A Summary of Pre-Claim Review for Home Health Agencies

By now, home health agencies are well aware of the new program under development by CMS to crack down on what they believe is a major problem with improper payments for their services.  This is referred to as the “Pre-Claim Review Demonstration”.

This document describes these new regulations that were published in the Federal Register in June.

This effort is a drastic attempt by CMS to reduce the increasing improper payment rates associated directly with home health services.  Essentially, developing a process to examine 100% of all claims submitted by Home Health Agencies (HHA) prior to their approval and final payment.

Pre Claims Review for Home Health

CMS’s Comprehensive Error Rate Testing (CERT) program annually estimates the percentage of payments that did not meet Medicare coverage, coding and billing rules.  For 2015, they calculated the improper payment rate for home health claims at 59%.  This compares to 51.4% in 2014 and 17.3% in 2013.  CERT determined that a majority of errors that occurred in 2014 were due to the fact that the narrative documentation associated with face-to-face encounters did not support the patient’s homebound status and the need for skilled services.  Now CMS no longer requires separate narrative documentation for the face-to-face, but they are still seeing many cases where the documentation provided by the HHA in the medical record does not support the home health benefit they are providing.  These improper payments do not necessarily indicate fraud, it may simply be a lack of documentation, documentation errors, or a lack of understanding of Medicare rules.  However, fraud is a substantial contributor to the problem.

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MEDTranDirect Takes on Late NOEs with the New NOE Tracker

Since October of 2014, timely filing of NOE/NOTRs (Notice of Election/Notice of Termination-Revocation) has been a leading issue for the hospice industry.  As a software company that works on Medicare electronic transaction processing, when these regulations were announced, they caught our attention as a possible opportunity for a new product that might resolve some of the issues that CMS and the hospice industry dealt with regarding the efficiency of these transactions.

Notice of Election Tracker

One of the most difficult tasks you deal with regarding developing new software solutions is understanding the actual issues involved with a process and what the problems really are for the entities involved.  When these regulations were announced, it was clear that CMS felt that it was important to get these transactions submitted within five days.  This told us two things.   First, they were not being processed within this window a substantial portion of the time and second, that this delay presented problems for CMS and the industry.

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Healthcare Analytics – Analyzing the Cookie Jar

Healthcare analytics can be used to identify successful treatments, control costs, and make processes more efficient.  It can also be used to shed light on practices and industry relationships that might not be considered entirely healthy for the industry as a whole.

It is no secret that drug manufacturers make payments or provide services to physicians in an effort to strengthen their relationship with these providers.  Providers have long argued that these practices in no way influence their decision on which drugs they prescribe to their patients.

ProPublica, (www.propublica.org) an internet news site, has used this public data to create a database on providers and how much they collect through these payments from drug and medical device manufacturers.  They have made this database available through their site and you can look up the payments reported as paid to your physicians from these vendors.

analytics cookie jar

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Drones and Healthcare IT

It has been a month since my last post.  I normally don’t take so long, but sometimes life takes over and you don’t always have the free time to get your thoughts down on virtual paper.  Although my writing has been lax, I have been reading quite a bit lately.  Now it’s time to write again.

Around this time of year, we see the obligatory bests and worst lists of the ending year.  Like most people, when I read these lists I often think of what is missing that makes these lists incomplete or rankings that seem irrational or unjust.  There were several examples of these I saw regarding healthcare IT that examined the past year and what is coming in 2016.

Instead of discussing a list, I would like to point out a single completed objective that all of us should reflect on as we evaluate 2015 and look toward the future adoption of new technology in healthcare.  During late 2015, we converted from the ICD9 to ICD10 diagnosis code set.  This was over 90 days ago and the expected major disruptions associated with this change have never materialized.  Like Y2K and Obamacare, we have once again proven that healthcare is an industry that can absorb change and adapt to new procedures.  We have demonstrated again that we normally overestimate the negative impact of change and our ability to cope.

 

Drones and Healthcare IT

 

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The Recovery Audit Program: The Big Business of Medicare Audits

The MACs (Medicare Administrative Contractors) audit claims submitted by providers within their jurisdictions.  These organizations are mostly insurance companies who administer the contracts awarded by CMS to process claims submitted electronically by providers in a given geographic area.   As part of this responsibility, these MACs are required to make sure that the claims submitted are complete and submitted in accordance with the rules developed by Medicare to assure that these claims are for services that are medically necessary and properly documented.

