Integrated Coding Compliance Program

The Department of Justice recently stated that it is not their policy to assess fines and penalties for honest billing mistakes. However, DOJ also stated that hospitals, physicians and health plans must establish adequate internal procedures to ensure the accuracy of submissions.

Components of an Integrated Coding Compliance Program:

1.  Auditing – Identification of potential coding compliance problems.
2.   Education – Educate to correct identified areas of deficiencies.
3. Action – Digital tracking to monitor progress in real time.
4. Engagement – Patient and Provider outreach to minimize gaps and add value.

ERM’s Innovative Education Program has proven success.

Our Pilot has shown an ROI of over 300%.

 Innovative, Effective and Transparent Solutions For $3 PMPM

Call today for a free consultation: 877-938-9232

UnitedHealth Issues Warning Over Medicare Advantage Cuts - Kaiser Health News

UnitedHealth Issues Warning Over Medicare Advantage Cuts - Kaiser Health News

UnitedHealth Issues Warning Over Medicare Advantage Cuts

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TOPICS: INSURANCE, MARKETPLACE, MEDICARE, HEALTH COSTS

APR 19, 2013

UnitedHealth attributed a 14 percent drop in profits in the first quarter to higher medical costs. The nation's largest insurer also warned that cuts to Medicare Advantage plans could hamper its earnings growth next year.

The Wall Street Journal: UnitedHealth's Outlook Cautious Amid Medicare Debate
UnitedHealth Group Inc. on Thursday sounded a cautious tone as it deals with the near-term impact of the government's crackdown on spending and looks ahead to lower funding for its Medicare plans. The comments, from the nation's largest managed-care company by both revenue and members, indicate the uncertainty that the industry is experiencing as insurers gear up for fuller implementation of the Affordable Care Act in 2014. That process has been made more complicated by the recent automatic U.S. spending cuts known as the sequestration and expectations for lower incoming payments for Medicare Advantage plans next year (Kamp, 4/18).

Kaiser Health News: Capsules: Despite Win, UnitedHealth Criticizes Medicare Rates, Eyes Pruning Business
If the Obama administration expected the biggest health insurance company to give thanks for this month’s decision to reverse cuts to private Medicare plans, it was wrong. UnitedHealth Group CEO Stephen Hemsley said Thursday that Medicare Advantage rates are still far too low and that the company may shrink its business of managing care for seniors. ... But in Thursday’s call to discuss the company’s quarterly profits of $2.1 billion on revenue of $30.3 billion, Hemsley said other changes — including the Affordable Care Act’s long-term reduction in Medicare Advantage payments – would still lead to a net reduction next year of more than 4 percent. That's inadequate when medical costs are rising in the 3 percent neighborhood, he said" (Hancock, 4/19).

Los Angeles Times: UnitedHealth Reports Lower First-Quarter Profit, Higher Costs
UnitedHealth Group Inc., the nation's largest health insurer, said its first-quarter profit dropped 14 percent as medical costs climbed higher. The Minnetonka, Minn., company said its health plan membership increased 18 percent in the quarter to 42 million people, boosted by international growth (Terhune, 4/18).

The Associated Press: UnitedHealth Warns Of Medicare Profit Squeeze
UnitedHealth Group, the largest provider of Medicare Advantage plans, warned Thursday that funding cuts for the privately-run versions of the federal Medicare program will force it to reconsider its expectations for earnings growth next year. CEO Stephen Hemsley told analysts that the government-subsidized coverage for elderly and disabled people faces a reimbursement cut of about 4 percent next year (Murphy, 4/18).

In the meantime, Humana has launched an internal investigation after leak of a significant government policy change led to some suspicious stock trading --

The Wall Street Journal: Humana Fires Lobbying Firm, Launches Internal Review
Health insurer Humana Inc. said it has started an internal probe into the circumstances surrounding the leak of a significant change in government health-care policy. "We have launched an internal review primarily to determine whether our interests were harmed" by the tie between an outside lobbyist employed by Humana and an investment firm that sent out early word of the policy shift, a Humana spokesman said. That alert set off a sudden jump in shares of Humana and other insurers late April 1 (Mullins and Mathews, 4/18).

Planned CMS Changes on MA HRAs Draw Criticism, Questions on Need

CMS’s surprising proposal in the Feb. 15 “45-day notice” for Medicare Advantage plans’ 2014 payment rates to place strict limits on the use of health risk assessments (HRAs) for risk-adjustment purposes is getting mixed reviews from MA industry participants.

