New ADR Limits Good News for Providers

New ADR Limits Good News for Providers

Written by Dawn Crump Created on Thursday, 02 May 2013 10:00

April 15 is typically a day of dread for many U.S. taxpayers. This year, however, it's a day for celebration among providers participating in Medicare's fee-for-service RAC program. Beginning April 15, 2013, additional documentation request (ADR) limits for the RAC program are essentially reduced for Medicare providers (excluding suppliers and physicians).

Prior to April 15, RACs could select up to 100 percent of any claim type for review. Now they are limited to a maximum of 75 percent on any particular claim type. When combined with the maximum number of ADRs and percent of claims limitations, providers should see a reduction in requests for the most burdensome of RAC audits—acute hospital inpatient (IPPS) stays.

More variability in the type of requests may equate to less paperwork and smaller administrative burdens. Here are the two changes to understand.

Claim Type Combines with ADR Limits to Reduce Administrative Burden

Now only 75 percent of a campus's ADR limit from any single claim type can be requested by the RAC. This is down from 100 percent previously and represents good news for hospitals with a high number of inpatient RAC requests.

The administrative burden of processing ADRs for acute hospital inpatient cases is huge. Now, just 75 percent of the ADRs per 45-day period can be for IPPS records. The remaining 25 percent can be requested from all other types (OPPS, SNF, IRF, IPF, ASC, or physician claims). This change is good news for larger organizations, where the 2 percent Medicare claims volume limit calculation often pushes the number of ADRs received over the limit of 400 or 600 every 45 days.

In other words, while Medicare's original calculations for ADR limits still apply, the layering of the new 75 percent limitation by claim type will reduce the number of inpatient ADRs campuses must process every 45 days.

New Minimum Number of ADRs Helps Smaller Hospitals

Smaller hospitals also benefit from the changes on April 15. In the past, RACs were able to request a minimum of 35 records every 45 days. Smaller facilities often reached their 2 percent Medicare claims volume limit before reaching the 35-record minimum, allowing the RAC to request more records than initially intended.

Now, the minimum number of ADRs that RACs may request is 20 records per 45 days. We expect this change to reduce the number of requests received by smaller hospitals, regardless of claim type.

What Remains the Same

Three pieces of the ADR limit calculation remain the same.

400 or 600 ADR maximum every 45 days

There is still a maximum number of ADRs per 45 days of 400 for providers with less than $100M in MS-DRG payments and 600 for providers with over $100M in MS-DRG payments. Both the 400 and 600 request limits are per every 45 days and across all claim types, including professional services.

2 percent of Medicare claims volume

The AHA-supported Medicare Audit Improvement Act (HR 1250) introduced March 19 also limits RAC medical record requests by campus to 2 percent of the Medicare claims submitted for a particular care setting in the previous calendar year. When combined with the 400 or 600 maximum and 2 percent claims volume calculation, the 75 percent limitation in ADRs from any single claim type is expected to minimize the number of inpatient records requested—relieving the RAC administrative burden for healthcare providers.

Campus concept

Finally, the campus concept is still in use. Multiple locations with the same Tax Identification Number (TIN) and located nearby are now counted as one campus unit, and they share the maximum record request burden. Area is determined by the first three positions of the ZIP code. If the TIN and first three numbers of the ZIP code are the same, multiple locations are counted as one campus.

Demand Letter is Still Key to Managing ADRs

Regardless of the number of ADRs received, ensuring that initial RAC demand letters reach the right contact at each campus is still a serious provider issue nationwide—and a general complaint of the RAC program.

Centralizing audit management to cross all campuses and encompass all claim types is an important step in overcoming this issue. Once the audit management process is herded into one corral, a single point of contact can be established with the RAC or RACs.

It is only by ensuring that the right contact receives all initial demand letters that providers truly improve the audit process, reduce administrative burdens, and take full advantage of new ADR limits.

$65 Billion in Improper Payments in 2012, OAS Deputy Inspector General Tells Monitor Monday Listeners

$65 Billion in Improper Payments in 2012, OAS Deputy Inspector General Tells Monitor Monday Listeners

Written by Janis Oppelt Created on Thursday, 21 March 2013 10:48

The Department of Health and Human Services (HHS) reported $65 billion in improper payments across eight of its high-risk programs in 2012. This is just one of the morsels of information that listeners of the March 18 Monitor Monday broadcast heard from special guest Gloria Jarmon, Deputy Inspector General (IG) for the Office of Audit Services (OAS) in the Office of Inspector General (OIG) for HHS.

As some readers may know, the OAS is the largest civilian audit agency in the federal government and the biggest section of the OIG. It is the job of OAS investigators—about 600 of them (out of a total staff of 700)—to examine whether HHS and its affiliates are fulfilling their responsibilities.

To do so, the OAS conducts independent audits of HHS programs and operations, either by using its own resources or by overseeing audit work done by others. Investigators also audit the performance of HHS programs and/or its grantees and contractors to determine whether they are fulfilling their respective responsibilities. The goals, says Jarmon, are "to help reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the department."

In addition to explaining the audits on HHS programs, she provided examples of the amount of improper Medicare and Medicaid payments collected from providers. She also reviewed the purpose of, and results from, Improper Payments Information Act of 2002 (IPIA) as amended by the Improper Payments Elimination and Recovery Act of 2010 (IPERA).

