
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Updates From
OHA
This Is My World. Welcome To It!
February 18,2011
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NE Ohio HFMA
AAHAM Western Reserve
This is my World – Welcome to it!
OHA Updates
Charles Cataline
Senior Director, Health Policy
Ohio Hospital Association
charlesc@ohanet.org
www.ohanet.org
NE Ohio HFMA / AAHAM
February 18, 2011
Agenda
Ohio 2012/2013 State Budget
Medicaid RAC & MIP
Medicaid MITS & Other Medicaid Items
Medicare Administrative Contractor
VBP Proposed Rule & Other Medicare
Items
o BWC IHPPS & OPPS
o Etc., etc.
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February 18, 2011
Ohio’s 2012-2013 Budget Challenges
• Budget Due March 15 (Beware the Ides…?!)
• Estimated $8 to $9 Billion Deficit in General
Revenue Fund
• Reduced FMAP
• Federal Stimulus Money Gone
• Medicaid Enrollment & Cost Up (if no Changes)
• JFS Says +4.5% in 2012
• $18.9B in 2012 / $20.2B in 2013
• Cost of Ongoing Health Care Delivery &
Payment Reform
February 18, 2011
Ohio’s 2012-2013 Budget Challenges
What do we Expect?
• Conservative Shift to Funding, Payment & Coverage
• Tough Fight for Available Resources (“Get on the Bus!”)
• Call to “Transform” Medicaid; Appoint Health “Czar”
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Eliminate Duplication
Expand Managed Care; Possibly Require Provider Contracting
Focus on Primary & Preventative Care
Cut Medicaid Rolls
• Recalibrate FFS DRG Weights (Flow to Managed Care?)
• Cuts to State Agency Staff
• Possible State Payment Slowdown
– Increase Float or Move Payments from One Year to the Next
February 18, 2011
Medicaid Strategies: Short-Term Balance
Other State Responses
2010
2011
Number of States
Health Management Associates
February 18, 2011
Medicaid RAC
• State Plan to CMS 12/31/10; Contract(s) with RAC(s) Due
4/1/11
• Actual Start Date May be Six to Nine Months Beyond That
• RFP out for Contractor(s) – None Named Yet
• Will not Replace Medicaid Integrity Program (MIP) or
Provider Error Rate Measurement (PERM) Program
• Organized like Medicare RAC, but ODJFS Will Take
the FI/MAC Role, With State-Specific Medical
Records, Recovery and Audit Policies
• ODJFS Expected to Take the Lead –
Look for Rollout in Fall /Winter 2011/2012
February 18, 2011
Medicaid Integrity Program
• Ordered in Deficit Reduction Act 2005
• Not RAC: Rules, Players, Look-Back & Appeals Differ
 No Contingency Fees, MICs Paid Contract Fee
 Post-Pay Reviews Focus on Overpayments, no
Underpayments
 Supposed to Work in Concert with State Medicaid Agencies &
State Law Enforcement
 Look-Back Period Supposed to Mirror State Standards (5
Years?)
 No Records Limits, No Copying Costs
 All Medicaid Providers Included, but not Necessarily Linked
• Includes Three CMS-Appointed Regional Medicaid
Integrity Contractors (MICs)
 Review MIC, Audit MIC & Education MIC
February 18, 2011
Review MIC
• Review of Provider MIC Works with CMS
Medicaid Integrity Group (MIG) & Audit MIC
 Analyzes Paid Claims Data and Other “Leads”
from State, Medicare MAC & Other Partners
 No Direct Provider Contact
• Using “Algorithms,” Identifies “Aberrant” Practices and
Patterns, High-risk Areas and Potential Vulnerabilities
 CMS: “Data-driven Approach Ensures Focused Efforts”
• Recommends Projects & Targets to MIG & Audit MICs
• Works with States (& Feds?) to Avoid Duplicate Audits
 Not Clear yet Whether MIC or ODJFS Holds Sway with MIG
February 18, 2011
Who Are the Review MICs
– AdvanceMed (CMS REGION V)
– ACS Healthcare
– Thomson Reuters
– Safeguard Solutions
– IMS Govt. Solutions
February 18, 2011
Possible MIC “Projects”
Providers
 Provider & Patient Eligibility
 Billing for Services not Provided, Billing for Services Provided After
Death
 Billing for Excessive Drug Units and Unapproved Drugs
 Duplicate Billing
 Billing for Medically Unnecessary Services and Services of Poor
Quality
 “Upcoding” & Unbundling
 Billing for Services Provided by Unlicensed or Untrained Personnel
 Billing for Inappropriate or Unapproved Transportation Services
 Billing Outpatient Claims During an Inpatient Stay
 Excessive or Inappropriate Payments to Consultants and
Intermediaries
February 18, 2011
Possible MIC “Projects”
MCPs
 Provider & Patient Eligibility
 Kickbacks Between MCPs and Providers
 Falsifying Contract & Certification Information
 Misinformation in MCO Marketing
 Medicaid Eligibility in Multiple States
 Excessive Medicaid Administrative Cost
 Embezzlement and Theft
February 18, 2011
Audit MIC
• Audit MICs Conduct Post-Pay Reviews of Providers
and Managed Care Plans; Requests Records
 GAGAS Standards (“Yellow Book”)
 Audits Done by “Appropriate & Qualified” Professionals:
Physician Medical Directors & RN Reviewers
 Could Involve Medical Record, Bill Data & Other Records
 Audit MIC Reports Can be Shared with Federal or State
Law Enforcement Agencies
• Identifies Overpayments
 Can go Back Five Years
 Can Extrapolate Sample Reviews
• ODJFS Recovers Payments and
Handles Appeals Using State Policies and
Processes
February 18, 2011
Who Are the Audit MICs
- Booz Allen Hamilton
- Fox & Associates
- IPRO
- Health Management Solutions
- Health Integrity, LLC (CMS Region V)
February 18, 2011
Education MIC
• Works with CMS MIG & Other MICs to Prevent
Future Medicaid Fraud, Waste and Abuse,
and Ensure Quality of Care
• Interacts with all Medicaid Stakeholders
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Providers
Medicaid Enrollees & Recipients
MCPs
Medicaid Agencies (ODJFS SUR)
Medicare FI/MAC
State & Federal Law Enforcement / State Auditor(?)
• Develops Training Materials, Awareness
Campaigns & Conducts Provider Education.
February 18, 2011
Who Are the Education MICs
• Information Experts
• Strategic Health Solutions
No Specific Geographic Assignment Noted
• No
• No Specific
February 18, 2011
How the MIP is Supposed to Work
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Review MIC identifies projects/targets
Using sample data from the Review MIC, CMS outlines projects/targets with
ODJFS, MAC & state agencies to avoid duplication. (Note: This does not mean
the same account could not be reviewed by different agencies for different
issues, time periods or programs.) CMS holds right of final approval.
CMS forwards approved projects/targets to Audit MIC. CMS vets provider and
paid claims data with ODJFS to ensure data is complete and current.
Audit MIC notifies provider contact and requests medical and billing records,
where appropriate. Records request will also identify audit manager, audit site
and additional instructions and requirements.
