The Financial Risks of Transitioning to ICD-10: Key Considerations for Hospitals and Health Systems

The following content is sponsored by VitalWare.

Concerning ICD-10 preparation, the time has come for hospital finance executives to put pen to paper, says Kerry Martin, CEO and founder of healthcare intelligence provider VitalWare. Waiting too long could result in getting caught in "rush hour" as providers leave crucial tasks until the last-minute scramble to catch up before the deadline next year.

"Being an early adopter in the ICD-10 world is the smartest thing they can do," Mr. Martin says of hospitals and health systems.

A key part of preparing for the transition is assessing the potential financial impact and taking steps to prevent a decline in physician and coder productivity, which could lead to revenue loss. The fiscal risk depends on various factors including physician documentation, coder education and DRG Grouper version updates, which will change in the months before ICD-10 goes live Oct. 1, according to Mr. Martin.

The process is definitely "more like a marathon than a sprint," he says. He shared some advice to help healthcare providers make it across the finish line by the implementation deadline.

Look beyond predictive analysis and top DRGsMany companies in the healthcare marketplace promote predictive analysis, which involves "cross-walking" ICD-9 claims to ICD-10, using general equivalence mappings or some other translation tool, to determine whether diagnosis-related group shift will occur or not. But Mr. Martin says this technique isn't the best way to determine financial risk comprehensively.

"To me, the only way they can assess their risk is by pulling charts, coding those charts and grouping those charts natively," he says. "Until a coder looks at a chart and codes it [in ICD-10], they have no idea what their financial risk is. It's not fun and it's not easy, but it's the only way for them to get their arms around that."

VitalWare has natively ten-coded 7,500 inpatient charts from hospitals around the country and can run a hospital's claims against this data to get a good understanding of what lies ahead for the provider's finances, he says. Based on those coded cases, they've discovered the real risk lies outside of the top 20 or 100 high-volume DRGs, according to Mr. Martin. Therefore, it's crucial for hospitals and health systems to look beyond those DRGs when preparing for the transition to ICD-10.

"That's exactly where CMS has said they're going to be financially neutral," he says of the top DRGs. "They've made sure the grouper is solid in those top DRGs."

Focus on physicians: The risk is in the charts Lost coder productivity has emerged as a point of concern for providers as the ICD-10 changeover date looms closer. Based on other countries that have already switched to their own uses of the coding system, some health information management leaders have projected a 20 to 40 percent decrease in coder productivity, which could lead to delayed cash flow and lost revenue.

Mr. Martin says providers must address the coder's productivity in unison with physician productivity.  Why should healthcare executives look to the physician to prevent a drop in productivity?  Because, he says, "it all starts with documentation."  That's what coders code from and, if the right details are not in the chart, then the physician will need to be "queried" for additional information.

"The best thing we can do is educate the physician," he says. "If we focus on physician productivity, the coder productivity loss will be nominal."  

It's only when coders are searching charts for information that doesn't exist that their productivity really suffers, he says.

For hospitals and health systems looking to keep physicians productive, it all comes down to training them to document the right things so coders don't have to use not-otherwise-specified codes or query back to the physician for clarification, he says.

"If [the physician is] interrupted the next day for more information from the previous day that he didn't document, the physician's productivity is going to go down," he says. "We should be focused on how we can keep the physician's productivity such as it is today and not decreased due to additional queries and interruptions by clinical documentation specialists."

He advises providers to pull charts, look at what's in their current documentation and note any deficits. For instance, physicians might not include documentation that may lead to major complications or comorbidity designation in the DRG groupers, resulting in the patient looking less sick on paper and the hospital getting reimbursed less than it should.

"The physician needs to be trained on their specific cases," he says. "You pull a case and you say, 'Hey Dr. Green, let me show you some of the information necessary for ICD-10 coding. If it is missing I will have to come interrupt you to get it.'  This is why training needs to be laser-focused."

Training physicians on their specific case documentation is only part of the equation, however. Mr. Martin says providers should also implement technology that will prompt clinicians on what to record on their charts, "a tool that specifically says to a physician, 'Here's what you need to document when you're dealing with heart failure,'" for instance.

Hospital executives should consider tools and applications that will accomplish this and can be embedded in electronic medical records or installed on devices such as iPads, he says.

Coder approach: Train and auditAlthough they aren't the main focus, long-term coder productivity issues are still a concern when it comes to financial risk, Mr. Martin says.