Trade group America’s Health Insurance Plans (AHIP), in a March 1 letter to CMS, for instance, urged the agency to “reconsider” the proposal (MAN 2/28/13, p. 1) so that it “does not inappropriately limit inclusion of diagnoses from the 2014 data year that are valid predictors of health status in the subsequent payment year.” But the CEO of one firm that specializes in assessing MA beneficiaries in their homes suggests that what CMS is asking — primarily for HRA findings to be followed up in a subsequent clinical encounter — is what the MA plans with which it works already are doing.
CMS in the 45-day notice said it “is concerned that these risk assessments could be used as a vehicle for collecting risk adjustment diagnoses without follow-up care or treatment being provided to the beneficiary by the plan.” The HRAs, according to the agency, contribute to “increased risk scores and differences in coding patterns between MA and” fee-for-service (FFS), and thus to higher payments for MA plans.
To analyze what is occurring, CMS proposed that beginning with 2013 dates of service, MA plans will have to flag those diagnoses collected in an MA enrollee HRA. And for 2015, the agency added, “CMS is considering excluding, for risk adjustment payment purposes, the diagnosis data collected from MA enrollee risk assessments that are not confirmed by a subsequent clinical encounter by a provider type” approved for such purposes.
AHIP, in detailed comments to CMS, notes first that HRAs “must be offered” to new MA enrollees and as part of the annual wellness visit available for both MA and Medicare FFS beneficiaries. Regardless of whether they occur in a physician’s office or, as some MA plans arrange, in the beneficiary’s home or another location “convenient for the enrollee,” AHIP asserts, “it is our understanding that the results can currently be included in the patient’s medical record, and diagnoses may be reported for risk adjustment” when the assessments are conducted “face-to-face by medical professionals.”
Adds the trade group: “CMS’ proposal appears to signal a re-evaluation of its policies in the fundamental areas of medical record documentation and the role of chronic conditions in the risk adjustment model. We strongly disagree with the conclusions reflected in the draft Call Letter.” If CMS “has concerns that some health risk assessments are not sufficiently thorough,” AHIP says, it should consider developing criteria for HRAs to address this issue “rather than potentially disallowing all diagnoses collected through these efforts.”
And the group calls the HRAs the foundation of care management programs and counseling for beneficiaries that, while they may “not be documented in a subsequent medical record,” are valued by beneficiaries and “clinically significant.”
Jack McCallum, M.D., CEO of CenseoHealth, a Dallas-based firm that conducts in-home health evaluations for MA and other health plans, tells MAN that “what MA is doing is not upcoding; it’s more accurate coding.” And he says the issue CMS is raising is just a short-term one, since in about 2016 it will have enough provider encounter data from MA plans that it can rely on an “MA-specific model” as a basis for diagnosis-related decisions.
There are several problems with what CMS is proposing in the 45-day notice regarding HRAs, according to McCallum. One is that there now is no specified method for collecting data from HRAs, and there is not even a definition of what constitutes an HRA. It can’t be limited to what is done by primary care physicians, since many Medicare beneficiaries don’t get care from PCPs, he says.
And the “underlying beauty” of the risk-adjustment system, in McCallum’s view, is that it gives MA plans an incentive to figure out where there are gaps in care and to be “productively involved” in finding non-inpatient ways to furnish this treatment since a good HRA will lower costs of care “down the road.”
CenseoHealth, he asserts, never captures a diagnosis on a beneficiary in a home HRA without recommending follow-up care for that beneficiary. Moreover, it has ways, including via its call center and claims tracking, to check whether these recommendations are acted on, McCallum notes. He says that CMS verification of such follow-up would not be a problem for CenseoHealth, and to the extent that there are plans doing HRAs just “for the money,” he would “share the agency’s concern.”
If the CMS proposal were adopted, McCallum tells MAN, it would be “my suspicion” that some entities just collecting diagnoses and not doing anything about what they find “might go away.” The extra scrutiny in this aspect of what CMS is considering is “fine” and “appropriate,” he says, but he adds that “I’m not sure how much of what CMS is worried about is really going on.”

Reprinted from MEDICARE ADVANTAGE NEWS,

By James Gutman, Managing Editor

March 14, 2013Volume 19Issue 5

Physician turnover rate hits all-time high

By Frank Irving, PhysBizTech.com

Medical groups reported an average turnover rate of 6.8 percent in 2012, according to the annual Physician Retention Survey from Cejka Search and the American Medical Group Association (AMGA), who released their findings March 18.
The 2012 physician turnover rate rose from 6.5 percent in 2011. It was significantly higher than the lowest rate of 5.9 percent reported in 2009 at the depth of the recession, according to researchers, and exceeded 6.4 percent reported in 2005, the first year data was collected.
Survey respondents also reported turnover of 11.5 percent among advanced practice clinicians (APCs), which includes physician assistants and nurse practitioners. This was essentially unchanged from 2011, the first year APC data was collected.
The Cejka Search and AMGA 2012 Physician Retention Survey was distributed electronically via e-mail to 2,174 medical organizations, representing both AMGA medical group members and non-members. Researchers collected survey data from October 2012 through January 2013, and attained a 3.6 percent survey response rate. Eighty respondents, who collectively employed 19,596 physicians, reported the 2012 physician turnover data. A subset of 72 groups, who collectively employed 4,213 advanced practice clinicians, reported the APC data.
This increased turnover tracks with improvements in the housing market and recovery in stock prices and marks a shift from physicians delaying relocation and retirement due to depressed home and investment portfolio values, researchers reported.
Medical groups do not expect relief in turnover in the coming year, the researchers commented. The report indicates that competition to hire and retain top performing physicians will intensify as retirement accelerates among an aging physician workforce and health reform increases the demand for primary care.
“The survey findings provide evidence that recruitment and retention continue to be major challenges for health systems,” stated Donald W. Fisher, PhD, president and CEO of AMGA, in a prepared statement. “To rise to these challenges, medical groups are demonstrating remarkable leadership by investing in new staffing and delivery models, building and nurturing their teams in a strategic way, and making accountable care work for their patients and their communities.”
“The implementation of healthcare reform and changing demographics make efficient recruitment and effective retention paramount for medical groups,” stated Lori Schutte, president of Cejka Search, in a prepared statement. “Delivering data and insight points the way toward best practices and drives our industry toward innovative solutions.”
Other key findings from the report:

•   More than one-third (36 percent) of reporting groups expect the pace of retirements to increase in the coming year, compared with 27 percent with that expectation two years ago.