– Look-back period is five years from notification letter date.
– No records limits at present.
– 30 business-day notice with roster of accounts. Extensions granted upon
request for large projects; Expect no more than 45 business days, total!
– Audit MIC will also outline details in “Entrance Conference,” when noted
on request letter.
– Patient identifying data is limited (Medicaid #, SSI # & DOS)
– Audits will most often be done offsite. Unless, specifically noted on
request letter, records are required to be submitted accordingly. No
Copying Costs
February 18, 2011
How the MIP is Supposed to Work
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Audit MIC performs audit according to GAGAS
Audit MIC prepares draft report or “No Action” letter
– No specific timeframe noted
– Extrapolation of sample findings is permitted
Audit MIC Shares Draft Report with CMS. CMS reviews and forwards
to ODJFS and provider
– ODJFS and provider have opportunity to comment or provide
additional information
CMS mediates differences, finalizes report and determines amount of
overpayment
CMS issues final report to ODJFS and triggers one-year FFP
repayment timeline.
ODJFS issues final report to provider; No specific timeline noted
– State manages appeals according to its existing policies
– State recoups overpayments according to existing process
February 18, 2011
Medicare Administrative Contractor
 J-15 (OH & KY) MAC Award to CIGNA; Part A Subcontracted to
Riverbend Government Benefits
 Not Home Health or Hospice in OH & KY
 Few Details Yet; Most Work Currently Behind the Scenes
 Transition Schedule Announced (CR 6999, 1/1/11)
 KY Part B > April 30 / Ohio Part B > June 18
 Ohio & KY Part A > Oct. 17
 Expect Formal Six-Month Transition
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All Part A & B
All Beneficiary
All RAC-Related Activity (6- Month Moratorium?)
All Audit & Reimbursement
All Crossover Activity
 CMS Still Required to Re-bid and Expand MAC Jurisdictions in 2015
February 18, 2011
More Medicare Stuff
• Three-day DRG Window “Clarifications”
Documentation Still to Come
• Tightened Medicare/Medicaid Enrollment Standards
• Physician Signature Requirements on Diagnostic Test
Requisitions Will Not be Enforced After All
• .25% ACA Payment Reduction Mass Adjustment
• New CMS Provider Compliance Webpage at
http://www.cms.gov/MLNProducts/45_ProviderCompli
ance.asp
• Good MedPAC Medicare Payment Basics Website
Available at http://medpac.gov/payment_basics.cfm
February 18, 2011
Bureau of Workers’ Compensation
• Outpatient Medicare-based PPS Effective 1/1/11
• Two-Year+ Transition
• 198% Medicare 1/1/11 – 3/31/12 (Childrens = 253% / CAH Exempt)
• 181% Medicare 4/1/12 – 3/31/13
• 166% Medicare After
• 2010 Medicare Pricing Factors in Place Until 3/31/11
• Processing & Pricing Testing Underway
• Medicare v. BWC PPS Chart Available at
http://www.ohanet.org/Issue/BWC
• (See Announcement Section)
• FFY 2011 Inpatient PPS Effective 2/1/11
• BWC Won’t Adopt Medicare/PPACA
Programs and Cuts
February 18, 2011
Other Updates
• ACA-Based Requirements on for Financial
Assistance Policies, Billing & Collection and Charge
Limits Effective in FY 2011, but Still Waiting
on Final IRS Rules
• Medicare End-Stage Renal Disease Provider
PPS Starts 1/1/11, Does not Affect ED or
Inpatient Hospital
• DMEPOS Competitive Bidding Started Jan. 1 in
Cleveland & Cincinnati; Other Ohio Metro Areas,
Additional Items will be Added in 2012
• Aetna Studying ED E&M Codes; May Link Hospital &
Physician Reimbursement
February 18, 2011
“The RAC”
Past, Present and Future
February 18,2011
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30+ years experience in healthcare finance at individual hospital and health system level as CFO and VP of Revenue Cycle
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Past President and Chairman of the Board – Northeast Ohio Chapter of HFMA
Chairman of HFMA’s National Advisory Council
Chairman of National HFMA CFO Forum
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Mr. Paulson holds a MBA in Business Policy from Case Western Reserve University, a BS in Accounting from Miami University, and is a Fellow with HFMA.
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Since 1998, Mr. Paulson has been the VP Finance Revenue Cycle for University Hospitals, currently holding responsibility for:
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Development, interpretation, coordination and administration of the health system's policies and operations for the revenue cycle which include the academic medical center and six community hospitals. The management and operations of the CBO, as well as Patient Assess and HIM.
Previously, Don was CFO for UH Community Hospitals (1997‐99), and VP Finance and CFO for University Hospitals Bedford Medical Center.
February 18,2011
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Lyman G. Sornberger, Executive Director, Patient Financial Services, Cleveland Clinic Health Systems
Lyman Sornberger joined Cleveland Clinic Health Systems in 2006 and is the Executive Director of Patient Financial Services for CCHS. Prior to his affiliation with CCHS he was with University of Pittsburgh Medical Center for 22 years (revenue cycle leadership).
His role at CCHS is comprised of the Revenue Cycle Management for all 11 CCHS Ohio and Florida Hospitals, and 1800 Foundation Physicians. His responsibilities include: all CCHS Patient Access Services, Health Information Management, and Billing. In total there are 1900 employees under his direction with a model that is both centrally and de‐centrally dispersed.
In parallel in the past 12 years, Lyman is proud to have served as a consultant and advisor with various practices nationally. He has authored numerous articles for HFMA, AHAM, and other leaders in the Revenue Cycle arena. Mr. Sornberger earned his BS and Masters at the University of Pittsburgh, a Masters in Non Profit Management, and a Masters in Health Administration. February 18,2011
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Ms. Legerski has over 25+ years with MetroHealth System, currently functioning as the Chief Compliance Officer and Associate General Counsel. Previously roles held at MetroHealth include:
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Compliance and Risk Officer, Risk Manager and Staff Attorney
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Unit Manager II – Medical Intensive Care Unit, Medical Division
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Assistant Unit Manager – Surgical Vascular Division
