Are You Ready for CMS’s multi-faceted Reimbursement Reduction Movement? (Part 1)

Healthcare Finance News posted this back in May. I love the first line of this article:

“Take heed, hospital administrators – Uncle Sam is watching.”

Oh how true. Most everyone involved in healthcare knows that “Uncle Sam is watching.”

And we also know that good ole CMS is getting pickier and pickier about what they are going to pay for these days.

“While no healthcare sector is being spared from the reimbursement knife, the Value-Based Purchasing initiative is aimed squarely at hospitals.” {Value-based purchasing (VBP), which links payment more directly to the quality of care provided, is a strategy that can help to transform the current payment system by rewarding providers for delivering high quality, efficient clinical care. Click here for more details.} “It is part of a larger reimbursement reduction movement that also includes the Recovery Audit Contractor (RAC) program, Medicare-Severity DRGs (MS-DRGs) and pay-for-performance (P4P).”

“The intent is to use the combination of transparency and fiscal reward to drive clinical quality, patient-centric services and operational efficiency.”

“This program, which I call the ‘Hospital Acquired Payment Adjustment Provision,’ is an overall movement to control costs at the Medicare and Medicaid levels,” said Walt Zywiak, principal researcher for CSC. “CMS has decided it will not make payments for hospital-acquired conditions. Overall, how it works is that if a hospital submits a Medicare claim for any of 10 CMS-identified conditions that were not present upon the patient’s admission, payments for those claims will be reduced.”

The 10 categories of conditions that CMS selected for the Hospital Acquired Conditions (HAC) payment provision are:

1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Stage III and IV Pressure Ulcers
5. Falls and Trauma
   • Fractures
   • Dislocations
   • Intracranial Injuries
   • Crushing Injuries
   • Burns
   • Electric Shock
6. Manifestations of Poor Glycemic Control
   • Diabetic Ketoacidosis
   • Nonketotic Hyperosmolar Coma
   • Hypoglycemic Coma
   • Secondary Diabetes with Ketoacidosis
   • Secondary Diabetes with Hyperosmolarity
7. Catheter-Associated Urinary Tract Infection          (UTI)
8. Vascular Catheter-Associated Infection
9. Surgical Site Infection Following:
   • Coronary Artery Bypass Graft (CABG) – Mediastinitis
   • Bariatric Surgery
     • Laparoscopic Gastric Bypass
     • Gastroenterostomy
     • Laparoscopic Gastric Restrictive Surgery
   • Orthopedic Procedures
     • Spine
     • Neck
     • Shoulder
     • Elbow
10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

• Total Knee Replacement
• Hip Replacement

Source: http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp

So, we see that CMS is putting hospitals to the test when it comes to transparency in documentation and quality of care. As an administrator, how do you ensure that your physicians are accurately documenting care administered to patients, according to the rules of CMS? Are you relying on them to include this in their dictated reports? If so, how do you remind them {uh, change their behavior} to include documentation of POA conditions? Post-it notes? Posters on the wall? Notes in the Physician Lounge? {All of which make little-to-no impression on the physician.}

OR, have you invested in a compliance-driven documentation program, like ComplyMD, that will help your physicians deliver robust documentation to your facility? Chances are, you have not. Chances are, your EMR will not do this either.

Better documentation is becoming increasingly important. Remember, Uncle Sam is in fact watching. You better get equipped to handle all of his demands.

Do You Know What The Financial Success of Your Facility Hinges Upon?

“Documentation is an intrinsic component of every patient encounter. The financial success of a facility depends upon the completeness of the process. The major factor affecting the quality of an organization’s data (and therefore its revenue stream) is the accuracy of documentation. If you are not already convinced of the importance of accuracy in documentation, a study by the Centers for Medicare & Medicaid Services (CMS) found that of all of the improper Medicare benefit payments made during 2001, 43% were due to documentation errors. It is well known that patient quality of care is also related to quality of documentation. Furthermore, documentation is essential to meet the changing demands of regulatory bodies such as The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Office of the Inspector General (OIG), and CMS.”