•   Nearly three-quarters (74 percent) of groups with fewer than 50 physicians said they expect turnover to “stay the same.” However this small group segment is already experiencing the highest rate of turnover among physicians over 64, at 19.4 percent, compared with an average 12.7 percent for physicians of this age in all groups.

•   The average turnover rate for physicians in their second to third year of practice is 12.4 percent and small groups suffer from 20.8 percent turnover among physicians in those early years.

•   More than three-quarters (76 percent) of respondents plan to hire more primary care physicians in the next 12 months.

•   Within that group, 22 percent said they will hire “significantly more” – more than twice the 9 percent reported in 2011.

•   Hiring plans for APCs will also accelerate: 67 percent plan to hire more nurse practitioners and 61 percent plan to hire more physician assistants. This compares with 49 percent and 48 percent (respectively) in 2011.

•   A significant majority (85 percent) have an onboarding process for physicians, yet only one-third (33 percent) of these groups stated that their process is formalized through an onboarding committee or task force.

•   Groups who assign a mentor during onboarding reported a lower overall turnover rate of 6.0 percent compared with the 6.8 percent average turnover rate for all groups.

•   Extended onboarding correlates to higher retention of physicians in the early years with a practice. Groups that provide a year-long onboarding process reported a turnover rate of 10.5 percent compared with the average 12.5 percent for physicians between two and three years with the practice, when turnover peaks.

OIG pressures CMS on home health sanctions

By Stephanie Bouchard, Managing Editor

As the number of home health agencies and fraud cases related to home health agencies continues to skyrocket, the Office of Inspector General (OIG) is exerting more pressure on the Centers for Medicare & Medicaid Services (CMS) to fulfill an obligation that is 15 years old.
Back in 1987, the Omnibus Budget Reconciliation Act (OBRA) directed CMS to implement intermediate sanctions for noncompliant home health agencies (HHAs). OBRA specified that the intermediate sanctions CMS created should include civil money penalties, payment suspension and appointment of temporary management. While there is a corrective process for noncompliant HHAs, the only HHA sanction option CMS currently has at its disposal is termination, an option it doesn’t use often.
Even though the number of Medicare-certified HHAs has seen a 59 percent increase between 2002 and 2009, CMS still has not issued a final rule for intermediate sanctions. It did issue a Notice of Proposed Rulemaking in 1991 but later withdrew it.
In 2008, OIG issued a report about HHAs with repeat deficiency citations and the lack of intermediate sanctions. OIG recommended that CMS follow OBRA’s 1987 directive to implement intermediate sanctions. CMS agreed with OIG’s recommendations but as of the spring of 2012, had yet to issue a proposed rule on intermediate sanctions. (CMS did not respond to an interview request for this story.)
Last March, OIG again pressed CMS on implementing the intermediate sanctions. In a letter to Marilyn Tavenner, CMS’ acting administrator, OIG reminded CMS of its legal obligations and that OIG had already prodded the agency on this issue in 2008.
“Although CMS indicated activities toward promulgating regulations to implement HHA intermediate sanctions, it has not yet issued a proposed rule,” OIG’s letter to Tavenner said. “Given the length of time since the passage of the original statute, CMS should make HHA intermediate sanctions a high priority and should complete their implementation as soon as possible.”
HHAs are aware that a proposed rule on intermediate sanctions may be issued soon – by some reports, in September – so there is some concern within the industry, said Mary St. Pierre, vice president, regulatory affairs, the National Association for Home Care and Hospice, about what additional burdens the new rule may add.
“Agencies now have condition levels, they are writing their plan aggression, they are being resurveyed, they are staying in the program and so they would look on this as an additional burden,” she said. “Having to either pay a fine or have some sort of management over them or whatever else CMS comes up with.”
HHAs need to begin preparing themselves now for more CMS scrutiny, said Neil Hoffman, an Atlanta-based lawyer with Arnall Golden Gregory, who represents home health agencies and providers.
“Any home health agency that has been experiencing (problems related to Medicare conditions of participation), try and get their house in order because, obviously, the ultimate penalty is the exclusion from Medicare and nobody wants that,” Hoffman said.
While HHAs are not excited about the likelihood of more hoops to jump through, they also recognize more oversight from CMS could help the industry tamp down the dark cloud it labors under because of the many reports of home healthcare fraud.
“I would politely state that we do not believe that CMS is doing all that they could/should to enforce home health rules and penalize noncompliant, sometimes fraudulent and abusive providers,” said Vicki Purgavie, executive director, Home Care and Hospice Alliance of Maine. “Instead, we have been battling for years with the constant ‘broad brush’ and black eye given to the entire industry for the behaviors of a few providers.”
“It’s too easy for CMS to say ‘Let’s regulate them more,’” she added. “They just keep putting out more regulations but they’re not providing the oversight.”