Obeying the IPERA

Lest healthcare providers think that they are the only ones undergoing federal government scrutiny, think again. Although many readers may not have heard of the IPERA, it's an important piece of legislation designed to ensure that DHHS is doing its job. (A summary can be found at https://oig.hhs.gov/oas/reports/region1/171352000.asp.)

Specifically, the legislation requires the OIG to review and report on annual improper payment information included in the agencies' financial reports (AFR). The OAS established the following objectives for this review:

• Determine whether HHS complied with the IPIA for fiscal year 2012 in accordance with related Office of Management and Budget (OMB) guidance.
• Evaluate the accuracy and completeness of the HHS's reporting.
• Evaluate HHS's performance in reducing and recapturing improper payments.

Although HHS has met many of the requirements, it is not, says Jarmon, in full compliance—even though, as stated above, the department reported $64.8 billion in improper payments in 2012. The payment came from eight programs deemed to be high-risk by the OMB. It did not, however, report an error rate for the Temporary Assistance for Needy Families (TANF) program.

HHS also reported that four of the nine programs met their improper rate-reduction targets, but three of nine did not (Medicare fee-for-service, Medicare Advantage, and foster care). This requirement didn't apply to the two remaining programs (TANF and the Children's Health Insurance Program [CHIP] because a target hadn't been established for either of them. The department achieved improper payment rates below 10 percent—another requirement of the act—for each of the other programs reported on except Medicare Advantage.

As Jarmon says, "The challenge remains for the department to further reduce improper payments and to meet its target rates and develop error-rate reduction targets and corrective action plans for CHIP and ensure effective monitoring of TANF. We do acknowledge that the department plans to take action to address our recommendations."

Monitoring Medicare and Medicaid

A primary focus of the OIG is to identify and reduce improper payments and create opportunities to achieve cost savings, and Jarmon shared examples of audits being conducted to achieve these goals.

For example, in 2012, the HHS reported about $65 billion in improper payments—most from Medicare or Medicaid claims. Recent work has focused on improper hospital payments. The OAS reviewed and issued reports of its findings from 50 hospitals and performed audit work on another 50 hospitals for which no reports have yet been issued. The purpose of these audits, says Jarmon, is "to improve internal hospital controls, increase provider awareness and compliance with Medicare rules, and recommend recovery of identified overpayments."

OAS investigators also have recently reviewed the Medicare overpayment collection efforts of the Centers for Medicare & Medicaid Services (CMS) and recommended improvements to those efforts. CMS has already taken steps to address those concerns.

Medicaid audits also are being conducted, and, like in the Medicare program, auditors are looking for improper payments and potential ways to achieve cost savings.

For example, "In New York, we reported on the issue of excessive rates charged to the federal government related to the care of small populations of developmentally disabled individuals at an intermediate care facility. This audit showed that the federal government would have saved $700 million in the audit year," she said. This uncovering resulted in a congressional hearing last September.

Another example: In the past six years, OAS has issued 20 reports on Medicaid personal care services' and conducted numerous investigations. For a full description of this program, Jarmon recommends consulting the OIG's portfolio entitled Personal Care Services: Trends, Vulnerabilities and Recommendations for Improvement, which outlines the steps taken to uncover about $580 million in questionable charges from several state programs.

The OAS also conducts Medicaid audits in home health agencies, military providers, and durable medical equipment suppliers.
"Our responsibility spans a department with a budget of $900 billion. We have a very large audit responsibility," said Jarmon.

