CMS Proposes Extension of RAC Audit to Medicare Advantage Plans

Guest post by Rajeev Rajagopal, president, Outsource Strategies.

Rajeev Rajagopal
Rajeev Rajagopal

The proposal of the Centers for Medicare & Medicaid Services (CMS) to expand its Recovery Audit Program to Medicare Part C or Medicare Advantage (MA) plans is a new step in its efforts to fight fraud, waste and abuse in the Medicare program. The move is aimed at identifying overpayments and underpayments made on claims for services provided to Medicare beneficiaries. For physicians’ practices, the expanded recovery audit program would mean that they will have to take proactive steps to reduce their risks of falling prey to recovery audits by pay ensuring error-free submission of the claims of MA patients.  Outsourcing medical billing and coding is a great option to accomplish this task.

Medicare Advantage (MA) Plans and Allegations of Billing Fraud

MA plans or Medicare Part C are offered by private insurance companies approved by Medicare, which receive payment from Medicare for the coverage provided. There are different types of MA plans which provide all of a Medicare patient’s Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Part C plans are different from standard Medicare in that they are paid a set fee every month for each patient based on a complex formula called a risk score. CMS pays higher rates for sicker MA beneficiaries than for those in good health. CMS scrutinizes the diagnosis information reported by MA organizations and calculates risk scores for each enrollee using the Hierarchical Condition Category risk adjustment model. The risk score is calculated based on the enrollee’s demographic characteristics and health conditions. This practice aims to improve the accuracy of Medicare’s payments to MA organizations and reduces the incentives for plans to select only the healthiest beneficiaries.

Identifying Improper Medicare Payments with Recovery Audits

However, in recent years, there have been various reports of overbilling MA plans, costing taxpayers billions of dollars more than warranted. In Jan. 1, 2010, the government set up the Recovery Audit Program to fight fraud, waste and abuse in the Medicare program. It detects overpayments and underpayments for Medicare claims so that CMS can implement actions to prevent improper payments in all 50 states. Under the program, Recovery Audit Contractors (RACs) — private companies hired by CMS — have the authority to review medical records at short notice. RACs notify health care providers of the outcomes of the reviews via demand letters. An RAC demand letter would contain details of the problem with a claim, such as the coverage, coding or payment policy that was violated, a description of the overpayment made, recommended corrective actions, and explanations on the provider’s right to submit a rebuttal statement prior to recoupment of any overpayment and appeal and more.

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Prescription Drug Costs: In Washington’s Line of Fire

Guest post by Ken Perez, vice president of healthcare policy, Omnicell.

Ken Perez
Ken Perez

At two recent healthcare conferences run primarily for provider organizations, speakers spent a considerable amount of time highlighting the sharply increased U.S. spending on prescription drugs in 2014 (+12.5 percent versus 2013) and 2015 (+7.8 percent versus 2014)—about double overall healthcare cost inflation for those two years. In 2015, prescription drugs accounted for one-sixth of all the money spent on personal healthcare services. While drug spending growth is expected to moderate in the coming years, the attendees at the conferences were left with the lingering impression that pharmaceutical companies may have gotten away with inappropriate levels of profiteering in recent years.

Of course, that impression was made—and some would say cemented—last year when Martin Shkreli, former CEO of Turing Pharmaceuticals, famously hiked the price of Daraprim, a 62-year-old treatment for parasitic infections, by 5,455 percent overnight from $13.50 a tablet to $750. Similarly, Michael Pearson, outgoing CEO of Valeant Pharmaceuticals, raised by 1,800 percent the prices of two drugs used to treat cancer-related skin conditions: Targretin gel, a topical treatment for cutaneous T-cell lymphoma, and Carac cream, used to treat precancerous skin lesions called actinic keratosis. A 2012 report by Ipsos Public Affairs concluded that the U.S. pharmaceutical sector had a “net negative” favorability score with consumers, and the much-publicized actions of Shkreli and Pearson three years later obviously did not improve the public’s view of pharma.

As expected, the aforementioned price hikes by Turing and Valeant were denounced by numerous presidential candidates, and drug prices became a popular political football. Both former Secretary of State Hillary Clinton and Vermont Senator Bernie Sanders have made lowering prescription drug costs significant planks of their respective policy platforms. They both advocate allowing Medicare to negotiate drug prices with pharmaceutical companies. Sanders goes even further—to the brink of outright drug price controls—pledging to require pharmaceutical companies to publicly disclose information regarding drug pricing and research and development costs—with the obvious implication that there should be some reasonable relationship between the two.

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Why Medical Translators Need to be Professionals

Guest post by Sean Patrick Hopwood, MBA, president, Day Translations, Inc.

