Transcript 252214

3rd Annual
Association of Clinical
Documentation
Improvement
Specialists Conference
Creating a Point-of-Entry
Clinical Documentation
Specialist/Case Manager
Kathleen A. Bower, DNSc, RN, FAAN
Arinda F. Kennedy, RN, CCDS
The Center for Case Management
Wellesley, MA
Today’s environment of
increasing scrutiny
(or, they’re here and there
are more on the way)
Oversight of enforcement efforts
U.S. Department of Health
and Human Services (HHS)
Office of Inspector General
(OIG)
Centers for Medicare &
Medicaid Services (CMS)
• Conducts Medicare and
Medicaid Investigations
• Enforcement of antikickback statute
• Issue compliance
program guidance
• Monitors integrity activities
– Medicare & Medicaid
reimbursement
– HIPPA security
– Stark Law
OIG and CMS oversight
• Recovery Audit
Contractors (RAC)
• Office of Audit Services
(OAS)
– Detect past improper
payments
– Focus on payments
• Medicare Administrative
Contractors (MAC)
• Office of Investigation
(OI)
– Prevent future improper
payments
– Criminal and civil referrals
to DOJ
• Office of Counsel to IG
(OCIG)
– Focus on anti-kickback,
quality
• Office of Evaluation and
Inspections (OEI)
– Focus on policy and
systems
• Medicaid Fraud Control
Units (MFCU)
– Medicaid fraud
Providers
• Quality Improvement
Organizations (QIO)
– DRG reviews/quality
• Zone Program Integrity
Contractors (ZPIC)
– Focus on patterns that
constitute fraud
• Medicaid Integrity
Contractors (MIC)
– Focus on Medicaid
claims
Today’s increasing audit
environment
• OIG
• QIO
• MIP
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Medical review
PSCs
CERT
MEDICs
Medi-Medi
PERM
• MAC
• MFCU
• MIG
– MIP
– MIC
• ZPIC
• RAC
Office of Inspector General
• Current Inspector General: Daniel R. Levinson
• OIG combats fraud, waste, and abuse in
Medicare and Medicaid
• Nonpartisan agency committed to protecting the
integrity of the more than 300 programs
administered by the U.S. Department of Health
and Human Services (HHS)
• Approximately 80% of the OIG’s resources are
dedicated to promoting efficiency and
effectiveness of the Medicare and Medicaid
programs
Medicare Fraud Control Units
• The MFCUs, created by Congress in 1977,
are federal- and state-funded law
enforcement entities that investigate and
prosecute provider fraud and violations of
state law pertaining to fraud in the
administration of the Medicaid program
• In addition, the MFCUs are required to review
complaints of resident abuse or neglect in
nursing homes and other healthcare facilities
Quality Improvement Organizations
• Core functions:
– Improve quality of care for beneficiaries
– Ensure that Medicare pays only for services
that are reasonable, necessary, and provided
in the most appropriate setting
– Protect beneficiaries by expeditiously
addressing individual complaints and
provider-based notice appeals
• Conduct individual case reviews for specific
categories
Medicare Integrity Programs
• Medical review: Involves analysis of claims data
for aberrances, pre-payment reviews triggered
by system edits, and post-payment reviews, all
of which involve claims data and therefore ICD
codes.
• Program Safeguard Contractors (PSC):
Investigate Medicare fraud, waste and abuse
within Medicare Parts A and B. Investigations
are based on FFS claims data obtained from
CMS claims processing systems and thus
involve ICD codes.
MIP
(cont.)
• Comprehensive Error Rate Testing
Program (CERT): Estimates payment error
rates and monitors the accuracy of
Medicare’s fee-for-service payments within
Medicare Part A and B
• Medicare Drug Integrity Contractors
(MEDIC): Investigate fraud, waste, and
abuse in the Medicare Part D program
MIP (cont.)
• Medi-Medi program: Investigates fraud, waste,
and abuse of services and payments rendered
on behalf of Medicare and Medicaid dualeligible beneficiaries.
