Hospital administrator and businessmen sentenced to prison for submitting fraudulent cost reports to Medicare

MONROE, La. (AP) — A former Madison Parish Hospital administrator and two of its vendors have been sentenced for health care fraud.

U.S. Attorney Stephanie A. Finley said Tuesday that U.S. District Judge Robert G. James sentenced Charles W. Alford, 71, of Newellton, to 37 months in prison and ordered him to pay $1.3 million in restitution.

James also sentenced Barney W.I. Hughes IV, 45, of Keller, Texas, to a year in prison and ordered him to pay $566,874 restitution and Henry R. Ham, 65, of West Monroe, to 14 months in prison and $817,000 in restitution.

According to evidence presented at Monday's guilty plea, Alford was hospital administrator for Madison Parish Hospital in Tallulah; Hughes served as owner of Tech Solutions of Keller, Texas; and Ham, was owner of Insurance World in Monroe.

Both Hughes and Ham paid Alford a combined total of more than $1.3 million in kickbacks for his approval and continuation of their business agreements.

Madison Parish Hospital leased equipment and personnel from Tech Solutions to operate the hospital's nuclear medicine and ultrasound departments.

At no time did Alford or Hughes disclose to the hospital's board or Medicare that they had an exclusive agreement. From October 2006 to June 2012, the hospital paid Hughes' company $2,029,504, and Hughes paid Alford $566,874 of that total. They submitted fraudulent cost reports to Medicare at least six times from December 2006 to 2011.

Madison Parish Hospital purchased a majority of its health insurance and life insurance products from Ham. Alford and Ham negotiated and set the insurance policy rates and Alford approved Ham's billings as well as the hospital's payments to Ham.

From 2007 through April 2012, the hospital paid Ham $4,979,487, and Ham paid Alford $817,000 of that total. They submitted fraudulent cost reports to Medicare at least five times from December 2007 to 2011.

http://www.khou.com/news/national/243660141.html

Husband, wife and business associate charged with health care fraud

William Owuama, 55, Marla Owuama, 46, and Florida Holiday Island, 64, all of Houston, have been charged in an eight-count indictment alleging conspiracy to commit health care fraud, health care fraud and conspiracy to violate the federal anti-kickback statute, announced United States Attorney Kenneth Magidson.

The sealed indictment, returned Jan. 22, was unsealed this afternoon as all three defendants made their initial appearance before U.S. Magistrate Judge Frances Stacy at 2 p.m. At the hearing, Judge Stacy permitted Marla Owuama and Island be released upon posting bond. Upon surrendering his passport, William Owuama is also expected to be released upon posting bond.

The indictment alleges William Owuama was the owner of Wilmar Healthcare Systems, his wife Marla was a registered nurse and Island transported patients to and from the clinic. According to allegations, they not only paid patients for visiting the clinic in violation of the anti-kickback statute, but billed Medicare and Medicaid for vestibular testing that was never performed. The indictment also alleges the clinic billed Medicare and Medicaid under the provider number of a local doctor while that doctor was incarcerated on unrelated charges. From January 2006 through October 2009, Medicare and Medicaid paid Wilmar more than $4 million based on the alleged fraudulent claims.

If convicted, all three defendants face up to five years in federal prison and a $250,000 fine for conspiring to commit healthcare fraud and violating the anti-kickback statute. The Owuamas also face up to 10 years in prison and a $250,000 fine for the substantive healthcare fraud charges.

The investigation leading to the charges in this case was conducted by the U.S. Department of Health and Human Services – Office of Inspector General and the Texas Attorney General’s Office Medicaid Fraud Control Unit. Special Assistant United States Attorney (SAUSA) Adrienne Frazior and AUSAs Andrew Leuchtmann and John Pearson are prosecuting the case.

http://www.yourhoustonnews.com/memorial/news/husband-wife-and-business-associate-charged-with-health-care-fraud/article_13e3906b-a9f5-5b62-973f-9b3c3b2b3f2a.html?mode=jqm

USDA awards millions for telemedicine

Posted on Feb 05, 2014

By Bernie Monegain, Editor

Ozarks Medical Center in Missouri and Flagstaff Medical Center in Arizona are just two hospitals in 25 states across the country that will receive federal funding for telemedicine projects. Agriculture Secretary Tom Vilsack announced nearly $16 million in USDA grants would be disbursed for distant learning and telemedicine services.
The USDA's Distance Learning and Telemedicine Loan and Grant program provides funding to rural hospitals, clinics, schools and libraries for equipment and technical assistance for telemedicine and distance learning. Grant recipients must demonstrate that they serve rural America, prove there is an economic need and provide at least 15 percent in matching funds.


