the virginia mason production system, integrity, and leadership€¦ · • e/m coding payment,...

The Virginia Mason Production System, Integrity, and Leadership

Inland Empire AAHAM 2019 Conference

November 8, 2019

© 2014 Virginia Mason Medical Center

Objectives

• High level introduction to the Virginia Mason Production System and leadership

• Shifts in reimbursement landscape and impact to Integrity Programs

• A leadership reflection

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The Virginia Mason Production SystemWe adopted the Toyota Production System philosophies and practices and applied them to health care because the industry lacked an effective management approach that would produce:

• Customer first orientation

• Highest quality

• Obsession with safety

• Highest staff engagement

• A successful economic enterprise

© 2019 Virginia Mason Institute

Learning from Other Industries

4

Efficiency ≠ Faster

Value is determined by the customer


VMMC Strategic Plan

5

Focus on the customer

Be the quality leader

VMPS is foundation for change

Reduce burden on the team

Remove waste


VMM Strategic Plan

6


Our Quality Equation

7

Q:

A:

O:

S:

W:

Quality

Appropriateness

Outcomes

Service

Waste


Taisha Ohio's Seven Wastes


Sensei Sato’s Eight Wastes of Information

Information Waste

Invisibility

Hidden or incomplete information

Complication

Complicated information being sent or received

Waiting

Information must wait to be delivered,

approved, verified or completed

Redundancy

Duplicate work or same information kept in more than

one area

Process Variation

Everyone sets their own pace and does the

work they chooseTypos

Human error

Paperwork

Producing any unnecessary

documentation and forms

Re-work

Having to do it over or repeating

prior work


Concepts and Tools

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Value Stream

Mapping

Daily Management -Visibility and

Accountability

A3s – Strategic

Goal Development and

Deployment

Root Cause Analysis

Innovation –PDSA Cycles

Product Quantity

(PQ) AnalysisRPIW 3P

The Revenue “Cycle”

BILLING

CDMP

SCHEDULING

REGISTRATION

INSURANCEVERIFICATION

FINANCIALCOUNSELING

CASE MGMT/QUR

CDM/CHARGECAPTUREMEDICAL

RECORDS

CUSTOMER SERVICE

THIRD PARTYFOLLOW- UP

SELF PAYCOLLECTIONS

PROGRAMADMINISTRATION

CASH POSTING

POSTPAYMENT REVIEW

POINT OF SERVICE

COLLECTIONS

DENIALS

MANAGEMENT

FINANCIAL

CLEARANCE

Patient

Access

Documentation

Of

Services

BillingReceivables

Management

Customer

ServiceHospital

Scheduling

Registration

Pre-

Registration

Eligibility &

Verification

Financial

Counseling

Care

Delivery

Patient

Discharge

Transcription

Charge

Master

Coding/

CDMP

Charge

Capture

Payment

Posting

Claims

Editor

Customer

Inquiries

Bill

Reconciliation

Contractual

Adjustments

Legal

Collections

Issue

Resolution

Secondary

Billing

Bad Debt/

Write OffsPatient

Statements

Process Flow by Department

Late

Charges

Utilization

Management

Discharge

Planning

Case

Management

Claims

SubmissionFollow-Up

Appeals/

Denial Mgmt.

Feedback


The Importance of Leadership

The World-Class Management System is a leadership system that provides focus, direction,

alignment, and a method of management for daily work

This Or This

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VMMC Leadership CompactOrganization’s Responsibilities

Foster Excellence

• Recruit and retain the best people

• Acknowledge and reward contributions to patient care and the organization

• Provide opportunities for growth of leaders

• Continuously strive to be the quality leader in health care

• Create an environment of innovation and learning

Lead and Align

• Create alignment with clear and focused goals and strategies

• Continuously measure and improve our patient care, service and efficiency

• Manage and lead organization with integrity and accountability

• Resolve conflict with openness and empathy

• Ensure safe and healthy environment and systems for patients and staff

Listen and Communicate

• Share information regarding strategic intent, organizational priorities, business decisions and business outcomes

