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ACHIEVING REVENUE CYCLE EXCELLENCE THROUGH CASE MANAGEMENT COMPLIANCE
Toni G. Cesta, Ph.D., RN, FAANConsultant and Partner Case Management ConceptsNew York Office
Bev Cunningham, MS, RNVice President Resource ManagementMedical City Dallas Hospital Dallas, TexasConsultant and Partner Case Management ConceptsDallas Office
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Tuesday, July 22nd, 2014
FACULTY
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Bev Cunningham, RN, MS is Vice President, Resource Management at Medical City Dallas Hospital. Her areas of responsibility include Case Management, Health Information Management, Clinical Documentation Integrity, Patient Access and Transplant Financial Services. Bev is a well‐known speaker in the Case Management field. Involved in the development of case management for over twenty five years, her areas of expertise include denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process. She has served as a Commissioner on the Commission for Case Management Certification. Bev is also a partner and consultant in Case Management Concepts, a company that provides support to hospitals regarding effective Case Management model development and evaluation. Bev's publications include a chapter in CMSA's Core Curriculum for Case Management Certification and most recently, co‐author of the book, Core Skills for Hospital Case Management. She is also on the advisory board for Hospital Case Management.
Toni G. Cesta, Ph.D., RN, FAAN is Partner and Healthcare Consultant in Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing and evaluating acute care and community case management models, new documentation systems, and other strategies for improving care and reducing cost. The author of eight books, and a frequently sought after speaker, lecturer and consultant,
Dr. Cesta is considered one of the primary thought leaders in the field of case management. Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management. Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President –Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York.
LEARNING OBJECTIVES
1. Review the impact of noncompliance on the revenue cycle.
2. Discuss strategies to assure case management compliance with the case manager role.
3. Explain new and revised case management standards, regulations, and laws put forth by CMS, TJC and the federal government.
4. Evaluate case management protocols and penalties.
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COMPLIANCEIn general, compliancemeans conforming to a rule, such as a specification, policy, standard or law. Regulatory compliance describes the goal that corporations or public agencies aspire to achieve in their efforts to ensure that personnel are aware of and take steps to comply with relevant laws and regulations.
Wikipedia
Cooperation or obedience: Compliance with the law is expected of all.
Dictionary.com
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HOW CONFIDENT CAN YOU REALLY BE WITH ALL OF THE COMPLIANCE THAT IS EXPECTED?
EMTALAMEDICAL NECESSITY
APPROPRIATEPATIENT
PLACEMENT
APPROPRIATEAND ACCURATE
ORDERS
OBSERVATIONSERVICE
CONDITIONCODE 44
PROVIDERLIABLE
3 DAYSNF RULE
INPATIENTOR OUTPATIENT
STATUS
RACOVERSIGHT
PROVIDERLIABLE
MEDICARE3 DAY WINDOW
READMISSION PENALTY
HOSPITAL ACQUIRED CONDITIONS PENALTY
CORE MEASUREREPORTING
CONDITIONS OFPARTICIPATION
UM COMMITTEEREQUIREMENTS
IMPORTANTMESSAGE
READMISSIONS
CMS RULESAND REGS
STATE INSURANCERULES AND REGS
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CORRECT ORDERTO ADMIT
2 MIDNIGHTRULE
THE BALANCE OF COMPLIANCE: FINANCIAL AND CLINICAL
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CLINICAL COMPLIANCE• FFY 2013
– Accountable core measures– Patient experience: HCAHPS scores– Readmissions– Hospital acquired conditions
• FFY 2014– Mortality (HF, Pneumonia, and AMI) added to those from 2013
• FY 2015– Patient safety indicators– CLABSI– Efficiency measure: spending/Medicare beneficiary
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CLINICAL COMPLIANCE
• FFY 2016– Outcome measures
• PSI composite: complication/patient safety for selected indicators (composite)