Since 2009, USDA has invested almost $150 million in the Distance Learning and Telemedicine program. The investments complement other USDA efforts to improve rural communications. In FY 2013, USDA provided $305 million in loans for broadband infrastructure. These loans will result in new or upgraded broadband service for about 120,000 rural households, businesses and community institutions once the projects are completed.



Hospitals receiving telemedicine grants are:

Alaska
Chugachmiut: $180,656
Funds will be used to re-establish a telemedicine network between Native village sites in the Chugach region and offices in Seward and Anchorage. Clinics in the villages of Tatitlek, Chenega, Port Graham and Nanwalek will be linked with Anchorage and the North Star Clinic.

Alaska Native Tribal Health Consortium: $114,842
Funds will be used to purchase video teleconferencing equipment systems for virtual sessions between patients and health care providers. It is projected that nearly 3,200 people will benefit in the first year alone. The Alaska Native Tribal Health Consortium includes nine organizations that deliver innovative telehealth solutions throughout the  Alaska Federal Health Care system.

Arizona
Flagstaff Medical  Center: $129,412
Funds will be used to purchase digital electronics and software for a telemedicine system linking the Flagstaff medical center with clinics in Coconino, Apache, Mohave and Navajo Counties. This system will connect local caregivers and their patients with specialists at Flagstaff.

Kentucky
Norton Healthcare Foundation: $259,607
Funds will be used to expand the Norton Rural Medicine Initiative. The equipment will allow Norton physicians and other medical specialists in Louisville to consult medical staff and their patients at Breckinridge Health and Westlake Regional Hospitals in Kentucky; and Scott Memorial Hospital in Indiana. With the telemedicine network, patients no longer will have to travel for pulmonary, cardiology, neurology, infectious disease and critical care.

Maine
Community Health & Counseling Services: $103,235
Funds will be used to purchase in-home patient monitors, medication dispensers and screening monitors for Community Health and Counseling Services, which serves patients in Piscataquis and Washington counties with congestive heart failure, medication compliance issues, patients who need speech pathology to address swallowing disorders. The project is expected to reduce preventable hospital visits and emergency room visits, saving time and money.

Missouri
Ozarks Medical Center: $274,638
Funds will be used to buy equipment to expand medical services to Ozarks Medical Center's four hospitals and nine clinics. Services will include tele-stroke, tele-psychiatry, tele-speech therapy and tele-dermatology.

Harrison County Community Hospital District: $500,000
Funds will be used to purchase software and equipment for Harrison County’s teleradiology system. A Radiology Information System will be purchased to connect end-user workstations at clinics in Princeton, Cainsville and Bethany. The project will also fund a new telemedicine unit for the hospital's outpatient clinic. The hospital will be able to improve operations in several departments, including emergency, respiratory therapy
and cardiac rehabilitation.

Mercy Health: $382,748
Funds will be used to purchase equipment and devices for exam rooms in 11 sites in Missouri, Arkansas and Oklahoma. Physicians and other medical specialists at Mercy Hospital in St. Louis will use the audio/video equipment for face-to-face consultations, observation and diagnosis, and treatment planning.

Mississippi
University of Mississippi Medical Center: $378,360
Funds will help a consortium of rural hospitals in Mississippi acquire high-definition video teleconferencing units for their emergency rooms, and mobile units for ambulatory care at each hospital. The University of Mississippi Medical Center will make specialists and medical personnel available through the video network to respond interactively to live emergencies from any of the participating sites.

North Carolina
Grandfather Home for Children: $393,368
Funds will be used to install video teleconferencing equipment. Grandfather Home is a facility in Banner Elk, N.C., for abused and neglected children. Video conferencing will provide critical therapeutic services for children and a direct line of communication between children and their foster parents.

New Hampshire
Mary Hitchcock Memorial Hospital: $498,356
Funds will be used to purchase equipment and software to expand the telemedicine network at the Mary Hitchcock Memorial Hospital to new sites in New Hampshire and Vermont. After this expansion is deployed, the system is projected to provide medical expertise for more than 5,000 rural residents.

Mary Hitchcock Memorial Hospital: $500,000
Funds will be used to purchase telemedical carts and related equipment for 18 rural sites. The participating sites include rural acute care hospitals, ambulatory care sites, rehabilitation sites and behavioral health centers in
Woodsville, Littleton, Greenfield, Colebrook, New London, Whitefield, Lancaster and Groveton.

South Carolina
Hampton Regional Medical Center: $249,162
Funds will be used to purchase a variety of video teleconferencing equipment and digital exam devices for the medical center and nine end-user sites. Roper St. Francis Hospital in Charleston will serve as a hub site for medical specialists and video system management. The video teleconferencing platform will allow face-to-face consultations between patients and physicians and between local health care providers and medical staff at the hub site.