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Ms. Legerski’s extensive eductional and professional background includes a number of distinguished licensure, certifications, and degrees:
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Certified Professional Coder (CPC‐A) and Certified Healthcare Compliance o
MBA and MPA from Cleveland State University
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Admission to Ohio Bar
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BSN from Ursuline College
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Additionally, Mary is currently active with many professional and community organizations including:
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Ohio Patient Safety Institute (Education Committee member), Ohio State Bar Association, Providence House Board member (past Executive Committee of the Board, Chari Compliance Committee), Tri‐C Corporate College (educational coding seminars), Health Care Compliance Association, American Health Lawyers Association, and past Board member for Concordia Care.
February 18,2011
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“The RAC”
Past
Present
and Future
Don Paulsen, University Hospitals
Lyman Sornberger, Cleveland Clinic
UH RAC Activity
Medicare Discharges
and Requests
40887
Case
Total Discharges
Requests
% of Discharges
Requested
Bedford
Conneaut
Geauga
9,685
1,743
521
2,466
135
54
0
164
1.4%
3.1%
0.0%
6.7%
Geneva
862
0.0%
Richmond
Total
1,710
16,987
118
471
6.9%
2.8%
UH RAC Outcomes
University Hospitals
RAC Experience
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Case
Bedford
Geauga
% of Requests/Discharges
Richmond
Total
% of Overpayments/Discharges
UH RAC Outcomes
• ADR’s (additional documentation requests) to date
• 30% - Outstanding
• 56% - No Findings
• Remainder in Appeals
UH RAC Outcomes
• Initial Inquiries
• Aspiration Pneumonia
• COPD vs.’ Pneumonia as PDX
• Excisional Debridement
• Oxaliplatin
• Acute Renal Failure
• Acute Postoperative Respiratory Insufficiency
• Protein Malnutrition
• Many of the cases are questioning the clinical diagnosis
documented (particularly the last 3 types above)
UH RAC Outcomes
• Demand letters are only to be expected on Community
Hospitals – Non-PIP facilities
• Of the take backs for Non-PIP facilities, a demand letter has
been received on 73% of them
• Appealed Cases
• 75% Reversed, 25% Undetermined
UH RAC Outcomes
• CMC will not receive Demand letters as PIP facility (on
periodic payment plan)
• Of the 21 overpayments for PIP facility, adjustments occurred
on 10% of them (2/21)
• Agreed = 50% (1/2)
• Appealed = 50% (1/2) - Still undetermined
UH Process Improvement Initiatives
Documentation Improvement
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Appealing is only the first step
Process improvement is equally important
Both you and the RAC now identified a potential process
flaw
Steps must be taken to avoid
– Further audit denials
– To demonstrate than the provider is not “willfully”
continuing a practice they now know to be in error.
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It is no longer sufficient to chart and code an
appropriate physician diagnoses
Physicians must add robust documentation that justifies
diagnoses
The RAC just keeps asking the question “”Why?”
When you don’t answer, then the claim is rejected for
lacking clinical documentation
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Electronic medical records present both new opportunities
and challenges
“ClinDoc” can be used to imbed preset comments and
documentation into the medical record
Imbed comments in drop down windows that a medical staff
will agree to will be extremely difficult
EMR teams need to include clinical documentation
specialists in the build phases
– Including HIS staff and physicians
What industry can provide the best customer
experience with the most sophisticated technology
and not be paid because lack of documentation?
• Answer: Healthcare
– With billions of dollars of reimbursement at stake,
quality measures that can either reward or punish
provider, why do healthcare organizations put so little
investment into physician documentation education?
– There isn’t anyone that would ever argue that clinical
documentation is not important. Mitigation of potential
mal-practice suits, comprehensive patient care follow
up , meeting the standards of JCAHO/regulatory
agencies and reimbursement all are benefactors of
complete clinical documentation.
UH Physician Manager of Clinical
Documentation/Education
Provide continuous education to the attending and
resident staff
• ICD-10 physician education
• Assist with denials/appeals related to
coding/documentation
• Provide support to the Documentation Improvement
Programs
• Work with the EMR team to insure electronic
documentation is compliant from a regulatory and
coding perspective.
Provide continuous education to the attending and
resident staff
• Work collaboratively with the CMO’s, department
chairmen and general medical staff at the system level
to raise the level of physician awareness to
documentation issues.
• This individual will also represent the Hospitals at local,
state, or national meetings that have an influence on
clinical documentation requirements and
reimbursement issues.
Position Requirements:
• Desire to become the physician clinical documentation
expert, excellent communication and presentation skills,
flexibility to attend medical staff meetings, ability to
effectively deal with sometimes difficult situations.
UH Revenue Cycle Audit Supervisor
• Assure data integrity of coding/documentation
requests/denials/appeals in Midas and related
systems
• Work in conjunction of Physician Documentation
Manager to provide education
• Coordinate the coding/documentation denial process
at HIS System Level—appeals, reports,2nd level
reviews
RAC Cooperative
RAC Cooperative Mission
• The purpose of the RAC Cooperative is to share best practices in documentation, coding, billing and appeals processes in order to promote compliance with industry standards. These goals will be achieved through identification of best practices and establishing open‐lines of communication with the RAC, Fiscal Intermediary* and Carrier*. • *Transitioning to MAC Membership
• Group participants include representatives for the following departments:
– Finance
– Patient accounts
– Compliance
– Staff dealing with RAC denials
– Care management
– Physicians [ad hoc]
What Has Been Done So Far?
• Initial meeting outlined purposes of group • Held conference call with RAC and addressed common questions we had on processes, such as:
– Discussion period