A Documentation Improvement Success Story

A Documentation Improvement Success Story
By Judy Sturgeon, CCS
For The Record
Vol. 23 No. 8 P. 8
Is your documentation everything it should be? Are your physicians providing all the information your coders need for accurate coding and reimbursement? Will the information be good enough when ICD-10 is implemented? Has your budget prevented you from enlisting help from a top-shelf consultant’s clinical documentation improvement (CDI) program?
There is a viable solution. Just ask the HIM department at Monroe Clinic, part of an integrated clinic-hospital organization licensed as a 100-bed hospital with an 80-provider multispecialty clinic in Monroe, Wis., and 11 community clinics in southwest Wisconsin and northwest Illinois.
Regardless of a facility’s size, several issues are crucial for all HIM departments. Monroe’s HIM department has the same needs and concerns as the largest university or national medical conglomerates: good documentation, ongoing communication with physicians, improved coding, and a positive response to a staggering number of industry changes.
Laurie Schimek, RHIT, Monroe’s HIM manager and privacy officer, says it was a whirlwind experience as the clinic attempted to take better control of its documentation practices. By addressing its needs one step at a time, Monroe has been able to keep on top of healthcare’s shifting landscape. In 2009, after converting its coding from paper documentation to a new EMR, Monroe began discussing ways to improve physician documentation in the new system.
Rather than enlist help from a vendor, Monroe felt it was imperative to create its own documentation improvement project. The reason? “We had a need to communicate. We already have the knowledge, and we know where the needs are,” Schimek says. “We identified what we did know and built on that. Then one of the inpatient coders volunteered to go talk to the hospitalists to help clear up some of the documentation questions.”
For the project to have any chance at succeeding, Schimek says gaining support throughout the clinic was critical. “We’ve been extremely fortunate in having leadership who consistently provide excellent support and have confidence in our knowledge and ability,” she says. “We quickly received buy-in from the director of information services to whom we report and from both the chief financial officer and the chief medical officer. Our initial outreach coder did her homework, too, by researching the basic concepts and needs involved in order to create an effective and compliant clinical documentation improvement program.”
The project may have seemed overwhelming, but the extensive requirements for the final product did not discourage Schimek, who recalls telling the novice CDI coder, “Let’s just look at this as an experiment. Introduce yourself; ask if there’s anything you can do to help them [physicians].”
By keeping the immediate task at hand manageable, Monroe forged ahead toward its ultimate goal.
“We don’t have any extreme extroverts here,” Schimek says. “Our first few meetings included some white-knuckle moments for our coder, but she began her first encounter by explaining the need to understand why physicians documented as they did. The coder included clinical examples of how their documentation affected the physicians’ level-of-service coding. Then she asked if they had any questions for her and once the dialogue began, there was no stopping it.”
Schimek says the idea was to create a peer relationship with the physician staff. It turned out to be beneficial for both sides, a positive experience that offered assistance to physicians as well as to the coding department. Schimek says several strategies were employed to create this cooperative effort.
“We went in to understand, not to tell them what to do,” she says. “We stopped using punitive and threatening words like ‘audit’ and ‘benchmark’ and ‘review.’ We wanted to develop an interactive relationship, so we created in their place interactive coding sessions and encouraged a peer role relationship. We made certain that our clinical examples were not identified by physician, only by the documentation issue that was of concern. We maintained an attitude of respect and we receive respect in return.”
In addition to these behavior changes, Monroe’s CDI coders created personal business cards and bumped their dress code up a notch to reflect their competence as clinical professionals. “You can’t let clothing cause you to be prejudged,” Schimek notes.
Rather than try to tackle everything at once, the CDI program focused on each department’s top five issues and required that a coder was available for 15 minutes at regular department meetings. As documentation needed clarification, coders jotted down the basic issues daily. At each meeting, the top five reoccurring items were brought to the attention of physicians and staff. As the physicians became more attentive to the most pressing problems, new ones were introduced.
Arrangements were made for a coder to participate in daily rounds, and the medical staff’s demand for her input quickly increased as more departments opted into the program. One skilled coder representative soon became several with a little time and training. Eventually, the program expanded to address outpatient clinic needs as well as inpatient concerns.
One step on a tentative path, created by need and fueled by a coder champion with little nerve and built on a foundation of good planning and cooperation, has brought significantly more to the clinic than some basic documentation improvement.
Letters of commendation from the hospitalists to the chief medical officer further validated the project’s value and gained esteem for the coders and the department as a whole. Meanwhile, case mix has improved noticeably. Trepidation surrounding recovery audit contractor audits has subsided thanks to the improvement in specific and detailed documentation. The thought of a new ICD-10 coding system and its expectations for greater documentation detail is less intimidating.
In addition to those benefits, the program has enhanced employee satisfaction, an important accomplishment in an environment where there is increased demand for competent coders. In fact, the project’s original coder champion has been promoted to coding supervisor.
“Our confidence levels have improved noticeably all around. As awareness of the knowledge and capability of the coding staff spreads even wider, their self-esteem and respectability continue to increase along with their reputation,” Schimek says.
Monroe Clinic has succeeded in turning reaction into action, initiating change rather than waiting around to find out how badly change will affect them. Their world is no longer a static environment. It’s an exciting place to work and an example to other facilities that a generous portion of ‘will do’ can become a successful story of ‘can do.’
If you’d like to learn more about the Monroe Clinic CDI program, visit www.monroeclinic.org or contact Laurie Schimek at laurie.schimek@monroeclinic.org or 608-324-2192.

 

Please contact ERM for more information about on-site and remote training. Education is the only solution. 772-210-2823 or kgifford@ermconsultinginc.com

CMS Restructures RAC Program: Five RACs, Not Four

CMS Restructures RAC Program: Five RACs, Not Four

Written by Chuck Buck Created on Thursday, 18 April 2013

 

Beset by legal challenges and a burdensome backlog of pending appeals, the Centers for Medicare & Medicaid Services (CMS) is implementing sweeping changes to its Recovery Auditor (RAC) program, as evidenced by documents obtained by RAC monitor.

Among those documents is the request for proposal (RFP) issued by CMS for the re-procurement of recovery auditor contracts. As reported here recently, PRGX Global, formerly known as PRGX Global-Schultz and currently a subcontractor to three RACs, is among those known to have submitted an RFP in hopes of becoming a prime RAC contractor.
Current RAC contracts are expected to expire in February 2014. The deadline for RFP submittal was April 4, 2013. The new RAC contract period is to extend from 2014 to 2018. 
The most sweeping of all anticipated changes is that CMS will have recovery auditors in all four geographical RAC regions, as currently configured, with a fifth “nationwide” RAC responsible for identifying overpayments among home health hospice facilities and durable medical equipment (DME). 
Under the plan, the four regional RACs no longer will handle improper payments for home health, hospice or DME.
Still another change to the RAC program is that CMS is requiring recovery auditors to support the agency throughout the entire appeals process, including at the administrative law judge (ALJ) level. According to its 2013 Statement of Work (SOW), CMS writes: 
“For any Recovery Auditor-identified improper payment that is appealed by the provider, the Recovery Auditor shall provide support to CMS throughout the administrative appeals process and, where applicable, (during) a subsequent appeal to the appropriate federal court. This includes participating or taking party status at the administrative law judge (ALJ) level of appeal in a minimum of 25 percent of the cases that reach this level.”
“The RACs will also now be required to participate and support CMS to defend against provider appeals,” Emily Evans of the Nashville, Tenn.-based Obsidian Research Group (ORG) wrote in a memo to investors. “The time frame for completing claims reviews is cut in half, from 60 to 30 days, and the new program will give CMS more teeth to stop work with a contractor that does not follow guidelines.”
CMS has been under siege on two fronts recently: first via the lawsuit filed in federal court on Nov. 1, 2012 by the American Hospital Association against the U.S. Department of Health and Human Services, and second, the recently proposed legislation by U.S. Rep. Sam Graves (R-Mo.) and Rep. Adam Schiff (D-Calif.), who introduced the Medicare Audit Improvement Act of 2013 (HR 1250) on March 19, 2013.
Evans writes that while ORG believes the changes to the RAC program are “not favorable in the short run,” the company believes that long-term opportunities remain “robust.”  
About the Author 
Chuck Buck is publisher of RACmonitor. 
Contact the Author 
cbuck@racmonitor.com This email address is being protected from spambots. You need JavaScript enabled to view it.
To comment on this article please go to editor@racmonitor.com This email address is being protected from spambots. You need JavaScript enabled to view it.
References 
Recovery Audit Scope of Work
Statement of Work for Recovery Audit Program (DME) Home Health and Hospice
RAC Regions

