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  • Rhetoric and the Health Reform Appeal
    are not covered by health insurance distracts us from the realities of today s healthcare market This is a sample article from HFMA s Legal Regulatory Forum a discussion and networking community for legal and compliance leaders in hospitals and health systems Learn more about the Legal Regulatory Forum Change Is Inevitable Politicians and the media are giving too much attention to the individual mandate and not enough to the changes that are already taking place Silhol says The mandate and the lawsuit are important to be sure but there will be transformation in the healthcare system regardless of the outcome of the Supreme Court decision He cites these examples of important reform provisions in the ACA Increased financing for anti fraud enforcement A ban on physician owned hospitals Changes to the Stark physician self referral law Elimination of annual and lifetime benefits limitations Prevention of policy rescission due to illness Coverage of children to age 26 on their parents plans Guaranteed coverage for children with pre existing conditions Preventive services at no cost to Medicare beneficiaries Phase out of the Medicare prescription drug donut hole Encouragement of accountable care organizations Reforms that alter insurers underwriting practices Creation of state run health insurance exchanges Expansion of Medicaid eligibility and subsidies The industry is already adapting to these changes so even if the Supreme Court strikes down the law it is going to be impossible to put the toothpaste back in the tube Silhol says Regardless of what the court decides market forces will continue to push us toward greater quality and efficiency Politics Birth Control and Broccoli Recalling that President Nixon proposed comprehensive national health insurance in the 1970s a and that the individual mandate was originally proposed by Stuart Butler of the conservative Heritage Foundation in the late 1980s b Silhol expressed amazement and wonder at how politics has twisted recent health reform discussions He notes that there is consensus among experts and even the politicians that the current cost trends in healthcare are not sustainable And there is general agreement about a large majority of the ACA s specific provisions But we re fiddling while Rome burns he says We have so much work to do it s a shame to waste time on distracting details like birth control and broccoli The latter references are to whether religious organizations can be forced to insure contraceptive services and to an analogy used by one lower court judge to strike down the mandate The judge s reasoning later overruled was that if the justification for the individual mandate is valid Congress could force people to buy broccoli because sales of broccoli have an effect on the overall vegetable market But Silhol emphasizes that the healthcare market is literally unique To analyze this case by analogy does not do justice to the issues The broccoli analogy is a Trojan horse a distraction a red herring But the media and some politicians picked up on it It s background noise It s not important The Court Won t Punt He noted that some commentators have speculated the Court might avoid deciding the case by relying on the Tax Anti Injunction Act AIA a 145 year old law that bars challenges to taxes before they go into effect If the individual mandate requirement is characterized as a tax rather than a penalty so the AIA argument goes the petitioners in the Supreme Court case would be barred from challenging the law until 2014 when the mandate is scheduled to take effect I don t think the Court is going to use the AIA as a way to punt this case Silhol said It s pretty clear to me that the individual mandate involves a penalty for noncompliance not a tax so the AIA should not come into play The Remaining Issues If Silhol is right about the AIA being inapplicable then the key remaining issues are Does Congress have the power to require individuals to buy health insurance In the main case under review a challenge brought by 26 states and decided by the 11th Circuit the lower court held that Congress does not have that power under the Constitution however two other appeals courts have found otherwise If the mandate is not valid can it be severed from the rest of the statute or is the entire ACA invalid Even though it struck down the individual mandate the 11th Circuit held that the remaining ACA provisions remain fully operative If the ACA survives either with or without the individual mandate can the states be forced to expand their Medicaid programs and thus incur greater costs at the risk of losing federal money if they do not comply The 11th Circuit held the Medicaid expansion to be valid The Bottom Line Silhol was hesitant to forecast the ultimate outcome of the Supreme Court case but he did make one prediction If the individual mandate does not survive and if provisions like guaranteed coverage and prohibitions on exclusions for pre existing condition remain in force insurance premiums will skyrocket For premiums not to rise sharply the risk must be spread over as large a population as possible and spreading risk was the intent of the individual mandate Without it those who choose to be insured will be the people who are most likely to need care This point was reinforced by a recent Robert Wood Johnson Foundation report that stated Insurers fear substantial adverse selection in the nongroup individual market in the absence of an individual mandate The report estimates that premiums would rise ten to twenty five percent without the mandate depending on participation in health exchanges As we await the Supreme Court s decision Silhol recommends that providers continue to respond to market trends by working toward greater integration collaboration and efficiency A decision is expected by the end of the Supreme Court term typically late June or early July J Stuart Showalter JD MFS is a contributing editor to HFMA s Legal Regulatory Forum Footnotes a Nixon s Plan for Health Reform in His Own Words Kaiser Health News Sept 3 2009 b S Butler Assuring Affordable Health Care for All Americans The Heritage Lectures Oct 2 1989 Publication Date Friday March 16 2012 BACK TO PAGINATION By J Stuart Showalter Despite political rhetoric changes to our healthcare system are inevitable regardless of the pending Supreme Court case one expert says The U S Supreme Court is set to hear arguments March 26 28 in a set of cases challenging the validity of the health reform law the Affordable Care Act ACA In anticipation of the decision the Legal Regulatory Forum consulted Michael Silhol counsel for Haynes and Boone LLP in Dallas for some perspective A former general counsel for Parkland Hospital Silhol has closely studied the ACA and the related lawsuits and recently led a panel discussion on the subject in Dallas for more than 150 providers and legal professionals In his view hubbub over the case and in particular over the ACA s individual mandate the requirement that individuals pay a penalty if they are not covered by health insurance distracts us from the realities of today s healthcare market This is a sample article from HFMA s Legal Regulatory Forum a discussion and networking community for legal and compliance leaders in hospitals and health systems Learn more about the Legal Regulatory Forum Change Is Inevitable Politicians and the media are giving too much attention to the individual mandate and not enough to the changes that are already taking place Silhol says The mandate and the lawsuit are important to be sure but there will be transformation in the healthcare system regardless of the outcome of the Supreme Court decision He cites these examples of important reform provisions in the ACA Increased financing for anti fraud enforcement A ban on physician owned hospitals Changes to the Stark physician self referral law Elimination of annual and lifetime benefits limitations Prevention of policy rescission due to illness Coverage of children to age 26 on their parents plans Guaranteed coverage for children with pre existing conditions Preventive services at no cost to Medicare beneficiaries Phase out of the Medicare prescription drug donut hole Encouragement of accountable care organizations Reforms that alter insurers underwriting practices Creation of state run health insurance exchanges Expansion of Medicaid eligibility and subsidies The industry is already adapting to these changes so even if the Supreme Court strikes down the law it is going to be impossible to put the toothpaste back in the tube Silhol says Regardless of what the court decides market forces will continue to push us toward greater quality and efficiency Politics Birth Control and Broccoli Recalling that President Nixon proposed comprehensive national health insurance in the 1970s a and that the individual mandate was originally proposed by Stuart Butler of the conservative Heritage Foundation in the late 1980s b Silhol expressed amazement and wonder at how politics has twisted recent health reform discussions He notes that there is consensus among experts and even the politicians that the current cost trends in healthcare are not sustainable And there is general agreement about a large majority of the ACA s specific provisions But we re fiddling while Rome burns he says We have so much work to do it s a shame to waste time on distracting details like birth control and broccoli The latter references are to whether religious organizations can be forced to insure contraceptive services and to an analogy used by one lower court judge to strike down the mandate The judge s reasoning later overruled was that if the justification for the individual mandate is valid Congress could force people to buy broccoli because sales of broccoli have an effect on the overall vegetable market But Silhol emphasizes that the healthcare market is literally unique To analyze this case by analogy does not do justice to the issues The broccoli analogy is a Trojan horse a distraction a red herring