"The risk could be in the coder’s inability to forget the ICD-9 guidelines and use the ICD-10 guidelines.  It is hard to forget 10, 20, or 30 years of coding expertise overnight.  However this is exactly what we are asking the coders to do he says.

The number one action providers can take to address this issue is to pull charts, have their staff code them natively and have an outside company audit those charts. Ideally, the outside company should have certified ICD-10 trainers on staff who have coded at least 500 charts in the new coding system, he says.

"That exercise allows you to see how long it's going to take coders to actually code charts," he says. "You're definitely alleviating risk."

Pay attention to payers: Get the analytics from the coded cases to managed care teamsOnce providers have cases their coders have completed in accordance with ICD-10, they should prioritize getting that information to their managed care teams, according to Mr. Martin. He says assessing cases for all payers — not just Medicare — is important for negotiating contracts.

"If you don't give that managed care person any of this analytic data, then they're basically negotiating with a blindfold on," he says.

A managed care team with all of the proper ICD-10 financial analytic data about various DRGs and the provider's financial risk, will know what and how to deal with health insurers and possibly be able to work out neutrality clauses, he says.

The grouper factor: Wait and see and testThe current grouper logic that assigns MS-DRGs presents a certain level of risk for hospitals and health systems preparing for ICD-10. Right now, most organizations are using version 30 of the MS-DRG Grouper to group claims in ICD-10, but Mr. Martin says version 31 should be out within the next month or two, Version 32 will probably be in use when ICD-10 goes live.

"We're still dealing with a 'pilot grouper' that isn’t going to be the production grouper for ICD-10," he says.

Depending on adjustments to future versions and potential added calculations and weightings, providers who think they've adequately minimized their risk at this point could be in for an unpleasant surprise next year if they don't consider grouper changes. Subsequently, he says providers shouldn't do just one risk assessment but several, conducting new analyses as the new versions come out.

Providers who aren't dual-coding inside their patient accounting systems and are using another application such as Excel should strongly consider implementing a database system that can regroup quickly, he says.

"If you put it into Excel, it's not going to be easy to put it back through the grouper," he says.

In the end, though, there's only so much providers can do to avoid snafus. "The grouper is the grouper," Mr. Martin says. "We can't do anything about it except wait and see what the next version does."

ConclusionOverall, Mr. Martin says the biggest financial risk for providers is doing nothing.

At this point, providers should have started the process of pulling charts and should carry out a focused dual-coding effort, he says. By January or February, they should have a blueprint for physician training by individual physician or by specialty.

"There's a huge risk in just sitting back and waiting and not doing any of these exercises," he says.

http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/the-financial-risks-of-transitioning-to-icd-10-key-considerations-for-hospitals-and-health-systems.html

Highmark eyes deal with Blue Cross company in northeast Pa.

Health giant Highmark Inc. is eyeing opportunities to grow outside of Western Pennsylvania as it prepares for the possibility of losing customers in the region when its contract with rival UPMC expires.

Highmark said on Tuesday that it is talking with Blue Cross of Northeastern Pennsylvania about creating a “stronger affiliation” between two of the state's four nonprofit Blue Cross companies.

Highmark, the state's largest health insurer with about 5 million members, purchased Blue Cross companies in Delaware and West Virginia in recent years, adding about 600,000 members.

If talks between Highmark and the much smaller Blue Cross of Northeastern Pennsylvania lead to a takeover, Highmark would gain about 545,000 members in 13 counties.

With about 60 percent of the health insurance market in Western Pennsylvania, Highmark is the dominant carrier. That could change if UPMC's insurance division and several national companies persuade employers to leave Highmark for health plans that will keep in-network access to UPMC's hospitals and doctors after 2014.

UPMC refused to negotiate a reimbursement contract with Highmark because the insurer bought West Penn Allegheny Health System and converted itself into UPMC's chief competitor for medical services and health insurance. Without a contract, Highmark members will pay more expensive out-of-network rates at UPMC starting Jan. 1, 2015.

Highmark “could be faced with losing market share” if the UPMC contract expires, said Tom Tomczyk, a principal in the practice of Buck Consultants, a Downtown benefits consulting firm. That means growth could come only from outside the region, he said.

“Highmark branched out into other states to expand their business,” he said. “Highmark's ongoing business plan is to continue to grow.”

Highmark tried to merge with another of the state's Blue Cross companies. But in 2009, Highmark and Independence Blue Cross in Philadelphia dropped their proposed merger, citing conditions that state regulators wanted to place on the deal to maintain a competitive insurance market.