– RAC responsiveness – Allowed them to outline what they expected from us as providers
What Has Been Done So Far?
• Next meeting we held a conference call with the FI to discuss:
– Appeal process and timelines
– How much information they need for an appeal – Other miscellaneous questions
• Shared information on amount of record requests and types of denials institutions were receiving
What We Plan To Do Next
• We will be bringing physician staff to our next meeting to discuss common denials and how they as physicians would handle
– Example: Respiratory insufficiency/ respiratory failure denials as primary or secondary diagnoses in post‐
operative patients
• Share process/procedural changes that institutions have implemented to prevent further RAC denials
Medical Necessity Cases in 2010
• Started seeing Medical Necessity cases 3rd Q’10 (428 Cases)
• CGI – Methodology for Requests
– Admit Order, DRG & Medical Necessity
(same case)
• Connolly – Methodology for Requests
– DRG and Medical Necessity
(more focused on MN leaving out
the DRG review within the same
case)
Technical Coding – 49%
Med Necessity / DRG – 15%
Automated MUEs – 8%
• Primary focus - One Day or Short Stays
Medical Necessity – 4%
Different Types of Automated –
24%
Medical Necessity Issues to date
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Per CGI
– Acute Inpatient Respiratory Conditions **New 2/2011
– Acute Inpatient Infections **New 2/2011
– Acute Inpatient Musculoskeletal Disorders **New 2/2011
– Atherosclerosis w/ MCC
Chronic Obstructive Pulmonary Disease
– Esophagitis, Gastroenteritis & Misc Digestive Disorders
– Kidney & Urinary Tract Infections w/ MCC
– Neurological Disorders **New 2/2011
– Nutritional and Metabolic Disorders
– Other Circulatory System Diagnoses
– Other Vascular Procedures w/ CC w/o CC/MCC
– Red Blood Cell Disorders w/ MCC
– Renal and Urinary Tract Disorders
– Renal Failure **New 2/2011
– Syncope & Collapse
5 New areas this
month
Determining Medical Necessity
Medical Necessity Results Letter
Medical Necessity – How will 2011 look
different for us?
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Shift from volume being focused on Coding / Automated to increased volume in
Medical Necessity cases.
(CC) YTD 2011, 32% of the cases received for Medical Necessity
(180 cases)
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Increased involvement with Case Management and Utilization Management
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Monthly presentations to Administration, Compliance, Finance, HIM, and Case
Management
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Implementation of E H R to assist with appeals for Medical Necessity requiring
physician expertise
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Stay on top of potential change of tool for identifying Medical Necessity –
InterQual vs. Milliman (how will we manage to that change)
Differences in Interqual vs. Milliman
• Florida Scenario
– Our health system uses Interqual
– Connolly uses Milliman
– Patient may meet Interqual Criteria but does not meet Milliman
Medical Necessity – Process Improvement
Initiatives
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Clinical Review as part of Appeals Process
– How will you accomplish this?
– Do you have a Physician Champion?
– Will you utilize and external service ie. E.H.R. to
support?
Will use this documentation if RAC requests
money to be returned!
Medical Necessity – Process Reviews
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Admission Orders – review the requirement of a physician’s order
in order to qualify and be paid as an inpatient stay.
IP Only Listing - Review w/ Case Management and Surgical
Scheduling to ensure correct patient status at time of admission.
Outpatient Surgical Procedures performed in an Inpatient Setting
Direct Admits – patient admitted from home
or a physician office.
Elective/ planned admissions Educate physician and interdisciplinary
team on CMS guidelines regarding
status orders.
Overall RAC Initiatives 2011
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Continue with successes from 2010
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Monthly publication of RAC
Informer Newsletter
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At a minimum, quarterly
meetings with each hospital
including Rev Cycle,
Finance, HIM and UR
Specific to each hospital:
Teams
Overall RAC Initiatives 2011
Continue with successful processes from 2010
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Monthly publication of RAC Exec Packet
•Volumes & Dollars
•Cases in Appeal Status
•Net Loss / Net Gain
•Risk Levels of Cases in Review
•Audit Types / Categories
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Monthly Steering Committee Meeting
•Chief Compliance Officer
•Chief Nursing Officer
•VP Case Management
•VP Finance
•PFS Exec Director
•Chief Medical Officer
Audit Reasons through 12/31/10
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Automated
Complex Units
Coding
Med Nec/Coding/Adm Order
Complex Medical Nec
The MIG, the MIP and the MIC
• The MIG – the component within CMS that has been charged
by the US Department of Health and Humans Services to
carry out the Medicaid Integrity Program
• The MIP – the Medicaid Integrity Program has been charged
with ensuring compliant billing practices and eliminating fraud
• The MIC - Medicaid Integrity Contractors / private companies
that conduct audit-related activities under contract to the
Medicaid Integrity Group (MIG)
• There are three primary MICs
– 1) the Review MICs
– 2) the Audit MICs
– 3) the Education MICs
Other Payer Audits
Things to think about
• Communicate to all departments to be on the watch for any type
of audit requests. Turnaround time is short – there is not time to
waste
• Payer audits are on the rise – how will you handle
Everyone wants to ride the coattails of the RAC!
?
• Need a central location to manage and monitor these new
requests
Just like with the Medicare RAC, there are PI opportunities!!!
Contact Information
Don Paulson, University Hospitals - (216) 767-8601
Don.Paulson@UHhospitals.org
Lyman Sornberger, Cleveland Clinic – (216) 312-9297
sornbel@ccf.org
Break
10:30 - 10:45
Charity Care:
From Vague Law to Concrete Practice
February 18,2011
67
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30+ years experience in healthcare finance at individual hospital and health system level as CFO and VP of Revenue Cycle
o
o
o
Past President and Chairman of the Board – Northeast Ohio Chapter of HFMA
Chairman of HFMA’s National Advisory Council
Chairman of National HFMA CFO Forum