“Documentation: The 30,000 Foot View”. Today’s Wound Clinic. Caroline Fife, MD, FAAFP, CWS. May 2008

Accurate documentation is vastly important for several reasons, as it proves the quality of an organization’s data, accuracy of reimbursements, improved compliance and overall quality of patient care. And yes, the financial success of any facility does depend on the accuracy and completeness of documentation.

Should Doctors Get Bonuses? Should they be rewarded for ‘good work’?

This is a great article from Time (also featured on CNN Headline News) that looks at CMS’s Pay-for-Performance program efforts. The title “Should Doctors Get Bonuses?” prompts many to think, “Don’t they already get paid enough!” Well, what most of us don’t realize is that, according to the Journal of the American College of Surgeons (January 2008), ‘Projections are that payment rates (for physicians) will decrease by an average of 5% each year for at least the next 9 years, resulting in reductions of as much as 40% by 2015.’ (Physician, do you realize this?) So, what do we think? I say, SURE, reward physicians for good performance. Now, the real question will be HOW will they gather correct information and documentation to prove their performance? You’ll find out………through a system such as ComplyMD.

In the article, they point out that,

“Corporate America has long doled out bonuses to employees who do the best work. Such pay-for-performance programs have only recently caught on in the health care industry, but caught on they have — more than half of U.S. health plans, including Medicare, report offering some type of incentive pay to doctors and hospitals for meeting certain basic standards of care…..”

Well stated. If the rest of corporate America is rewarding employees for good work performance, why not do so in healthcare? And, even more so. Physicians are taking care of people everyday, and peoples’ lives are at stake? Would we not want them to be on some sort of incentive program? YES, we all think that ‘ideally’ every physician in America should take the 100% utmost care of their patients. And many of them do. Yet we must remember, physicians are humans and think like most of us as well – they’d like a little financial pat on the back, just like the rest of us in corporate America.

“In the absence of systematic reform, many insurers have turned to pay-for-performance programs to try to improve quality of care, and cut costs along the way. Early efforts have shown positive signs. In the first three years of an ongoing pay-for-performance demonstration project led by the Centers for Medicare and Medicaid…..findings released in January, researchers following the project concluded that quality scores in the five measured clinical areas had improved on average 17%, and costs had been reduced $1,000 per patient on average. Researchers estimated that if all American hospitals adopted similar bonus schemes, we could save 70,000 patient lives per year and $4.5 billion in hospital costs annually.”

So this data proves that P4P can work. Well, how can we attempt to save 70,000 patient lives per year and $4.5 billion in hospital costs annually in American hospitals? Yes, through P4P initiatives. But HOW will they gather more information to prove their performance rates are up? The issue is documentation: PHYSICIANS MUST PROVIDE PROPER DOCUMENTATION IN ORDER TO DOCUMENT THEIR GOOD PERFORMANCE. Will their coder be able to provide proper documentation for increased performance? No….the coder is not in the room during the procedure to know of a performance increase. The physician and his/her staff MUST document well in order to warrant their pay-for-performance.

And physicians must have the TOOLS to document well… an 8½ x 11 “Remember to Document ‘X Y & Z’ Diagnoses on Your Patients!” stuck to the wall in the physician’s lounge is not a tool to help doctors document well. Give them an easy to use product (ComplyMD) that will enable them to capture appropriate data to document appropriate diagnostic and procedural data to warrant accurate reimbursement and rewards for performance.  

Point-of-Service Documentation: Do you know the value?

“IPA’s should use point-of-service methods to increase quality and ensure the collection of quality data, by central distribution of prompts containing quality codes. Prompts and reminders are important tools to assist physicians in addressing care that may be overlooked or missed.”

“Medicare Quality Codes & Their Impact on Physicians” ICLOPS, LLC. December 2005

Independent Practice Associations (IPA’s), along with other types of healthcare organizations should use point-of-service methods to capture quality data. Capturing quality codes is vastly important. How will physicians know what and how to capture if they don’t have the knowledge and the tools to do so? ComplyMD’s point-of-service documentation solution allows physicians to properly document their procedures and diagnoses, in a code-ready format.

The software doesn’t necessarily ‘prompt’ physicians; however, it provides them with an ‘other procedures/diagnoses to consider’ suggestion box.