The state Insurance Department declined to comment on the talks between Highmark and Blue Cross of Northeastern Pennsylvania. Spokeswoman Melissa Fox said neither company filed documents with the regulator regarding an acquisition or merger.

Mark Pauly, a professor of health care management at the University of Pennsylvania's Wharton School, said it is unlikely that state regulators would object to Highmark's absorbing the Wilkes-Barre-based Blue Cross company because the markets don't overlap.

It's more likely the smaller Blue Cross wants the protection of a larger company as implementation of the Affordable Care Act creates uncertainty for insurers, he said: “They believe there's safety in numbers and safety in size.”

Some insurers worry they'll lose business from individuals with chronic illnesses who previously could buy coverage only from Blue Cross companies. Under the law, dubbed Obamacare, those individuals can buy insurance through a government website where a number of insurers offer plans. Other customers, who may buy insurance for the first time because their illnesses made them costly to cover, might flock to these same insurers and increase the companies' risk.

Health insurers “are going to need money to deal with negative selection and losses,” said James McTiernan, a health care consultant with Triad Gallagher, a Downtown benefits consulting company.

Pennsylvania is unusual among states for having four nonprofit Blue Cross companies. Only five other states have more than one; there are 37 Blue Cross companies across the country. Several companies, most notably Anthem Blue Cross, are building multi-state companies through consolidation.

“There are not going to be a lot of niche players left,” McTiernan said.

Highmark and Blue Cross of Northeastern Pennsylvania have existing partnerships, officials said. Blue Cross of Northeastern Pennsylvania uses Highmark's information technology systems for claims processing, spokesman Aaron Billger said. The companies jointly own First Priority Health, an insurance subsidiary that sells group health plans to companies in northeastern Pennsylvania. They partner on Medicare Advantage plans sold to seniors there.

Highmark views that region “as very important to the community,” William Winkenwerder, Highmark CEO, said in a statement. His counterpart, CEO Denise S. Cesare, said the discussions are meant to “best serve the long-term needs of the residents” in 13 northeastern counties.

Blue Cross of Northeastern Pennsylvania's revenue averaged $750 million per year in 2011 and 2012, the company told the Tribune-Review this year. Highmark's annual revenue in 2012 was $15.2 billion.

Alex Nixon is a Trib Total Media staff writer. Read More:  http://triblive.com/mobile/5055230-96/blue-cross-highmark

Keogh review puts GPs at heart of urgent care reform

GPs should work with other NHS services to deliver fast, consistent advice and urgent care outside hospitals around the clock, an NHS England review has said.

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Sir Bruce Keogh: urgent care reform plan

The bureaucratic burden on GP practices must be cut to boost access to primary care and reduce pressure on A&E, the review by NHS England medical director Sir Bruce Keogh argues.

RCGP chairwoman Professor Clare Gerada welcomed the report for highlighting GPs' vital role in urgent care without blaming the profession for existing problems.

Transforming urgent and emergency care services in England calls for a dramatic rise in the proportion of urgent care delivered closer to home.

But it warns that ‘many people are struggling to navigate and access a confusing and inconsistent array of urgent care services provided outside of hospital, so they default to A&E’.

Sir Bruce says A&E is a ‘trusted brand’, with an average wait of just 50 minutes for treatment and most patients treated within four hours.

But in a letter to health secretary Jeremy Hunt and NHS England chairman Sir Malcolm Grant, he warns: ‘The opportunities for bringing about a shift from hospital to home are enormous.

‘We know that 40% of patients attending A&E are discharged requiring no treatment at all; there were over 1m avoidable hospital admissions last year; and up to 50% of 999 calls requiring an ambulance to be dispatched could be managed at the scene.’

Sir Bruce argues that ‘starting from scratch, nobody would design the current array of alternatives and their configuration’, warning that the complicated NHS system itself is driving up demand by ‘sending people around various services, confused about who to call and where to go’.

The review calls for a series of changes to improve urgent and emergency care including:

• A ‘significantly enhanced’ NHS 111 with access to patient records, offering advice from a range of clinicians, appointment booking or call back by GPs and others, or a transfer to 999 services if necessary.
• Faster and consistent same day, every day access to primary care and community services for people with urgent care needs.
• Improved 999 services to handle more cases ‘at scene’, with support from GP advice.
• Two levels of hospital-based emergency centre, with standard centres and a tier of ‘major emergency centres’ with consistent levels of senior clinical staffing and more specialist capability.
• The ‘array’ of confusing terms for services should be reduced by co-locating community-based urgent care services in facilities uniformly referred to as ‘urgent care centres’.