Practice Management: Key Resource for Medicare Advantage

 

Practice Management: Key Resource for Medicare Advantage

Who has more face time with your members than anyone else? Is it their primary care physician? Probably not. Think back to your last doctor’s appointment, how much time did you spend face to face with the doctor? What about the nurse or the front office?

A physician’s closest ally is his office manager. Why aren’t health plans tapping this important resource?

Patient engagement has recently taken center stage as everyone is focused on finding new and meaningful ways to connect with their members.

As a practice manager for over 10 years, I urge health plans to open up new lines of communication with practice managers and office staff.

If a plan wants to change processes within the delivery of care, you must start with the initial point of contact.

If a plan wants to know what their members want, ask the person who answers the phone at their PCP’s office.
 

The perspective of practice management can offer incredible insight and adds value that the patient will understand.

Contact ERM today for Innovative Solutions
www.ermconsultinginc.com

Will The Leaders of Today, Be The Leaders of Tomorrow?

Will The Leaders of Today, Be The Leaders of Tomorrow?

If history repeats itself, they will not. Today’s leaders and their corporations will be replaced by new companies that no one has heard of with young innovative leaders at the helm. The uptown offices will be exchanged for Wellness Centers in neighborhoods because patients will demand greater shared decision making and value-based care with increased fiscal responsibility.

Why will the industry’s strongest and most powerful corporations loose the innovation race? Because their “Innovation Department” will never be able to convince the most senior executives that innovation is more than just a new product or a marketing angle. It is a mindset, a corporate culture that originates from the top and is woven into the foundation of a corporation.

The most brilliantly written legislation supported by the best and brightest auditors with access to the entire collection of big data will NEVER change the current trend in healthcare spending if patients are not involved. This involvement, or patient engagement must be center stage over the entire continuum of care; not a follow up call after a hospital admission by a Case Manager. We must look outside the box to address the needs of patients and not insurers. Then, we must create flexible solutions that meet those specific needs.

The ability to adapt quickly will be necessary and this conflicts with current corporate ethos. Accountability has been diluted by board meetings and conference calls. While emails are shuffled around from person to person, no one wanting to take action. Instead of teaching physicians and clinical staff how to document to a higher level of specificity we are hiring companies to re-code medical records. Is that really a solution?

 

Be proactive. Start making changes today. The next wave of innovation is on the horizon.

Empirical Risk Management www.ermconsultinginc.com 877-938-9232

Whose Patient Engagement Goals Are We Talking About? | Center for Advancing Health

Whose Patient Engagement Goals Are We Talking About? | Center for Advancing Health

ICD-10 Transition Basics

The ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. 

1. What does ICD-10 compliance mean?
ICD-10 compliance means that everyone covered by HIPAA is able to successfully conduct health care transactions using ICD-10 codes.

2. Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding? 
No. The switch to ICD-10 does not affect CPT coding for outpatient procedures. Like ICD-9 procedure codes, ICD-10-PCS codes are for hospital inpatient procedures only.

3. Who is affected by the transition to ICD-10? If I don’t deal with Medicare claims, will I have to transition?
Everyone covered by HIPAA must transition to ICD-10. This includes providers and payers who do not accept Medicare. 

4. Do state Medicaid programs need to transition to ICD-10?
Yes. Like everyone else covered by HIPAA, state Medicaid programs must comply with ICD-10. 

5. What happens if I don’t switch to ICD-10?
Claims for all services and hospital inpatient procedures performed on or after the compliance deadline must use ICD-10 diagnosis and inpatient procedure codes. (This does not apply to CPT coding for outpatient procedures.) Claims that do not use ICD-10 diagnosis and inpatient procedure codes cannot be processed. It is important to note, however, that claims for services and inpatient procedures provided before the compliance date must use ICD-9 codes.

6. If I transition early to ICD-10, will CMS be able to process my claims?
No. CMS and other payers will not be able to process claims using ICD-10 until the compliance date. However, providers should expect ICD-10 testing to take up to 19 months. 

7. Codes change every year, so why is the transition to ICD-10 any different from the annual code changes?
ICD-10 codes are different from ICD-9 codes and have a completely different structure. Currently, ICD-9 codes are mostly numeric and have 3 to 5 digits. ICD-10 codes are alphanumeric and contain 3 to 7 characters. ICD-10 is more robust and descriptive with “one-to-many” matches in some instances.

Like ICD-9 codes, ICD-10 codes will be updated every year.

What strategies have you developed to successfully transition your company to ICD-10? 
Have you completed Documentation Improvement Initiatives? Have you mapped your 50 most commonly billed codes to ICD-10? Are you tracking and monitoring your progress through internal compliance reviews?  How will you protect your revenue while managing the costs of transition?

If not, you must start now. The deadline is fast approaching!