Highmark’s $1B Acquisition of West Penn Approved by PA

Highmark’s $1B Acquisition of West Penn Approved by PA

CMS updates NCD with ICD-10 codes | ICD10 Watch

CMS updates NCD with ICD-10 codes | ICD10 Watch

CMS updates NCD with ICD-10 codes

Posted on Tue, Apr 02, 2013 - 07:41 am

The Centers for Medicare and Medicaid Services (CMS) has updated its national coverage determination (NCD) edits to include ICD-10 codes.

The NCDs define what Medicare will cover. These updates will help healthcare providers determine how reimbursements may changed after Oct. 1, 2014.

Here's the list of files with explanations and the actual changes:

• MM8197 [PDF, 105KB]
• R1199OTN.pdf [PDF, 70KB]
• R1199OTN1.zip [ZIP, 134KB]
• R1199OTN2.zip [ZIP, 64KB]
• R1199OTN3.zip [ZIP, 76KB]
• R1199OTN4.zip [ZIP, 338KB]

Digital Disruption Will Drive Mergers and Acquisitions In 2013

Digital Disruption Will Drive M&A In 2013

by Mark Walsh, Apr 23, 2013, 7:00 AM

Read more: http://www.mediapost.com/publications/article/198650/digital-disruption-will-drive-ma-in-2013.html#ixzz2RsyMPf9r

2013 is shaping up as another active year for mergers and acquisitions in the media, communications and entertainment industries as companies scramble to keep up with the consumer shift to digital and mobile technologies.

Digital disruption of the media landscape will continue to drive M&A, partnerships and joint ventures this year.

A new outlook report by PricewaterhouseCoopers outlines five key themes for 2013:

*Consumer demand for bandwidth drives need for spectrum. The communications industry will see continued consolidation this year as a result of growing demand for bandwidth supporting content consumption, social networking and location-based services. In January, AT&T announced a pair of deals worth $2.7 billion to expand its wireless spectrum, while Dish made a $25.5 billion bid to acquire Sprint.

*The race for content. Consumer expectations for ubiquitous viewing require distributors to offer more premium and library content than ever. This has accelerated efforts to license and/or acquire content to keep customers from fleeing to competing services. Disney’s $4.1 billion acquisition of Lucasfilm highlights the trend.

*Cross-border M&A. As U.S. and foreign market players look to meet the demand for content, they are increasingly looking to international markets for acquisition targets. Several overseas broadcasters invested in U.S.-based production companies last year, and PwC expects to see more inbound interest in U.S.-based content. Conversely, China will attract digital and entertainment investors because of its growing online population.

*Non-core divestitures. Businesses are expected to exit non-essential assets as a way to increase profitability and allocate capital to key units. This trend has been especially prevalent in the publishing world, where traditional newspaper and other businesses have been especially hard hit by the digital shift. Tribune Co., for example, hired advisers in February to explore the sale of its newspaper publishing unit.

*Digital blurring line between media and technology. Technological innovations will require media companies to continue experimenting with new business models aligned with changing consumer habits. Key to that effort are new digital metrics designed to be more transparent and available in real-time. But many companies are still learning to collect only the most basic information and generate real value from Big Data.

While the total volume of media and communications deals dipped from 931 to 839 deals in 2012, data compiled by PwC showed that the dollar value of deals jumped to $96.2 billion from $55 billion last year. Even excluding Softbank’s planned $20 billion purchase of Sprint (thrown into question by the recent Dish bid), the deal value in 2012 still rose 38%.

The number of deals in the Internet software and services category increased to 149 from 186, while the total deal value increased to $9.5 billion from $6 billion last year. PwC anticipates that the market for Internet deals will remain active this year, mostly consisting of middle-market transactions.

Read more: http://www.mediapost.com/publications/article/198650/digital-disruption-will-drive-ma-in-2013.html#ixzz2RsyHUIqB

HHS preparing to offer HIPAA omnibus guidance: Update

HIPAA Being Misinterpreted, Congress Told

By David Pittman, Washington Correspondent, MedPage Today

Published: April 26, 2013

WASHINGTON -- Healthcare providers often misunderstand or over-interpret a 1996 health privacy law and as a result frequently do not share vital health information with family, caregivers, and others, lawmakers heard Friday.