Sean Hopwood
Sean Hopwood

While no one can deny that electronic technology has made giant leaps towards protecting patient information and preventing errors and misuse, you may be surprised to learn that many health care practitioners and facilities are still cutting corners when it comes to medical translations or interpretation.

Inaccurate medical interpreting, or translations carried out incorrectly have the potential to put patients’ lives at risk, and there have been several cases of medical mistranslations documented that have led to severe complications, incorrect diagnosis, and even death.

Check out the following cases that could have had different outcomes had the correctly trained language professionals been used:

  1. Willie Ramirez

In 1980, a young baseball player called Willie Ramirez was taken to a hospital in South Florida, in a comatose state. A medical interpreter was called in to translate the family’s explanation of events; however, the interpreter was not familiar with the Cuban Spanish word “intoxicado,” which was translated as intoxicated, and the doctors assumed that Mr. Ramirez had taken a drug overdose.

This is one of the most famous cases in history of inaccuracy in medical interpretation, as what seems like a fairly small error led to the young baseball player waking up as a quadriplegic. How? Well, in Cuban Spanish, the word “intoxicado” means to be sick after ingesting something, which could be a food, drug, liquid, or anything else that could cause a person to be unwell.

When Ramirez’s doctors dismissed his case as an overdose, they failed to consider other possibilities and overlooked the fact that the patient was actually experiencing bleeding in the brain. By the time the mistake was detected and the proper course of treatment initiated, it was too late. The damage had been done and no amount of neurosurgery could reverse Ramirez’s quadriplegia.

  1. Maria Guevara

If ever there were a more heart-wrenching tale than that of Ms. Guevara’s, it would be hard to imagine, and this tragic example of a medical facility’s negligence has been hotly disputed over the last couple of years. Because of the absence of a medical interpreter, Ms. Guevara was accidentally given a prescription to induce abortion after apparently replying “yes”, to a question she did not understand.

While the doctor was asking her if she wanted to abort the baby, Maria thought the question was whether she wanted to keep the baby, and with no professional medical interpreter to translate between herself and the doctor, the outcome was losing the baby in a Californian hospital where almost half of all patients are Spanish speakers with English as their second language.

Occurring in 2013, the case of Guevara has forced the medical profession to come to terms with the real risk involved in inaccurate or total absence of professional linguists on hand to avoid liable and save lives; especially with the Hispanic population set to outnumber white Caucasians by 2060.

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Who Can Turn Your Staff’s “Medical Minds” into “Data-Driven Docs?”

Guest post by Nora Lissy, RN, BSN, MBA, director of healthcare information, Dimensional Insight.

Nora Lissy
Nora Lissy

A recent report from Research and Markets predicts that the healthcare data analytics sector will grow to more than $34.27 billion by the end of 2022. This is indicative of how hospitals and health systems are realizing the intrinsic value in an analytics capability—which can be leveraged for everything from capturing information to interpreting the data—to make more informed care decisions. From a provider standpoint however, many physicians are still struggling to close the gap between turning data insights into actionable care improvements. For example, looking at a data set of former pharmaceutical plans for patients with asthma and using the information to make a more informed prescribing decisions for a current patient.

So what can healthcare organizations do to help bridge the divide between the clinical staff and the IT department to make it easier for doctors and clinicians to see how analytics can be applied in their day-to-day care routine? To start, they need to identify which members of their clinical staff have a “data mind” and can easily see how data can be turned into care improvement. For example, looking at an analysis of a hospital’s patient care transitions and adjusting patient handoffs to be more streamlined across departments. A person in this role can communicate to both the clinical and IT sides of the house why data needs to be presented in a certain way and where care adjustments and enhancements can be made.

So how can you find this diamond in the rough who has the ability to turn providers’ “Medical Minds” into “Data Docs” of tomorrow? Here are three tips to help determine who the best person at your organization would be to help fill these shoes:

Who is your organization’s “go-to?”

Who is the one person in your organization/department who everyone goes to with questions? It can be anything from a question about a schedule change or process to a new patient’s medication history. In many cases, this doesn’t even need to be someone from the clinical side or from the IT side. It simply should be someone who has a global view of the organization and who is familiar with the clinical side and has an understanding of what needs to happen on the technical side.

Who has good business intuition?

Someone who has a natural knack in the business world also typically has a data-oriented mindset. This is someone who is not afraid to question the reasoning behind certain recommendations and processes. This is not to say that this individual is counterproductive, but instead is the problem solver. Much like the organization’s go-to contact, this person also sees the full organizational picture rather than just through the lens of the department that they work for and are instilled with ability to translate the business and operational needs into the technical needs.

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Progress in Medicare Reimbursement for Telehealth and New Primary Care Model

Guest post by Dr. Deborah A. Jeffries, director of sales, Revolve Robotics.