They work similar to the IRS, examining submitted claim data for outliers and patterns of suspicious behavior.   Like the IRS, they perform this service as part of their contractual obligation to the government, not as a revenue generating activity.

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The Value Proposition of Hospice Transfers under Medicare Reimbursement

“Medicare coverage of hospice depends on a physician’s certification that an individual’s prognosis is a life expectancy of six months or less if the terminal illness runs its normal course.”

This is the criteria set by Medicare for admitting a patient into hospice. CMS provides several documents that provide guidelines for determining if patients qualify based on their clinical situation and this definition. These documents state that this is an inexact science and that it is understood that some patients will last longer and that some clinical issues and indicators are much harder to use for predictions than others. For example, weight loss is a very good indicator, loss of cognitive function is not. These documents also describe how patients can be discharged by a hospice if the clinical data changes to the point where their remaining lifetime is expected to exceed this six month guideline.

Budgeted Hospice Caps

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The Potential of Data Analytics in Healthcare

Earlier this week, I attended a symposium on healthcare data analytics held by Health Data Management in Chicago.  This was the fourth year of the convention and the first year that I attended.  I have attended many healthcare conventions over the last 30 years, mostly related to financial transactions, data and topics related to revenue cycle management.  This meeting was unique in that it related data to all types of healthcare management and showed how numbers could be used to predict the future as well as analyze the past.

Forward thinking organizations were already using analytics to do some pretty amazing things.  One facility had developed tools to predict future readmission rates of their own patients, another had predictive analytics for projecting future short term emergency department demand so that they could staff for these fluctuations in advance.  This tool used internal data collected by the healthcare organization and external data like traffic, weather and social media.

Vendors had tools that could not only model historical data and test hypotheses, but could measure and identify trends from data unseen by users.  New algorithms used in other industries can be applied to healthcare data to allow computers to assist users to explore their own information.  Think of when Netflix shows you “other films you may like” or when Amazon suggests similar products.  This technology can be used in healthcare to suggest things you may be looking for, but may not have thought of yet.

Bubble Graph
Potential of Analytics

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The Perception of Quality

As a president of a software development company, I am both a vendor and a consumer of customer service.  After 30 years of working with my customers and obtaining supporting services for our tools and systems, I have learned the value of quality service and the damage that is caused when this aspect of our business is taken lightly.

Despite your opinion of the Supreme Court decision in the Citizen’s United case a few years ago, it seems to me to be a fact that corporations, and all forms of social organizations, develop a personality similar to individuals.  From this perspective, corporations really are like people.

Like individuals, corporations can be generous and caring, willing to sacrifice short term gains for long term results.  They can be driven, focused, and talented.  They can also be cold, vindictive and focused on the next measurable performance period at the expense of everything else.  Like people, the superficial organizations that talk about quality and teamwork without actually backing it up with action are much more common than those that actually exhibit these qualities.

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Obamacare and the Future of Healthcare

As everyone knows by now, the Supreme Court upheld the constitutionality of state healthcare insurance exchanges subsidized by the federal government.  If this decision had gone the other way, it could have had a significant impact on the percentage of insured patients currently, and in the coming years.  With this decision, this key component of Obamacare seems to be a permanent part of the future financial core of healthcare reimbursement.

I was traveling when I heard the announcement.  A few hours later, on CNN, I saw the news about large jumps in the value of stock for major healthcare insurance companies like Aetna, Cigna and United Healthcare.  Many of these organizations were seeing increases of 15% to 40% in a single day toward the value of their shares.  I began thinking about how this will impact my own company and healthcare delivery in general in the coming years.

obamacare
The future of healthcare.

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Medicare Public Use Files

CMS has provided access to data collected through the administration of claims to researchers since 2003 through the PUF (Public Use Files).  These files contain useful information on patients going back to 1999.  These files are offered for free as CSV (spreadsheet) files and offer valuable information on specific healthcare services.

These files are designed for researchers, but for you number crunchers out there, they can provide valuable insight into industry trends and how your own organization compares to your competitors.

For example, the current PUF file on hospice beneficiaries contains data for 2010 for a total of 56,943 beneficiaries.  The file contains eight pieces of information for each one.  These totals come from the data dictionary and code book describing this file.  The totals themselves are very interesting:

Public Use Files
Medicare Public Use Files

 

 

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/BSAPUFS/Downloads/2010_BSA_Hospice_Bene_PUF_DataDic_CB.pdf

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