But the media and some politicians picked up on it It s background noise It s not important The Court Won t Punt He noted that some commentators have speculated the Court might avoid deciding the case by relying on the Tax Anti Injunction Act AIA a 145 year old law that bars challenges to taxes before they go into effect If the individual mandate requirement is characterized as a tax rather than a penalty so the AIA argument goes the petitioners in the Supreme Court case would be barred from challenging the law until 2014 when the mandate is scheduled to take effect I don t think the Court is going to use the AIA as a way to punt this case Silhol said It s pretty clear to me that the individual mandate involves a penalty for noncompliance not a tax so the AIA should not come into play The Remaining Issues If Silhol is right about the AIA being inapplicable then the key remaining issues are Does Congress have the power to require individuals to buy health insurance In the main case under review a challenge brought by 26 states and decided by the 11th Circuit the lower court held that Congress does not have that power under the Constitution however two other appeals courts have found otherwise If the mandate is not valid can it be severed from the rest of the statute or is the entire ACA invalid Even though it struck down the individual mandate the 11th Circuit held that the remaining ACA provisions remain fully operative If the ACA survives either with or without the individual mandate can the states be forced to expand their Medicaid programs and thus incur greater costs at the risk of losing federal money if they do not comply The 11th Circuit held the Medicaid expansion to be valid The Bottom Line Silhol was hesitant to forecast the ultimate outcome of the Supreme Court case but he did make one prediction If the individual mandate does not survive and if provisions like guaranteed coverage and prohibitions on exclusions for pre existing condition remain in force insurance premiums will skyrocket For premiums not to rise sharply the risk must be spread over as large a population as possible and spreading risk was the intent of the individual mandate Without it those who choose to be insured will be the people who are most likely to need care This point was reinforced by a recent Robert Wood Johnson Foundation report that stated Insurers fear substantial adverse selection in the nongroup individual market in the absence of an individual mandate The report estimates that premiums would rise ten to twenty five percent without the mandate depending on participation in health exchanges As we await the Supreme Court s decision Silhol recommends that providers continue to respond to market trends by working toward greater integration collaboration and efficiency A decision is expected by the end of the Supreme Court term typically late June or early July J Stuart Showalter JD MFS is a contributing editor to HFMA s Legal Regulatory Forum Footnotes a Nixon s Plan for Health Reform in His Own Words Kaiser Health News Sept 3 2009 b S Butler Assuring Affordable Health Care for All Americans The Heritage Lectures Oct 2 1989 Publication Date Friday March 16 2012 Please login to add your comments Advertisements HFMA Business Profiles McKesson Leveraging Predictive Analytics to Rein in Operating Costs A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow HFMA RESOURCE LIBRARY 6 Patient Revenue Cycle Metrics You Should Be Tracking and How to Improve Your Results Patient financial engagement is more challenging than ever and more critical With patient responsibility as a percentage of revenue on the rise providers have seen their billing related costs and accounts receivable levels increase If increasing collection yield and reducing costs are a priority for your organization the metrics outlined in this presentation will provide the framework you need to understand what s working and what s not in order to guide your overall patient financial engagement initiatives and optimize results HFMA Business Profiles Accretive Health Partners with Providers to Excel in a Rapidly Transforming Revenue Cycle Environment Emad Rizk MD president and CEO of Accretive Health discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management HFMA RESOURCE LIBRARY 10 Ways to Reduce Patient Statement Volume and Reduce Costs No two patients are the same Each has a very personal healthcare experience and each has distinct financial needs and preferences that have an impact on how when and if they chose to pay their healthcare bill It s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients The need to tailor financial conversations and payment options to individual needs and preferences is critical This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach but take control of rising collection costs HFMA Business Profiles Conifer Health Solutions Helping Providers and Employers Build a Foundation for Better Health Jim Bohnsack vice president solution corporate development for Conifer Health Solutions explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements HFMA RESOURCE LIBRARY Reduce Patient Balances Sent to Collection Agencies Approaching New Problems with New Approaches This white paper written by Apex Vice President of Solutions and Services Carrie Romandine discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs but it will maximize the amount collected before sending to collections Further targeted messaging should be applied across all points of patient interaction i e point of service customer service patient statements and analyzed regularly for maximized results HFMA Business Profiles Ontario Systems Optimizing Accounts Receivable in a Rapidly Changing Environment Steve Scibetta senior director of channel sales for Ontario Systems healthcare product line shares insights into effectively managing receivables HFMA RESOURCE LIBRARY The Future of Online Patient Billing Portals This white paper written by Apex President Patrick Maurer discusses methods to increase patient adoption of online payments Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections This white paper shows why patient centric approaches to online payment portals are important complements to traditional provider centric approaches HFMA Business Profiles Optum Enabling Transformative Change Elena White vice president of risk quality and network solutions for Optum discusses how healthcare providers can leverage data and technology as they enable risk in their organization HFMA RESOURCE LIBRARY Payment Portals Can Improve Self Pay Collections and Support Meaningful Use Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs This article written by Apex Founder and CEO Brian Kueppers explores a number of strategies to create synergy between patient billing online payment portals and electronic health record EHR software to realize a high ROI in speed to payment patient satisfaction and portal adoption for meaningful use HFMA Business Profiles Somnia Bending the Healthcare Cost Curve Toward Improved Anesthesia Value Somnia President and CEO Marc Koch MD MBA explains how hospitals can drive transformative change in the perioperative experience for outstanding clinical and financial outcomes HFMA RESOURCE LIBRARY Large Health System Drives 10 UP Patient Payments and 10 DOWN Billing related Costs Faced with a rising tide of bad debt a large Southeastern healthcare system was seeing a sharp decline in net patient revenues The need to improve collections was dire By integrating critical tools and processes the health system was able to increase online payments and improve its financial position Taking

    Original URL path: http://www.hfma.org/Content.aspx?id=790 (2016-02-10)
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  • Avoiding and Managing CMS Audits
    advises This is a sample article from HFMA s Legal Regulatory Forum Learn more and subscribe The government gets about 8 in return for every 1 it spends on fraud and abuse enforcement including audits so the audit contractors are not going to go away and denials will continue Schulze says Talking about compliance is not enough Regular internal audits and periodic external compliance checks demonstrate to the entire staff that the provider is committed to accurate and complete documentation and billing It is critical for coders to feel comfortable to be encouraged to query physicians for more details when a medical record is incomplete or does not support the code being assigned They can only code what is supported by the record and need to have the provider s full support when they correct a code to a lower level Schulze says Physician education on proper documentation is also critical Schulze gave the example of an inpatient psychiatric hospital with physicians routinely listing Alzheimer s disease as the admitting Axis I diagnosis However the patients were sent to the hospital because of their disruptive behavior Unless there was conclusive evidence that the behavior was due solely to their Alzheimer s the disease would more appropriately be listed on Axis III as a chronic condition Even though the care was the same and medically appropriate routinely listing Alzheimer s on Axis I caused the provider s statistics to fall out of the industry norm and triggered an extensive ZPIC audit One caveat Coders may not intentionally lead a physician to documentation just to enable higher reimbursement they only may ask objective questions such as Did you mean or Can you be more specific about Denials Will Occur and Appeals Will Follow No matter how hard we try however there will always be claims denials and the process begins with a request for records Schulze and Koons stress that it is essential to organize the medical records carefully and make it easy for the CMS auditors to find important information in the record They suggest doing this by taking the following steps Reviewing every chart for completeness and uniformity of format Stamping every document page with identifying numbers e g Bates stamping a method for placing identifying numbers and date time