Call ERM today for a free consultation 877-938-9232

April 22, 2013, 9:08 a.m. ET

Quintiles Unlocks Path for Digital Patient Engagement

New report demonstrates how the digital patient can yield efficiencies throughout the biopharma product lifecycle

RESEARCH TRIANGLE PARK, N.C.--(BUSINESS WIRE)--April 22, 2013-- 

Harnessing the power of the digitally connected patient can not only help produce enormous amounts of savings in the health care system, but can also improve patient outcomes.
Companies that can successfully engage with the digital patient will distinguish themselves and increase their probability of success according to a new report from Quintiles, "Harnessing the Power of the Digital Patient." The report explores a more modern approach to patient engagement to streamline product development, prove product value and accelerate product adoption and adherence.
Declaring this, "The Age of the Digital Patient," Quintiles tracks the evolution of patient engagement models over time and argues that the patient is at the center of today's model--a change from the more company-centric models of the past.
The report dismisses the value of "old-school" patient databases to find patients, and declares the 2.4 billion people with an internet connection as "today's database."
Core to the Quintiles Digital Patient model is the building of trusted relationships via patient communities, and the creation of opportunities for patients to engage in managing their own health. These programs range from introductions to clinical trials, to enrollment in adherence programs, to virtual studies that include collection of patient reported outcomes, medical records, lab data and device diagnostics to prove a product's value or safety--all collected directly from patients without introducing site burden.
"It's not a question of 'when' these capabilities will be available," says co-author David Coman, senior vice president Quintiles communications, "it's a question of when the industry will give itself permission to make these approaches standard. We have been preparing for 'The Age of the Digital Patient' since 2007, and have the capabilities and experience to provide transformational change today."
Quintiles digital patient experience extends back to its creation of Mediguard.org in 2007 and ClinicalResearch.com in 2009, and its completion of more than 350 custom patient programs on behalf of sponsors in its Digital Patient Unit. To date, Quintiles manages relationships with more than three million clinically profiled patients across nearly every therapeutic area.
First Patient Enrolled in Six Minutes
An example of the promise the digital patient holds can be found in an observational research study in which Quintiles recruited 425 patients with chronic obstructive pulmonary disease (COPD) from its online patient community. The first digital patient was enrolled in the study in a mere six minutes with the last patient confirmed in only nine calendar days.
59% Increase in Retention Rates
A second example can be found in a 1,255-patient women's health study in which Quintiles developed a custom communication plan for each patient in order to reduce the number of patients that become lost to follow up or drop out of the study entirely. The customized communication program kept patient engagement high and resulted in a 59% increase in the retention rate for the duration of the study.
The full Quintiles report, "Harnessing the Power of the Digital Patient, " can be accessed here.
About Quintiles
Quintiles is the world's largest provider of biopharmaceutical development and commercial outsourcing services with a network of more than 27,000 employees conducting business in approximately 100 countries. We have helped develop or commercialize all of the top-50 best-selling drugs on the market. Quintiles applies the breadth and depth of our service offerings along with extensive therapeutic, scientific and analytics expertise to help our customers navigate an increasingly complex healthcare environment as they seek to improve efficiency and effectiveness in the delivery of better healthcare outcomes.

Medicare Health Risk Assessments

Medicare Health Risk Assessment  

CMS is considering excluding from risk adjusted payment any diagnosis data collected from MA enrollee Health Risk Assessments which are not confirmed by a subsequent clinical encounter.  

CMS planned to collect flags in 2013 of these risk assessments.
Based on comments received, CMS is delaying the collection of flags until calendar year 2014.  

Further determination about exclusion of these data will be published in the 2015 Advance Notice

Audit Your Records, Before Someone Else Does

AUDIT YOUR PRACTICE BEFORE SOMEONE ELSE DOES

Medicare and Medicaid now require physicians to establish a compliance plan that can effectively detect "criminal, civil, and administrative violations."  That means you must have a plan to address key compliance issues such as billing discrepancies and appropriate coding and documentation. 

Contact ERM today for a FREE Consultation

1-877-938-9232

Schedule On-Site or On-line Training Today and Learn:

·         The basic laws involved with Medicare fraud and abuse,

·         How to identify hot areas that are often the subject of audits,

·         How to develop and maintain a workable compliance plan, and

·         The importance of documentation and frequent self-auditing.

BONUS: Discounted Compliance Plan Guide + Template and Provider Documentation Guide

The Digital Disruption

The Digital Disruption

Medicine is destined to be the most regulated industry in the world. The current culture of healthcare in America challenges traditional business models on everything from cost to implementation to how we gather feedback about the patient experience. This paramount shift in the way we evaluate our physicians and choose our health plans further supports the need for continual innovation. In this new generation of due diligence, the entire healthcare community has become accountable not only in the state and federal courts but in the court of public opinion as well. This new arena demands strong fiscal oversight, tangible transparency and outcomes that are determined by the level of patient engagement. The old boardrooms dialogue, centered around the acquisition and internal uses of big data, have given way to new questions. Senior executives and are now asking, “How do we get our members excited about using all of this data?”

The fact that this question is now being asked by the most influential decision makers in healthcare signals the beginning of a new kind of disruption, a digital disruption.

This digital disruption will be pioneered by leaders using technology to create innovative platforms to engage patients and change behavior. The champions of the future will be determined by the individual capacity of a corporation to modify and adapt. Inventions will no longer depend on handcrafted products but instead be shaped from ideas, concepts and processes presented across multiple platforms that can be accessed from anywhere any time any place.