Dr. Deb Jeffries
Dr. Deb Jeffries

There are exciting developments with telehealth reimbursement thanks to the progress in moving towards Patient Centered Care, and a focus on Prevention and Wellness. Early in 2016 we saw the introduction of Senate bill 2484 and with it a proposed path to remove many of the obstacles to providing access to patient centered care and telehealth. Now we are seeing the Comprehensive Primary Care Plus model take shape that further supports telehealth adoption and reimbursements. Imagine a connected care team, in collaboration with patient and family members, the relevant data is available as needed, and an empowered healthcare provider who is able to ‘do the right thing’ with respect to each patient.

Wouldn’t it be great if care was accessible independent of the patient’s or doctor’s location, whether they are rural or urban, whether they are in their home or in a clinic? Well, Senate bill 2484 may do just that. It is looking at removing obstacles to delivering telehealth services and opening the door to the delivery of care where and when it is needed.

Additionally, wouldn’t it be great if the primary care practitioner were free to utilize the right delivery of care at the right time?

To date it has been difficult to find a model that empowers the primary care provider and provides the freedom to do what they know is best for their patients including telehealth as appropriate. This year, a change is kicking off that may go a long way toward enabling the primary care practitioner. It comes in the form of the recent announcement from CMS in an interview with Joyce Freidon from Medpage Today published in article on 4-11-16: “The 5-year initiative, known as the Comprehensive Primary Care Plus model, will give doctors the freedom and flexibility to practice medicine the best way they know how, to return to what matters most to doctors and their patients,” said Patrick Conway, MD, CMS chief medical officer, on a phone call with reporters.

And Dr. Conway states “If telehealth makes sense, they can do that.” As the program kicks off this summer and goes into action January 2017, look for more details to unfold.

The article further quotes Dr. Patrick Conway:
“Doctors will be given more freedom to design the type and amount of care that best meets the needs of their patients,” said Conway. “If telehealth makes sense, they can do that … This initiative will also make it easier for doctors to communicate with each other and have all the information they need … to get better support from nurses, specialists, and others on the patient’s care team.”

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Will Meaningful Use Flatline in 2016?

Guest post by Emily Tyson, director of emerging markets, Curaspan.

Emily Tyson
Emily Tyson

On the cusp of many important changes currently impacting major healthcare policies, Andy Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS), made a striking statement to the audience at the J.P. Morgan Health Care Conference earlier this year: “The meaningful use program as it has existed will now be effectively over and replaced with something better.” This remark created a stir within the healthcare community, which has long lamented the burdensome documentation and lackluster results most often associated with the Meaningful Use (MU) program, and left many providers and healthcare organizations wondering what that really meant for the future of reimbursement, along with healthcare technology and EHR regulation.

What do we know today?

Slavitt’s comments reference a transition – not a replacement – to a new payment program. The government is making a concerted effort to lessen the burden associated with its programs and push the industry toward value-based care. Last year Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA). The Act made three notable, high impact changes to Medicare reimbursement:

With the recent release of the proposed MACRA ruling, the Act and associated rules may take effect on January 1, 2017 and will offer healthcare providers two options for participating in quality programs: (1) Fee-for-service (FFS) combined with greater incentives through a new Merit-Based Incentive Payment System (MIPS), or (2) Alternative Payment Models (APMs). The current payment adjustments associated with the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBPM), and MU will be phased out and replaced with a consolidated approach. MIPS will provide payment adjustments based on four weighted performance categories: Quality (30 percent), Resource Use (30 percent), Meaningful Use of Certified EHR Technology (25 percent), and Clinical Practice Improvement Activities (15 percent). APMs include reimbursement models, such as ACOs, patient centered medical homes, and bundled payments.

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How to Prevent Ransomware from Holding You Hostage

Guest post by Mike Baker, founder and principal, Mosaic451.

Mike Baker
Mike Baker

Over the past couple of months, hospitals and other healthcare facilities have come under siege by cyber-criminals. However, the hackers aren’t after patient data; they never even access it. Instead, they are infecting computers with ransomware, a type of malware that locks down a system and prevents the owner from accessing their data until they pay a ransom, usually in Bitcoin. Among the high-profile attacks that have made headlines:

Although any organization can fall prey to ransomware, lately healthcare facilities have been the primary targets. Some experts feel the problem has reached crisis levels – and hackers are only getting started.

Why Ransomware Attacks are on the Rise

Ransomware is growing in popularity because it is far more lucrative than more traditional cyberattacks where hackers access and steal data. Once the data is stolen, the hacker must find a buyer. Then, the hacker has to negotiate a price. Conversely, in a ransomware attack, the hacker has a built-in “buyer” — the owner of the data, who is not in a position to negotiate on price.