Professor Gerada said: 'We are pleased that this report recognises the vital role of general practice and other community primary care services in providing care to patients with urgent needs. It is encouraging to see a report that sets out landmark changes in the way NHS emergency and urgent care will look in the future but that doesn't blame GPs.

'It explicitly recognises the sustained pressure and multiple demands on general practice in recent years, and the need to "create headroom" to transform the way we work so that we can continue to provide safe care for our patients. For the recommendations in this report to become a reality, that "headroom" has to include greater government funding and resources, including more GPs.'

GPC deputy chairman Dr Richard Vautrey said: ‘We would agree that the current system is too complicated and fragmented.'

Proposals to overhaul NHS 111 show the GPC is 'being listened to’, he added. ‘There is a need for more clinicians involved in dealing with calls so that patients are not only directed to the right service, but are given appropriate advice and if possible treatment through that one contact,’ he said. ‘The NHS 111 call service needs to be integrated with the see and treat elements of the urgent care service.’

Dr Vautrey said GPs already provide 24/7 services through daytime work and out-of-hours care. But he warned: ‘Both services are running hot in terms of coping with high demand and workload pressures.

‘We need a commitment from NHS England to reverse the fall in the proportion of funding spent on general practice so that both practices and out-of-hours organisations can start to take on additional staff to meet these growing demands. Expecting the current number of GPs to work harder and longer will simply lead to more GP burnout.’

http://www.gponline.com/News/article/1220721/Keogh-review-puts-GPs-heart-urgent-care-reform/

Private company offers Alaskans health insurance option

ANCHORAGE - The troubled HealthCare.gov website has kept many people from signing up for health insurance. 

Now, a private company is working to get people covered outside the federal marketplace.

Enroll Alaska is taking steps to sign Alaskans up for health insurance.  Problems with HealthCare.gov forced them to suspend operations last month, but they're back and have ditched the federal website. 

Instead, Enroll Alaska is helping people who don't qualify for federal subsidies sign up for plans not offered in the marketplace. 

"And what's important is that if an individual comes [to] us and they don't think they qualify for a subsidy, and we'll help make that determination for them, and if they do qualify for a subsidy, we'll wait and enroll them when HealthCare.gov is functioning, when the marketplace is working," said Enroll Alaska COO Tyann Boling.

Enroll Alaska estimates that about 25,000 uninsured Alaskans won't qualify for help paying insurance. That means they can enroll in an insurance plan without losing out on government subsidies.

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Report Highlights Role of Health IT in Managing Patient Population Health

November 06, 2013 01:36 pm Sheri Porter – Family physicians in the throes of creating patient-centered medical home (PCMH) practices, learning about medical neighborhoods, and gaining full functionality of their electronic health records (EHRs) may appreciate a new report that illustrates how those three activities work together to benefit patients.

The report, "Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood,(www.pcpcc.org)" was released by the Patient-Centered Primary Care Collaborative (PCPCC) at its annual meeting in October.

Report co-author Michelle Shaljian, M.P.A., the PCPCC's director of public affairs, sums up the report's value to busy family physicians this way: "We're seeing the evolution of the patient-centered medical home from a practice-level philosophy to a community-level philosophy, so we really wanted to give physicians, clinicians and community stakeholders a perspective on how this could be done at a much broader level."


Key Points

Report authors note that a population health approach -- where stakeholders calculate the health outcomes of a group of individuals -- requires collaboration among patients, physicians, insurance companies, the government, the private sector and local communities.

"While our current system is designed to respond to the acute needs of individual patients, it must transition to one that anticipates and shapes patterns of care for populations and addresses the environmental and social determinants of health," says the report.

According to the report, the PCMH sits at the center of the model and is surrounded by the larger and more inclusive medical neighborhood. It is the neighborhood that connects physician practices to hospitals, home health agencies, mental health agencies, and community organizations that encourage healthy lifestyles and safe environments. But health information technology (IT) is the foundation of it all.

"We believe a critical tool in this effort will be the widespread adoption of health information technology," says the report. Health IT offers a structure to help primary care practices within and throughout the medical neighborhood provide better access to care, communicate more effectively and work together as teams.