The health plan of the future will engage patients through digital apps that can monitor compliance, Create custom QR Codes for HEDIS Measures to allow for real time tracking, all while assessing member satisfaction with the plan, pharmacy benefits and primary care providers.

In fact, the tools themselves will have nothing to do with the digital disruption, it will be the meaningful ways in which we use these tools to meet the needs of patients. Success or failure will be contingent not on what you create but what you do with it next.

The cost of healthcare is unsustainable. First premiums were raised to try and get consumer involvement. That was followed by employing variable cost shares and quality incentives. None of which have influenced behaviors. Perhaps because all of those affect us indirectly.

Innovative platforms such as Mobile Apps and Telemedicine have been able to reach their audience in the most intimate of places. 

How are you engaging your patients? Are you prepared for the digital disruption?

Kameron Gifford, CPC

ERM Consulting Inc

www.ermconsultinginc.com

CMS has updated ICD-10 resources to reflect October 1, 2014 DEADLINE

Updated resources are now available to reflect the October 1, 2014, deadline. The CMS implementation guides, checklists, and timelines have been adapted and provide step-by-step guidance around the transitions.

• The ICD-10 implementation guides provide detailed information for planning and executing the ICD-10 transition. The downloadable PDF versions are available below:
  • Small and Medium Practices
  • Large Provider Practices
  • Small Hospitals 
  • Payers 

• Checklists and timelines with ICD-10 tasks and estimated timeframes are now available for:
  • Small and Medium Practices - Checklist and Timeline
  • Large Provider Practices - Checklist and Timeline
  • Small Hospitals - Checklist and Timeline
  • Payers - Checklist and Timeline

Medicare Fee-For-Service National Provider Call – Last Chance to Register

Thursday, April 18; 1:30-3pm ET

On September 5, 2012, CMS published a final rule that delays the ICD-10 compliance date from October 1, 2013 to October 1, 2014. Are you ready to transition to ICD-10? Now is the time to prepare. Join us to learn how to prepare in 2013 for the transition. CMS Subject matter experts will review basic information on the transition to ICD-10 and discuss implementation planning and preparation strategies. A question and answer session will follow the presentations. Learn more about the call on the April 18 call web page.  

ICD-10 Conferences

• ACP Internal Medicine Conference (April 9 – 11, 2013; San Francisco)
  • ICD-10 - Are You Ready? technology briefing; Thursday, April 11 at 10:45 am; in the exhibit hall
  • ICD-10 Implementation: A Practical Roadmap; Thursday, April 11 from 2:15 pm - 3:45 pm; Room PN 033
• The AHIMA ICD-10-CM/PCS and Computer-Assisted Coding (CAC) Summit is April 22-24 in Baltimore
  • MDCMS representatives will be at table 29. We encourage you to stop by to hear about CMS tools and resources available to help with ICD-10.  

Health Plan’s Secret Sauce is Social Media

Health Plan’s Secret Sauce is Social Media

Health Plan's Secret Sauce is Social Media

Jacqueline Fellows, for HealthLeaders Media , April 17, 2013

Every industry, including healthcare, has been trying to figure out a way to get the most out of social media in general, and Facebook, specifically. The real winners are, of course, consumers because myriad online ads, coupon sites, and Facebook posts drive prices lower.

Hospitals and health systems trying to compete in this space can't win a price war, but they may win on patient engagement. Unfortunately, the results are soft, at best, as the strategy generally revolves around hoping someone comments on a Facebook post about a wellness goal, such as losing weight, managing stress, or quitting a tobacco habit.

Magellan Health Services, a specialty managed healthcare provider, seems to have hit upon an effective way to not only engage patients, but also change the behavior that is contributing to patients' health problems. And they're doing it with social media.

In 2012, Magellan launched a pilot project with a "large health plan in the Northeast" aimed at reducing the readmission rates of members who had been admitted to a hospital for substance abuse. In addition to a phone call after being discharged from the hospital, health plan members were invited to join a social media site that looks, feels, and functions like Facebook, but is tailored specifically for them.

---

"The people we're engaging on this [website] we probably never would've gotten on the telephone," says Laurie Gondek, senior vice president of product innovation at Magellan. "You have people who want to engage in many different ways. Some, with their providers… and then there are those who prefer to start out online."

Though the pilot project has ended, the site is still being used by Magellan and for the company's health plan customers who buy it under a private label to brand the site how they want. Gondek says she is seeing a lot of interest from Blue Cross Blue Shield plans and others who are interested in the site's potential for bridging care gaps and for chronic conditions.

"We've started to talk to ACO's and other entities that are looking for ways to have the medical practitioners have something in their toolbox that has some behavioral components to it for those individuals who do not want to see behavioral practitioners or specialists. We've got some ACO's we're working with in California and some in the southeast," she says.

The way it works is patients sign in with their usernames (it can be whatever the patients choose) and then check in with an emoticon to indicate how they're feeling. There are 28 different emotions a user can choose from, ranging from happy to in pain. The small icons are also color coded red, yellow, or green. The color is important and can serve as an SOS signal of sorts. For example, if a user checks in as being "in pain," which is red, then everyone in that user's support group—the Facebook equivalent of friends—is notified and they can jump to offer support. Friends can then comment, and also hit the equivalent of a "like" button, except the statements are empathic, ranging from, "I relate," to "I feel like that too" (sic).