• Clarify expectations to each individual

• Offer opportunities for constructive open dialogue

• Ensure regular feedback and written evaluations are provided

• Encourage balance between work life and life outside of work

Educate

• Support and facilitate leadership training

• Provide information and tools necessary to improve individual and staff performance

Recognize and Reward

• Provide clear and equitable compensation aligned with organizational goals and performance

• Create an environment that recognizes teams and individuals

Leader’s Responsibilities

Focus on Patients

• Promote a culture where the patient comes first in everything we do

• Continuously improve quality, safety and compliance

Promote Team Medicine

• Develop exceptional working-together relationships that achieve results

• Demonstrate the highest levels of ethical and professional conduct

• Promote trust and accountability within the team

Listen and Communicate

• Communicate Virginia Mason values

• Courageously give and receive feedback

• Actively request information and resources to support strategic intent, organizational priorities, business decisions and business outcomes

Take Ownership

• Implement and monitor Virginia Mason approved standard work

• Foster understanding of individual/team impact on Virginia Mason economics

• Continuously develop one’s ability to lead and implement the Virginia Mason Production System

• Participate in and actively support organization/group decisions

• Maintain an organizational perspective when making decisions

• Continually develop oneself as a Virginia Mason leader

Foster Change and Develop Others

• Promote innovation and continuous improvement

• Coach individuals and teams to effectively manage transitions

• Demonstrate flexibility in accepting assignments and opportunities

• Evaluate, develop and reward performance daily

• Accept mistakes as part of learning

• Be enthusiastic and energize others


1. Know your business

2. RUN your business

3. IMPROVE your business

Daily management

is HOW you

accomplish

this…

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Leadership Expectations


VMMC: Connecting the Dots

Our Strategic

Plan

Organizational

Goals

Department

Priorities

Cascading Goals

Department

Kaizen PlanDaily

Management


Change…

Disequilibrium

Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press,

2002, p 108.


Pause forQuestions or Comments

before we move into Integrity


Happy Compliance & Ethics Week!

• Standards, Policies, Procedures

• Program Administration

• Scanning and Evaluation of Employees, Physicians, Vendors and other Agents

• Communication, Education and Training on Compliance Issues

• Monitoring, Auditing and Internal Reporting Systems

• Discipline for Non-Compliance

• Investigations and Remedial Measures

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Not an Integrity Officer, obviously

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OIG FY 2018 year in review

764 criminal actions

813 civil actions

$2.91B anticipated recovery

2712 excluded individuals/entities

CMS will continue to fund efforts to “detect” and efforts to “prevent”

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Big Dollars

Of the $2.8 billion actually recovered by the government from 2018 fraud cases, $2.5 billion involved healthcare.

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Employee Engagement

Of the $2.5 billion recovered from healthcare in 2018, $2.1 billion began with a whistleblower.

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CMS Savings

• Medicare “saved” an estimated $15.5 billion in Fiscal Year (FY) 2017, for an annual return on investment of $10.8 to $1

• The 2018 Medicare fee-for-service (FFS) improper payment rate was 8.12%, the lowest since 2010.

• This translates to about $4.5 billion less in estimated improper payments from 2017.

• For Medicaid, in FY 2018 CMS recovered $10.5 billion in FFS improper payments

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Professional Service Reimbursement

• Primarily still fee-for-service. Procedural reimbursement (time based, fee schedules, conversion factors)

• 2019 E/M documentation requirements

• Making way for heightened CMS focus on growing risk adjustment/quality reimbursement

• Integrity: Shifting our internal monitoring practices to expand our diagnostic coding education, analysis, and reviews


Growing CMS FFS Recognition for Non-Traditional Services

• Past few years: Reimbursement of “non-traditional” services

• Transitional Care Management

• Chronic Care Management

• Indirect Care (via portal or phone)

• With every payment opportunity CMS allows for these population health services, there are an array of exceptions and requirements

• We should expect to see these heavily audited in the near future; Integrity monitoring and auditing “opportunities”