Some members of Congress have expressed concern that certain provisions of the Health Insurance Portability and Accountability Act -- called HIPAA for short -- have prevented providers from sharing information with loved ones and law enforcement that may have saved a patient's life or the lives of others. The law restricts the sharing of information in most circumstances unless the patient grants permission.

During a hearing Friday, Rep. Tim Murphy, PhD, (R-Pa.) noted instance when doctors did not share concerns about patients with the family, citing the 1996 HIPAA law as the reason, and the patients later took their own life.

Murphy, a clinical psychologist and chair of the House Energy and Commerce Oversight and Investigations subcommittee, expressed worry that actions like this could hinder patient care and might fail to prevent public health tragedies. For example, patients with mental illness could be at risk of killing themselves or others, or patients with chronic conditions could miss out on obtaining the care they need.

Physicians frequently misinterpret what they're allowed to share under HIPAA, said Mark Rothstein, JD, director of the Institute for Bioethics, Health Policy and Law at the University of Louisville School of Medicine in Kentucky.

"The outcome is that some use of the disclosures permitted by the privacy rule are not allowed by some covered entities, perhaps out of ignorance or an overabundance of caution," Rothstein said.

Providers are allowed to share patients' health information with law enforcement, in certain public health instances, and to avert a serious health risk to the patient and others.

HIPAA allows providers to use their judgment on what they think is in the best interest of their patient, Leon Rodriguez, JD, director of the Office of Civil Rights for the Department of Health and Human Services (HHS), told lawmakers.

"We have never taken enforcement action because a provider has decided the best interest of the patient [is] to disclose information to a third party," Rodriguez said.

In fact, of the 80,000 complaints of HIPAA violations HHS has received, only 12 have resulted in monetary penalties, Rodriguez said.

That lack of enforcement hasn't stopped providers from fearing punishment or pleading ignorance to the nuances of what HIPAA allows them to say and not, lawmakers said.

"I can tell you that guy, that gal seeing a patient at 3 a.m. doesn't have your expertise," Rep. Bill Cassidy, MD (R-La.), told Rodriguez and Rothstein, giving the example of a emergency department doctor. "But what they do have are examples of physicians who have been grabbed by the law and not let loose until every one of their personal resources have been exhausted."

Other providers often use the law the shield themselves from conversations with caretakers they'd like to avoid.

"I wonder if some physicians don't hide behind HIPAA just to move onto the next patient, not wanting to be bothered with an aunt, or an uncle, or a cousin in regard to questions about their loved one," Rep. Phil Gingery, MD (R-Ga.), said. "I hope that doesn't exist too much, but it's something we need to think about."

Said Carol Levine, director of the Families and Health Care Project of the United Hospital Fund in New York City, "HIPAA has become a very convenient excuse to avoid difficult conversations with family members."

Lawmakers convened Friday's hearing in the wake of a March 5 gathering of families of the Newtown, Conn., shooting, where they learned that HIPAA may have prevented the release of vital health information.

The specific topic of preventing mass violence through disclosure was scarcely mentioned Friday. Meanwhile, the committee heard from families of those with mental illness and addiction who were blocked from learning more about their loved one's condition and treatment because providers cited HIPAA.

To combat provider misunderstanding around HIPAA, HHS issued a letter to providers reminding them of their rights and obligations on who they can and must notify when a patient is a serious threat to them self or others. Rodriguez said that letter has helped spur discussion in the provider community.

Rothstein and other lawmakers called on HHS to launch more and better provider education outreach.

Deven McGraw, JD, director of the Health Privacy Project at the Center for Democracy and Technology, suggested more guidance to providers informing them of rights and obligations, and that HHS should develop better ways to share such guidance with physicians. McGraw said HHS should work with professional societies who have more direct contact with physician members, rather than just posting documents on its website.

"It sounds like too many people are hiding behind [HIPAA] when there are clear exceptions when information can be shared," McGraw said.

HHS preparing to offer HIPAA omnibus guidance: Update

HHS preparing to offer HIPAA omnibus guidance: Update

Author Name Patrick Ouellette   |   Date April 26, 2013

http://healthitsecurity.com/2013/04/26/hhs-preparing-to-offer-hipaa-omnibus-guidance/

According to in-house HHS attorney Iliana Peters, the Department of Health and Human Services (HHS) will be offering additional guidance on the HIPAA omnibus rule. Rachel Seeger, Senior Health Information Privacy Outreach Specialist for the Office for Civil Rights (OCR), told HealthITSecurity.com in an email that she hopes this guidance is provided soon:

Before publishing the Omnibus Rule, HHS carried out an extensive process, incorporating input from a wide range of stakeholders. To clarify Ms. Peters’ comments, we will be issuing additional compliance guidance and technical assistance to covered entities and business associates that was not addressed in the preamble of the Omnibus Rule given space limitations. We hope to publish these materials on OCR’s website soon.

Peters had stopped short of going into specifics of that guidance, butHealthcareinfosecurity.com reports HHS is working to get guidance out quickly to covered entities, business associates and subcontractors.

It will be interesting to see the scope of what HHS offers these organizations that are trying to wrap their heads around the new HIPAA omnibus requirements. The most interesting quote from Peters was that the omnibus rule, which went into effect on March 26 and will become enforceable on Sept. 23, has was initially chopped down from an original, lengthier version. How will the new guidance expand upon security, privacy and breach notification language in the HIPAA omnibus rule?