• Mortality (30 day rate): AMI, HF, PN– 6 domains
• Clinical care ‐AMI core measures and mortality; HF mortality; pneumonia core measures and mortality; SCIP core measures
• Person‐ and caregiver‐centered experience and outcomes‐HCAHPS• Safety‐CLABIS and PSI composite• Efficiency and cost reduction‐Medicare spending per beneficiary• Care coordination (HF‐1 discharge instructions)• Community/population health
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COMPLIANCE
ED
Physician Office
Elective Cases
3 Day Treatment Window for Medicare
Transfer Center
Transfer In
RadiologyGI Lab
Surgery•Same Day•Main OR•ASC
Cath lab
ElectiveAdmission
HospitalClinic
Dialysis
COMPLIANCE STARTS AT THE ACCESS
POINTS FORYOUR FACILITY
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COMPLIANCE GOALS OF ACCESS POINT CASE MANAGEMENT CHANGED WITH
THE 2014 IPPS FINAL RULES• Assure compliance to 2 midnight rule
• Have an order to admit• Continue:
– Provide for alternative care when needed and appropriate (medical necessity)
– Assure compliance to rules and regulations, i.e. EMTALA
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PRESENCE OF ADMITTING DEPARTMENT AND EMERGENCY DEPARTMENT CASE
MANAGEMENT INCREASED SIGNIFICANTLY
Provides gate keeping function for:– Planned admissions– Urgent admissions– Direct admissions– Transfers– Potential breaches of compliance, especially the 2 midnight rule
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A QUICK REVIEW OF OBSERVATION
“Observation care is a well‐defined set of specific, clinically appropriate services, which
include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made
regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.”
Internet‐Only Manual (IOM), Publication 100‐04, Chapter 4, Section 290
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THE2 MIDNIGHT RULE• Defined physician documentation and made payment contingent upon
this documentation• Document expectation of patient stay to be greater or less than 1
midnight, with accompanying appropriate order• Documentation of reason for hospital services for any stay expected
longer than 1 midnight: must support medically reasonable and necessary care
• Reassess after 1 midnight, if expected stay less than 2 midnights and patient will continue to stay (with presumed inpatient order) and reason for extended hospital services
• Authentication of admission order before patient discharged• Inpatient only procedures are the exception—but check with your MAC• Lesson learned from “probe and educate”: any inpatient order with an
expected stay of 2 midnights or greater, but with a 1 midnight say, must have documented reason patient did not stay for at least 2 midnights
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CMS CONDITIONS OF PARTICIPATION FOR HOSPITALS (CoP) 42 C.F.R. PART 428
Rules from CMS by which Medicare and Medicaid enrolled hospitals must abide as a condition of participation in
federal health care programs
Any state regulation that is more restrictive than the CoP will “trump” the CoP
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42 C.F.R. PART 482—CONDITIONS OF PARTICIPATION (CoP) FOR HOSPITALS
• Subpart C: Basic hospital functions relating to case management (Attachment 1)– § 482.30 Condition of participation: Utilization review
– § 482.43 Condition of participation: Discharge planning Subpart E: Requirements for specialty hospitals
– § 482.66 Special requirements for hospital providers of long‐term care services (“swing‐beds”)
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TWO VERY IMPORTANT BILLING PROCESSES CHANGED
• Condition Code 44 – Ability to bill Medicare Part B if patient has admitting order, but did not meet medical necessity and has not been discharged
– Increased payment for hospital with this process• Provider Liable
– Ability to bill Medicare Part B if patient has admitting order, but did not meet medical necessity and has already been discharged
– Less payment for hospital with this process (than with condition code 44)
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MEDICARE CONDITIONS OF PARTICIPATION HAVE NOT CHANGED ALL OF THEIR RULES
TO REFLECT THE 2 MIDNIGHT RULE