Washington
Kadlec Regional Medical Center: $329,269
Funds will be used to purchase telemedicine equipment for a consortium of 12 health care organizations serving 19 sites at rural clinics along the Columbia River in Eastern Oregon and Washington. The Medical Center and participating hospitals will offer a comprehensive array of services and consultations.

West Virginia
Davis Memorial Hospital: $74,189
Funds will be used to establish telemedicine consultations between physicians at Davis Memorial Hospital and the Cortland Acres (Tucker County), Pendleton Manor (Pendleton County) and Mansfield Place (Barbour County) nursing homes. Physicians will be equipped with iPads and video-enabling software to increase their availability to observe and provide diagnosis for residents and patients.
Also USDA gave several awards that combined funding for both distance learning and telemedicine.

Missouri
Citizens Memorial Hospital District, $175,989
Funds will be used to provide telemedicine equipment for a partnership led by Citizens Memorial Hospital. The hospital and its hub partners will provide telemedicine services to rural clinics in Pleasant Hope, Rockville, El Dorado Springs, Stockton, Greenfield, Buffalo, Montrose, Wheatland, Hermitage, Humansville, Appleton City and Deepwater.

Montana
Kalispell Regional Medical Center, $363,326
Funds will be used to help Kalispell Regional Medical Center provide 24/7 telemedicine consultation services in its nine
county area. The equipment will create a telemedicine service among the Western Montana Tele-neurology Network, Kalispell Regional Medical Center and critical access hospitals in the region.

New York
Jefferson-Lewis-Hamilton-Herkimer-Oneida Board of Cooperative Educational Services, $487,267
Funds will be used to purchase video teleconferencing units for 37 schools in the Jefferson Lewis Hamilton Herkimer Oneida jurisdiction, 15 of which have never been connected to a distance learning system before. LeMoyne College in Syracuse, Clarkson University in Potsdam, Jefferson Community College in Watertown, and the Syracuse University School of Medicine will be part of the teleconference network.

Oklahoma
Board of Regents of the University of Oklahoma Health Sciences Center, $500,000
Funds will be used to purchase state-of-the-art digital equipment and software for a telemedicine initiative hosted by the University of Oklahoma Health Science Center. The initiative will use video teleconferencing to offer geriatric services to Choctaw Nation clinical sites -- including Stilwell Community Hospital -- and Choctaw clinics in Hugo, Broken Bow, Stigler, Idabel, Talihina and Atoka, and general services to health care facilities in Fort Cobb, Grandfield and Tipton.

South Carolina
South Carolina Department of Juvenile Justice, $196,809
Funds will be used to provide video teleconferencing systems for the South Carolina Department of Juvenile Justice. The equipment will give students a better chance of obtaining work skills and higher education opportunities

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Source URL: http://www.healthcareitnews.com/news/usda-awards-millions-telemedicine

Prestige Wins Florida Medicaid Contracts After the Contracted was Contested by Care Access

By CAROL GENTRY

With a billion dollars riding on the contested decision, Florida's Agency for Health Care Administration says it will award its Medicaid managed-care contract for Miami-Dade and Monroe counties to Prestige Health Choice.

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The final order, signed by AHCA Secretary Liz Dudek on Friday, rejects a recommendation from an administrative law judge who held hearings in the case in November.  The judge, John Van Laningham, wrote that the corporate structure of Prestige Health Choice did not meet the definition for a "provider service network," or PSN.

Care Access, the company that filed the protest that led to the hearings, issued a statement Monday expressing disappointment. The company plans to file an appeal with the First District Court of Appeal in Tallahassee, the statement says.

Each region of the state must offer a PSN as a choice for Medicaid enrollment, in addition to HMOs. So if Prestige was not a true PSN, then the contract would have to be awarded to a competitor. Care Access PSN, which brought the protest that led to the hearing, stood to inherit the contract if Prestige were not eligible.

Van Laningham said Prestige did not have majority ownership by doctors or other health-care providers, a requirement for designation as a PSN.   Florida True Health, a company formed by two insurers, Florida Blue and AmeriHealth Caritas, owns 40 percent of Prestige. In addition, the judge said, Florida True Health holds an option to purchase the other 60 percent of shares.

Another 13 percent of Prestige is owned by Florida Health Choice Network, which is a consortium of neighborhood health centers. Van Laningham ruled that that Florida Health Choice Network is not a Medicaid provider, so therefore Prestige could not qualify as a PSN.  His decision was issued on Jan. 2, and Health News Florida filed this report.

State agencies and boards can overrule the recommendations of hearing officers if they can cite specific errors in the legal reasoning used to arrive at a decision. They cannot override findings of fact.

In its ruling, AHCA said Van Laningham had misconstrued two sections of the law that established the statewide managed-care Medicaid program.

