Word-of-mouth has always been considered a most reliable source of information about the quality of traditional customer goods and services. So, it should be the same case for healthcare services, right? Well, so thinks CMS.
With growing concerns on Medicare’s future, the federal government has turned to customer reviews to institute the Hospital Inpatient Value-Based Purchasing Program (Hospital VBP Program). Section 3001(a) of the Affordable Care Act (ACA) added a new section 1886(o) to the Act, which requires the Secretary to establish a hospital value-based purchasing program under which incentive payments will be made in a fiscal year based upon a hospital meeting or exceeding the performance standards set for that specific fiscal year. The incentives will be funded by a reduction to the fiscal year’s base operating diagnosis-related group (DRG) payments from hospitals. The Centers for Medicare and Medicaid Services (CMS) have finalized the new reimbursement program under section 1886(o) of the Social Security Act and determined that for FY 2013 a 1.0 percent discharge will apply. The reductions increase to 1.25 percent in FY 2014, 1.50 in FY 2015, 1.75 in FY 2016, and by 2.0 percent in FY 2017. The Hospital VBP Program will apply to payments for discharges occurring on or after October 1, 2012, in accordance with section 1886(o). To be rewarded, the Hospital must meet or exceed the performance standards established with respect to the measures.
The initial measures for FY 2013’s Hospital VBP Program will be categorized into two domains – the first domain consisting of 17 measures based on clinical process of care and the second domain is adopting the Patient Experience of Care Measure – the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS). The methodology for assessing the total performance will be to calculate a total performance score for each hospital by combining the greater of the hospital’s achievement or improvement points for each measure to determine a score for each domain, then multiply each domain score by a proposed weight (clinical process of care by 70 percent, patient experience of care by 30 percent), and finally adding together the weighted domain scores.
What does this calculation mean to the bottom line? CMS has stated that it expects the VBP program to redistribute $850 million among hospitals in FY 2013. Let’s call this distribution of money a bonus and, therefore, the bonus will be directly proportional to the hospital’s quality score. This of course means some hospitals will earn back more than the amount withheld (winners), but some will earn back far less (losers). However, one study, using 2009 data from the Hospital Compare database, has described the program’s potential impact on individual hospitals as minimal stating that the average change would be $55,381 for the hospitals with the largest percentage gain and $125,000 for hospitals with the largest percentage loss. Of course, these numbers will increase as the percentage withheld from each hospital increases year after year.
Is the “bonus” the true moral behind the Hospital VBP Program? The bonus will not have a substantial impact on the bottom line, initially at least, but we need to keep in mind the other benefits from the program. In developing this program, CMS viewed value-based purchasing as an important step toward revamping how care and services are paid for, moving increasingly toward rewarding better value, outcomes, and innovations instead of merely volume. According to CMS, one in seven Medicare patients will experience some “adverse” event such as a preventable illness or injury while in the hospital. Medicare spent an estimated $4.4 billion in 2009 to care for patients who had been harmed in the hospital, and readmissions cost Medicare another $26 billion. These expenses, which negatively affect the bottom line, are avoidable if hospitals make the appropriate precautionary steps to increase the quality of care. It’s obvious that the penalty, at the moment, will not make huge strides, but if CMS releases the patient’s experience of care to the public, hospitals will immediately feel the impact. Everything is Reviewed – Why not the quality of your healthcare!!!
- State on impact from – http://www.anesthesiallc.com/publications/ealerts/543-value-based-purchasing-for-hospitals-starts-nowand-for-anesthesiologists-in-2015%22
The word “audit” usually accompanies thoughts of penalties, stress, and fear; however, a pro-active audit is an effective tool that should be used by all practices. In order to conduct an effective audit there are a few tips that should be considered:
1- If you do not currently audit your practice, what are you waiting for? The first audit will allow you to tailor subsequent audits, further educate coders, and give you a more in-depth perspective of what is going on in the practice.
2- If you already conduct audits, maintain a routine schedule. Depending upon the results of your initial audit, you may need only schedule audits once per year or twice per year. Perhaps you can audit the entire practice only once per year, yet you must audit a particular weak point four times per year. The frequency of the audits should be decided by each practice individually, but no less than once per year.
3- Ensure a qualified auditor is conducting the audit. Under no circumstances should the individual auditing the codes be the same person who coded originally. There is certainly little downside to hiring an independent coding auditor to conduct your audits.
While conducting pro-active audits may be a laborious process, it is a worthwhile endeavor that can save both time and money. Further, if you are selected for an audit, your practice should rest easy knowing there will be no unexpected (and unfortunate) surprises.
Health Information Exchanges or HIE is a major topic in healthcare discussions across the country. As we move to greater use of computers to collect information on patients and treatment protocols, HIEs are the next step to utilizing that data to derive better outcomes. For as long as I can remember, hospitals have gone to great lengths to coordinate their care across multidisciplinary teams to optimize care for their patients. Combining efforts of many hospital departments, clinicians, and physicians to share patient information and coordinate care plans that improve outcomes has been the goal. With HIEs, the healthcare industry faces the challenge of sharing information electronically beyond the hospital walls with multiple care entities. These entities utilize their own legacy systems presenting IT issues in determining a communication standard regarding how this information can be shared and what should be shared. To begin this process and get a positive result, we need to review why HIEs were proposed in the first place.