Mr. Paulson holds a MBA in Business Policy from Case Western Reserve University, a BS in Accounting from Miami University, and is a Fellow with HFMA.

Since 1998, Mr. Paulson has been the VP Finance Revenue Cycle for University Hospitals, currently holding responsibility for:
o

Development, interpretation, coordination and administration of the health system's policies and operations for the revenue cycle which include the academic medical center and six community hospitals. The management and operations of the CBO, as well as Patient Assess and HIM.
Previously, Don was CFO for UH Community Hospitals (1997‐99), and VP Finance and CFO for University Hospitals Bedford Medical Center.
February 18,2011
68

Matt Sheldon is currently Revenue Cycle Director at Lake Health

Areas of responsibility at Lake Health include Patient Access, Patient Accounting, Physician billing and Health Information Management. 
Over 20 years of experience in Healthcare and revenue cycle management

NEO HFMA Member 15+ years and past Co‐Chair for the Patient Financial Services Program Committee (3 years)
February 18,2011
69
Charity Care
From Vague Law to Concrete Practice
February 18, 2011
Patient Protection and
Affordable Care Act
OR
I fought the law and the law won
2/16/2011
University Hospitals Case Medical Center
71
Highlights of Section 9007, Paragraph 4
(A)Financial assistance policy.--A written
financial assistance policy which includes
(i) eligibility criteria for financial
assistance, and whether such assistance
includes free or discounted care
(ii) the basis for calculating amounts
charged to patient
(iii) the method for applying for financial
assistance
72
No Regulations, No Guidance
• eligibility criteria
• basis for calculating
• method for applying
73
(A)Financial assistance policy.--A written
financial assistance policy which includes
(iv) in the case of an organization which
does not have a separate billing and
collections policy, the actions the
organization may take in the event of nonpayment, including collections action and
reporting to credit agencies, and
(v) measures to widely publicize the policy
within the community to be served by the
organization.
74
• The actions the
• organization may take
• Measures to widely
• publicize
75
Limitation on charges.--An organization meets
the requirements of this paragraph if the
organization
(A) limits amounts charged for emergency or
other medically necessary care provided to
individuals eligible for assistance under the
financial assistance policy described in
paragraph (4)
(A) to not more than the lowest amounts
charged to individuals who have insurance
covering such care, and
(B) prohibits the use of gross charges.
76
• Medically necessary care
• Lowest amounts charged
• Who have insurance
77
• Extraordinary collection
actions
• Reasonable efforts
78
• The Secretary shall issue such
regulations and guidance as may be
necessary to carry out the provisions of
this subsection, including guidance
relating to what constitutes reasonable
efforts to determine the eligibility of a
patient under a financial
assistance policy
• When?
79
The 5 W’s
Who, What, When, Where, Why
but most importantly
HOW?
2/16/2011
University Hospitals Case Medical Center
80
Implementing Charity/Financial Assistance
Who Qualifies?
• Uninsured
• Emergency or medically
necessary care
• Not eligible of governmental
payment programs
• Are in your service area
• Provide financial information
81
How To Apply?
• They must make the effort to apply
– We cannot assume there is a need
• Can apply before, during or after care
– All accounts are held for collections
while the application is pending
• They must update the application yearly
– While any accounts are outstanding
82
Publicizing the Program
• Signs and brochures at all registration
and financial counseling sites
• By contacting the CBO
Financial Assistance office
• By providing information
on the UH website
• By providing information
on all bills and statements
83
Medical Indigency
• When a patient is:
– Uninsured
– And has total bill balances
that exceed their ability to pay
• Then they can apply for Financial
assistance because they are medically
indigent
84
Medical Indigency
• The patient must supply
financial information to
determine ability to pay
– sources of income
– other financial assets.
– Living expenses
• All bills will be combined in a 3 year,
interest free payment plan
85
Medical Indigency
• If the monthly total payment of bills
exceeds the monthly available income
• Then the shortfall will be written off for
the entire three year payment plan
86
The Underinsured
• Patients with insurance may also
be unable to pay their deductibles
and co-payment balances
• These patients may then apply for
financial assistance using the same
Medical Indigency program
87
The Underinsured
Why Two Separate Programs?
• The new law requires that all patients who
qualify for your charity policy must not be
billed at a rate greater than
– The lowest amounts charged to
individuals who have insurance
• Therefore you may have to RE-discount
the patient balances to the “lowest
amount”
• This would be an administrative nightmare
88
The Underinsured
• If all hospital and physician bills are subject
to the Charity write offs under a charity /
financial assistance program then the patient
payment will be subject to:
– The “lowest amount” billing discounts and,
– The % of the poverty guidelines discounts
89
The Underinsured
• The two separate discounts will incent Payers
and Employers to increase deductibles and copayments
– Payers and Employers will pay less of the
claim
– Patients will but be buffered from increased
payment obligations
90
The Underinsured
• Especially true for systems with both hospitals
and physicians subject to the policy
• Total care could have very little patient
payment obligations
91
How Charity friendly is your website?
Comparing what websites in Ohio are
saying to their patients about Charity
Hospital 1
•
•
•
•
100% charity adjustment for < 250% FPG
75% adjustment for < 300% FPG
93
Hospital 2
• 100% Charity Adjustment for < 250% FPG
• Adjust to Medicare allowed amount for
< 400% FPG
94
Hospital 3
• Patient receives a charge adjustment to set
Co-payment amount depending on income as
% of FPG. Co pay is based on type of
procedure. Available for county residents
only.
95
Hospitals 4 through 10
• Web site informs patient hospital offers
charity considerations and to contact Patient
billing or Financial counselor for assistance.
% of charity discount not listed.
96
Only two of the ten websites had links to the
hospitals charity policy.
Have you checked your website lately?
97
Laissez le bon temps rouler
98
Lunch
12:15 – 1:15
ICD‐10 Transition
Hospital and Vendor Perspectives
February 18,2011
100
 Christine is the Senior Director of Revenue Cycle at Akron General Health System. She has been in the Ohio market for 7 months, coming from Detroit, MI. Christine brings together Patient Access, Health Information Management, Patient Financial Services and Revenue Cycle Systems Support under the umbrella of Revenue Cycle.
 Akron General is a fully integrated health system with the flagship 500 bed hospital in Akron, a critical access hospital in Lodi, an inpatient and outpatient rehabilitation hospital in Cuyahoga Falls and multiple primary and specialty care clinics/providers throughout Northeast Ohio.