AHCA went ahead and signed a contract with Prestige to enroll patients in Miami-Dade, along with seven  other regions of the state (see list of plans by region). The three regions in which other PSNs were chosen were Region 2, Panhandle, Better Health Plan; Region 4, Northeast Florida,  First Coast Advantage; and Region 10, Broward County, South Florida Community Care Network.

Frank Reiner, attorney for Care Access, says the law requires AHCA to hold off on issuing the contract until the 1st District Court has ruled in the coming appeal. Health News Florida raised that question with AHCA Monday afternoon, but had not yet heard back by 6 p.m.

Miami-Dade has been hotly contested because it has the most Medicaid enrollees, and therefore the most potential new customers, for whom the state pays the premiums.  The Miami-Dade contract is expected to pay about $1 billion over five years, a Care Access spokeswoman said.

The Legislature created the law in 2011 that requires virtually all Medicaid beneficiaries -- including those in long-term care -- to enroll in a managed-care plan, either an HMO or a PSN. The Long-Term-Care rollout is under way, and the other beneficiaries will be shifted between May and August of this year.

The law does away with "fee-for-service" Medicaid payments, in which doctors, hospitals and other providers directly billed the state. Amid the gush of claims, the state found it difficult to prevent fraud and abuse. By privatizing the program -- turning management of treatment and payment over to managed-care plans -- Medicaid becomes a regulator, rather than a direct payer.

While HMOs and PSNs may seem similar from the point of view of the patient, an HMO is a commercial operation that is dually licensed by AHCA and the Office of Insurance Regulation. A PSN is a health-care network owned and run by the health-care professionals who treat the patients.

More information on the Statewide Medicaid Managed Medical Assistance Program is available here.

http://health.wusf.usf.edu/post/prestige-wins-medicaid-contracts?utm_referrer=http%3A//m.health.wusf.usf.edu/%3Futm_referrer%3D%23mobile/5383

Florida prepares to open its own health insurance exchange

Florida moves to open a state-run exchange

Florida may soon be operating its own health insurance exchange. The state has become a well known opponent of the Affordable Care Act , going so far as to seek the dismantling of the federal health care reform law through the Supreme Court as well as banning insurance navigators from working in the state. The state has missed its deadline to develop and operate a working exchange last year, meaning that a federal exchange has been set up for the state’s residents. Now, however, Florida Health Choices may soon be offering coverage.

Exchange finally shows signs of life after years of dormancy

Florida Health Choices was first established through state law in 2008. Since then, however, little has been done in regards to developing the exchange. Most of Florida’s legislative focus has been committed to opposing the health care reform law, but the state has found little success in this endeavor. State officials suggest that allowing the federal government to manage the health insurance market is dangerous and claim that the state should have more authority over the market. As such, Florida Health Choices is preparing to open itself to the public.

State-run exchange will not compete with the federal government

There is no news concerning which of the state’s insurance companies will be providing coverage through the state-run exchange. Rose Naff, CEO of Florida Health Choices, claims that the majority of Floridians are not purchasing coverage through the federal insurance exchange. Instead, these people are purchasing coverage through the private market. Naff suggests that the state-run health insurance exchange will not be competing with the federal government when it comes to selling policies.

STATE-RUN EXCHANGE EXPECTED TO BECOME OPERATIONAL IN EARLY FEBRUARY

Naff anticipates that the launch of the state-run exchange is only “a few days” away. The exchange is expected to begin operation in early to mid-February and will provide subsidies for consumers that can help them acquire the insurance coverage they need. The state-run exchange is expected to operate in a similar fashion to exchanges in other states, with Florida officials keen to ensure that the federal government has little control over the exchange itself.

http://www.liveinsurancenews.com/florida-prepares-open-health-insurance-exchange/8532045/

Innovative Pitt Competition Aims to Solve Health Problems through Patient Engagement

PITTSBURGH – In a creative, community-wide competition to spark fresh ideas that engage people in their own health care, the University of Pittsburgh is offering $300,000 in funding to three winners in its first Pitt Innovation Challenge, or PInCh.

Just as a reality TV show gives contestants an opportunity to share their inventions, PInCh will give scientists and other community members a venue to be creative and develop new ideas, said CTSI director Steven Reis, M.D., who also is associate vice chancellor for clinical research, health sciences, and a professor of medicine at the University of Pittsburgh School of Medicine. PInCh’s inaugural question is: “How do we empower individuals to take control of their own health outcomes?”

“Instead of trying to figure out the molecular mechanisms of hypertension, for example, the team might try to figure out how to reduce the rate of high blood pressure in a specific region,” Reis said. “We want to encourage researchers to approach their work in a different way. Rather than conducting experiments focused on scientific details, they must look at the big picture to try to solve a problem that has public health or clinical importance.”