Review of admission may be performed before, at or after hospital admission (more information at pub.100‐07, state operations manual, appendix a‐survey protocol, regulations and interpretive guidelines for hospitals) : http://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf
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Bed Assigned
Patient Transported to Bed
Patient Assessed
and Treated
DispositionPlanning
PatientNotified to
go to Hospital Admitting Department
Patient arrives in ED
PLANNED ADMISSION
Patient Registered
EMERGENCYADMISSION
PHYSICIAN
PATIENT ACCOUNTSADMITTINGCASE MANAGEMENT BED CONTROL
TRANSPORT
EMS OR WALK‐IN
PHYSICIANNURSINGCASE MANAGEMENTSOCIAL WORK
COMPLIANCEALERTS DURINGINPUT PROCESSES
PHYSICIANCASE MANAGEMENT
PatientDischarged Home With/Without Services
PatientAdmitted to Hospital
CASE MANAGEMENT
BED CONTROL
PHYSICIAN
CASE MANAGER
COMPLIANCE ALERT AREA
COMPLIANCE ALERT AREA QUALITY INTERFACE
PatientTriaged and Registered Care
DelayedWeekend/Other Issues
PATIENT ACCOUNTS
ADMITTING
Concurrent Denial Received
CASE MANAGER19
MEDICARE CONDITIONS OF PARTICIPATION
Requirement for a Utilization Review Committee
Medicare Conditions of Participation, Section 482.30 for IPPS and 485.66 for Critical Access HospitalsCAH State Operations Manual, Appendix WMedicare Claims Processing Manual, Chapter 1, 50.3
MEDICARE CONDITIONS OF PARTICIPATION (CoP)
• All hospitals must have a UR plan• All hospitals must have a UR committee• Hospital must ensure that all UR activities, including review of medical necessity of hospital admissions and continued stays are fulfilled as described in 42 CFR 482.30
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UTILIZATION REVIEW PLAN
Must have a plan that provides for review of services furnished by the institution and by
members of the medical staff to patients entitled to benefits under the Medicare and Medicaid
programs
Don’t forget to incorporate 2 midnight rule process
(both IPPS and Critical Access Hospital)
CRITICAL ACCESS HOSPITAL (CAH) UTILIZATION REVIEW PLAN AND PROCEDURES
CoP 485.66 Utilization Review
– Implemented at least each quarter– Assess the necessity of services– Promote the most efficient use of services provided by the facility
MAKING THE CASE FOR A UR COMMITTEE
• Compliance requirement for committee• Requirement to be medical staff committee• Membership of committee• Support of utilization management function of case management
• Future CMS efficiency measures: cost/Medicare beneficiary
ALIGNING THE PHYSICIAN ADVISORWITH THE UR COMMITTEE
• Physician advisor role• Often chair of committee• Physician advisor report to committee
– Interventions by reasons, section and/or specialty– Trends from past reports– Case study from past month
UR COMMITTEE SAMPLE AGENDA• Old business from past meeting• Annual UR plan review• Compliance reports• Utilization reports• CDI results• Patient outliers• Physician advisor report• Medical necessity criteria changes and updates• 2 midnight rule process• Any annual IPPS proposed and final rules relating to case management
SAMPLE UTILIZATION REPORTS– ALOS: Medicare, Medicaid, Self Pay, HMO, PPO, adult and
pediatrics– Medicare spending per beneficiary (from hospitalcompare.com)– Variable cost per case– Readmission rates– Medical necessity audit results– PEPPER reports– Probe and educate results– 2 midnight rule self denial reports– Denial rates
• Actual denials• Overturns• Denial reasons
RN CASE MANAGER PRE‐UR COMMITTEE MEETING
Medical Necessity Meeting• Monthly meeting RN case managers• Discuss payer issues• In‐depth discussion of one payer• Focus on any new Medicare changes• Review revenue cycle dashboard• Discuss value based purchasing impact on reimbursement
• Develop action plans for identified PI issues• Case studies
KNOW UTILIZATION MANAGEMENT RULES AND REGULATIONS
Medicare patient admitted• Important Message delivered•Documentation for at least 2 midnights, including reason for hospital services
•Appropriate order•Care delivered
Discharge planning begins•Patient and/or family involved in discharge plan
• Important Message delivered within 2 days of discharge (if stay longer than 2 days)
• Physician admission order authenticated before discharge
Discharge order written• Patient agrees with discharge
• Patient disagrees with discharge• Appeal process with QIO