• Payment Error Rate Measurement (PERM):
Measures improper payments in the Medicaid
program and the State’s Children Health
Insurance Program (SCHIP). The PERM
process estimates payment error rates for the
fee-for-service and managed care components
of both the Medicaid program and the SCHIP
program.
Medicaid Integrity Group
Medicaid Integrity Program
• Medicaid Integrity Contractors (MIC)
– Audit Medicaid claims
– Identify overpayments
– Educate providers and others about payment
integrity and quality of care
– Deter those who would exploit the program
ZPIC
Zone Program Integrity Contractors
• 7 Zone Program Integrity Contractors to replace
PSCs & MEDICs
– PSCs work with MACs to handle fraud and abuse
issues in their jurisdiction
– MEDICs investigates fraud, waste, and abuse in the
Medicare Part D program
• Responsibilities:
– Look for fraud and abuse in Medicare Parts A, B, C,
D, home health, DME, hospice
– Utilize data analysis in searching for outliers and
unusual patterns
ZPIC
(cont.)
• Seven zones:
– Zone 1: California, Nevada, Hawaii, American Samoa, Guam,
and the Mariana Islands
– Zone 2: Alaska, Washington, Oregon, Montana, Idaho,
Wyoming, Utah, Arizona
– Zone 3: Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio,
and Kentucky
– Zone 4: Texas, Oklahoma, Colorado, and New Mexico
(awarded to Health Integrity, LLC)
– Zone 5: West Virginia, Virginia, North Carolina, South
Carolina, Georgia, Alabama, Mississippi, Tennessee,
Arkansas, and Louisiana (awarded to AdvanceMed Corp.)
– Zone 6: Pennsylvania, New York, Maryland, Washington DC,
Delaware, Maine, Massachusetts, New Jersey, Connecticut,
Rhode Island, New Hampshire, and Vermont
– Zone 7: Florida, Puerto Rico, and the U.S. Virgin Islands
(awarded to Safeguard Services, LLC)
MAC
• Medicare Administrative Contractors:
– Medicare will move from a network of Part A
fiscal intermediaries (FI) and Part B carriers to the
MACs
– 19 MAC contracts awarded
– Implementation phase from 2005 to 2011
• Responsibilities:
– Process claims for Part A and Part B
– Serve as point of contact for healthcare providers
for the receipt, processing, and payment of claims
A/B MAC jurisdictions map
www.cms.hhs.gov/MedicareContractingReform
RAC
Recovery Audit Contractors
• Objective is to identify and correct past
overpayments and underpayments in the
Medicare fee-for-service program
• Implement actions that will prevent future
improper payments:
– Improve provider compliance with existing rules
– Identify fraud in the system
– Ensure the longevity of the Medicare Trust
Program
RAC demonstration project
• 3-year Medicare RAC demonstration
project lasted from March 2005 through
March 2008
– Phase 1
• 2005: California, Florida, New York
– Phase 2
• 2007: South Carolina, Arizona, Massachusetts,
and Mutual of Omaha fiscal intermediary hospitals
in any of the six demonstration states
Results of the RAC
demonstration program
Overpayment collected:
Less underpayments repaid
Less $ overturned on appeal
Less PRG IRF re-review
Less cost to run the demo
BACK TO TRUST FUND ▬►
Report available at www.coms.hhs.gov/RAC
3/27/05–3/27/08 (Claims & MSP RACs)
$992.7m
-($37.8m)
-($46.0m)
-($14.0m)
-($201.3m)
$693.6m
Overpayment by provider type
Overpayment by error type
Today’s reality
• Issue:
– Increased number of government contractors
actively trying to identify Medicare and
Medicaid overpayments and potential fraud
– Hospitals are held to strict criteria to
determine medical necessity for admission
level of care
Focus on admission status
• Compliance
– CMS – false claims and RAC program
– Documentation requirements to change the
status
– Lack of medical necessity sited as the largest
reason for overpayment – RAC
Physician documentation
Physician
documentation
accounts for 80% of
DRG billing errors*
(*per OIG)
Due to incomplete documentation,
lack of medical necessity.