Continuing challenges for Pro

• E/M Coding Payment, Coding and Documentation challenges, continued

• Expansion of telehealth services and advancement of virtual care…maybe

• Payment shifts and greater emphasis on site of service shifts (outpatient hospital to office, Ambulatory Surgical Centers vs Hospitals)

• And Integrity needs to adjust

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Facility Reimbursement

• Unstoppable rise of retrospective audits (Federal, State, and Commercial Plans)

• Challenging not only the codes but also the actual diagnosis documented by the provider

• Medical necessity of patient’s hospital status

• Medical necessity of services being provided

• The specificity of ICD-10 being used by payment community to micro-manage clinical decision making


Facility Reimbursement

• Seeking DRG downgrades and/or outright denials (“not medically necessary”)

• Outsourcing to vendors who do these retrospective audits on a contingency basis

• Volumes of pre-authorization, payment delays/medical review, chart requests, and denials on the rise


Regulatory Landscape for Integrity

CMS MAC data sharing—Parts A and B using RACs and ZPICs to target, then under DHHS:

State: MICs and MFCUs

Federal: HRSA, OCR, FBI, OIG, DOJ

DOJ

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Additional Integrity “Worries”

• Paying for value, price transparency, and “regulatory flexibility” are key topics in healthcare integrity

• Significant changes are either expected or already in progress

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CMS Shift to Quality

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© 2014 Virginia Mason Medical Center 45https://www.acc.org/membership/sections-and-councils/cardiovascular-management-section/section-updates/2018/01/18/12/07/the-transition-to-value-mostly-a-ripple-will-it-become-a-wave


Quality of Care and Compliance

• Quality of Care cases brought pursuant to FCA that seek to hold providers liable for substandard care.

• Submission of false claims when knowing failure to meet standards of care/evidence based practice…but wait for more….

• “Data competence”—EHR, quality data, patient data, revenue/payers, cost to deliver care, coding/billing 46


Provider Quality and Integrity Partnership• Quality and compliance build on each

other’s strengths

• Value-based care requires collaboration

• Conduct an assessment of where quality and compliance now intersect in your organization, and leverage this overlap.

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Jesep, Paul and Pelerin, Kristine; Quality and Compliance Defined;

Compliance Today, September 2019


Provider Quality and Integrity Partnership, continued

• Value based care and reimbursement

• Social determinates of health

• Risk stratification/Population health

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Jesep, Paul and Pelerin, Kristine; Quality and Compliance Defined;

Compliance Today, October 2019



before we move into Resources


CMS Provider Compliance Tips

https://go.cms.gov/2IpUkgi

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https://go.cms.gov/2IpUkgi


CMS Provider Compliance

https://go.cms.gov/2L2MECq

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https://go.cms.gov/2L2MECq


OIG Workplan

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Open Payments

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Open Payments, continued

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MPFSDB, IPPS, OPPS, ASC….

Physician Fee Schedule…final rule supposed to address “reducing burden, recognizing clinicians for the time they spend taking care of patients, removing unnecessary measures, and making it easier for clinicians to be on the path towards value-based care.”

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A word from our friends

• CMS bulletins

• Noridian A and B

• Many, many listservs and publications

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Pause forQuestions or Comments Before

we move into Hot Topics


New CMS Radiology Requirements

• Effective January 2021, CMS will not pay for advanced imaging orders (CT, MRI, PET, and Nuclear Medicine) unless providers consult a qualified Clinical Decision Support Mechanism

• CY 2020 is a education and testing year

• Impacted areas include Ambulatory, ED, and Observation settings

• Future rule making expected to refine requirements

• Integrity resources in all aspects of this topic!


Opioid Connection to Integrity• The largest ever federal takedown included opioid related charges against 600 individuals; defendants included 76 physicians charged for their roles in prescribing and distributing opioids.

• Between July 2017 and June 2018, OIG issued exclusion notices to 587 individuals based on their conduct related to opioid diversion and abuse

• OIG analyzed Medicare Part D data to identify opioid prescribing patterns, highlighting 15,000 beneficiaries appeared to be “doctor shopping.”