"Implemented effectively, it also has tremendous potential to identify health trends in local communities, exchange information across organizations, coordinate care as patients transition between providers, and enables secure communications between providers and their patients and families."
The report recommends 10 specific health IT tools and strategies that can help achieve population health management in the medical neighborhood. The essentials and their functions are

• electronic health records to perform documentation tasks, populate patient registries and create structured data;
• patient registries to act as the central database for patient monitoring and care management;
• health information exchange to enable coordination of care;
• risk stratification to classify patients by their health status and health risk;
• automated outreach to generate messaging to patients who need preventive or chronic disease care;
• referral tracking to ensure receipt of test results from outside consultations;
• patient portals to engage patients in health care self-management;
• telemedicine to engage patients between face-to-face visits and to help reduce those in-person encounters;
• remote patient monitoring to allow for quick physician intervention and enable patient control of chronic conditions; and
• advanced population analytics that allow evaluation of patient population segments and assessment of organizational performance.

Working Models

The report includes three case studies in population management. "I want to emphasize the diversity and range that we have included in the case studies," says Shaljian. The case studies focus on a group of pediatric practices in Winston-Salem, N.C.; a community health center in New York City; and a multispecialty group practice in Richmond, Va.

"These are very different practices, and they all are dealing with very different populations and different needs of their communities," says Shaljian. "But they all seem to make it work with this ideology in place."

For example, the case study focusing on Bon Secours Virginia Medical Group in Richmond examines how the organization -- with 140 locations and 25,000 patients -- manages patient risk in an accountable care organization model.

Bon Secours implemented a care team model as part of an advanced medical home pilot project in June 2010. The practice took a number of steps, including

embedding care managers in the form of nurse navigators into the primary care team,
implementing health IT that empowered the care team to efficiently manage the health of patient populations,
building a registry to identify high-risk and high-use patients,
implementing an automatic outreach program to prevent 30-day hospital readmissions, and
engaging patients via personal health records and email communication with caregivers.
"For the first few years of the project, Bon Secours shouldered the expense," says the report. "The organization is now poised to reap the rewards of its investment."

In the first six months of its value-based contract with CIGNA, the group practice achieved a 27 percent reduction in readmissions and is $1.8 million below its projected spending. The group has hit many care-quality metrics and soon will qualify for "gain sharing (with CIGNA), a development that will bring a projected annual savings of $4 million," says the report.

Looking Ahead

According to the report's authors, the United States is long overdue for payment reform that encourages a population-based approach to better health.

"PHM (population health management) strategies will not be possible until new financial incentives in health care evolve and become prevalent," say the authors. The current fee-for-service payment system "discourages providers from caring for patients outside of face-to-face encounters or proactively seeking out patients with gaps in their preventive or chronic disease care."

Improvements in health IT, including "out-of-the-box" features to simplify tasks, also are in order, say the authors, as is enhanced workforce education and training to educate physicians and other clinical staff members on how to effectively use EHRs and PHM tools.

"It will also be critical to incorporate the PHM and meaningful use model into medical school curricula and accreditation exams," say the authors.

Lastly, patients should be encouraged to manage their own health or disease status. "Accounting for population health requires a lot of things, but most importantly, it's the relationship between the patients and their providers, the providers and their colleagues, and those practices and the rest of the community," says Shaljian.

"It's an all-in kind of approach to population health, and it's not just health IT; it's about what people are doing with that health IT to make all of these improvements and innovations."

Shaljian says family physicians have always been extremely aware of the needs of patients and their families, so incorporating a population health philosophy would build a bridge "between the patients they've been taking care of for so long and the rest of the community."

Physicians can begin to address questions about which of their patients are most at risk and how to proactively reach out to them, says Shaljian. And, practices can identify where costs are coming from, which, in turn, will allow them to manage the business end of the practice more effectively.

"This is about bringing all the pieces together," says Shaljian. "It's a very forward-looking approach to family medicine."

Read more:  http://www.aafp.org/news-now/practice-professional-issues/20131106popmodel.html

Top-rated Medicare plan choices up dramatically in 2014

By Diane C. Lade, Staff writer

1:46 p.m. EST, November 7, 2013

Better choices for Floridians on Medicare may be in the stars for next year.

There are three times more Medicare Advantage plans in Broward and Palm Beach counties that earned above-average rankings for 2014 in Medicare's five-star rating system than there were for the previous year.

When shopping for health care, South Florida seniors can pick from 54 managed-care style plans that earned four stars or more — about 37 percent of the total 144 offered in both counties. That's a huge difference from last year, when consumers had access to only 17 above-average plans, or about 10 percent of the 163 South Florida choices listed on Medicare's online Plan Finder for 2013.

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Edith Gooden-Thompson, Broward County coordinator for Florida's Serving Health Insurance Needs of Elders program (SHINE), said the growing number of top-rated offerings is good news for seniors who look to the stars when making their Medicare decisions.