• HINN delivered
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CONSISTENTLY OPERATIONALIZE UTILIZATION MANAGEMENT CRITERIA
• Status assignment (for billing)– Outpatient– Observation service– Inpatient
• Level of care (for billing)– Medical/surgical– Intermediate– Critical care– NICU levels of care
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INCORPORATE 2 MIDNIGHT COMPLIANCE IN TO YOUR DAILY CASE MANAGEMENT ROUTINE
Patient admitted as inpatient with appropriate
order
CM reviews order and
documentation, using medical necessity
Physician documents appropriate medical necessity
One or two day stay
If one day stay, physician documents
reason for early discharge
Admission order authenticated
before discharge
Patient discharged
Appropriate billing
Best practice for 1‐2 day Medicare admissions: Admission/ED case manager with IP case manager 7 days a week with physician following documentation requirements of 2 midnight rule 31
INCORPORATE 2 MIDNIGHT RULE COMPLIANCE IN TO YOUR DAILY CASE MANAGEMENT ROUTINE
Patient admitted as inpatient
Physician documentation
not in compliance
with 2 MN rule
One or two day stay without
concurrent case manager review
Patient discharged
Account placed on hold
Case Manager does retro review after discharge
2 MN rule documentation requirements not followed
Self denial process followed
Best practice for Medicare 1‐2 day stays when no admission case manager and physician does not document appropriate medical necessity
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SELF DENIAL PROCESS: MLN MATTERS MM 8445
• Released February 2014, but effective October 1, 2013
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INCORPORATE UTILIZATION MANAGEMENT COMPLIANCE IN TO YOUR DAILY CASE MANAGEMENT ROUTINE
Patient admitted as inpatient
Physician documents
inappropriate or incomplete medical necessity
Case manager or attending physician identify
inappropriate admission
inpatient order
Attending physician and a member of the UM Committee agree patient status should not be IP
Physician and UM Committee
member document observation
appropriateness
Appropriate billing—
Condition Code 44
Best practice for Medicare 1‐2 day stays when no admission/ED case manager and IP case manager not present 7 days a week and physician does not document according to 2 midnight rule requirements 34
UTILIZATION MANAGEMENT AND COMPLIANCE ARE PART OF THE PATIENT’S FINANCIAL EXPERIENCE
• Assure you do everything you can to maximize the patient’s benefits– SNF days– LTR days– LTM limits– Timely communication with payer– Complete description of criteria met– Timely communication with physician– Incorporate physician in any appeals
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UTILIZATION MANAGEMENT AND COMPIANCE ARE PART OF THE PATIENT’S FINANCIAL EXPERIENCE
• Keep the patient in the loop about issues with the payer– IM– ABN– HINN– Benefits—reimbursement for noncovered services– Potential denial– Patient choice– Discharge limitations
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IMPORTANT MESSAGE: THE PATIENT’S RIGHT TO APPEAL
• 1st important message given on admission• 2nd important message give within 2 days of discharge
Are you compliant with delivery of thesetwo messages? Only an audit will
tell you of your compliance.
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COMPLIANCE GAP ANALYSISMEASURE CURRENTLY
IN PLACENEEDS TO
BE IMPROVED
2 Midnight Rule process in place and successful
2 Midnight Rule audit process in place and reported to UM Committee
UM Committee in place and following Condition of Participation requirements
ED Case Management in place during appropriate hours
Access Case Management in place, if appropriate
Physician advisor process in place and successful
All case managers understand role of medical necessity and 2 midnight rule expectations
All records have orders with correct order to admit
Effective self denial process in place
Important Message delivered appropriately with accurate appeal process in place with QIO
CMS CONDITIONS OF PARTICIPATION: DISCHARGE PLANNING 482.43The hospital must have in effect a discharge planning
process that applies to all patients. The hospital’s policies and procedures must be specified in writing.