According to PInCh program director John Maier, M.D., Ph.D., director of research and development and assistant professor, Department of Family Medicine, Pitt School of Medicine, the first step in the competition requires submitting a two-minute video by March 2 that introduces the team, defines the health problem that is being tackled and briefly outlines the creative solution. Early round winners will be invited to a final round of judging in May at a public event in which teams will make short presentations to a panel of judges.

“This will be a great opportunity to get new or risky ideas in front of judges who have experience in science, business, technology and other fields, so participation itself should be rewarding and fun,” Maier said. “We plan to have a ‘People’s Choice’ award, too, so everyone will have a chance to vote for projects that appeal to them.”

Anyone can enter, and teams that bring together collaborators from different perspectives, institutions and disciplines are encouraged, but at least one member of the team must be a Pitt faculty member. If needed, PInCh organizers will help community members connect with a member of the faculty. The solution could be a device, a software application, an intervention strategy or any other approach that could address the health problem the team identifies.

“We hope to de-risk wild ideas to solve clinical or public health problems by providing funding and project management to take them to the next level,” Reis said. “We think some amazing ideas will come out of this process, and we hope the PInCh model can be used in future competitions to stimulate innovative solutions to challenging issues.”

http://gantdaily.com/2014/02/03/innovative-pitt-competition-aims-to-solve-health-problems-through-patient-engagement/

A Sustainable Healthcare System Depends on Equal Access to Quality Education

“Without continual growth and progress, such words as improvement, achievement, and success have no meaning.” – Benjamin Franklin

HCMS

Health Care Management Systems was created to provide free, high quality, on-demand learning to all of those involved in the frontlines of healthcare!

Why?

Because we have proven that “equal access to high quality education” is the missing link in the healthcare equation.  Yes, proven through a unique double blind study that you have probably never heard of…

You see, this story begins about 3 years ago on the Texas gulf coast when two unlikely partners teamed up to change the way managed care was delivered to a certain Medicare population.

The strategy was devised from a simple physics theory – to influence the greatest amount of change in the shortest amount of time possible – equal pressure must be applied in all directions.

Education was the single greatest variable that was common to all groups – so our hypothesis was built on the assumption that through simultaneous and continuous education at the point of care, we could make a measurable impact on both the cost and the experience of care!

The project was a huge success from both a financial and cultural perspective. Two years later that “little experiment” is now out funding larger markers  – all without ever auditing a chart!

Lighting in a Bottle –

Okay, so our hypothesis was a success, but where do go from here? We were so amazed and excited about the outcome that we wanted to find a way to offer it to everyone – anywhere, anytime, anyplace and on any device!

So, we developed a vehicle: Global Health Care Management Systems (globalhcms.org) – an innovative learning platform that can deliver our proven education to everyone on the frontlines!

Anyone involved who wants to learn is invited to join the HCMS Academy!

To ensure that this tool will continue to be available to all of those we serve, we have teamed up with other healthcare leaders to provide employer sponsored learning as well.

A big THANK YOU to all of our partners and sponsors – without them none of this would be possible….

To learn more about our pilot program please visit: www.ermconsultinginc.com.

To find out how you can partner with us to ensure equal access to quality education email: kgifford@ermconsultinginc.com.

How Do I Sign Up?

HCMS ACADEMY-

We invite everyone currently working on the frontlines or those contemplating a new career in healthcare to register for the HCMS Academy. Register for free courses and receive certifications in Medicare Risk Adjustment, ICD-10 Coding and Rapid Practice Innovation. As a member of the Academy you are invited to join our conversation on the “Innovation X-Change.” The X-Change provides a secure, HIPPA compliant meeting space for visionaries to share ideas and collaborate on future projects. Join a group or start your own. Register today at www.globalhcms.org – What are you waiting on – it’s totally FREE!

SPONSOR E-LEARNING-

Are you involved in health care? If so, we invite you to join us in our mission! By sponsoring e-learning for your employees or industry partners you can help ensure that everyone has equal access to high quality education.

By partnering with HCMS, you extend our proven education to your organization at no cost and we are able to provide you with state of the art analytics including dashboards to track implementation and progress across large organizations in real time. This system was built on an API that accepts up to 5 data sources which potentially allows us to measure and analyze financial, educational and utilization data together for the first time. All of this at a fraction of the cost of traditional analytics.

To learn more about how we can partner for a better tomorrow, please contact: kgifford@ermconsultinginc.com

www.globalhcms.org

NYC gets cash to link 6 million patients with their health records

6 million patients to get their health records linked

Seven New York City health systems have been awarded $7 million in efforts to spur data sharing initiatives and more effective patient recruitment for clinical trials. 