Open enrollment in the Medicare Advantage and stand-alone prescription drug plans offered through private insurers approved by Medicare began Oct. 15 and will end Dec. 7. SHINE volunteer counselors, who work through a government-funded program and don't sell policies, help seniors review coverage and decide whether to stay with it or switch.

"We have some who tell us they only want the best, and flat-out ask for a five-star plan," Gooden-Thompson said.

There are no top-rated offerings in Broward and Palm Beach counties this year or next. But Cigna-HealthSpring earned five stars for 2014 for coveragethrough Leon Medical Centers, which serves Miami-Dade residents, as well as plans in Bay, Escambia and Santa Rosa counties. There were no five-star Florida choices in 2013.

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Federal officials say the upward trend is a sign that providers are ramping up customer service, chronic care management and safety standards — all among the more than 50 factors the Centers for Medicare and MedicaidServices measures when calculating a plan's rating.

Star rankings also are up nationally and statewide. Forty-five percent of Florida's Medicare Advantage plan contracts earned above-average rankings for 2014 as compared with 18 percent in 2013, according to Q1Group LLC, a St. Augustine research firm that analyzes Medicare coverage.

But experts say there's no research that proves the rankings are spurring more enrollment in top-rated coverage, as CMS has hoped. "The jury still is out in terms of how stars affects plan choice," said Gretchen Jacobson, associate director with the Kaiser Family Foundation's Program on Medicare Policy.

Shelly Siskin, a retired insurance broker and area coordinator for Palm Beach County's SHINE program, said he finds price and the doctors in a plan network loom much larger than star ratings when decision time comes.

"There has been a lot of shifting around this year, as people find a plan that was cheap last year is not so cheap this year," Siskin said. Still, he advises seniors to go with no fewer than three stars.

The Centers for Medicare and Medicaid Services originally created the five-star system in 2007 as a consumer-friendly tool for comparing plans. But in 2012, federal officials started using the rankings as a way to increase care quality by rewarding top performers and punishing underachievers.

The Centers is giving graduated bonus payments through 2014 to insurers whose plans rate three stars or more. And five-star providers earn additional rewards; seniors and disabled adults can switch to those plans at any time, rather than just sign up during open enrollment.

At the other end, poor performers are flagged with a warning sign on the Plan Finder, and seniors can't automatically re-enroll in them through the site. Members of plans earning fewer than three stars for three consecutive years also receive letters before open enrollment, suggesting they look for an alternative.

In 2013, there were 22 plans in Broward and Palm Beach counties labeled poor performers, the vast majority from St. Petersburg-based Universal Health Care. Universal declared bankruptcy early this year as federal agents investigated possible fraud, leaving plan participants searching for new coverage.

There are only two South Florida plans with a poor performance rating in 2014: one United Healthcare AARP HMO in Palm Beach County, and another in Broward.

"We remain committed to improving our star ratings," United Healthcare officials said in a written statement. "We are actively working to improve our results in these plans to help ensure our members receive quality service and support for their health care needs."

Humana, which has the most above-average rated plans in South Florida, has increased its focus on preventive care due to the star-rating incentives, said spokeswoman Nancy Hanewinckel.

"The goal is for people to use the ratings to become smarter health care consumers," Hanewinckel said.

dlade@tribune.com or 954-356-4295

http://www.sun-sentinel.com/health/fl-medicare-star-ratings-20131107,0,1260247.story

Fighting Medicaid Fraud, Waste, and Abuse Through Education - Medicare Blog

By Ted Doolittle, CMS Deputy Director, Center for Program Integrity

Nov. 7, 2013 - The Centers for Medicare & Medicaid Services (CMS) wants everyone to join in the fight against fraud, waste, and abuse as part of our comprehensive strategy to protect federal health care programs and taxpayer dollars.  We are now making it easier than ever before for health care providers, managed care plans, and individuals and families with Medicaid benefits to use the education and training materials on the new Medicaid Program Integrity website.

Resources available on the website include videos, fact sheets, and checklists, made specifically for providers and beneficiaries.  These tools are national in scope, but some information can be personalized by your State of residence (or where you live) upon request. 

One of the key resources is a brochure on how people with Medicaid can protect themselves and the Medicaid program from fraud. You can also email MedicaidProviderEducation@cms.hhs.gov for the state contact number for reporting fraud.

State program integrity professionals and counselors will also find valuable education and training materials on the site – all available at no cost.  We have developed toolkits to address hot issues and frequently asked questions about Medicaid program integrity, including beneficiary protections and compliance resources for dental professionals and managed care organizations. 