The creation of HIEs is supposed to bring higher quality care, lower cost, and better clinical outcomes. So, with this in mind, focusing on those outcomes should be the starting point, beginning with a chronic disease process such as Diabetes or Congestive Heart Failure where an intensive effort in resources could produce a dramatic improvement in outcomes and cost. Where are the patients treated? Hospitals, physician offices, nursing homes all have a role in the health of patients in these disease processes. Who else? Visiting nurses, retail pharmacies, urgent care centers also come in contact with these patient groups. How do we get them linked and what do we share? I am not an IT expert but do appreciate the challenge of moving information in and out of different software platforms so that shared data is available to the end-user. For the purpose of this blog, I am going to focus more on the data utilized by the end clinical user. With Diabetes and Congestive Heart Failure there are widely accepted clinical protocols relating to these patient groups. Coordinated care has been clinically proven to improve the long term outcomes for patients who have these disease processes. Coordinating that care and sharing the patient medical record has benefits, but what is shared? Who is ultimately responsible for interventions when shared data suggests an issue with a patient? If you are not directly involved with a patient’s care i.e. pharmacy, but have shared access – what is your role? Establishing a new care model to fully utilize the shared information will be necessary to take full advantage of an HIE’s capabilities.
HIEs are going to change how providers follow and treat their patient populations. HIEs and patient information that will be available will change how care is coordinated and that will lead to new and broader care models. HIEs will certainly reach beyond care providers. Payors, governmental agencies, maybe even industries like pharmaceutical and medical device companies, will be involved. As with any new healthcare model that has been explored in the past, HIEs will vary across the country to meet the needs and restrictions of the local markets. Having goals of higher quality and better outcomes will result in HIE models that make sense and are worth the effort.
Whenever the word audit is used it usually causes some anxiety. This is especially true with some physicians who feel keeping up with the latest coding changes and still trying to manage a busy patient schedule can be an impossible task. At MTBC, our coders have to continually educate to stay abreast of new coding changes. If you do not have access to coding resources an audit of your current coding practices could be very beneficial. To maximize the benefit of a coding audit a physician should have a representative sampling of his or her work. For primary care physicians, the focus will be mainly on E & M encounters but if the physician is doing additional diagnostics or procedures in the office it is important to include these in the review. Many specialists will also include diagnostics and procedures in the encounters that are audited in addition to their E & M encounters. To get a good review, all documentation relating to the encounter needs to be included in the audit, including office notes and op reports when appropriate.
Although gathering a good sample of encounters with supporting documentation is critical to a good audit, the real benefit is in the review. To maximize the outcome of the audit the physician will want to set aside uninterrupted time to review and discuss the findings with the auditor. Reviewing the patient encounters in detail allows the physician to understand the auditor’s coding rationale and how the provider’s coding compares to other providers. Much of our coding reviews are focused on the supporting documentation. Issues with documentation or the verbiage used to document often leads to down coding an encounter. The review process is invaluable as an educational tool to address these types of opportunities. Reviewing examples of issues and solutions will greatly improve your coding. Conducting your review as a group of providers can also provide additional benefit as more encounters are reviewed addressing scenarios that may not have been included in one providers encounter sample. Reviewing as a group also helps the providers discuss opportunities to standardize encounter documentation and discuss any office changes that may enhance the documentation function.
As CMS increases its frequency of RAC audits, providers can use an internal audit to address coding issues in advance and hopefully avoid future RAC audit repercussions. Accurate coding is worth the time and effort. Taking steps now to identify and correct coding issues through an audit will optimize reimbursement and help minimize issues that may result from a future RAC audit.
Employee Health Insurance: In 2013, healthcare providers must decide whether to provide employee health insurance. If you have 50 or more employees (eps), you must have an employee health insurance scheme? plan?, or pay a $2,000 fee for each employee above 30. (So 50 eps – 30 eps = 20 eps X $2000 = $40,000)
Medicaid Patients: In 2013, healthcare providers might want to accept Medicaid patients because Medicaid payments will be raised to 100% of the Medicare Fee Schedule in 2013 and 2014.
ICD-10 Coding: October 1, 2014 is the deadline for healthcare organizations to implement ICD-10 coding. But don’t underestimate the complexity of ICD-10, take time now and start learning the new ICD-10 codes.
Extracurricular Pay: In 2013, the Physician Payments Sunshine Act will begin its data collection, which requires drug and device manufacturers to disclose all gifts and fees valued over $10 that are given to healthcare providers.
Protest Medicare Pay Cuts: In 2014, IPAB could be recommending provider pay cuts for Medicare. Write to your Congressperson to support a bill by the American Medical Association to repeal this proposition.
All the above points can be referenced by clicking here.