 Her education includes: Master of Arts in Leadership from Siena Heights University , Adrian, MI and a Bachelor of Science in Business from Oakland University, Rochester, MI. She is currently working towards a fellow from American College of Healthcare Executives.
 Christine’s passion is healthcare revenue cycle and bringing the teams together in one flow that maximizes revenue capture, reduces costs, eliminates redundancies and adds value to the patient and employee experience.
February 18,2011
101
ICD-10 Transition
From a Hospital’s Perspective
Christine MacKay-Michels
Senior Director Revenue Cycle
Akron General Health System
Agenda
l
a
r
e
n ive
e
t
• Background
G
c
e
n
• Decision for Transition kro rsp
e
A
p
• Readiness Assessment
y ls
b
d era
• Assessment Focus
e
d
n
i
e
v
• Know Your
Data
o nG
r
p ro
• Statistics
s
i
k
n
A
• ioRemediation
s
t
e
a
i
f
• Cost
Structure
i
m
t
r en
o
f
d• Training
n
i
i
y • Timeframe
s
l
i
n
Th d o
• Take Aways
n
a
Background
• ICD-10 is the International Classification of Diseases
and Related Health Problems used to code and classify
disease and diagnoses, also know as codes.
• Affects 2 code sets:
– ICD-10 CM – Diagnostic Conditions
– ICD10 PCS – Inpatient Procedure Codes
• Utilized for all transmission of bills and to receive
payments.
• Establishes greater granularity in coding of diagnosis
and inpatient procedures.
• Information and education starting to be shared across
professional and trade organizations.
Decision for Transition Driven By:
•
•
•
•
•
CMS has mandated ICD-9 to ICD-10 transition effective 10/1/2013.
ICD-9 is not sustainable – running out of codes in logical grouping.
Impacts all revenue cycle applications and systems.
U.S. is last of the industrialized nations utilizing ICD-9 codes.
ICD-10 incorporates much greater specificity and clinical information.
– Greater detail of diagnosis and procedures
– Capture higher level of quality of clinical information to drive
transparency and higher quality of care.
– Recognition in advances of medicine, treatment and technology
– Ability to meet enhanced HIPAA electronic transactions
– Driving transparency of pay for performance reimbursement
ICD-10 Readiness Assessment
• PriceWaterhouseCoopers engaged in a 10-week
Readiness Assessment.
• Executive Steering Committee formed with key
stakeholders throughout the health system.
• Functional leads and workgroups identified
through knowledge and expertise and participated
in numerous meetings enterprise wide.
PriceWaterhouseCoopers
Readiness Assessment Focus
• In-depth analysis of :
– I.T. systems
– Applications
– People
– Processes
Know Your Data
• Important to know your data.
• Extract your ICD-9 code data to
project the ICD-10 impact and how it
will translate.
ICD-9 Current State
Approx.
2,000 Px
Approx.
10,000 Dx
Approx.
5,000 Dx
Source: YTD 2010 AGHS Inpatient and Outpatient Data
Code Translation for ICD-10
Approx
40,000 Px
Approx
55,000 Dx
Approx
40,000 Dx
AGMC ICD-9 translation to ICD-10
ICD-9 Analysis by Department Line
ICD-10 Analysis by Department Line
ICD-10 Mapping by Department Line (Diagnosis & Procedure Codes – All Patients)
ICD-9
1 to 0
1 to 1
1 to
Few
(1-11)
Service Line
B
3,516
0
1,639
5,252
2,919
35,938
45,748
A
3,476
0
1,461
5,336
4,223
31,713
42,733
F
1,679
0
528
2,646
3,237
33,998
40,409
D
2,463
0
913
3,734
3,652
31,145
39,444
C
3,498
0
1,337
5,693
3,932
28,038
39,000
G
1,497
0
693
2,099
1,700
24,114
28,606
E
1,966
0
898
2,974
1,453
15,989
21,314
H
1,138
0
562
1,559
979
5,522
8,622
I
880
0
410
1,209
801
6,783
9,203
J
856
0
426
1,328
634
2,638
5,026
Department Line
* Includes data for Akron General Medical Center (AGMC)
1 to
Several
(12-25)
1 to
Many
(26 +)
Total
ICD-10
Remediation
• AGHS has 48 current system applications that will require
remediation to continue to flow information.
• Costs are associated with our core revenue cycle applications, with
multiple “bolt-ons” to support charge capture, coding, billing and
payment posting.
• The project is expected to focus 81,200 internal dedicated with a
total of employee hours over 4-5 years for:
– project management,
– vendor management
– coordination of I.T. system upgrades
– application remediation.
• Training and education costs for all clinical providers, case
management, coding, managed care and billing staff to support the
highest level of reimbursement potential and clinical specificity.
ICD-10 Impact Assessment Statistics
Sources of Information gathered
Applications reviewed
Total number as of 9/30/10
125
* 48 will require remediation
Electronic and Paper Forms
2,474 (HIM and PFS)
Vendors
79
Interfaces
61
Meetings/Interviews
78 (Approximately)
Process Mapping and Flows
29 (HIM and PFS)
Provided by PriceWaterhouseCoopers
AGHS ICD-10 Assessment Remediation
Recommendations
•
Deploy an Enterprise Wide Project Management Office
•
•
•
•
•
Design Remediation Blueprint
Construct Next Generation Business Model
Implement Future State Blueprint
Review and Continuously Improve
Design a Training Curriculum and Provide Training
• Awareness Training
• Intermediate Training
• Advance Training
•
Implement a Vendor Management Program
• Manage Vendor Relationship
• Coordinate Vendor Patches, upgrades and implementations.
•
Identify opportunities to centralize and standardize operations and
policies.
AGHS ICD-10 Assessment Remediation
Recommendations
•
•
Conduct an enterprise wide HIPAA 5010 Assessment
– Meeting the HIPAA 5010 requirements are essential for ICD-10 adoption
– An enterprise wide evaluation of the impacts of HIPAA 5010 on AGHS
business processes, vendors and IT applications is required
– Try to adopt a “one-touch” methodology with vendors and processes that
overlap HIPAA 5010 and ICD-10 requirements.
Improve CPOE order sets with ICD-10 supporting diagnosis
documentation
– Design future CPOE order sets with ICD-10 documentation supporting
medical necessity of the ordered service
Cost Structure
and
Components
Areas of Greatest Cost
•
•
•
•
Project Management
Vendor Management
Human Resource allocation and hours
Training and Education
Impact of Not Participating
• Loss of revenue/Inability to transmit claims or
receive payments.
• Non compliance with CMS billing regulations.
• Inaccurate clinical metrics and pay for
performance reporting and reimbursement.
• Erroneous quality reporting.
• Non compliance with HIPAA electronic
transmission regulations.
• Non compliance with stage II of Meaningful Use
EHR requirements.
Take Aways
• Designate specific Oversight
– i.e.: PMO, I.S., Revenue Cycle, HIM etc
– Know it is a group effort
• Identify, develop and gather the teams and
members and identify Subject Matter Experts.
• Know your I.T. systems, applications &
Vendors
• KNOW YOUR DATA
Start mining your current data to know how it
will translate to ICD-10
Take Aways continued
• Identify your training needs
• How broad is the training scope
• Rank by level of intensity i.e. Awareness,
Intermediate or Advanced.
• Develop a training plan
• Determine what groups and when
• Determine what training program
• Boot camps, certified programs, train the trainers, online
education, etc.
• Develop a timeline
Questions?
Additional questions can be directed to
Christine MacKay-Michels
Senior Director Revenue Cycle
cmackaymichels@agmc.org
330-344-7502