marks on images and documents Providing a table of contents of the chart with Bates stamp page ranges Highlighting relevant portions Using attestations for incomplete sections Responding to all government requests in a timely manner Transcribing hard to read physician notes After the records are submitted a Medicare contractor reviews them a process that often takes a year or more and issues an audit results letter and a demand for repayment Auditors rarely rule in favor of providers at this stage and thus begins the first level of appeals First level appeals This first appeal is a request for redetermination by the auditor and it can usually be handled in house It may not be cost effective to hire outside counsel at this stage as long as the provider has trained personnel to prepare the appeal Schulze says He recommends appealing every denial because failure to do so may lead the government at some point to argue imputed knowledge an implicit admission of wrongdoing If you accept a denial and just repay the amount and if there s a pattern of the same kind of error the government will argue that you should have known what you did was wrong This could come back to haunt you Schulze says Second level appeals Once the redetermination decision has been issued usually an affirmation of the original denial comes the second level appeal a request for reconsideration by a Qualified Independent Contractor QIC Koons and Schulze recommend engaging the servicers of an experienced healthcare attorney at this stage and including the provider s entire argument and basis for appeal including statistical arguments if the agency extrapolated the claims to determine their repayment demand These points will form the administrative record for a possible administrative law judge ALJ decision at the next appeal level Because of the well publicized backlog of appeals at the ALJ level Schulze and Koons are beginning to see greater provider success rates for second level appeals but there is still no way for the system to keep up with the demand they say We ve recently had cases where we got 90 percent of the denials overturned at the second level A few years ago 30 percent was about all we could expect Schulze explained Third level appeals The third level appeal is made to the ALJ and although the delays have been reduced somewhat recently it is still common for this stage to take 18 to 24 months The wait is worth it because the ALJ level is where the most claim denials get overturned and we are beginning to see greater success rates Schulze says See related tool Summary of CMS Audit Procedures Proactive Steps Minimize Pitfalls Koons and Schulze concluded the webinar with these recommendations Create a dedicated audit team under the compliance department that includes revenue cycle personnel billers coders compliance and legal staff and nursing and physician advisers to audit all clinical documentation by physicians and other clinicians Establish a physician review program with respected physicians who can help improve medical record documentation and advise on appeals Koons uses employed physicians for this purpose and reports that among other benefits this has improved his system s case mix index Use audit tracking software to monitor all appeals because government payers and private insurance have different processes and timelines and it s impossible to track them all manually Use PEPPER Reports Microsoft Excel files summarizing provider specific Medicare data for target areas often associated with improper Medicare payments to help flag potential problem areas to be dealt with before denials occur Consider education to be a never ending journey for clinicians billers coders and other key personnel Recognize that the pay and chase system of Medicare reimbursement is an unfortunate way of life but its pitfalls can be minimized J Stuart Showalter JD MFS is a contributing editor for HFMA Interviewed for this article Joseph Koons is managing director revenue cycle Centra Health Inc Lynchburg Va and is a member of HFMA s Virginia Washington D C Chapter Michael R Schulze is managing member Sullivan Stolier Knight LC Lafayette La Discussion Starters Forum members What do you think Please share your thoughts in the comments section below How does your hospital handle Medicare appeals Do you employ full time physician advisers to assist with the appeals process Publication Date Thursday August 20 2015 BACK TO PAGINATION Routine internal and external auditing of Medicare claims is a critical step in avoiding denials and managing audits effectively when they do occur Hospital and health system finance leaders can take important steps such as self audits and accurate documentation to limit denials and avoid CMS audits This proactive approach is also helpful to successfully navigate the claim appeals process To Avoid Audits Perform Audits To avoid CMS audits you have to do your own audits says attorney Michael Schulze of the law firm Sullivan Stolier Knight LC in Lafayette Louisiana And you have to use the findings to provide ongoing education and training of coders billers and clinicians This may seem elementary but Schulze and Joseph Koons managing director of revenue cycle for Centra Health Inc Lynchburg Va who discussed denials and audits during a recent HFMA Forums webinar repeatedly stress the importance of internal and external compliance audits use of comparative data reports e g Program for Evaluating Payment Patterns Electronic Report known as PEPPER reports and regular training to avoid simple coding mistakes and keep up to date on billing rules Make internal and external auditing routine so that it doesn t get pushed aside by the daily grind Schulze advises This is a sample article from HFMA s Legal Regulatory Forum Learn more and subscribe The government gets about 8 in return for every 1 it spends on fraud and abuse enforcement including audits so the audit contractors are not going to go away and denials will continue Schulze says Talking about compliance is not enough Regular internal audits and periodic external compliance checks demonstrate to the entire staff that the provider is committed to accurate and complete documentation and billing It is critical for coders to feel comfortable to be encouraged to query physicians for more details when a medical record is incomplete or does not support the code being assigned They can only code what is supported by the record and need to have the provider s full support when they correct a code to a lower level Schulze says Physician education on proper documentation is also critical Schulze gave the example of an inpatient psychiatric hospital with physicians routinely listing Alzheimer s disease as the admitting Axis I diagnosis However the patients were sent to the hospital because of their disruptive behavior Unless there was conclusive evidence that the behavior was due solely to their Alzheimer s the disease would more appropriately be listed on Axis III as a chronic condition Even though the care was the same and medically appropriate routinely listing Alzheimer s on Axis I caused the provider s statistics to fall out of the industry norm and triggered an extensive ZPIC audit One caveat Coders may not intentionally lead a physician to documentation just to enable higher reimbursement they only may ask objective questions such as Did you mean or Can you be more specific about Denials Will Occur and Appeals Will Follow No matter how hard we try however there will always be claims denials and the process begins with a request for records Schulze and Koons stress that it is essential to organize the medical records carefully and make it easy for the CMS auditors to find important information in the record They suggest doing this by taking the following steps Reviewing every chart for completeness and uniformity of format Stamping every document page with identifying numbers e g Bates stamping a method for placing identifying numbers and date time marks on images and documents Providing a table of contents of the chart with Bates stamp page ranges Highlighting relevant portions Using attestations for incomplete sections Responding to all government requests in a timely manner Transcribing hard to read physician notes After the records are submitted a Medicare contractor reviews them a process that often takes a year or more and issues an audit results letter and a demand for repayment Auditors rarely rule in favor of providers at this stage and thus begins the first level of appeals First level appeals This first appeal is a request for redetermination by the auditor and it can usually be handled in house It may not be cost effective to hire outside counsel at this stage as long as the provider has trained personnel to prepare the appeal Schulze says He recommends appealing every denial because failure to do so may lead the government at some point to argue imputed knowledge an implicit admission of wrongdoing If you accept a denial and just repay the amount and if there s a pattern of the same kind of error the government will argue that you should have known what you did was wrong This could come back to haunt you Schulze says Second level appeals Once the redetermination decision has been issued usually an affirmation of the original denial comes the second level appeal a request for reconsideration by a Qualified Independent Contractor QIC Koons and Schulze recommend engaging the servicers of an experienced healthcare attorney at this stage and including the provider s entire argument and basis for appeal including statistical arguments if the agency extrapolated the claims to determine their repayment demand These points will form the administrative record for a possible administrative law judge ALJ decision at the next appeal level Because of the well publicized backlog of appeals at the ALJ level Schulze and Koons are beginning to see greater provider success rates for second level appeals but there is still no way for the system to keep up with the demand they say We ve recently had cases where we got 90 percent of the denials