2/11/2013

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The Road to and from Recovery

Pat Metzger, RNChief of Care ManagementMemorial Hermann Healthcare System

Our Goals

• To assure that Memorial Hermann, rather than being a target rich environment, was well positioned for the arrival of RAC/MAC activity

• To assure that the leadership and governing body of Memorial Hermann understands the implications of RAC for our System

• To have the continual guidance and direction of our leadership team and governing body in preparing for and addressing RAC issues

• To take the responsibility to correct our own issues and prevent future improper payments

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RAC Preparation

• Identified key focus areas as articulated by the demonstration states– One day stays

– 3 day qualifying stays for SNF

– Patients with avoidable days on the day of admission

– Coding opportunities

– ER Bell curve too high

– NCD paid in error when coding did not pass medical necessity test

– Too many units when it is known that only one surgery or procedure was done

RAC Preparation

• Actively engaged all CM Directors throughout the system to begin the initial retrospective review of records

• Began with an initial set of 5000 charts

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RAC Preparation

• Departmental engagement– PBS/Admitting

– Compliance

– HIM/ROI

– Surgery

– Emergency Centers

RAC Preparation

• Outpatient partners– OPID

– Imaging

– Lab

– Therapies

– Affiliates• Katy Rehab

• Home Health

• Memorial Hermann Medical Group

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Internal RAC Auditors

• Seven clinical staff

• One clerical staff

• Review:– Pre-bill DRGS

– AICDs

– Pacemakers

– Requested audit records

• All appeals prepared by this team

Campus Level Review

• One day stays

• Summary Flag reports– Case Management bill holds

• Appeal letters

• Provider liable validation

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Physician Engagement

• Clinical Program Committees

• Working directly with employed physicians

• Procedure area leadership working with private physicians

• Ongoing education

• Direct intervention with physician offices

HIM Considerations

• Copying Records– Volume

• Release of Records

• Definition of the Legal Record– RAC Record

• Bill Holds for One Day Stays

• Pre-Bill Holds for other Diagnoses

• Discharge Disposition

• Valid Admission Orders

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Order Sets

• Electronic order sets– Mandatory Bedding Orders

• Embedded in electronic orders• Challenge around non-electronic

– Proscribed way for ordering• Bedding order• Location• Service

• Work done with Clinical Programs Committees

Documentation

• No support for clinical presentation– Office findings not transmitted to support patient

status

• Clinical findings differing from dictated progress notes– Physician/nurse documentation doesn’t compare

• Progress notes – “no evidence of”– “no complications”– “tolerated procedure well”– treated but not documented

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Documentation

• Coordination of Consultants – “ok to discharge”

– Attending keeps and treats

– Secondary work ups

– “patient is fine, but we need to keep 2 more days to qualify for SNF”

• Legibility– Three person rule

Documentation

• Well defined checklists for specific procedures– AICD

– Dual Chamber Pacemakers

– Total Joint Replacement• Documentation not present = case not booked

– Spinal fusions

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Observation Services

• Dedicated Clinical Observation Units

• Daily report summarizing all patients and the number of hours patients have received OBS services

• Electronic documentation that forces compliance with OBS expectations

Observation Tasks

When a patient is admitted to observation they will receive:-all the admit forms with the exception of the admission assessment-Initial Observation Assessment (when observation starts) and the Ongoing Observation Assessment (Q2h) tasks on the Task List with the forms attached.Note: A full history must be completed on each observation patient so they get the same level of care as inpatient.

For patients that are admitted to inpatient then changed back to observation they will get the observation tasks each time.

If the patient is in observation more than 24 hours a RN daily assessment task will fire.

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Observation Admit Form

A start time must be documented . The start time is defined as when the Nurse begins taking care of the patient.

The time care is started is NOT determined by when the order is written or when the patient is bedded.

Note: A patient can be moved in and out of observation several times during their stay. The start time of each Observation is when the Nurse begins taking care of the patient.

This initial form is to be completed by the RN only.

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Critical nursing notes

Jumpers to Documentation

When you select the Assessment Review “yes”, then the Assessment Review Adult section opens.

Most of the radio buttons on the forms allow the nurse to document most needed items without having to pull forms from adhoc.

You must remember to document Core Measures.

Note: Documenting I&O, Wounds, Tubes, Lines and Drains will be in Iview.

The assessment will have Last Charted Values (LCV), if preferred there will be a version in the ad hoc folder without LCV.

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Observation Frequent Documentation Every 2 hours

The Required fields every 2 hours are the status of the treatment plan such as orders or progress note and patient’s response to treatment.

The nurse will get a task every 2 hours that will have the form “Ongoing Observation Assessment” attached.

The plan note can be one sentence such as pt tolerating ambulation if that was in the physician plan. 19

Test and ProcedureWhen a patient is going off the floor for a procedure. Click on the Test and Procedure Radio button, and the form will open to track the patient’s time off the unit.