Regardless of what HHS is able to provide these organizations, the fact that they were asking plenty of questions about guidance in the first place is noteworthy. There still seems to be confusion among some organization around their exact responsibilities and hopefully this new guidance can shore some of those questions up.

HIPAA/HITECH Omnibus Final Rule Makes Sweeping Changes

HIPAA/HITECH Omnibus Final Rule Makes Sweeping Changes

The 563-page final omnibus Health Insurance Portability and Accountability Act (HIPAA) rule, published in January, makes a long list of significant changes to existing regulations. These include, among others:

• Modification to the standard for reporting breaches of unsecured personal health information (PHI).
• Extension of HHS enforcement authority over business associates.
• Expansion of the definition of the term business associate to include Health Information Organizations, E-prescribing Gateways, entities that provide data transmission services for PHI and which require routine access to such PHI, and personal health record vendors.
• Modifications to the requirements for business associate agreements.
• New obligations for business associates to enter into business associate agreements with their own subcontractors.
• Removal of limitations on the liability of covered entities for the acts and omissions of business associates.
• Changes to the requirements for notices of privacy practices.
• New limitations on the sale of PHI.
• New limitations on and clarifications concerning the use and disclosure of PHI for marketing.
• Relaxation of certain limitations on the use of PHI for fundraising.
• Improvement to the regulations concerning authorizations for the use or disclosure of PHI for research.

The deadline for complying with the amended HIPAA regulations is September 23, 2013, except for provisions related to the requirements for business associate agreements and to arrangements relating to the sale of PHI. Those specific provisions allow existing agreements in effect prior to January 25, 2013, to continue through September 22, 2014, unless modified or amended within one year before that date.  

To review the final rule indepth, published at 78 Fed. Reg. 5566 (Omnibus Rule), visitFederalRegister.gov.

http://www.dpath.com/news/docs/2013_V12_I03(1).htm

Top 10 Medicare Risk Adjustment Coding Errors

Top 10 Medicare Risk Adjustment Coding Errors

March 20th, 2013

By Carol Olson, CPC, CPC-H, CPC-I, CEMC, CCS, CCS-P, CCDS

Medicare Advantage (MA) reimbursement can trip you up in ways you didn’t expect. If you are seeing MA patients, be mindful of opportunities and pitfalls.
MA health plans are reimbursed based on beneficiaries’ chronic conditions. Submitting an inaccurate diagnosis, or a diagnosis resulting in a different hierarchical condition category (HCC), is a compliance risk. Any change in the HCC could mean you are receiving too much or too little revenue. Either way, the code would not be validated and would be considered discrepant.
There are opportunities for you to capture a more appropriate HCC code. Consider this list of the top 10 coding errors for risk adjustment:

1. The record does not contain a legible signature with credential.
2. The electronic health record (EHR) was unauthenticated (not electronically signed).
3. The highest degree of specificity was not assigned the most precise ICD-9-CM code to fully explain the narrative description of the symptom or diagnosis in the medical chart.
4. A discrepancy was found between the diagnosis codes being billed versus the actual written description in the medical record. If the record indicates depression, NOS (311 Depressive disorder, not elsewhere classified), but the diagnosis code written on the encounter document is major depression (296.20 Major depressive affective disorder, single episode, unspecified), these codes do not match; they map to a different HCC category. The diagnosis code and the description should mirror each other.
5. Documentation does not indicate the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).
6. Status of cancer is unclear. Treatment is not documented.
7. Chronic conditions, such as hepatitis or renal insufficiency, are not documented as chronic.
8. Lack of specificity (e.g., an unspecified arrhythmia is coded rather than the specific type of arrhythmia).
9. Chronic conditions or status codes aren’t documented in the medical record at least once per year.
10. A link or cause relationship is missing for a diabetic complication, or there is a failure to report a mandatory manifestation code.

Regardless of where you find shortcomings in your facility, you should consider ways to improve clinical documentation. Develop a compliance plan and implement prospective and retrospective, internal and external chart reviews with ongoing monitoring and feedback. Be sure to review records based on official coding guidelines.

CMS Proposes 0.8% Boost in Medicare Inpatient Rates for 2014

Written by Bob Herman | April 26, 2013

CMS has issued its proposed rule for hospitals paid under the inpatient prospective payment system and the long-term care hospital perspective payment system. CMS has recommended acute-care hospitals receive a 0.8 percent increase in Medicare operating rates. 

The low proposed Medicare rate increases are due to several factors. First, when Congress passed the American Taxpayer Relief Act of 2012, better known as the fiscal cliff deal, legislators included $11 billion in MS-DRG documentation and coding adjustments. This meant hospitals and other providers would lose $11 billion in Medicare payments between fiscal year 2014 and FY 2017 due to past overpayments the government made to hospitals as the country transitioned to MS-DRGs.

In the proposed rule, CMS accounted for a 0.8 percent reduction in Medicare payments to follow the ATRA, though the agency is asking for public comments on how the documentation and coding adjustments should be enforced.

CMS also gave more details for the second year of the Value-Based Purchasing program. In FY 2014, hospitals will have 1.25 percent of their Medicare payments withheld, and the resulting $1.1 billion in incentive payments will be doled out to hospitals that deliver the best quality of care.

In addition, starting in October under the Hospital Readmissions Reduction program, hospitals could lose up to 2 percent of Medicare payments for excessive readmissions — up from 1 percent in FY 2013.