Take a moment to learn more about the CMS Medicaid Program Integrity education and training materials available by clicking on this link, that will take you to the CMS.gov website.

Click here to join our listserv to receive timely notices of new material as it becomes available. Listserv members are also notified when new training, education, or speaking events are scheduled.

We value your feedback, recommendations, questions, and requests and encourage you to e-mail the Education Medicaid Integrity Contractor at medicaidprovidereducation@cms.hhs.gov for further information.

Thank you for being a partner in Medicaid program integrity!

And for more information on CMS’s efforts to protect consumers in the Health Insurance Marketplace, please visit:http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-09-18.html

Mid-Hudson Medical Group to Pay $5 Million in Health Care Fraud Settlement

HUDSON VALLEY, N.Y. – The medical group that employed Spyros Panos, the Hopewell Junction surgeon who pleaded guilty last week to felony health care fraud, will pay the United States $5 million as part of a federal settlement agreement.

Preet Bharara, U.S. attorney for the Southern District of New York, said in a news release that the Mid-Hudson Medical Group (MHMG), which has offices throughout Dutchess and Putnam counties, received millions of dollars from two schemes to defraud Medicare, the New York State Insurance Fund, and other private health insurance providers. The settlement agreement was submitted to U.S. District Judge Vincent L. Briccetti Wednesday afternoon.

“The laws are clear and formidable when it comes to the bilking of health insurance providers: you cannot be permitted to keep and enjoy illicit proceeds of fraud,” Bharara said.

According to the complaint and other publicly filed documents, between at least 2006 and July 2011, Panos engaged in an unlawful scheme to defraud health insurance providers, where he and MHMG submitted fraudulent information regarding the nature and details of surgical procedures he performed. As a result, the insurance companies paid MHMG millions of dollars more than it was entitled to receive for the actual work that Panos performed.

On Oct. 31, Panos pleaded guilty to one count of engaging in a scheme to commit health care fraud.

Court documents also state that from approximately 2009 through June 2012, some employees at MHMG submitted requests to insurance companies that, in some cases, contained false information about patients. As a result the insurance companies paid MHMG more for MRI tests than the medical group was entitled to receive.

Under the terms of the settlement, MHMG is awarded credits for reimbursements it has already made to certain health insurance providers. The medical group is also required to transfer an additional $3.67 million to the United States in accordance with an agreed-upon schedule.

The settlement represents an estimate of the amount of proceeds MHMG obtained from health insurance providers as a result of the alleged fraud.

Panos faces up to 10 years in prison and owes millions of dollars after admitting to running a scheme that defrauded health insurance providers.

http://hudsonvalleyreporter.com/dutchess/2013/11/mid-hudson-medical-group-to-pay-5-million-in-health-care-fraud-settlement/

Outpatient coding and ICD-10-PCS

Initially, we thought that outpatient coders didn’t have to learn to code in ICD-10-PCS. They would still use CPT® codes to report physician services in the outpatient world.

Now it looks like that might not be the case everywhere. During the AHIMA Conference in Atlanta October 26-30 the topic of outpatient coders using ICD-10-PCS came up repeatedly.

Some facilities now require coders to report ICD-9-CM procedure codes for outpatient services so they can compare data for inpatient and outpatient services, outcomes, etc. Some commercial payers also require ICD-9-CM procedure codes for outpatient services.

The jury is still out on what payers will do once we transition to ICD-10. But facilities should start to think about training outpatient coders on ICD-10-PCS. Outpatient coders are used to looking for information in the operative report that inpatient coders don’t need to see now. That should help outpatient coders in ICD-10-PCS.

However, what physicians need to document for CPT code assignment is not always the same as what they need to document for ICD-10-PCS. You knew it couldn’t be easy, right?

Having everyone code in ICD-10-PCS could be a good thing. We would get standardized data on all procedures, regardless of the setting. We would also have more coders who can fill in when someone is on vacation, out sick, or leaves the organization.

On the downside, training all coders on ICD-10-PCS costs money and takes time. It will also probably decrease productivity, which could result in a slowdown in reimbursement.

Weigh the pros and cons at your organization and talk to your payers. Then decide whether to bring the outpatient coders into the ICD-10-PCS world.

- See more at: http://blogs.hcpro.com/icd-10/2013/11/outpatient-coding-and-icd-10-pcs/

Naples HMA to return $31 million in questionable incentive money

Health care giant promises more diligent oversight

Health Management Associates Inc. is repaying $31 million in technology incentives it improperly collected through federal and state programs and will tighten its financial controls as it restates financial results dating back to 2010, the Naples-based hospital company reported.