The funding, provided by the Patient-Centered Outcomes Research Institute, or PCORI, will establish a clinical data research network in New York City, one of 29 such networks nationwide, officials say. These networks together will form PCORnet, the National Patient-Center Clinical Research Network, a $93.5 million patient-centered research initiative. 

The New York City Clinical Data Research Network, or NYC-CDRN, is a consortium composed of 22 regional organizations. The network, officials explain, will share capabilities and develop systems to support data-networking efforts and advance patient-centered research. It will initially focus its efforts on identifying individuals with diabetes, obesity and cystic fibrosis, and will partner with patients and clinicians through disease-specific community workgroups. 

"This contract is an exciting opportunity for leading New York City institutions to work together, through patient-centered research, for the health of the people who live here," said Rainu Kaushal, MD, chair of Weill Cornell's department of healthcare policy and research and the project's principal investigator, in a press release. "It validates New York's infrastructural advances in clinical data sharing."

[See also: Kaiser eyes outcomes with new network.]

The NYC-CDRN builds on six existing National Institutes of Health Clinical and Translational Science Award Centers that already work on collaborative research, data sharing and patient engagement. The CTSA centers are at Albert Einstein College of Medicine of Yeshiva University/Montefiore Medical Center, College of Physicians and Surgeons at Columbia University, Icahn School of Medicine at Mount Sinai, NYU School of Medicine, Rockefeller University and Weill Cornell. The project also has received support from the New York State Department of Health and builds on infrastructure established by two New York health information exchanges, Healthix and the Bronx Regional Health Information Organization.

The NYC-CDRN network will link medical records for 6 million New York City residents, and all records will be anonymized to protect patient privacy. Over the next 18 months, award recipients will expand and improve their individuals systems and further work to standardize data. Project officials say the scale of the data-sharing between institutions will make it far easier and faster to enroll patients in clinical trials and conduct comparative effectiveness and clinical outcomes research. The goal is to allow patients and providers to have access to evidence-based information they can use to make clinical choices and ultimately to improve healthcare.

PCORI announced back in December it had approved $93.5 million to support the 29 clinical research data networks. 

Earlier this January, it was announced that Kaiser Permanente would be one of these 29 receiving $7 million to build a clinical network focused on obesity, cancer and heart disease.  

http://www.healthcareitnews.com/news/groups-get-cash-data-sharing-network

United States: CMS Proposed Rule Would Modify Risk Adjustment Data Collection, Data Validation Audits With Some Material Effects

Article by Ankur J. Goel, Anne W. Hance, Joel L. Michaels and Mary S. Moll

McDermott Will & Emery

The Centers for Medicare & Medicaid Services' proposal for risk adjustment data collection demonstrates the agency's continued concern that Medicare Advantage Organizations' activities are resulting in more "intense" coding, and higher risk scores affecting payments, as compared to Medicare fee-for-service.

Among the proposed policy changes in the Centers for Medicare & Medicaid Services' (CMS's) proposed rule (Proposed Rule) are revisions to risk adjustment data collection requirements as well as risk adjustment data validation (RADV) audits.  Although many of the proposed changes are procedural and not likely to have a material impact on industry stakeholders, a few of the proposals, including limits on medical record reviews and changes to risk adjustment data validation appeals, could prove to be more significant.

This summary is the fourth in a series regarding the Proposed Rule.  The first three On the Subjects in this series address issues of interest for both Medicare Advantage (MA) Organizations and Part D Plan Sponsors, issues specific to the Part D Program, and the overpayment identification and repayment obligations imposed under Section 6402 of the Affordable Care Act.

Comments on the Proposed Rule, which was published in the Federal Register on January 10, 2014, are due to CMS by 5 p.m. EST on March 7, 2014.

Medical Record Reviews

In recent years, Medicare Advantage (MA) Organizations have sometimes reviewed medical records to identify and submit to CMS additional diagnoses codes that were documented in the medical records but were not submitted by providers in their claims or encounter data.  These diagnoses could have the effect of raising the risk score of the MA Plan-enrolled beneficiary, potentially enhancing CMS's risk-adjusted payment to the MA Organization.  In the Proposed Rule, CMS proposes to require that any retrospective review be "designed to determine the accuracy of diagnoses" submitted by the provider in addition to identifying diagnoses that were not submitted and that would warrant additional payments.  According to CMS, this restriction is part of an effort to enhance the accuracy of risk adjustment data.