Study: Practice Support Facilitates PCMH Transition

Written by Heather Punke | April 25, 2013

When small or solo physician practices are given practice redesign and embedded care management support, they are more likely to improve care quality and efficiency when transitioning to a patient-centered medical home, according to study results published in the Journal of General Internal Medicine. 

Researchers performed a randomized controlled trial in which intervention practices received 18 months of practice redesign support, two years of revised payment and 18 months of embedded care management support. The control practices received participation payments.

The intervention physicians improved on two quality indicators — hypertensive blood pressure control and breast cancer screenings — and one efficiency indicator — reduced emergency department visits. In the control practices, quality and efficiency of care was either unchanged or worse, according to the study.

15 Recent Issues Between Hospitals and Payors

Written by Jim McLaughlin | April 26, 2013

Here are 15 recent issues that occurred between hospitals, health systems and payors within the past month, starting with the most recent. 

1. Aetna, Baptist Memorial Health Care Make Collaborative Care Agreement 
Baptist Memorial Health Care in Memphis, Tenn., and Aetna partnered in a collaborative care agreement to offer Aetna Whole Health, a commercial healthcare product.

2. Aetna, Carolinas HealthCare Announce Accountable Care Collaboration
Aetna and Charlotte, N.C.-based Carolinas HealthCare System are using a clinically integrated organization model to support patient-centered medical homes and other accountable care efforts.

3. Minnesota Hospitals Denounce Blue Cross Payment Changes  
The Minnesota Hospital Association called out Blue Cross and Blue Shield of Minnesota, saying the health insurer is slashing payments to rural hospitals that will "put them into deep, deep red ink."

4. Bill Requiring North Carolina Hospitals to Post Prices Passes Senate Committee 
A bipartisan North Carolina Senate committee threw its support behind a bill that would require hospitals to make their bills more transparent and comprehensible to patients.

5. CMS Rejects Pioneer ACOs' Plea for Pay-for-Performance Delay 
CMS did not accept a request from its Pioneer accountable care organizations to delay tying pay to outcomes.

6. BCBS of Tennessee, Erlanger Form Strategic Partnership 
BlueCross BlueShield of Tennessee and Erlanger Health System in Chattanooga, Tenn., signed a five-year strategic network partnership agreement, effective July 1.

7. Cornerstone Health Care, BCBS of North Carolina Form ACO 
Cornerstone Health Care, a Highpoint, N.C.-based physician group with more than 365 physicians, partnered with Blue Cross and Blue Shield of North Carolina to form an accountable care organization.

8. Pennsylvania Lawmakers: Highmark-West Penn Deal May Hurt Small Hospitals 
Four Pennsylvania state senators sent a letter to Gov. Tom Corbett, arguing the pending merger between Pittsburgh-based health insurer Highmark and West Penn Allegheny Health System could hurt small local hospitals if safeguards are not put in place.

9. Report: U.S. Healthcare System Can Save $560B in Public, Private Reforms 
If the United States tinkered with Medicare more, reformed tax policies, prioritized healthcare quality and incented states to improve care, the healthcare system could save roughly $560 billion over the next decade, according to a report from the Bipartisan Policy Center Health Care Cost Containment Initiative. 

10. UC Health, Anthem Reach New Contract 
UC Health and Anthem Blue Cross and Blue Shield of Ohio reached a new contract, meaning all UC Health hospitals and providers are now in-network again for Anthem patients.

11. Study: Bundled Payment Structures Show Promise 
When structured well, bundled payment models can be effective and profitable for hospitals that can reduce the cost of each episode of care, according to a study conducted by Singletrak Analytics and DataGen.

12. Cooper University Health Care Acquires 20% Interest in New Jersey Health Insurer 
Camden, N.J.-based Cooper University Health Care announced it will acquire a 20 percent interest in health insurer AmeriHealth New Jersey, marking the state's first hospital-payor acquisition of its kind. During a conference call announcing the deal, leaders also announced there was room at the table for more providers to join in the partnership.

13. $24M Ruling Against UnitedHealth May Enhance Payors' Scrutiny of In-Network Providers 
A Nevada jury ruled that two affiliates of UnitedHealth Group must pay $24 million in damages for negligent oversight of a physician who gave two patients hepatitis C through unsterile care.

14. Superior Health Partners, BCBS of Michigan Partner for Accountable Care 
Superior Health Partners, an alliance of eight independent health systems in Michigan's Upper Peninsula, announced an accountable care organization-like partnership with Blue Cross Blue Shield of Michigan.

15. Mountain States Health Alliance Nears Expiration of BlueCross BlueShield Contract 
The contract between BlueCross BlueShield of Tennessee and the 13 hospitals of Johnson City, Tenn.-based Mountain States Health Alliance is due to expire at the end of May, with no renewal agreement yet finalized.

Survey: Hospitals are not ready for ICD-10

More than 50% of hospitals have not started training for coding staff

Topics: Information Technology, Clinical Documentation

April 26, 2013

Almost half of small- and mid-sized hospitals are lagging behind official CMS timelines for the transition to ICD-10 code sets, according to a survey.
Is your hospital ready for ICD-10? Evaluate your preparedness across six areas using our Readiness Diagnostic. U.S. health care organizations are working to transition from ICD-9 to ICD-10 code sets to accommodate codes for new diseases and procedures. The switch from ICD-9 to ICD-10 code sets is slated for Oct. 1, 2014 and will require health care providers and insurers to change out about 14,000 codes for about 69,000 codes.
For the survey, Health Revenue Assurance Holdings polled more than 120 hospitals with fewer than 400 beds. The survey aimed to determine whether the facilities were following official CMS timelines for ICD-10 preparation.
About 20% of the surveyed hospitals said they have not begun education or training for the ICD-10 transition, according to the survey. HRAA also found that 55% of surveyed hospitals have not started training their coding staff on the ICD-10 procedure coding system, known as ICD-10-PCS.