Karen has been with Siemens Healthcare for 28 years in a variety of roles. She is currently the Product Manager for a number of Patient Access applications in both legacy and non‐legacy product lines. She is Co‐Chair of the Siemens ICD‐10 Core team responsible for aligning ICD‐10 software updates and customer communications across the Siemens healthcare IT applications. Her education includes a BA from Penn State University and a Masters in Public Administration from Temple University. Siemens Healthcare is one of the world’s largest suppliers to the healthcare industry and a trendsetter in medical imaging, laboratory diagnostics, medical information technology and hearing aids. The Siemens Complete and Modular EHRs are 2011/2012 compliant and have been certified by the Certification Commission for Health Information Technology (CCHIT®), an ONC‐ATCB, in accordance with the applicable certification criteria for Hospitals adopted by the Secretary of Health and Human Services.
As a Platinum Sponsor of HFMA Siemens is hosting an exhibit at the HFMA Virtual Healthcare Finance Conference from December 2010 thru February.
February 18,2011
125
Karen Melton, Product Manager and ICD‐10‐CM/PCS Core Team Co‐Chair
Siemens Health Services
February 18,2011
126
February 18,2011

Background

Aligning Organization with Industry

Fitting ICD‐10‐CM/PCS into the “perfect storm”

So what are the Requirements

Coordinating Internally and Externally

Designing for Easy Install and Implementation

Some Challenges for Provider Testing

Communicate, Communicate, Communicate
127
ICD‐9‐CM – Procedure Codes
ICD‐10‐CM – Procedure codes
 3,824 Total Codes
 3‐4 characters with decimal
 All characters are numeric
 All codes have at least 3 characters






February 18,2011
72,589 Total Codes
7 characters and no decimal
Each can be alpha or numeric
Numbers 0‐9; letters A‐H, J‐N, P‐Z
Alpha characters not case sensitive
Each code has 7 characters
128
ICD‐9‐CM DX Codes 14,025 Total Codes  3–5 characters;  1st character is alpha (E or V) or numeric
 Alpha characters not case sensitive);  Character 2–5 are numeric;  Decimal after third character. February 18,2011
ICD‐10‐CM – DX codes
 68,069 Total Codes
 3–7 characters;  Character 1 is alpha; Char 2 is numeric;  Character 3–7 are alpha or numeric (alpha characters not case sensitive);  Decimal after third character. 129
ICD‐9‐CM and ICD‐10‐CM/PCS Code Freeze information
 Last regular annual updates to both ICD‐9‐CM and ICD‐10‐
CM/PCS code update will be 10/1/2011;  On 10/1/2012 limited updates to capture new technology and diseases for both ICD‐9‐CM and ICD‐10 CM/PCS.
 Note: Last ICD‐9‐CM code update
 On 10/1/2013 limited code update to capture new technology diseases only for ICD‐10‐CM/PCS only  On 10/1/2014 regular updates begin.
February 18,2011
130
HIMSS December 2010 Readiness Survey:
 47% of providers have staffed/funded project
 56% have started or completed impact assessment
 83% will upgrade existing systems, 21% will replace systems
 64% ‐ staffing is the most significant obstacle
February 18,2011
131
Healthcare Industry
Laws, Regulations
and Statutes
Government
& Industry
Initiatives
Standards
Community
Health Services Strategy
Regulatory
Council
Industry
Council
Standards
Council
Product Management
R&D Processes
February 18,2011
132
 Cross‐organizational core team in place since early 2009
o 48 people representing all affected applications, and stakeholders
o Monitor progress
o Share best practices
o Develop communication strategies
o Address risks through mitigation strategies.
February 18,2011
133
Lvl 1 Testing
Lvl 2 Testing
Live
5010
Planning
Testing
ICD10
Meaningful Use of Certified EHRs
ARRA
Health Reform
February 18,2011
Live
Many new provisions
1/2010
1/2011
1/2012
1/2013
1/2014
1/2015
134
Single implementation/compliance date – 10/1/2013  Date of service for ambulatory and physician reporting
 Date of discharge for inpatient settings
Exceptions and Open Questions







Non HIPAA‐covered payers
State Medicaids Readiness?
State data tapes?
Cross over patients?
Short Description length?
SNIF?
Authorizations / Referrals?
February 18,2011
135
 Within Siemens more than a dozen affected applications
o Clinical, Ambulatory, Financial, Ancillaries (Lab, Radiology, Pharmacy), Decision Support, Eligibility & Referral Services, Scheduling
 ADT partners inbound and outbound
 Coding System interfaces
February 18,2011
136
Making updated software backward compatible
Managing different timeframes
Service Offerings
What (exactly) happens on Oct 1, 2013?
Ease of Use with expanded number of codes
February 18,2011
137
Availability of software for training
Overlap with Meaningful Use Stage II
o According to HIMSS Survey competing as well as synergistic initiative Different timelines for every product and vendor
Testing in Test vs Production
February 18,2011
138









Industry participation
Customer Website ‐‐ Regulatory Infopedia
User Group Meetings
Customer Validation Sessions
Questionnaires
Industry level Webcasts for customers
Product Specific Webcasts
Product Specific Planning Memos and Report Cards
Implementation Guides, Test Plans
February 18,2011
139
February 18,2011
140
Break
2:30 – 2:45

President of Summa Health Network, Chief Operations Officer of Summa Accountable Care Organization (ACO) and Vice‐President of Managed Care for Summa Health System. Mr. Vignos has been with Summa Health System since 2001. He oversees the managed care contracting activities for Summa Health System hospitals. He also oversees the Clinical Integration Model and Messenger activities of the 1300 member physician‐hospital organization (PHO). Most recently he has been given the responsibility of the development of the operations of the ACO. 
Prior to joining Summa Health System in 2001, Mr. Vignos spent 11 years as Vice President of Finance for Hometown Health Network in Massillon, Ohio and also served 7 years as a public accountant prior to Hometown Health Network. 
Currently a member of Healthcare Roundtable for Managed Care and Ohio Society of Certified Public Accountants. Additionally serving as a Board Member for several organizations including: Cleveland Health Network‐Managed Care Organization, Ohio Health Choice, Akron Better Business Bureau, Golden Eagles Athletic Association, and also currently serves as Chairman of the endowment committee for Community Services of Stark County (previously President).