CMS's proposal would apparently address the type of MA Organization activity that was alleged in a recent False Claims Act settlement (United States ex rel. _____ v. SCAN Health Plan)that involved an alleged retrospective chart review.CMS's proposal demonstrates its continued concern that MA Organizations' activities are resulting in more "intense" coding, and higher risk scores, for MA Organizations as compared to Medicare fee-for-service (FFS).  CMS has already signaled that it intends to rein in some aspects of MA Organizations' use of so-called "prospective" risk adjustment programs—specifically, submission of risk adjustment codes based on risk assessment visits conducted in the home.  (Although the CY 2014 "call letter" released in April 2013 indicated concerns regarding these house call programs, CMS does not address them specifically in the Proposed Rule.)

Risk Adjustment Data Validation Appeals

The Proposed Rule also would modify the RADV administrative appeals process.  A few changes are procedural in nature.  Under the current rules, there are separate appeals procedures for medical record review determination appeals and RADV payment error calculation appeals.  CMS proposes to consolidate these two types of appeals.  The Proposed Rule also reaffirms and expands the list of the types of issues that are not eligible for appeal; the current prohibition on challenges to the payment error calculation methodology for RADV audits would be expanded to include a prohibition on the medical record review determination methodology.

CMS also states that it will not necessarily publish the RADV payment calculation methodology each year, but will publish it only if there is a change that would require publication.  CMS does not address when or through what mechanism it will publish the amount of the so-called "FFS Adjuster," described in the February 2012 Notice of Final Payment Error Calculation Methodology for Part C Medicare Advantage Risk Adjustment Data Validation Contract-Level Audits (Methodology Notice), or whether CMS will reveal the analysis behind the calculation.  The FFS Adjuster, according to CMS in the Methodology Notice, "accounts for the fact that the documentation standard used in RADV audits to determine a contract's payment error (medical records) is different from the documentation standard used to develop the Part C risk-adjustment model (FFS claims)."

Conclusion

Risk adjustment continues to be significant to MA Organizations' financial performance and presents significant audit and False Claims Act risks.  Therefore, Plan Sponsors should consider the implications of CMS's proposal on their current and anticipated operations.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

http://www.mondaq.com/unitedstates/x/289540/Healthcare/CMS+Proposed+Rule+Would+Modify+Risk+Adjustment+Data+Collection+Data+Validation+Audits+with+Some+Material+Effects

Can you GAME your way to 5 STARS?

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Medicare plans and providers face a crucial task each year: achieve the highest Medicare star ratings possible or face the consequences. With major revenue and competitive positioning at stake — including the possibility of losing Medicare contracts if certain measures earn fewer than three stars for three consecutive years — Medicare Advantage and Medicare Part D prescription drug plans must take every step possible to maximize performance on all of the star rating quality measures. 

But what if we could game our way to a 5 STAR Rating? 

What if we could make all of these initiatives in healthcare fun?

How could we influence both the experience and the outcome of healthcare through innovative learning?

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Become a Leader Without Knowing It All: How to Improve Employee Engagement Through Leadership Standard Work

by Bill Kirkwood | January 23, 2014 11:29 am
How many years have we been hearing and reading about the decline in employee engagement?  If the research and surveys are to be believed, close to half of employees are unengaged in both their work and their employer.  There are countless solutions out there, yet the employee engagement numbers are holding steady. What can we do to get our employees on board?
Leadership standard work (LSW) can be a powerful response. It is a cornerstone to a Lean management system.  LSW specifies a leader’s daily, weekly and monthly practices that bring a disciplined focus to process, improvement opportunities and measurable outcomes of processes. This standard work is not ad hoc but rather documented with defined frequency of practice or, should I say engagement.  Importantly, these practices, which include a formal review of active performance improvement efforts and current performance against agreed to targets, takes place at the workplace—at the gemba.  Why at the gemba and not the traditional conference table preferred by many leaders?  Because that is where the work takes place by those unengaged employees.
A core element of LSW is coaching and teaching.  It is within the coaching process that leaders change the organizational conversation by engaging employees in the process of continual improvement. Think of what is being communicated when a leader shows-up in the workplace to conduct a review and coaching session.  In many cases this conveys the message “we are no longer in Kansas,” the past approach to work is no longer sufficient to assure success and conveys you and I are in this together.”  It affords a larger number of employees the ability to actively participate in a new way of talking with the leader about the problems they are confronted with and to share their ideas for continual improvement.  When done well, coaching in the gemba:

• Provides employees an opportunity to contribute their ideas for improvement
• Clarifies what is expected of them
• Takes on real-time development opportunities with employees engaging in small tests of change
• Provides recognition for work well done
• Demonstrates a sense of genuine caring from the leader.