Patients can also choose which groups pertain to them, such as depression or alcoholism, and they'll be connected with other patients in a social media forum that offers what traditional support groups do not—anonymity. There are also real meetings online as well as webinars with doctors or other medical experts, explains Gondek.

"What's interesting is as these individuals start out online, they are signing up for the online meetings and the talks with the expert, so we're achieving a kind of a mixed model with them being able to enter with their preference. When we say, 'We have a national expert talking about eating disorders today at noon, would you like to join?' They join, and then they ask them questions."

In the pilot project, which included 1,000 patients, Gondek says the effort generated a 20% engagement rate.

"If you look at a traditional coaching program where we are fortunate to get engagement of 2 to 3% using a telephonic model," says Gondek. "By reaching out to these individuals with a welcome home call and an invite to the program, we achieved 20%, which, that's pretty high—double what we thought it was going to be."

Gondek also says that once patients engage with the program they're more apt to take a phone call from a coach, if needed.

And while the hard data from readmission rates is still a few months off, Gondek is optimistic.

"I had a goal of reducing it [the readmission rate] from 2 to 5%, and it's a little too soon to tell, but some of our numbers are looking very promising. We're thinking we're going to save somewhere between $1,000–$2,000 per individual, which is pretty significant."

Gondek says Magellan is running with its early success in substance abuse readmission rates and including other conditions such as eating disorders, chronic pain and autism, among others.

"It's HIPAA-compliant; it's got experts [and] we're monitoring the site. I really think that we could find something here that could be super helpful that would keep costs down. We actually see this as having tremendous power in a number of ways."

Engaged Patients Cost Less

Engaged Patients Cost Less

Marianne Aiello, for HealthLeaders Media , April 17, 2013

It's safe to say that practically everyone reading this article would be an engaged patient. It would be hard not to, being in the industry that we are. While this is beneficial to us personally, I wonder if it skews our views of how many patients are truly engaged and what the value of that engagement actually is.

This question is something I've been thinking about a lot lately as I prepare for the second surgery to repair the damage I did to my left thumb in a gruesome vegetable-chopping incident. (If you're sick of me harping on about this since November, just think of how tired I am of dealing with it.)

During my pre-op phone screen for my coming out-patient surgery, the RN rattled off a list of preparations and rules I had to follow before arriving for my procedure; track down and wash with a particular antiseptic soap three days prior, don't eat anything after midnight the day before, take this medication the morning of but not that, acetaminophen is okay for pain but no ibuprofen or aspirin, etc. 

I dutifully wrote all of this down and, of course, am following it to the T. But what about the people who don't? I can think of several happy-go-lucky (that's putting it kindly) friends and relatives who would easily brush off most of these instructions, who wouldn't bother trekking to three different pharmacies before they found the correct antiseptic.

There are also the varying levels of health literacy to consider. I had to ask the RN on the phone to clarify a few things for me, including the scientific name of the antiseptic, which she had spat out as if it were a common item for the everyday person. Had I not felt empowered to ask, I would not have understood or followed that particular instruction.

Spacey, disinterested, and low-health literate patients are out there, in abundance. Some patients do the best they can and still fall short. Others simply 'go with the flow,' essentially relinquishing responsibility for their care to others.

Improving communication with these types of patients is something healthcare marketers should focus on. And it's more than just good medicine—it can improve costs.

A study in the February issue of Health Affairs looked at the role that patients play in determining health-related outcomes. Researchers found that patients who were more knowledgeable, skilled, and confident about managing their day-to-day health had healthcare costs that were 8% lower in the base year and 21% lower in the next year compared to patients who lacked this type of confidence and skill.

These savings held true even after adjusting for patient differences, such as demographic factors and the severity of illnesses.

Furthermore, engaged patients with the same chronic illness had lower healthcare costs than their less-engaged counterparts; less-engaged asthma patients had 21% higher costs than the most engaged patients. With high blood pressure, the cost differential was 14%.

"There is ample evidence that the behaviors people engage in and the health care choices they make have a very clear effect on both health and costs, positively and negatively," the study authors wrote.

"The most innovative healthcare delivery systems recognize this and see their patients as assets who can help them achieve the goals of better health at lower costs. From this point of view, 'investing' in patients and helping them to be more effective partners in care makes good sense."

Dave deBronkart, a.k.a. e-Patient Dave, also talks about the value of engaged patients in his most recent Forbes column, says "Let patients help." In the article, he describes how being an engaged and informed patient when diagnosed with stage-IV kidney cancer improved his outcome and possibly even saved his life.

The question for marketers, then, is how can we most effectively invest in patients in a way that fosters higher levels of engagement? The Health Affairs study authors offer two suggestions:

1. Build into every step of the care process a meaningful role for patients and their families.
2. Tailor and customize care in a way that helps patients acquire the knowledge and skills they need to effectively manage their health.

I've seen some organizations tackle these steps by creating easy-to-understand brochures and literature for patients to take with them after their hospitalization. Some take the next step of a follow-up call to make sure patients understand the instructions and are following them. And many hospitals, like the one where I'm receiving my care, check in with patients before their procedure.