overturned at the second level A few years ago 30 percent was about all we could expect Schulze explained Third level appeals The third level appeal is made to the ALJ and although the delays have been reduced somewhat recently it is still common for this stage to take 18 to 24 months The wait is worth it because the ALJ level is where the most claim denials get overturned and we are beginning to see greater success rates Schulze says See related tool Summary of CMS Audit Procedures Proactive Steps Minimize Pitfalls Koons and Schulze concluded the webinar with these recommendations Create a dedicated audit team under the compliance department that includes revenue cycle personnel billers coders compliance and legal staff and nursing and physician advisers to audit all clinical documentation by physicians and other clinicians Establish a physician review program with respected physicians who can help improve medical record documentation and advise on appeals Koons uses employed physicians for this purpose and reports that among other benefits this has improved his system s case mix index Use audit tracking software to monitor all appeals because government payers and private insurance have different processes and timelines and it s impossible to track them all manually Use PEPPER Reports Microsoft Excel files summarizing provider specific Medicare data for target areas often associated with improper Medicare payments to help flag potential problem areas to be dealt with before denials occur Consider education to be a never ending journey for clinicians billers coders and other key personnel Recognize that the pay and chase system of Medicare reimbursement is an unfortunate way of life but its pitfalls can be minimized J Stuart Showalter JD MFS is a contributing editor for HFMA Interviewed for this article Joseph Koons is managing director revenue cycle Centra Health Inc Lynchburg Va and is a member of HFMA s Virginia Washington D C Chapter Michael R Schulze is managing member Sullivan Stolier Knight LC Lafayette La Discussion Starters Forum members What do you think Please share your thoughts in the comments section below How does your hospital handle Medicare appeals Do you employ full time physician advisers to assist with the appeals process Publication Date Thursday August 20 2015 Comments Please login to add your comments Add Comment Text Only 2000 character limit Advertisements HFMA Business Profiles McKesson Leveraging Predictive Analytics to Rein in Operating Costs A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow HFMA RESOURCE LIBRARY 6 Patient Revenue Cycle Metrics You Should Be Tracking and How to Improve Your Results Patient financial engagement is more challenging than ever and more critical With patient responsibility as a percentage of revenue on the rise providers have seen their billing related costs and accounts receivable levels increase If increasing collection yield and reducing costs are a priority for your organization the metrics outlined in this presentation will provide the framework you need to understand what s working and what s not in order to guide your overall patient financial engagement initiatives and optimize results HFMA Business Profiles Accretive Health Partners with Providers to Excel in a Rapidly Transforming Revenue Cycle Environment Emad Rizk MD president and CEO of Accretive Health discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management HFMA RESOURCE LIBRARY 10 Ways to Reduce Patient Statement Volume and Reduce Costs No two patients are the same Each has a very personal healthcare experience and each has distinct financial needs and preferences that have an impact on how when and if they chose to pay their healthcare bill It s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients The need to tailor financial conversations and payment options to individual needs and preferences is critical This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach but take control of rising collection costs HFMA Business Profiles Conifer Health Solutions Helping Providers and Employers Build a Foundation for Better Health Jim Bohnsack vice president solution corporate development for Conifer Health Solutions explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements HFMA RESOURCE LIBRARY Reduce Patient Balances Sent to Collection Agencies Approaching New Problems with New Approaches This white paper written by Apex Vice President of Solutions and Services Carrie Romandine discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs but it will maximize the amount collected before sending to collections Further targeted messaging should be applied across all points of patient interaction i e point of service customer service patient statements and analyzed regularly for maximized results HFMA Business Profiles Ontario Systems Optimizing Accounts Receivable in a Rapidly Changing Environment Steve Scibetta senior director of channel sales for Ontario Systems healthcare product line shares insights into effectively managing receivables HFMA RESOURCE LIBRARY The Future of Online Patient Billing Portals This white paper written by Apex President Patrick Maurer discusses methods to increase patient adoption of online payments Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections This white paper shows why patient centric approaches to online payment portals are important complements to traditional provider centric approaches HFMA Business Profiles Optum Enabling Transformative Change Elena White vice president of risk quality and network solutions for Optum

    Original URL path: http://www.hfma.org/Content.aspx?id=40706 (2016-02-10)
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  • Changes to Two-Midnight Rule Raise Concerns
    Meet the 2 Midnight Rule Legal Regulatory Forum membership required to access this article J Stuart Showalter JD MFS is a contributing editor for HFMA Interviewed for this article Day Egusquiza is president AR Systems Inc Twin Falls Idaho and a member of HFMA s Idaho Chapter Discussion Starters Forum members What do you think Please share your thoughts in the comments section below Do you believe the proposed changes to the two midnight rule will help your hospitals comply with the rule or are they a hindrance to compliance What are some of your most effective strategies for managing the two midnight rule Publication Date Tuesday July 21 2015 BACK TO PAGINATION One billing and coding expert explains her concerns about CMS s proposed changes to the two midnight rule for hospital short stays The Centers for Medicare and Medicaid Services CMS recently proposed changes to Medicare s controversial two midnight rule governing short hospital stays The proposed changes which were prompted by feedback from hospitals and physicians and are meant to emphasize the role of physician judgment were reported in the July 3 2015 HFMA Weekly News Highlights of the changes are as follows For stays that are expected not to span two midnights an inpatient admission would be payable under Medicare Part A on a case by case basis depending on the judgment of the admitting physician The documentation in the medical record must support that an inpatient admission is necessary and is subject to medical review It is expected that it would be rare and unusual for a beneficiary to require an inpatient admission only for a few hours and not at least an overnight CMS will monitor the number of these types of admissions and plans to prioritize them for medical review For hospital stays that are expected to be two midnights or longer the CMS policy is unchanged If the admitting physician expects the patient to require hospital care that spans at least two midnights the services are usually appropriate for Medicare Part A payment The changes do not apply to procedures on the inpatient only list or those that are otherwise listed as a national exception Concerns Raised and Education Needed This new standard merely brings back an old vague definition of inpatient and recasts it as rare and unusual says Day Egusquiza president of AR Systems Inc Twin Falls Idaho It will require serious re education of clinicians and UR and PFS staff she says Hospitals will need to be vigilant in their front end screening of patient type to see whether patients care will necessarily span two midnights if so they should be admitted as inpatients But if the individual is the rare and unusual case who doesn t require two midnights but needs to be an inpatient anyway rather than in an observation bed the record will have to clearly support why inpatient status is necessary based on severity of illness intensity of service and clinical guidelines Why would a hospital want to go back to the documentation challenges that created the massive RAC recoupments of recent years This change just opened the floodgates again Egusquiza says She points out that the two midnight rule is still being used but it is overlaid with this rare and unusual exception If the industry would use the current two midnight rule correctly both its presumption and benchmark rather than continue to ask for changes we would not be seeing a loss of patients classified as inpatients and life would be easier Instead I expect that the mess we wanted to avoid will explode again CMS Seeks Comments The proposed two midnight changes are included in the Hospital Outpatient Prospective Payment System OPPS and Ambulatory Surgical Center ASC Payment System proposed rule Hospitals and health systems interested in submitting comments on the two midnight portion of the proposed rule should do so by Aug 31 2015 CMS will respond to comments in a final rule to be issued on or around Nov 1 2015 Related articles and resources Fact Sheet Two Midnight Rule What Inpatient Cases Meet the 2 Midnight Rule Legal Regulatory Forum membership required to access this article J Stuart Showalter JD MFS is a contributing editor for HFMA Interviewed for this article Day Egusquiza is president AR Systems Inc Twin Falls Idaho and a member of HFMA s Idaho Chapter Discussion Starters Forum members What do you think Please