Current process
• Patient is admitted to the hospital
• Hospital is required to review the case and determine
the medical necessity of the case; particularly
important for Medicare/Medicaid
– Inpatient
– Observation
• Medical necessity review is done by case manager/
utilization review manager using:
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InterQual
Milliman
MCAP
Other screening criteria
• Possibly a secondary review if hospital has process
outlined
Medical necessity screening
Hospitals require case manager/utilization
manager to screen all admissions with tools
that all have disclaimers about their criteria
NOT being applicable to ALL patients
Disclaimer
(Insert name here) Criteria reflect clinical interpretations and
analyses and cannot alone either resolve medial ambiguities
of particular situations or provide the sole basis for definitive
decisions. The criteria are intended solely for use as
screening guidelines with respect to the medical
appropriateness of healthcare services and not for final
clinical or payment determinations concerning the type or
level of medical care provided, or proposed to be provided, to
a patient.
Licensee acknowledges that the criteria are not a substitute
for physician judgment regarding patient care decisions and
that (insert name here) has no control over licensee’s use of
the criteria or over any patient care decisions made by or on
behalf of licensee based upon such use …
Observation problems
• Overuse or underuse of observation status
– Revenue: APC vs. DRG
– LOS artificially low or high
– Patient copays
– Outpatient outliers
Observation problems
(cont.)
Many patients placed in observation status could
meet inpatient criteria with improved clinical
documentation by the physician
Many patients admitted to inpatient status do not
meet medical necessity for this level of care, but
could with additional physician documentation
Case/utilization managers are typically not trained
in clinical documentation improvement
Observation problems
(cont.)
• Solution:
– Hospitals need effective processes to
facilitate proactive strategies to manage
today’s increasing rules and regulations
without swinging too far in the opposite
direction and losing reimbursement for
which they are compliantly entitled to
receive
A new role
• Point-of-entry clinical documentation
specialist cross-trained in utilization
review?
• Point-of-entry case/utilization manager
cross-trained in clinical documentation
improvement?
• Access managers?
A hybrid role is needed
• Access managers (would include ED case
managers)
– Clinical documentation specialist and case manager
roles combined
– Placed at all points of entry into facility
• Admission department
• ED
• Or one access manager who floats/covers all admissions
• Hours
– Best case scenario 24/7
– Realistic scenario 10–12 hours daily, 7 days/week
• 10 a.m.–10 p.m.
– Stark reality: Whatever administration is willing to
support
Basic responsibilities
• Following CMS guidelines, review all admissions to
hospital for medical necessity/documentation
improvement opportunities
• Intervene with physicians for complete and accurate
documentation of:
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Working clinical diagnoses
Comorbid conditions
Physician’s impressions/clinical judgment
Physician’s plan of treatment/medical decision-making (orders)
Appropriate level of care
• Deliver admission/preadmission HINN or ABN when
necessary
• Communicate effectively with care coordination team
• Education of staff and physicians
Focus points for the access manager
Is there missing documentation that would impact
the acuity of this case?
Are all the physician’s concerns from a clinical
perspective documented?
Do all medications ordered have a corresponding
clinical condition documented?
Are all tests ordered pertinent to the reason(s) for
admission?
Focus points for the access manager
What provisional diagnoses are likely in the
physician’s clinical judgment and impressions but
are not included in the documented clinical
impressions?
What is needed to substantiate the need for
inpatient admission?
Are there any abnormal lab or diagnostic results
available at the time of admission? Are they
addressed in the physician’s clinical impression or
provisional diagnoses?
Access manager role
• Education/background
– RN
– Excellent communication skills
– Preferred clinical background in ED or ICU (willing to
interview nurses with background in other areas
requiring a broad clinical knowledge base)
– Best-case scenario: Expert in clinical documentation
improvement and utilization review
– Realistic but hopeful scenario: Expert in utilization
review or clinical documentation improvement and
willing to learn the other role
– Probable scenario: RN with the right clinical
experience who is willing to take on this role
Benefits of merging the roles
• Improved physician documentation at the point of entry, or
before it
• Increased compliance with CMS rules and regulations,
Conditions of Participation, etc.