While these are all likely effective, it seems to me that hospitals need to move away from fostering incident-based engagement and toward patient-based engagement. Patients should be engaged in their health and healthcare at all times, not just when they are having surgery or contract an illness.

It's up to marketers, working with physicians, administrators, and patients, to figure out what that balance is.

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• HEDIS and Star Improvement Programs

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2014 Medicare Advantage Final Call Letter

Announcement of Calendar Year (CY) 2014 Medicare Advantage Capitation 
Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter

4/1/13


Key Changes from the Advance Notice:

Growth Percentages: Attachment I provides the final estimates of the National MA Growth
Percentage and the FFS Growth Percentage and information on deductibles for MSAs.
Calculation of FFS Rates: In 2014, we will begin transitioning to a methodology in which the
historical claims data are adjusted to reflect the most current hospital wage index and physician
geographic practice cost index. More information on this methodology change is provided in
Attachment III, Section C. For CY 2014, the blend between the repriced and non-repriced AGAs
will be done based on a 50-50 split.
CMS-HCC Risk Adjustment Model: We will implement the updated, clinically revised CMS-HCC
risk adjustment model proposed in the Advance Notice with the following differences: (1) we will
not adjust the denominator and (2) we will blend the risk scores calculated using this model with the
risk scores calculated using the 2013 CMS-HCC model, weighting the risk scores from the 2013
CMS-HCC model by 25 percent and the risk scores from the 2014 CMS-HCC model by 75 percent.
We include in this Announcement the final version of the updated, clinically revised model,
including community, institutional, new enrollee, and C-SNP new enrollee segments. The
relative factors for 2013 CMS-HCC model can be found in the 2013 Announcement.
PACE Model: We will continue to use the same risk adjustment model for PACE paymentsthat
we have used in 2012 and 2013.
Normalization Factor for the CMS-HCC Model: Because the normalized risk scores from the
2014 and 2013CMS-HCC models will be blended, there are two normalization factors for 2014.
They are:
• 2013 CMS-HCC model: 1.041.
• 2014 CMS-HCC model: 1.026.
Normalization Factor for the PACE Model: The final normalization factor for the PACE
model is 1.085.
Normalization Factor for the RxHCC Model: The final normalization factor for the RxHCC
model is 1.030. 3
Frailty Adjustment: The 2014 frailty factors for PACE organizations are the same frailty factors
posted in the 2013 Advance Notice. There are two sets of FIDE SNP frailty factors for 2014; we
will calculate frailty scores using the frailty factors associated with the 2014 CMS-HCC model
and using the frailty factors associated with the 2013 CMS-HCC model. The FIDE SNP frailty
factors associated with the 2014 CMS-HCC model are finalized in this Announcement. The
FIDE SNP frailty factors associated with the 2013 CMS-HCC model are posted in the 2013
Advance Notice. CMS will separately calculate frailty scores for FIDE SNPs using each set of
factors and blend the two frailty scores in the same manner as the 2014 risk scores. These
blended frailty scores will be used both to determine a FIDE SNP’s eligibility for frailty
payments and, if eligibility is met, for payment.
MA Enrollee Risk Assessments: In response to comments received on the proposed policy for
MA Enrollee Risk Assessments, CMS is delaying the collection of “flags” for these assessments
until 2014 dates of service. We will propose and finalize a policy on the extent to which
diagnoses from 2014 Enrollee Risk Assessments will be used to calculate risk scores for payment
year 2015 in the 2015 Advance Notice and Rate Announcement.

For more information, the entire notice can be viewed at: http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2014.pdf

TOP 10 HCC's

This list identifies the most commonly submitting HCC's.

COPD $3112

496 COPD

493.20 Asthma w/chronic COPD (Chronic Obstructive Asthma)

491.9 Chronic Bronchitis

492.8 Emphysema

CHF $3198

428.0 CHF

425.4 Primary Cardiomyopathy (Ischemic is not an HCC)

402.91 Hypertensive Heart Disease w/heart failure

Vascular Disease $2465

443.9 Peripheral Vascular Disease

443.81 PVD in other diseases (diabetes)

453.40 Acute DVT

440.0 Atherosclerosis of Aorta

441.4 Abdominal Aortic Aneurysm

Cancer $1622-$8213

All malignant neoplasm’s including Melanoma but not skin cancer

All secondary malignant neoplasm’s –

Highest HCC if site is documented $17,753

Ischemic Heart Disease $2215

411.1 Unstable Angina

Specified Heart Arrhythmia $2285

426.0 Complete AV block

427.31 Atrial Fibrillation

427.81 Sick Sinus Syndrome

Diabetes $1264 - $3962

·         all diabetes (250.XX) and most of the manifestations

Ischemic or Unspecified Stroke $2067

436 CVA

434.91 Unspecified cerebral artery occlusion, w/infarction

Angina/Old MI $1903

413.9 Angina

412 Old MI

Rheumatoid Arthritis & Inflammatory Connective Tissue Disease $2699

714.0 Rheumatoid Arthritis

710.0 SLE

Physicians and providers should report all diagnoses that impact

the patient's care, and ensure that these diagnoses are accurately

documented in the medical record. This includes the main reason for

the episode of care, and all co-existing, acute or chronic conditions,

and pertinent past conditions that impact clinical evaluation and

therapeutic treatment.