share your thoughts in the comments section below Do you believe the proposed changes to the two midnight rule will help your hospitals comply with the rule or are they a hindrance to compliance What are some of your most effective strategies for managing the two midnight rule Publication Date Tuesday July 21 2015 Comments Please login to add your comments Add Comment Text Only 2000 character limit Advertisements HFMA Business Profiles McKesson Leveraging Predictive Analytics to Rein in Operating Costs A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow HFMA RESOURCE LIBRARY 6 Patient Revenue Cycle Metrics You Should Be Tracking and How to Improve Your Results Patient financial engagement is more challenging than ever and more critical With patient responsibility as a percentage of revenue on the rise providers have seen their billing related costs and accounts receivable levels increase If increasing collection yield and reducing costs are a priority for your organization the metrics outlined in this presentation will provide the framework you need to understand what s working and what s not in order to guide your overall patient financial engagement initiatives and optimize results HFMA Business Profiles Accretive Health Partners with Providers to Excel in a Rapidly Transforming Revenue Cycle Environment Emad Rizk MD president and CEO of Accretive Health discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management HFMA RESOURCE LIBRARY 10 Ways to Reduce Patient Statement Volume and Reduce Costs No two patients are the

    Original URL path: http://www.hfma.org/Content.aspx?id=32302 (2016-02-10)
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  • A Perfectly Legal Way to Help Patients Pick Higher-Quality Post-Acute Providers
    to skilled nursing facility SNF and that patient is later readmitted for pressure ulcers or other complications then the hospital risks getting slapped with readmission penalties from Medicare Given this it is in the hospital s interest not to mention the patient s to facilitate the choice of a high quality home health agency or skilled nursing facility Thus the question arises How can hospitals share unbiased information about the quality of care at a post acute provider without violating any laws This is a sample article from HFMA s Legal Regulatory Forum Learn more about HFMA Forums Balancing Patient Autonomy and Safety In the hospital setting it usually falls on case managers or discharge planners to help patients make wise decisions about post acute care The case manager must tell the patient or the patient s family about their freedom to choose and must disclose any financial interest that the hospital has in a home health agency or skilled nursing facility The hospital must not specify or otherwise limit the qualified providers that are available to the patient 42 C F R 482 43 c 7 In other words to make an intelligent choice patients must have unbiased information about what providers are available for the care they need and it is a conflict of interest for hospital personnel to steer patients to post acute providers affiliated with the hospital For these reasons conscientious discharge planners typically provide patients with a list of qualified providers but do not make specific recommendations on which ones are preferred Yet there is a way for discharge planners to legally provide unbiased information about home health agencies and skilled nursing facilities to patients Medicare s Home Health Compare and Nursing Home Compare websites have information about the quality of care provided by Medicare certified home health agencies and skilled nursing facilities throughout the nation These sites allow patients and families to learn how well various providers cared for their patients how often they used best practices and what other patients said about their experience The sites allow patients to search by location or by provider name and provides checklists and other helpful information These online quality reports can be used as tools by case managers who want to help patients differentiate among providers while supporting patient autonomy Some states such as Rhode Island and New York have similar online quality reports Identifying Barriers A study published recently in the Journal of General Internal Medicine points to the need to educate case managers about the availability of quality reports Interviews and focus groups with 28 case managers and 13 home health consumers at five Rhode Island hospitals revealed that no one was aware of Rhode Island s or the federal home health quality reports It was huge surprise to us author Rosa R Baier of Brown University said Consumers wanted access to more information that could inform their decision but they weren t getting it Rhode Island may not be the only state where consumers aren t seeing quality reports The researchers informally surveyed another 40 case managers in five other states finding that in 7 out of every 8 cases those managers also shared only bare bones lists with no quality information from or references to online reports The process in other states seems very similar to what is happening in Rhode Island Baier said The focus groups yielded other insights about barriers to informed decision making Most importantly case managers confessed feeling that federal laws or hospital policy prohibited them from answering patients questions about which agency they should choose And although they can share unbiased quality information if they have any the case managers apparently feel constrained by the laws from doing so One case manager in the study said she basically tells patients and families I can t tell you what everybody does and I can t make decisions for you I can t help you choose The study s senior author Melissa Clark a professor at the Brown University School of Public Health said the findings are notable in light of recent changes in healthcare policy designed to reward quality outcomes Arming case managers with existing home health quality reports could improve overall care quality That said quality reports are not yet perfect and the data on these sites needs to be considered in light of other information about a post acute provider including first hand accounts of friends family For instance the website maintained by the New York Department of Health states Where possible quality of care measurements are provided Please be mindful that while we believe these quality measures are among the most reliable measuring quality is difficult because of variations among agencies in the types of patients for whom they care Educating Case Managers The authors encourage state agencies to be more assertive in pushing quality reports directly to case managers And they say case management departments should regularly access the reports and make them available to discharge planners For their part compliance officers and legal counsel should educate case managers about the patient choice laws so they understand what is permissible They can also explain how to help patients make informed decisions without restricting the patient s freedom to choose Case managers can be a reliable conduit to share information directly with consumers during discharge planning but only if they are aware of existing resources and feel able to use them Baier said Public reports should be marketed as tools that case managers can use to help patients differentiate among providers while supporting patient autonomy Stefan Gravenstein MD a Healthcentric Advisors investigator on the study and a geriatrician at University Hospitals in Cleveland adds that public reports can serve as a neutral resource to help case managers abide by patient choice laws Although directing patients to choose specific providers may create a conflict of interest he says pointing them towards government data intended to help them make better choices makes inherent sense J Stuart Showalter JD MFS is a contributing editor for HFMA Interviewed for this article Rosa R Baier MPH is associate director Brown University Center for Long Term Care Quality Innovation and consulting senior scientist Healthcentric Advisors Providence RI Melissa Clark PhD is professor of epidemiology Brown University School of Public Health Providence RI Stefan Gravenstein MD MPH is director Center for Geriatric Medicine University Hospital Case Medical Center Cleveland Ohio Discussion Starters Forum members What do you think Please share your thoughts in the comments section below How does your hospital handle giving patients information on post acute providers Does your state publish quality data on post acute providers Publication Date Thursday April 16 2015 BACK TO PAGINATION Hospitals are increasingly held accountable for patients post discharge outcomes thus giving them incentive to help patients choose high quality post acute providers However a new study finds that many hospital case managers erroneously think they will be breaking the law if they share quality reports on post acute providers with patients and their families It is axiomatic that patients have the right to select their own healthcare providers This principle was codified in federal law at least as early as July 30 1965 the day Medicare took effect The Medicare patient freedom of choice provision as it is known reads Any individual entitled to Medicare benefits may obtain health services from any institution agency or person qualified to participate in the Medicare program if such institution agency or person undertakes to provide him such services 42 U S C 1395a a Similar language guarantees the right for Medicaid beneficiaries The principle is buttressed by numerous court decisions by various fraud provisions and by regulations such as the discharge planning requirements of the Medicare Conditions of Participation See 42 C F R 482 43 Yet hospitals are increasingly being held accountable for the quality of care during the acute care stay and beyond If a hospital discharges a patient to skilled nursing facility SNF and that patient is later readmitted for pressure ulcers or other