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Procedure Type and Time

The nurse will document the date & time the patient is sent to one of these 4 procedure areas and also determine and document how long the patient was away from the unit rounding to the nearest hour.Example: 1hour 24 minutes =1 hour (Less than 30 minutes rounds down; 30 minutes or more rounds up to the next hour)

The time observation care started and the time in each procedure area will display in this field and pull forward to each form.

The time a patient is off the unit for “actively monitored” procedures cannot be charged as observation time. “Actively monitored” procedure are only procedures in the 4 areas listed below. The time off the unit must be documented to accurately compute total observation hours.

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Clarification “blue text” as to when to fill out this form

A sample of what will display in the Diagnostic Tests and ProceduresBox on the observation forms.

Test and Procedure

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At any point in the observation stay the staff can document name and the contact number of the person responsible for discharge transportation and it will show as last charted value (LCV).

Discharge Transportation Name and Contact Number

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Observation time ends when the patient is admitted as an inpatient or the patient care is complete for discharge. The time waiting for transportation is not included. The Nurse must document the “Observation Stop Time”.

Observation Stop Time

The nurse will get a reminder task to document the stop time on the ongoing form.

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Sample ReportForm Errors for Review

Daily Overview

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Daily Summary

Post Acute Placement

• Commitments to families

• Three day medically necessary qualifying stay– Physician level of understanding

– Family level of understanding

– Every day must be medically necessary

– Remember the admit order starts when the attending writes the order

• Communication with post acute providers

• CMS review of LTACH in the Houston market

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Case Management Operations

• Deployment of resources– Coverage– Points of entry

• Timeliness of reviews• Accuracy of reviews• Frequency of reviews• Actions taken when medical necessity not met

– ABNs– HINNS– Secondary Medical Review– Code 44

• External Secondary Physician Review

What is External Secondary Physician Review?

• Experienced Physician Advisor review of Patient Status Classifications to provide timely Recommendations/Affirmations

• Ability to use Clinical Judgment to Assess Factors beyond narrow Objective Criteria, i.e., InterQual®

• Real Time Dialogue with Attending Physicians to provide Rationale for Recommendation and drive Defensible Documentation

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Why External Secondary Physician Review?

• Physicians want to Bed and Treat Patients• Changing Criteria and Regulations • Individuals with the “Knowledge” NOT Available

at all Times– CMMDs, Case Managers

• Timing of Accurate Patient Classification Matters• Provides Case Specific MD to MD Education to

improve First Time Patient Classification accuracy– Avoids Missed Opportunities in the Future

Why External Physician Secondary Review?

• Increased External Audits by Government and Commercial Payors

– Take Backs Impact Physicians and Hospitals

• Drives Compliant Revenue Capture

• Provides Consistent, Evidence Based Documentation to Defend Billing/ Appeal Denials

– Demonstrate Severity, Supports Coding

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ESPR Service Expectations

• Physician Advisors:

– Available 18 hrs/day, 7days/ wk, 365 days/yr

• Hours of Operation:

– 6am-12 MN

• Scope of Review:

– Medicare, Medicaid, both Traditional FFS and Managed

– Observation Patients out of the ED

– Extended Observation Patients from Floor

– Failed Inpatient Criteria Patients from Floor

• Turnaround Time for Recommendations:

– ED Cases - Average 45 minutes

– Floor Cases - Average 2 hours

• Contact Attending Physician on Status Change Recommendations

Attending Physician Role

• Be Open and Responsive to Physician Advisor Telephone Calls

• Evaluate and Discuss Recommendations

• Act TIMELY on those Recommendations if in Agreement

– Enter Order in Care4

– Provide E-verbal Order to Hospital Staff

– Document in the Record Additional Clinical Rationale to Support Bedding Status

• View Recommendation in Care4 Form

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Benefits

• Physician– Documentation Supports Billed Level of Service

• Differential of IP vs. OP/Observation Codes

• Decreased Risk of Take Backs by External Auditors

• Patient– Status Impacts Financial Liability

• 20% Coinsurance as Op/OBS vs. IP deductible

• Dissatisfaction Relative to the Cost of Excessive Observation Length of Stay

• Benefit Impact – 3 Day Qualifying Stay for SNF

• Hospital– Compliant Process to Support Services Billed

• OIG Target Area around Observation vs. IP Billing

• Commensurate Reimbursement for Level of Service Provided

Medicare Auditing and Enforcement Agencies

Medicare Secondary Payer

Recovery Contractor (MSPRC)

QualifiedIndependent

Contractors (QICs)

Medicare Drug IntegrityContractors (MEDICs)

Zone Program Integrity Contractors

(ZPICs)

Department of Justice(DOJ) and Federal

Bureau of Investigations (FBI)

MedicareAdministrative

Contractors (MACs)

Comprehensive Error

Rate Testing (CERT)Program

Quality ImprovementOrganization

(QIO)

Beneficiary Contact

Center (BCC)

Office of Inspector General

(OIG)

Health Care FraudPrevention and

Enforcement ActionTeam (HEAT)

Recovery Audit

Contractors (RACs)

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RAC/MAC Volumes

• Proactive (8/11 to present)

• Complex Reviews (12/09 to present)