Mr. Vignos received his B.S. in accounting from the University of Akron.
February 18,2011
142
Accountable Care?
No Turning Back.
February 18,2011
143
Accountable Care? No turning back.
Charles Vignos, CPA
President, Summa Health Network
System VP, Managed Care
ACO Chief Operating Officer
Summa Health System
I:/Charles Vignos/ACO Educational Session
That’s more than healthcare. That’s smartcare.
144
Questions To Be Answered
 Why is there an Urgency to Change?
 What is an Accountable Care Organization (“ACO”)?
 What is the functions of an ACO?
145
Why is there an Urgency to Change?
Healthcare Spending Growth
CMS Projections for National Healthcare Spending
CY 2003 - 2018
(Amount in Billions)
$5,000
21.0%
$4,353
$4,500
$4,062
$4,000
$3,790
19.3%
National Health Expenditures (billions)
20.3%
20.0%
19.8%
$3,541
National Health Expenditures as a
Percent of Gross Domestic Product
$3,500
$3,313
18.9%
19.0%
$3,111
18.5%
$2,931
$3,000
$2,770
$2,624
$2,510
17.9%
$2,379
$2,500
$2,241
17.6%
18.2%
18.0%
18.0%
17.7%
$2,113
$2,000
$1,735
$1,855
$1,981
17.0%
16.6%
$1,500
16.2%
$1,000
15.8%
15.9%
15.9%
2004
2005
16.0%
16.0%
$500
$0
15.0%
2003
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Source: Cen ters fo r Med icaid & Med icare Services - NHE Projections 2008-2018, Forecast Summary and Selected Tables
146
Why is there an Urgency to Change?
Medicare Spending
Medicare Spending
CY 1970 - 2016
900
799
$ in billions; figures for 2006 and beyond are projections
863
742
800
690
641
700
594
600
500
418
445
479
516
554
342
400
300
209 213 224
184 199 210
200
248 266
284
313
110
100
$8
37
0
'70 '80 '90 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16
Source: Modern Healthcare's By The Numbers - December 2007 (CMS, 877-267-2323, cms.gov)
147
Health Care Reform
 The Patient Protection and Affordable Care Act
 Attempts to address many fundamental problems with the current
healthcare system
 Extends healthcare coverage to 32 million uninsured people
 Begins to reform the payment system toward accountable,
coordinated healthcare delivery
 “Bending the Cost Curve”
 Reform attempts to slow down the rate of increase of healthcare
costs, specifically for Medicare
 Authorizes a number of value-based pilots that focus on reducing
costs and increasing quality
 Medicare Accountable Care Organization (ACO) pilots will begin
January 1, 2012
148
Our Burning Platform
 Reform has created 2 options for the future of the healthcare system
Value-Based Purchasing
Healthcare
Reform
Insurance-centered approach leading to continuous
ratcheting down of prices year after year
$$$ leave the healthcare system and go to
insurance company investors
Accountable Care
Patient-centered approach that is a new way of
delivering care to improve quality and reduce the
total cost of care for a defined population
$$$ are reinvested in providing healthcare
services in local communities
149
Medicare VBP Principles
 Reimbursement at  risk
 Penalties tied to DRGs
 Public Reporting
 Reward-then-Penalty Progression
150
Why Change How We Provide Care?
Everyone is working in their own silos…
Primary
Care
Specialty
Care
Ambulatory
Hospital
and ED
Skilled
Nursing
Nursing
Home
Home
Health
151
Accountable Care as the Integrator
Primary
Care
Specialty
Care
Ambulatory
Hospital
Patients
and ED
Skilled
Nursing
Nursing
Home
Home
Health
152
What is Accountable Care?
The concept of Accountable Care highlights the need
for physicians, hospitals, other providers, payers, and
patients and their caregivers to work collaboratively to
ensure and measurably improve appropriate, highquality, efficient and cost-effective delivery of healthcare.
153
What is Accountable Care?
Accountable Care is…
 Moving away from the current fee-for-service payment system that rewards doing
more to a new payment system that incentivizes a focus on primary care, wellness
and population health
 Engage providers that are clinically and fiscally accountable for the populations they
serve
 Engage patients to actively take responsibility for their health
 Hospitals and physicians building upon their relationships with each other and
partnering in a deeper way with patients, populations and payers
154
Functional Components of an ACO
• Care Models
• Financial Models
• Technology
• Participation Requirements
155
Care Models
 Reviewing high-cost and high-utilization clinical
conditions (i.e. heart failure)
 Redesigning transitions of care (i.e. hospital to home) to
address readmissions
 Care coordination by care manager to facilitate the
relationship between hospital, physician and patient
156
Financial Model – Shared Savings
157
Technology to Support ACO
 Developing call center to support transitions of care
 Care coordination
 Clinical patient support
 Physician office extenders
 Data management
 Clinical decision support
 Clinical reporting
158
Provider Participation Requirement
 Operational Requirements:
 Participation in educational initiatives
 Practice open to all new enrollees
 Quality of Care Requirements:
 Adherence to ACO Care Models
 Referrals to other ACO Members
 Clinical Information Exchange Requirements:
 ACO approved EMR
 Exchange of clinical and demographic information necessary for
ACO operations
159
What Does This Mean for Providers
 Enhanced practice support
 Less calls and more (nursing) help at night
 Less physician calls and more help during the day
 Increased size of patient panels without increased patient-seeing
hours/day
 More patient education and care management by
nurses
 Telephonic and/or office-based
 Allows physicians to do more of what requires physician skills and
physician-patient relationships
160
What Does This Mean for Providers
(continued)
 Investments spread over a large organization and
across the community
 Lower costs and less duplication
 Focus on care management, communications, informatics and
measurement infrastructure, and business intelligence analytics
 Actionable information allowing for continual self-improvement
 The focus of productivity shifts over time
 Productivity becomes measured more by the results of patient
engagement, preventive health, and proactively dealing with the
anticipated needs of the ACO chronic care patient populations
161
Why ACO’s Will Survive?
Financial Perspective
 National Debt
 Growth of Health Care Spending
 Provider Reimbursement Being Reduced
 Health Care Reform – One of the few items that
addressed “Bending the Cost Curve”
 Funding comes from savings
162
Bill Gates Quote
We always overestimate the change that
will occur in the next two years and
underestimate the change that will occur
in the next ten. Don't let yourself be lulled
into inaction.
Questions?
Charles Vignos, CPA
vignosc@summahealthnetwork.org
330.996.8486
163
Please Be Sure To:
Complete Program Survey
Pick Up CEU/CPE Certificates
This Is My World.
Welcome To It!
Akron General Health and Wellness Center
February 18,2011
164

PFS Program Presentation - AAHAM Western Reserve Chapter

Transcription

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