How the Advisory Board can help your organization build an ICD-10 transition plan

Moreover, despite CMS recommendations that hospitals begin ICD-10 testing in 2013, 25% of surveyed hospitals said they plan to start testing in January 2014, and 24% said they plan to begin testing in April 2014 (Walsh, Clinical Innovation & Technology, 4/24; McCann, Healthcare IT News, 4/24).

HIPAA Compliance: What Providers Should Know About HITECH Act Mandatory Audits

HIPAA Compliance: What Providers Should Know About HITECH Act Mandatory Audits

Written by Holly Carnell, JD, and Meggan Bushee, JD, McGuireWoods  | April 17, 2013

 

1. HHS mandated audits
Investigations by the Office for Civil Rights related to compliance with the Health Insurance Portability and Accountability Act will no longer be initiated by only complaints and self-reported breaches. Section 13411 of the HITECH Act requires HHS to provide for periodic audits of covered entities' and business associates' compliance with the HIPAA Privacy Rule, Security Rule and Breach Notification standards. While the audits are not intended to be investigations, an audit could reveal a serious compliance issue that could lead to a separate enforcement investigation by OCR. These mandatory audits are further evidence of the increased enforcement efforts of HHS. 

2. What we learned from the pilot audit program
KPMG, on behalf of HHS, conducted a yearlong pilot audit program from November 2011 through December 2012 that included 115 audits of covered entities. The audits focused on key compliance requirements under HIPAA, including (a) various requirements of the Privacy Rule, such as notice of privacy practices and uses and disclosures of protected health information, (b) Security Rule requirements for administrative, physical and technical safeguards, and (c) requirements for the Breach Notification Rule.

The large majority of entities that were audited were providers, rather than health plans or clearinghouses (all of which are covered entities under HIPAA). The preliminary results from the pilot audit program revealed that 65 percent of the compliance issues were related to the Security Rule, while only 26 percent and 9 percent of the compliance issues were related to the Privacy Rule and Breach Notification Rule, respectively. Generally, smaller covered entities, such as physician practices and smaller providers, had more compliance issues than larger covered entities. In the future, both covered entities and business associates will be subject to audits. 

OCR is currently evaluating the pilot program to assess whether changes should be made before routine audits commence. The evaluation will focus on the pilot audit program's effectiveness, analyze the program's strengths and weaknesses and give recommendations for future audits. The evaluation process is scheduled to conclude in September 2013. We anticipate that routine audits will commence after this time. 

3. Audit process
An OCR audit begins the audit process by sending document request to the audit target, which includes an introduction to the audit contractor and a request for required HIPAA documents, including copies of privacy policies and procedures, workforce training documentation, incident response plans, risk analyses and risk mitigation plans. This documentation will generally be due to OCR within 10 business days of the request for information. Following review of the documentation, the auditor will conduct a site visit.
During the site visit, OCR will interview key personnel. Covered entities and business associates should ensure that all members of management and higher-level staff members are familiar with the entity's privacy and security policies, procedures and compliance efforts — the entity's privacy officer will not be the only workforce member interviewed by OCR.

After the site visit is completed, the auditor will provide the covered entity with a draft final report. The entity will then have 10 business days to review and provide written comments back to the auditor. The auditor will complete a final audit report within 30 business days after the entity’s response and submit it to OCR. The reports will be used by OCR to determine what types of technical assistance should be developed and whether a compliance review is necessary to address any serious issues detected during the audit.

4. How to prepare for an audit
The audit protocol can be found on the OCR website and is a great resource for entities looking to perform self-evaluations of their HIPAA compliance. As part of these self-evaluations, the audit protocol can be used by covered entities and business associates to conduct a self-audit. This process will help identify compliance gaps and prepare for an OCR audit. 

Covered entities and business associates should ensure, at a minimum, that the following HIPAA compliance measures are being taken:

a. In the case of a covered entity, provide the entity's form of Notice of Privacy Practices to every patient and update such NPP to reflect the changes under the Omnibus Final Rule (required by September 23, 2013).
b. Have written and signed business associate agreements with all entities considered a business associate.
c. Conduct an accurate and thorough assessment of the risk to electronic protected health information.
d. Implement required physical, technical and administrative safeguards to protect ePHI.
e. Have formal policies and procedures for the privacy and security of protected health information and ensure these are updated to reflect the changes under the Omnibus Final Rule (required by September 23, 2013).
f. Train all employees on privacy and security policies and procedures. Those employees who job duties are affected by the changes resulting from the Omnibus Final Rule will need to receive additional training on such changes.
g. Maintain all documentation required under HIPAA, including documentation of all employee training, disclosure logs, documentation of all breach analyses and documentation of sanctions taken against employees for violations of privacy and security policies.

Covered entities and business associates should start to prepare now rather than after receiving notice from OCR of its intent to audit. Preparing for a potential audit may also help protect covered entities and business associates from complaints to OCR related to HIPAA violations.

M&A trends suggest shift from 'blockbuster' to 'strategic' deals | The Advisory Board Daily Briefing

M&A trends suggest shift from 'blockbuster' to 'strategic' deals | The Advisory Board Daily Briefing