• Automated (10/10 to present)

• Total

• 2967

• 3172

• 1297

• 7436

Provider Liable

• Goal is to decrease the numbers billed provider liable monthly

• Demonstrates that consistent education is having an impact

• Presence of an appropriate bedding order is drives a significant volume of provider liable billing– Surgical ownership on provider liable billing

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Top DRGs

312 Syncope and Collapse 71

470

Major Joint Replacement or Reattachment of Lower Extremity without MCC 57

291Heart Failure and Shock with MCC 46

392

Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders without MCC 34

640

Nutritional and Miscellaneous Metabolic Disorders with MCC 32

714Transurethral Prostatectomy without CC/MCC 21

811Red Blood Cell Disorders with MCC 21

556

Signs and Symptoms of Musculoskeletal System and Connective Tissue without MCC 20

628

Other Endocrine, Nutritional and Metabolic O.R. Procedures with MCC 16

981

Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC 15

Grand Total 333

Trailblazers Transition

• October 29th was cutover date for Novitas

• There was a 6 month black out period during which review activity slowed as Novitas cleaned up existing work from Trailblazers

• The day before the black out ended, received the first request for records from Novitas– Probes vs pre-payment

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Data Management

• One common database used by all departments involved– Compliance 360

• Process flows for each type of denial/demand

• Proactive review of cases with provider liable billing

• Centralized denial management

Quantifying the Cost

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Claims by Type

1364, 11%

4487, 36%6572, 53%

Claims (Total)by Type

Automated

Complex

Proactive

Claims by Fiscal Year

483 995

59654980

0

1000

2000

3000

4000

5000

6000

7000

FY2010 FY2011 FY2012 FY2013

Claims (Total)by Fiscal Year

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Claims by Type

0

500

1000

1500

2000

2500

3000

3500

4000

FY2010 FY2011 FY2012 FY2013

Claims (by Type)Fiscal Year Trend

Automated

Complex

Proactive

Open vs. Closed Claims

10765

1592

0

2000

4000

6000

8000

10000

12000

Closed Open

Claims (All)Open vs. Closed

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Claims by Type

0

200

400

600

800

1000

1200

1400D

ec-

09

Feb

-10

Jun-

10

Sep

-10

No

v-10

Jan-

11

Mar

-11

May

-11

Jul-1

1

Sep

-11

No

v-11

Jan-

12

Mar

-12

May

-12

Jul-1

2

Sep

-12

No

v-12

Jan-

13

Claims (by Type)Monthly Trend

Proactive

Complex

Automated

Automated and Complex

1961

1149605

546

425

181

146

1289493

8273

68

41

33

30

25

23

128

7

6

6654444222211111111

Claims by Status

Automated and Complex

(Open and Closed)Total Claims = 5785

Closed - NAR

Closed - Recouped

Pending InitialDeterminationClosed - FundsRecvd/RetainedPull Med Records

Update Signatory

Closed - Underpaid

Closed - Overturned

Closed - Bill Part B

Pending FIDeterminationClosed - Recouped - BillPart BAwaiting TB Inquiry

Closed - Part ABRebillingClosed - Invalid Claim

Awaiting Demand LetterNARAC Nurses Review

Decision to Appeal to FI

Pending QICDeterminationPending ALJDetermination

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Open Cases Only

605

425

181

93

73

33

27

25 2312 8

76

665

444

222211111

1 1 1

Claims (by Status)Open Cases Only

Automated and Compex

Total Open: 1563

Pending Initial DeterminationPull Med RecordsUpdate SignatoryPending FI DeterminationAwaiting TB InquiryAwaiting Demand Letter NARAC Nurses ReviewDecision to Appeal to FIPending QIC DeterminationPending ALJ DeterminationAwaiting Demand Letter ResultsAwaiting Demand Letter ABRequest for RefundWaiting on FI/MACAwaiting Appeal Letter NAAwaiting Appeal 2 Letter ResultsRef/Ret Ltr RecOverdue - Pending ClosurePreparing Appeal 2 RecordsValidate ClaimSend Medical RecordsAwaiting Appeal 3 Letter ResultsDecision to Appeal to QICClosed - RecoupedDecision to Appeal to ALJInitialAwaiting Demand LetterRecords Shipment LateReopenedPBS - No Known EditReceive Medical Records

Closed Cases Only

1961

1148

546

146128

94 82

68

414

3 1

Claims (by Status)Closed Cases Only

Automated and Complex

Total Closed: 4222

Closed - NAR

Closed - Recouped

Closed - Funds Recvd/Retained

Closed - Underpaid

Closed - Overturned

Closed - Bill Part B

Closed - Recouped - Bill Part B

Closed - Part AB Rebilling

Closed - Invalid Claim

Closed - Bill Dropped

RAC Nurses Review

Closed

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Summary

• Medicare remains our risk to manage – Business as usual isn’t business as usual anymore

• We don’t know what we don’t know

• The RACs are getting more aggressive

• This RAC program is a permanent part of the Medicare program

• We are in it for the long haul

• We need to know how to manage to it