complications then the hospital risks getting slapped with readmission penalties from Medicare Given this it is in the hospital s interest not to mention the patient s to facilitate the choice of a high quality home health agency or skilled nursing facility Thus the question arises How can hospitals share unbiased information about the quality of care at a post acute provider without violating any laws This is a sample article from HFMA s Legal Regulatory Forum Learn more about HFMA Forums Balancing Patient Autonomy and Safety In the hospital setting it usually falls on case managers or discharge planners to help patients make wise decisions about post acute care The case manager must tell the patient or the patient s family about their freedom to choose and must disclose any financial interest that the hospital has in a home health agency or skilled nursing facility The hospital must not specify or otherwise limit the qualified providers that are available to the patient 42 C F R 482 43 c 7 In other words to make an intelligent choice patients must have unbiased information about what providers are available for the care they need and it is a conflict of interest for hospital personnel to steer patients to post acute providers affiliated with the hospital For these reasons conscientious discharge planners typically provide patients with a list of qualified providers but do not make specific recommendations on which ones are preferred Yet there is a way for discharge planners to legally provide unbiased information about home health agencies and skilled nursing facilities to patients Medicare s Home Health Compare and Nursing Home Compare websites have information about the quality of care provided by Medicare certified home health agencies and skilled nursing facilities throughout the nation These sites allow patients and families to learn how well various providers cared for their patients how often they used best practices and what other patients said about their experience The sites allow patients to search by location or by provider name and provides checklists and other helpful information These online quality reports can be used as tools by case managers who want to help patients differentiate among providers while supporting patient autonomy Some states such as Rhode Island and New York have similar online quality reports Identifying Barriers A study published recently in the Journal of General Internal Medicine points to the need to educate case managers about the availability of quality reports Interviews and focus groups with 28 case managers and 13 home health consumers at five Rhode Island hospitals revealed that no one was aware of Rhode Island s or the federal home health quality reports It was huge surprise to us author Rosa R Baier of Brown University said Consumers wanted access to more information that could inform their decision but they weren t getting it Rhode Island may not be the only state where consumers aren t seeing quality reports The researchers informally surveyed another 40 case managers in five other states finding that in 7 out of every 8 cases those managers also shared only bare bones lists with no quality information from or references to online reports The process in other states seems very similar to what is happening in Rhode Island Baier said The focus groups yielded other insights about barriers to informed decision making Most importantly case managers confessed feeling that federal laws or hospital policy prohibited them from answering patients questions about which agency they should choose And although they can share unbiased quality information if they have any the case managers apparently feel constrained by the laws from doing so One case manager in the study said she basically tells patients and families I can t tell you what everybody does and I can t make decisions for you I can t help you choose The study s senior author Melissa Clark a professor at the Brown University School of Public Health said the findings are notable in light of recent changes in healthcare policy designed to reward quality outcomes Arming case managers with existing home health quality reports could improve overall care quality That said quality reports are not yet perfect and the data on these sites needs to be considered in light of other information about a post acute provider including first hand accounts of friends family For instance the website maintained by the New York Department of Health states Where possible quality of care measurements are provided Please be mindful that while we believe these quality measures are among the most reliable measuring quality is difficult because of variations among agencies in the types of patients for whom they care Educating Case Managers The authors encourage state agencies to be more assertive in pushing quality reports directly to case managers And they say case management departments should regularly access the reports and make them available to discharge planners For their part compliance officers and legal counsel should educate case managers about the patient choice laws so they understand what is permissible They can also explain how to help patients make informed decisions without restricting the patient s freedom to choose Case managers can be a reliable conduit to share information directly with consumers during discharge planning but only if they are aware of existing resources and feel able to use them Baier said Public reports should be marketed as tools that case managers can use to help patients differentiate among providers while supporting patient autonomy Stefan Gravenstein MD a Healthcentric Advisors investigator on the study and a geriatrician at University Hospitals in Cleveland adds that public reports can serve as a neutral resource to help case managers abide by patient choice laws Although directing patients to choose specific providers may create a conflict of interest he says pointing them towards government data intended to help them make better choices makes inherent sense J Stuart Showalter JD MFS is a contributing editor for HFMA Interviewed for this article Rosa R Baier MPH is associate director Brown University Center for Long Term Care Quality Innovation and consulting senior scientist Healthcentric Advisors Providence RI Melissa Clark PhD is professor of epidemiology Brown University School of Public Health Providence RI Stefan Gravenstein MD MPH is director Center for Geriatric Medicine University Hospital Case Medical Center Cleveland Ohio Discussion Starters Forum members What do you think Please share your thoughts in the comments section below How does your hospital handle giving patients information on post acute providers Does your state publish quality data on post acute providers Publication Date Thursday April 16 2015 Comments Please login to add your comments Add Comment Text Only 2000 character limit Advertisements HFMA Business Profiles McKesson Leveraging Predictive Analytics to Rein in Operating Costs A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow HFMA RESOURCE LIBRARY 6 Patient Revenue Cycle Metrics You Should Be Tracking and How to Improve Your Results Patient financial engagement is more challenging than ever and more critical With patient responsibility as a percentage of revenue on the rise providers have seen their billing related costs and accounts receivable levels increase If increasing collection yield and reducing costs are a priority for your organization the metrics outlined in this presentation will provide the framework you need to understand what s working and what s not in order to guide your overall patient financial engagement initiatives and optimize results HFMA Business Profiles Accretive Health Partners with Providers to Excel in a Rapidly Transforming Revenue Cycle Environment Emad Rizk MD president and CEO of Accretive Health discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management HFMA RESOURCE LIBRARY 10 Ways to Reduce Patient Statement Volume and Reduce Costs No two patients are the same Each has a very personal healthcare experience and each has distinct financial needs and preferences that have an impact on how when and if they chose to pay their healthcare bill It s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients The need to tailor financial conversations and payment options to individual needs and preferences is critical This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach but take control of rising collection costs HFMA Business Profiles Conifer Health Solutions Helping Providers and Employers Build a Foundation for Better Health Jim Bohnsack vice president solution corporate development for Conifer Health Solutions explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements HFMA RESOURCE LIBRARY Reduce Patient Balances Sent to Collection Agencies Approaching New Problems with New Approaches This white paper written by Apex Vice President of Solutions and Services Carrie Romandine discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs but it will maximize the amount collected before sending to collections Further targeted messaging should be applied across all points of patient interaction i e point of service customer service patient statements and analyzed regularly for maximized results HFMA Business Profiles Ontario Systems Optimizing Accounts Receivable in a Rapidly Changing Environment Steve Scibetta senior director of channel sales for Ontario Systems healthcare product line shares insights into effectively managing receivables HFMA RESOURCE LIBRARY The Future of Online Patient Billing Portals This white paper written by Apex President Patrick Maurer discusses methods to increase patient adoption of online payments Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections This white paper shows why patient centric approaches to online payment portals are important complements to traditional provider centric approaches HFMA Business Profiles Optum Enabling

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  • What Inpatient Cases Meet the 2-Midnight Rule?