HMA disclosed that 11 of its hospitals collected the $31 million through the Medicare and Medicaid Health Information Technology program, but made an error in applying the requirements of the program. The program is intended to encourage health care providers to upgrade their electronic records systems.

HMA did not name the hospitals involved and did not return calls seeking additional information on Wednesday.

In a press release, HMA said it has notified the Centers for Medicare and Medicaid Services and has repaid “the majority of the funds” and is still working to pay back some state agencies that participate in the programs.

HMA operates 71 hospitals in 15 states, including Lehigh Regional Medical Center in Lehigh Acres; two Physicians Regional Healthcare System hospitals in the Naples area; Bayfront Health Port Charlotte; and Bayfront Health Punta Gorda.

The $31 million recorded as income from the program was consistently less than 2 percent of earnings before interest, taxes, depreciation and amortization in each impacted quarter, said analyst Sheryl Skolnick, analyst with CRT Capital Group.

“As these kinds of restatements go, it is fairly minor,” Skolnick said. “The degree of overstatement is not huge, but it is not acceptable. It’s the material failure of the controls that raises the level of seriousness.”

Skolnick said HMA will likely get some leniency for reporting the problem itself, but the Securities and Exchange Commission may investigate the company’s controls further.

HMA already faces whistle-blower suits alleging Medicaid and Medicare fraud, federal investigations from the Department of Justice and the Securities and Exchange Commission and class-action suits from shareholders saying the company isn't acting in their best interest.

In August, Glenview Capital Management — HMA's largest shareholder — replaced the company's board and put its own directors in place.

On July 30, Franklin, Tenn.-based Community Health Systems Inc. announced it intended to buy HMA for cash and stock valued at about $13.78 a share, or about $7.6 billion, including $3.7 billion in debt. That deal is expected to close in the first quarter, HMA said in its statement.

http://www.news-press.com/article/20131107/BUSINESS/311070041/Naples-HMA-to-return-31-million-in-questionable-incentive-money?nclick_check=1

Miami-Dade community health centers win government grants

More than a dozen Florida community health centers — including seven in Miami-Dade County — were awarded $8.3 million in grants Thursday to expand their practices and hire more physicians, nurses, dentists, psychologists and other providers in an effort to increase Americans’ access to healthcare under the Affordable Care Act, federal officials announced.

The grants from the U.S. Department of Health and Human Services are part of a national effort by the federal government, which awarded about $150 million to 236 health centers in 43 states, including 16 centers in Florida.

Seven centers in Miami-Dade will share more than $3.9 million, with the largest single amounts awarded to Borinquen Health Care Center in Miami and the Center for Family and Child Enrichment in Miami Gardens. Each received grants of $775,000.

Altogether, Florida’s grants will help deliver healthcare to approximately 73,000 Floridians who otherwise may not have had access to care. Florida has 48 health centers that served 1.1 million patients in 2012, with about 44 percent of them uninsured, according to HHS.

Mary Wakefield, a registered nurse and administrator for the Health Resources and Services Administration, an agency within HHS, said the grants were written into the healthcare reform law. She said the ACA set aside $11 billion to be awarded over five years, beginning in 2011, to support the expansion of community health centers. Total grants to be awarded for 2014, including the ones announced Thursday, will total $2.2 billion.

“All of us in the Obama administration are working hard to make sure that Americans who aren’t in the healthcare system finally get in,’’ Wakefield said.

Wakefield added that community health centers can use the grants to hire more providers or to rent new healthcare delivery sites, but not for the construction of new clinics. They can also use the funds to purchase medical equipment.

But the emphasis, Wakefield said, will be on providing more primary care services that will help individuals manage chronic diseases and prevent illnesses.

Nationwide about 1,200 community health centers operate more than 9,000 delivery sites that provide care to more than 21 million patients in every state, according to HHS.

Thursday’s grants are the latest round to be awarded to community health centers as part of the ACA. In July, HHS awarded 46 grants totaling $8 million to 46 Florida health centers to hire about 160 outreach workers who would help uninsured individuals obtain health coverage through the federally run online marketplace, or exchange.

“Today’s investment,’’ Wakefield said, “is about expanding service capacity.’’

http://www.miamiherald.com/2013/11/07/3736376/miami-dade-community-health-centers.html

Read more here: http://www.miamiherald.com/2013/11/07/3736376/miami-dade-community-health-centers.html#storylink=cpy