(a) Standard: Identification of patients in need of discharge planning. The hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning.
(b) Standard: Discharge planning evaluation.(1) The hospital must provide a discharge planning evaluation to the patients
identified in paragraph (a) of this section, and to other patients upon the patient’s request, the request of a person acting on the patient’s behalf, or the request of the physician.
(2) A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, the evaluation.
http://edocket.access.gpo.gov/cfr_2004/octqtr/pdf/42cfr482.43.pdf39
A PAYER’S COMPLIANCE EXPECTATIONS
• Best resource: contract• Utilization management portion of contract
– Criteria payer uses– Time for calls for medical necessity– Frequency of calls– On‐site case management
• Billing contract regulations
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COMPLIANCE AND THE INTERDISCIPLINARY TEAM
• Basic understanding of compliance rules and regulations
• Develop strategies to assure compliance with rules and regulations
• Monitor compliance outcomes
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THE BLEND OF QUALITY, COMPLIANCE AND REIMBURSEMENT
• Value Based Purchasing – Core Measures– HCAHPS– Mortality – Medicare spending per beneficiary
• Reimbursement penalties• Hospital acquired conditions• Never events• Readmissions
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COMPLIANCE ROLESCASE MANAGEMENT LEADER
• Follow CMS Conditions of Participation• Follow 2 midnight rule requirements• Assure compliance at every entry point • Educate case managers regarding compliance• Complete gap analysis• Develop compliance dashboard• Evaluate outcomes• Keep up with IPPS rules
– Proposed rules each May– Final rules each August
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DEVELOP MODEL FOR CASE MANAGEMENT’S FOCUS ON COMPLIANCE AT ALL ACCESS POINTS
• Staffing• Hours of coverage• Orientation• Established annual competencies• Outcome metrics• Staff and organizational training• Assure model encompasses compliance sites and processes where opportunity exists
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COMPLIANCE
WHERE ARE YOUR
COMPLIANCEENTRY
POINTS?
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CMS FACT SHEET 4/30/14 FROM 2015 IPPS
PROPOSED RULE: ALTERNATIVE PAYMENT APPROACHES FOR SHORT HOSPITAL STAYS
• Proposed rule notes that some members of the hospital community have expressed support for the general concept of an alternative payment methodology under the Medicare program for short inpatient hospital stays.
• CMS is soliciting comments on such a payment methodology, specifically how it might be designed. The proposed rule asks for public input on an alternative payment methodology for short stay inpatient cases that also may be treated on an outpatient basis, including how to define short stays and what an appropriate payment would be.
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RESOURCES• CMS: Hospital inpatient order and certification:
http://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/AcuteInpatientPPS/Downloads/IP‐Certification‐and‐Order‐01‐30‐14.pdf
• CMS: FAQ’s 2 midnight rule guidance: http://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Monitoring‐Programs/Medicare‐FFS‐Compliance‐Programs/Medical‐Review/Downloads/Questions_andAnswersRelatingtoPatientStatusReviewsforPosting_31214.pdf
• CMS Probe and educate status: http://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Monitoring‐Programs/Medicare‐FFS‐Compliance‐Programs/Medical‐Review/Downloads/UpdateOnProbeEducateProcessForPosting02242014.pdf
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This presentation is intended solely to provide general information and does not constitute legal advice. Attendance at the presentation or later review of these printed materials
does not create an attorney-client relationship with the presenter(s). You should not take any action based upon any information in this presentation without first consulting legal
counsel familiar with your particular circumstances.
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