How many approaches to rounding have you initiated in your organization?  LSW provides a very important ingredient to overcoming leader reluctance to rounding.  Speaking from personal experience, rounding was intimidating because I thought I had to be all knowing and going to the workplace could expose my ignorance.  Many leaders having earned their stripes by being  perceived experts and giving orders from a distance. It worked, or so they and I thought. Going to the gemba violates that comfort zone.
LSW, with its coaching approach, allows leaders to mentor and teach using the Socratic method. It removes the responsibility of being all-knowing.  Coaching shifts from one way “communication” to active inquiry and teaching.  The many leaders I have worked with over the years find this a positive challenge and not an onerous task, once they know there is someone to coach and guide them.  It is our role as Lean coaches and advocates to coach and mentor leaders; to make it acceptable not to know everything; and to coach and teach them on understanding the PDSA cycle, quality and Lean tools.  The return for these efforts are engaged leaders and employees.

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Today’s post was written by Bill Kirkwood, Ph.D., Director at HPP.

Bill has 30 years healthcare leadership experience in both system and individual hospital settings in the Mid-West and North-East, and oversight of change management activities and Lean Transformation engagements.  This experience includes serving in an executive capacity in Quality, Operations and Human Resources. 

Source URL: http://www.leanhealthcareexchange.com/?p=4125&print=0

Healthcare software innovation: Why in-house accelerators are better

This post was originally published on Vector, Boston Children’s Hospital’s science & innovation blog.

Considering that Boston is home to some of the country’s best medical, scientific and technological minds, it is little surprise that the city has a vibrant startup ecosystem. That ecosystem lowers barriers to creating groundbreaking innovations, connecting innovators to funding, mentorship and human capital. Yet, it isn’t very well-suited to help health care software innovators, who face a unique set of challenges.

The unique and increasingly complex IT environment within health care institutions is one of the biggest barriers to the development of novel clinical software solutions. To start with, health care delivery IT environments boast complicated safeguards to keep medical information secure. In addition, as these environments grow in scope and complexity, keeping pace with advances in clinical technology, it becomes harder to incorporate new software. Breakthroughs that enable Boston Children’s Hospital to be a leader in robotic surgery, for example, also make it harder to design technologies that can easily integrate with a hospital’s IT system.

The clinical IT environment is further complicated by a myriad of regulatory requirements. Plotting a course through the IT complexity, while complying with stringent security and HIPAA requirements, can be daunting. Furthermore, the FDA may soon be regulating clinical mobile apps and novel software as it does medical devices and pharmaceuticals. With regulatory concerns and complexity, it’s not difficult to see why many potential health care software innovators can get stuck in the early stages of the innovation lifecycle.

And the IT environment is not the only challenge for innovators wanting to develop new clinical solutions. Innovators need not only time and resources, but also highly specialized technical skills. Typically, innovators will reach out to their institution’s IT developers for help—only to discover that those developers have limited bandwidth and are busy working on higher priority projects.

As a result, innovators may seek an external software development vendor to build the solution they have in mind. But finding the right vendor is not easy. And even when there is a good health care software developer with which to partner, there are hurdles to negotiating contracts—and that is assuming there is money available to pay for the work.

Looking inward for answers

At Boston Children’s Hospital, we have built a unique program to help free aspiring innovators from many of the traditional challenges in building new clinical IT software. Known as FastTrack Innovation in Technology (FIT), part of the hospital’s Innovation Acceleration Program, it offers annual software development awards in the form of time with a special team of Boston Children’s project managers, business analysts and software developers.

The FIT team can rapidly translate a clinician’s idea into functional software that can be piloted in the hospital setting—and generally does so more efficiently and at a lower cost than most traditional software development vendors. FIT solutions have ranged from clinical software to mobile apps, and from clinician to patient-oriented solutions. Here are three examples:

• A Twitter-inspired app, called BEAPPER, allows emergency department staff to easily share and update information about their patients in real time and to get lab results on their mobile device.

• Another mobile app, MyPassport, helps inpatients communicate with their clinicians, access their care plan and track their progress toward discharge.

• ALICE, a digital “smart board,” has replaced the white boards and hand notations Boston Children’s clinicians used to keep track of patients in each unit.

A harvest of solutions

Having an in-house incubator has allowed Boston Children’s to rapidly create and test novel software solutions. Because our FIT developers understand the hospital’s IT environment, their technologies integrate far more smoothly than most vendors’ solutions to the same problem.

Innovating around clinical software solutions has traditionally been difficult. Because we can provide dedicated healthcare software development resources, our staff’s ideas are bearing fruit and helping us to enhance the delivery of pediatric care. To see so many innovators embrace these resources is not only gratifying to all of us in the IAP, it is also tremendously beneficial to the people who matter most—our patients.

Read more: http://medcitynews.com/2014/01/healthcare-software-innovation-house-accelerators-better/#ixzz2rbV0pFKT

Join Dr. D. and Natalie for ICD-10-CM SHOOT OUT

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