    the definition of what is an inpatient J Stuart Showalter JD MFS is a contributing editor to HFMA s Legal Regulatory Forum Interviewed for this article Day Egusquiza is president AR Systems Inc Twin Falls Idaho and a member of HFMA s Idaho Chapter Discussion Starters Forum members What do you think Please share your thoughts in the comments section below Do you have other example cases that you are not sure comply with the two midnight rule Post them in the comments section and we will ask our Forum experts for their advice What additional questions do you have about the two midnight rule Publication Date Tuesday January 20 2015 BACK TO PAGINATION For more than a year hospitals have struggled with a much maligned rule that is fertile ground for claims denials by Medicare contractors and even managed care plans Medicare regulations contain the following standard for inpatient hospital stays Surgical procedures diagnostic tests and other treatment are generally appropriate for inpatient admission and inpatient hospital payment under Medicare Part A when the physician expects the patient to require a stay that crosses at least 2 midnights 42 C F R 412 3 d This is a sample article from HFMA s Legal Regulatory Forum a networking community for healthcare legal and finance leaders Learn more about HFMA Forums This is the so called two midnight rule that hospitals have struggled with for going on two years and it now appears that some Medicare managed care plans are including it in their contracts and denying claims on that basis According to Day Egusquiza president AR Systems Inc these denials are often difficult to defend against and amount to a huge risk area Egusquiza says hospitals need to understand clearly what cases comply with the two midnight rule Examples that Meet the 2 Midnight Rule The clearest case was explained during a National Provider Call last January If a claim shows two or more midnights after the formal inpatient order was written Medicare contractors will normally assume that the admission was appropriate and will not select it for review under the two midnight rule Medicare will however be monitoring for evidence of systematic gaming or abuse such as unnecessary delays in the provision of care to surpass the two midnights When the fact situations are less straightforward the two midnight rule sometimes leads to confusion The following examples may help to clarify Example 1 The beneficiary is an outpatient receiving observation services at 2200 on Dec 1 and is still receiving observation services in the early morning hours the next day At 0300 she is admitted as an inpatient with the expectation that she will require medically necessary services beyond an additional midnight She is discharged at 0900 on Dec 3 The total time in the hospital outpatient and inpatient meets the two midnight benchmark Example 2 Beneficiary is being treated in the emergency department ED at 2300 on Dec 11 and is still in the ED as an outpatient until 0200 on the 12th at which time he is admitted as an inpatient with the expectation of requiring treatment beyond midnight that second day He is discharged at 0800 on Dec 13 Again the total time in the hospital meets the two midnight benchmark Example 3 Beneficiary is in ambulatory surgery at 1800 on Dec 21 and continues as an outpatient until admission At 0100 on Dec 22 her condition is such that she needs to be admitted as an inpatient It is expected that she will require medically necessary services for at least an additional midnight She is discharged at 0800 on Dec 23 Total time in the hospital meets the two midnight benchmark When a patient is on outpatient status for one midnight and then converted to inpatient as in Examples 1 3 span code 72 can be used on the claim to show contiguous outpatient hospital services that preceded the inpatient admission For more information on this access MLN Matters No MM8586 Example 4 At the time of inpatient admission on Jan 3 it is expected that the patient will stay for two midnights but he leaves against medical advice the next day Even though he was not in the hospital for two midnights the case meets an exception to the two midnight rule If an unforeseen circumstance such as a beneficiary s death or transfer results in a shorter beneficiary stay than the physician s expectation of at least 2 midnights the patient may be considered to be appropriately treated on an inpatient basis and hospital inpatient payment may be made under Medicare Part A 42 C F R 412 3 d 2 2 Midnight Rule Versus Short Stay DRGs Under current payment regulations hospitals today are entitled to a full DRG payment under each of the examples described above However there are efforts by the American Hospital Association and some providers to do away with the Medicare two midnight rule and attendees at the RAC Summit held in November learned that the Medicare Payment Advisory Commission MEDPAC appears to support short stay DRGs This would result in smaller payments and Egusquiza is nervous about the implications of such a change I m not sure everyone has a good handle on the implications of MEDPAC s proposal she says Short stay DRGs could result in significant reductions in inpatient payments so be careful what you ask for Additionally Egusquiza wonders how a change would affect payments for the more than 1 300 critical access hospitals that are currently paid a per diem for inpatients It is also an open question how a change would affect payments under the outpatient prospective payment system OPPS Under OPPS today hospitals are paid nothing for post procedure care rendered to observation patients it remains to be seen how they would be paid under a short stay DRG payment system It is possible that observation could be included which would be a win for hospitals but the issues are

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  • Straddling the Line Between Patient Privacy and Law Enforcement Requests
    in this article Linda Hake senior attorney Martin Health System Stuart Fla Linda Hake martinhealth org Kristen Rosati partner Coppersmith Schermer Brockelman PLC Phoenix kristen b rosati gmail com Discussion Starters Forum members Please add your insights questions and comments about this article on the Legal Regulatory Forum s LinkedIn discussion board What obstacles have you encountered when handling the nuances of sharing protected health information What other awkward requests have you received for protected health information How have you handled these Or perhaps you have another discussion starter BACK TO PAGINATION PHI requests from law enforcement present vexing questions for healthcare providers A new form helps staff document and respond appropriately to such requests HIPAA regulations are well known for being somewhat arcane That is especially so in regard to a healthcare provider s relationship with law enforcement When the authorities request information about a patient the provider often feels unsure how to proceed On the one hand physicians hospitals and other providers have a duty to protect their patients privacy and to maintain confidentiality of any information obtained during the course of treatment That is after all why the HIPAA regulations refer to such confidential information as protected health information PHI On the other hand there is sometimes a responsibility to work for the common good and cooperate with law enforcement To help deal with these situations Martin Health System MHS in Stuart Fla has prepared a form that staff can use to document and respond to law enforcement PHI requests Approved by MHS legal and health information departments the document has been in use for a number of months and has proven quite successful Access the form Law Enforcement Request for Information Records Without Patient Authorization Consulting HIPAA The MHS form complies with HIPAA regulations which permit disclosure of PHI without the patient s consent under some circumstances When required by law For public health activities To report instances of abuse neglect or domestic violence For health oversight activities For judicial and administrative proceedings To medical examiners and funeral directors regarding decedents For organ procurement or donation For medical research purposes For certain specialized government functions To avert serious threats to health or safety For law enforcement purposes Establishing Consistent Policies Most of these permitted HIPAA disclosures can be handled routinely by a hospital s health information management legal or compliance departments However law enforcement issues and threats to health or safety can arise at any time and authorities may need the information outside of normal business hours The requests often come to clinical areas such as the emergency department where staff members may not be familiar with the obscure nuances of federal regulations In addition state laws must be considered in addition to the federal HIPAA regulations This form really works says Linda Hake MHS senior attorney It helps staff think through the issues and get the information they need for documentation purposes and it makes life easier for both the hospital staff and the law enforcement personnel MHS has promoted the form to local police and sheriff departments the state department of law enforcement and the FBI They are aware of the form and have even been known to ask for it if the emergency department staff member is unaware she says Accounting for Nuances In some situations law enforcement personnel are entitled to PHI without the individual s authorization For example disclosure of some limited identifying information is permitted when necessary to locate a suspect fugitive material witness or missing person At other times such as when the patient is a crime victim the individual must be given the option to agree to the disclosure The MHS form addresses these nuances and guides the staff to make a proper decision without consulting the esoteric and complex HIPAA regulations An occasional quandary relates to law enforcement requests made over the telephone The legitimacy of such a request is obviously in question yet there may be valid justification for it Hake explains one such case in which a caller wanted information on a deceased patient who had been brought into the ED from another county I faxed the form to him and he completed it and faxed it back I verified the number and that he was in fact with the sheriff s department and I got him the information he needed She adds that this approach is much easier and quicker than having the officer write