– Documentation of medical necessity up front
– If medical necessity is not present, HINN or ABN would be given
– Decreasing hospital’s audit risks
• Decreased RAC/MAC/MIC/ZPIC … audit risks
• More accurate reflection of patient’s severity of illness and risk
of mortality
– Potential to improve staffing ratios
• Improved hospital and physician profiles
• Increased compliant reimbursement
• Decreased risk of litigation
Potential barriers
• How many super nurses are out there?
• Once you get them trained and they
realize how much they are worth to your
facility, could you afford to pay them?
• Are consulting agencies scouting these
conferences looking for these experts right
now?
• Are you thinking you need to look into this
new field ASAP?
Real potential barriers
• Training has to be tailored to the needs of this
role
– Expert clinical documentation specialist
• Physician documentation improvement
– Expert case manager/utilization review manager
• Medical necessity
Time required to become expert in
this combined role
Keeping up with CMS changes
Keeping up with commercial payer contracts
Physician buy-in
Process
• Identify your facility’s top medical necessity or observation
admission targets
• Using your medical necessity criteria tool (InterQual,
Milliman, etc.), develop strategies to identify patients who
could meet inpatient criteria with additional documentation
• Using these same criteria, develop educational material
(including improving physician documentation to meet
medical necessity) around your top problematic areas
• Educate your access management staff
• Educate your physician advisors or secondary reviewers
• We also recommend that you educate your clinical denial
analysts in both
Process
(cont.)
Track your interventions
Track your responses
Track your improvements
Demonstrating your influence on the hospital’s revenue
cycle = more staff
Policies and procedures reflect new role
Recognize lasting change is not achieved
overnight
Adoption of consistent processes is key to
compliance and billing accuracy
Typical medical necessity targets
• 1, 2, and 3 day stays
• Symptom diagnoses – chest pain, syncope,
weakness, change in mental status
• High-cost procedures with short hospital stays –
cardiac procedures (PCI stent, ICD placement,
pacemakers)
• High-risk MS-DRGs
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Heart failure and shock
Kidney and urinary tract infections or procedures
Simple pneumonia
COPD
Diabetes
Risk adjustments
Some patients are high risk before they get sick.
Completing documentation of these risks is key to
accurate MS-DRG assignment and reimbursement,
and it also impacts severity of illness, risk of mortality,
and level of care.
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Multiple comorbid conditions • New diagnosis of ongoing
disease
12 or more medications
• Inability to manage disease(s)
• Barriers to care
Lives alone
– Disabilities
Frequent readmissions
– Educational level
– 3rd admission in 6 months
is a red flag
• Cultural issues
– Poverty
– Language
Physician education
• Communication with physician staff is critical
• Link education on improved documentation of medical
necessity with how it can benefit the physician’s practice
(WIIFM)
– Reduced administrative hassles
– Increased business success
– Decreased denials
• Certain physicians need targeted and ongoing
education:
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ED physicians
Hospitalists
Residents/fellows and attending physician staff
Physician advisors
Chief medical officers
Emergency department
• ED primary access point for most patients
entering hospitals
• Daily demands of patient care responsibilities
(often life-and-death issues) are a priority
• Designation of a patient’s observation or
admission status is not a priority
• ED physicians practice defensive medicine
• Access manager position is critical in this area
– Access management may be done by ED case
managers if cross-trained
Discussion
• Chest pain
– Unstable angina? R/O AMI?
• Syncope
– History of CAD? Telemetry monitoring?
Cardiac workup?
• Cardiac procedure
– Comorbid conditions or risk factors present
that would support inpatient level of care?
Conclusion
• The complexity of observation service versus
admission status coupled with the increasing
need to get the status compliantly correct the
first time has become a major issue for hospitals
• This is an area that could be positively affected
with clinical documentation improvement by
physicians
• Preparation including point-of-entry access
managers, policies and procedures, focused
education, and ongoing reviews are critical to
your facility surviving in today’s high-risk arena
Questions?