• In Ohio, OIG completed the first state-specific Medicaid review focused on curbing the opioid epidemic and found more than 700 beneficiaries in Ohio at risk of prescription opioid misuse; nearly 50 prescribers stood out by ordering opioids for more of these beneficiaries than other prescribers

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Source: https://oig.hhs.gov/reports-and-publications/archives/semiannual/2018/2018-fall-sar.pdf


Telehealth

• The CMS Medicare Learning Network, “Telehealth Services,” ICN 901705 dated January 2019

• Information on Medicare Telehealthreleased by the Centers for Medicare & Medicaid Services on November 15, 2018, further explored the future of telehealth services and current barriers that might prevent the expansion of telehealth services

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Hospital-Physician Payments

Stark (Physician Self Referral Law) Law—the physician must act on behalf of the patient

• Physician Compensation Arrangements May Result in Significant Liability (DOJ Fraud Alert, June 9, 2015)

• September 15, 2015, the Yates Memo—no protection of individuals involved

• May 13, 2019, a unanimous United States Supreme Court ruled in Cochise Consultancy, Inc., et. al. v. U.S. ex rel. Hunt, increasing the amount of time that whistleblowers have to come forward

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Patient Complaint Monitoring

Yes, and have a process to identify those complaints that relate to compliance concerns

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What is Covered?

• LCDs getting stripped of CPT/ICD

• MACs moving codes to Local Coverage Articles—removed from clinical criteria

• Supposedly by January 2020

• No notice or comment period—so can add or delete codes without input from healthcare

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FCA & Medical Judgment

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The court in U.S. v. AseraCare Inc., et al, No. 16-13004 (11th Cir. September 9, 2019) held that Medicare claims are not capable of being “false” under the False Claims Act if the claim of “falsify” amounts to a disagreement over medical judgement.


ICD-11….what?????

Timeline, legislation, funding, bugeting based on upcoming research of what is missing from ICD-10

The WHO fully electronic 1th edition of the ICD contains _________ codes, compared to the 14,400 in ICD-10.

31 countries are field testing.

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New Enforcement Authorities

• Program Integrity Enhancements to the Provider Enrollment Process (CMS-6058-FC)—effective 11/4/2019

• A new “affiliations” authority allows CMS to identify individuals and organizations that pose an undue risk of fraud, waste or abuse based on their relationships with other previously sanctioned entities

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DOJ Issues Guidance May 2019

https://www.justice.gov/opa/pr/department-justice-issues-guidance-false-claims-act-matters-and-updates-justice-manual

• Key: voluntary disclosure of misconduct & cooperation may lead to more favorable “resolution”

• Need to demonstrate certain provider-led compliance program elements 67

https://www.justice.gov/opa/pr/department-justice-issues-guidance-false-claims-act-matters-and-updates-justice-manual


Patient Discharge Status Codes

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before we wrap up


Be sure you

put your feet in

the right place,

then stand firm.

– Abraham Lincoln

72

Be sure you

put your feet in

the right place,

then stand firm.

– Abraham Lincoln

Fry Family Vacation 2018


Integrity: Flexible and Innovative

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• Change how we assess risk, monitor and audit

• Look for enhancements in our electronic health record system and data reporting

• Understand data integrity monitoring/management programs

• Partner with providers across the care continuum


Board Focus: Integrity Behaviors

“Prior View”: Focus on metrics, trainings, calls/hotline, data, tools

“Future View”: Focus on behaviors, ethical decision-making, organizational justice, and freedom of expression

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Getty Images


Leadership Lessons from Apollo 11

1. Visions can come true

2. Teamwork matters

3. Be confident in your mission

4. Commit to getting the job done

5. Encourage ideas

6. It takes a village

7. Learn from mistakes

8. Be fascinated and motivated

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https://www.forbes.com/sites/michaelperegrine/2019/07/16/apollo-11s-

transcendent-leadership-lessons/#5e2543b5b6a7


Contact Information

Thank you.

Julie Fry

(206) 223-6397

[email protected]

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