a request on official letterhead which is the typical advice for handling such situations Building Rapport with Local Officials and Agencies MHS modeled its form on one originally developed by Arizona attorney Kristen Rosati for the Arizona Hospital and Healthcare Association Rosati says that developing this form and an associated FAQ have helped to reduce the tension between Arizona hospitals and law enforcement officials The documents were developed in collaboration with Arizona law enforcement and they take into account HIPAA compliance and the practical needs of law enforcement she says The MHS form also includes reference to the Florida Department of Children and Families which often needs information for investigation of possible abuse neglect cases Facilities that adopt a form like this should include any state agency authorized by law to investigate alleged abuse of vulnerable individuals Legal counsel should be asked to review for state law principles that may apply and instructions can be printed on the reverse of the form if necessary J Stuart Showalter JD MFS is a contributing editor to HFMA s Legal Regulatory Forum Quoted in this article Linda Hake senior attorney Martin Health System Stuart Fla Linda Hake martinhealth org Kristen Rosati partner Coppersmith Schermer Brockelman PLC Phoenix kristen b rosati gmail com Discussion Starters Forum members Please add your insights questions and comments about this article on the Legal Regulatory Forum s LinkedIn discussion board What obstacles have you encountered when handling the nuances of sharing protected health information What other awkward requests have you received for protected health information How have

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  • Tool: Sample RAC Appeal Letter
    revenue on the rise providers have seen their billing related costs and accounts receivable levels increase If increasing collection yield and reducing costs are a priority for your organization the metrics outlined in this presentation will provide the framework you need to understand what s working and what s not in order to guide your overall patient financial engagement initiatives and optimize results HFMA Business Profiles Accretive Health Partners with Providers to Excel in a Rapidly Transforming Revenue Cycle Environment Emad Rizk MD president and CEO of Accretive Health discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management HFMA RESOURCE LIBRARY 10 Ways to Reduce Patient Statement Volume and Reduce Costs No two patients are the same Each has a very personal healthcare experience and each has distinct financial needs and preferences that have an impact on how when and if they chose to pay their healthcare bill It s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients The need to tailor financial conversations and payment options to individual needs and preferences is critical This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach but take control of rising collection costs HFMA Business Profiles Conifer Health Solutions Helping Providers and Employers Build a Foundation for Better Health Jim Bohnsack vice president solution corporate development for Conifer Health Solutions explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements HFMA RESOURCE LIBRARY Reduce Patient Balances Sent to Collection Agencies Approaching New Problems with New Approaches This white paper written by Apex Vice President of Solutions and Services Carrie Romandine discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs but it will maximize the amount collected before sending to collections Further targeted messaging should be applied across all points of patient interaction i e point of service customer service patient statements and analyzed regularly for maximized results HFMA Business Profiles Ontario Systems Optimizing Accounts Receivable in a Rapidly Changing Environment Steve Scibetta senior director of channel sales for Ontario Systems healthcare product line shares insights into effectively managing receivables HFMA RESOURCE LIBRARY The Future of Online Patient Billing Portals This white paper written by Apex President Patrick Maurer discusses methods to increase patient adoption of online payments Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections This white paper shows why patient centric approaches to online payment portals are important complements to traditional provider centric approaches HFMA Business Profiles Optum Enabling Transformative Change Elena White vice president of risk quality and network solutions for Optum discusses how healthcare providers can leverage data and technology as they enable

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  • Diagnosing Physician Practice Financial Pains
    And it s likely they ll never get to them Almost 20 percent of claims are denied annually and 65 percent of those denials are never worked These questions can reveal a problem common in physician practices Historically billing has always been a back office function Leighton said Physicians and other practice administrators don t have insight into any errors that the coding staff is making and they re not always alerted to cash flow problems To address financial issues proactively many practices turn to professional revenue cycle management services This article is reprinted from Greenway Health s blog Learn more about Greenway Health Publication Date Monday May 18 2015 BACK TO PAGINATION Here are three important questions to ask to discover the cause of a practice s revenue shortfalls If your practice were your patient with a chief complaint of shrinking profitability how would you improve its financial health At first glance you may attribute the symptoms to repercussions of the Affordable Care Act and other increased regulations or the overall decline in reimbursements from payers But in assuming your financial issues are out of your control you could be ignoring a significant underlying issue The true answers to the cause of your financial pains might be your revenue cycle processes you may just not be asking yourself the right questions Do you know what your payers are paying I once talked to an orthopedic group that was being underpaid for a common injection they billed for quite often which resulted in a loss of hundreds of thousands of dollars each year said Leighton Noel regional field RCM specialist all because of a processing error To bill accurately and collect what you re owed practices must frequently research changing payer rules update fee schedules and ensure payers are reimbursing the correct amounts Are you collecting from your patients As unpredictable as insurance payers may be they re not the worst of the offenders Believe it or not patients are much more unreliable payers than insurance companies Leighton said With the rise of high deductible insurance plans patients will more often be responsible for payments but practices who are used to traditional billing don t always successfully collect what they re owed And once patients leave the office they re much less likely to pay which isn t all that surprising considering only 32 percent of patients who owe money receive a collection letter When s the last time you tackled your claims denial backlog Some practices have a backlog of denials that has been sitting out there for 90 plus days Leighton revealed And it s likely they ll never get to them Almost 20 percent of claims are denied annually and 65 percent of those denials are never worked These questions can reveal a problem common in physician practices Historically billing has always been a back office function Leighton said Physicians and other practice administrators don t have insight into any errors that the coding staff is making and they re not always alerted to cash flow problems To address financial issues proactively many practices turn to professional revenue cycle management services This article is reprinted from Greenway Health s blog Learn more about Greenway Health Publication Date Monday May 18 2015 Comments Please login to add your comments Add Comment Text Only 2000 character limit Advertisements HFMA Business Profiles McKesson Leveraging Predictive Analytics to Rein in Operating Costs A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow HFMA RESOURCE LIBRARY 6 Patient Revenue Cycle Metrics You Should Be Tracking and How to Improve Your Results Patient financial engagement is more challenging than ever and more critical With patient responsibility as a percentage of revenue on the rise providers have seen their billing related costs and accounts receivable levels increase If increasing collection yield and reducing costs are a priority for your organization the metrics outlined in this presentation will provide the framework you need to understand what s working and what s not in order to guide your overall patient financial engagement initiatives and optimize results HFMA Business Profiles Accretive Health Partners with Providers to Excel in a Rapidly Transforming Revenue Cycle Environment Emad Rizk MD president and CEO of Accretive Health discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management HFMA RESOURCE LIBRARY 10 Ways to Reduce Patient Statement Volume and Reduce Costs No two patients are the same Each has a very personal healthcare experience and each has distinct financial needs and preferences that have an impact on how when and if they chose to pay their healthcare bill It s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients The need to tailor financial conversations and payment options to individual needs and preferences is critical This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach but take control of rising collection costs HFMA Business Profiles Conifer Health Solutions Helping Providers and Employers Build a Foundation for Better Health Jim Bohnsack vice president solution corporate development for Conifer Health Solutions explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements HFMA RESOURCE LIBRARY Reduce Patient Balances Sent to Collection Agencies Approaching New Problems with New Approaches This white paper written by Apex Vice President of Solutions and Services Carrie Romandine discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs but it will maximize the amount collected before sending to collections Further targeted messaging should be applied across all points of patient interaction i e point of service customer service patient statements and analyzed regularly for maximized results HFMA

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  •