Ransomware is also a simpler and quicker mode of attack than a data breach. Once a hacker has breached a system, downloading a large data set can take some time, during which the attack could be identified and halted. Because ransomware never actually accesses a system’s data – it just locks it down – it works far more quickly and covertly. Victims have no idea they have been compromised until they find they cannot access their system.

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Tackling Patient Safety with Real-Time, Data-Driven Clinical Intelligence

Guest post by Adam Klass, chief technology officer, VigiLanz.

Adam Klass
Adam Klass

Here are some downright chilling patient safety statistics keeping healthcare leaders up at night: Each year more than one million hospital patients – that’s 136 per hour, every day – are affected by sepsis, and 280,000 die. In addition, 82 people in hospitals are affected every hour, every day, by hospital-acquired infections (HAI), and 217 experience a preventable Adverse Drug Event (ADE).

The good news is that an emerging category of technology known as enterprise intelligence resources (EIR) can empower clinicians to more quickly and effectively tackle these infections and ADEs – and even prevent them from occurring in the first place. By integrating and analyzing massive amounts of data generated by multiple sources, EIRs are not only able to identify at-risk patients, but also to tell frontline clinicians in real-time what is happening – and likely to happen – with their patients. Equally important, the EIRs fit seamlessly into clinicians’ workflows, generating only essential alerts.

Built on flexible, interoperable data architectures, EIR platforms extend the value of existing EMRs by integrating real-time clinical and business intelligence with predictive analytics to address sepsis, HAIs and ADEs as well as a wide range of other patient safety and public health risks such as deep vein thrombosis (DVT), venous thromboembolism (VTE), C. difficile (C.Diff), MRSA, surgery site infections, Ebola and MERS. Armed with EIR-provided actionable insights, clinicians can optimize appropriate interventions that improve patient outcomes, reduce patient safety risk and support quality initiatives.

Measurable benefits

Time is of the absolute essence in addressing patient safety risk, particularly in the case of sepsis. Research has shown that the earlier the intervention, the significantly lower the mortality and morbidity.  EIRs can help significantly reduce sepsis risk by enabling clinicians to:

Implementing this approach has been shown to reduce sepsis occurrence by double digits.  Most importantly, patients’ lives are saved. At the same time, reducing sepsis occurrence can also significantly reduce costs, given that sepsis accounts for 40 percent of ICU spending and nearly $29 billion in healthcare expenditures.

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How the Internet of Things Will Reshape Healthcare: One Experience at a Time

Guest post by Puneet Gupta, chief technology officer, Brillio.

Puneet Gupta
Puneet Gupta

For those in the healthcare industry, the future feels at once full of promise and always just out of reach. Transformational advances in technology are on the horizon and fast approaching—but anticipating and adopting new tech can seem like an impossible task.

Perhaps the most promising tech trend for healthcare is the Internet of Things (IoT): the increasingly interconnected network of intelligent devices and objects that share data and enable the physical world to be integrated into digital systems.

While nearly every industry can employ IoT systems to create greater efficiencies and support new business models, the healthcare industry is particularly poised for major gains. According to a recent report, IoT in healthcare alone will be a $117 billion market by 2020.

IoT technology and digital integration has enormous potential to create meaningful experiences and better outcomes for patients, doctors, and healthcare professionals. And yet, amid all this promise, the current state of healthcare IoT leaves a lot to be desired.

How Healthcare Companies Need to Re-Imagine Change

Why is IoT adoption still lagging in the healthcare industry, despite all this potential? Many companies are simply thinking about technological change the wrong way.

Naturally, most people try to think about such changes from a 30,000-foot perspective. IoT is such a huge strategic transformation, it’s easy to get overwhelmed and not know where to begin.

I prefer to look at things differently. Instead of surveying major paradigm shifts from a million miles away, let’s flip the model and focus in on micro-experiences—small, concrete touch points along a user’s journey where technology can make a meaningful intervention.

By building from the ground up in real-world contexts—instead of from the top down in the abstract air—you’ll be able to quickly implement a number of IoT solutions and see the impact. Overarching systems will organically develop up over time as you create valuable micro-experiences on the ground.

While contemplating a global shift only generates new questions, breaking IoT down into bite-sized, tangible moments grounded in reality opens the door for immediate achievements. That’s what we call the art of the possible.

4 Examples of IoT Micro-Experiences in the Healthcare Industry

 In the spirit of focusing on context and individual instances, let’s look at four real examples of how we’ve deployed IoT micro-experiences in healthcare.

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Aligning the Patient Financial Experience to Retail Best Practices

Guest post by Laurie Hurwitz, executive director revenue cycle, Gundersen Health System.

Laurie Hurwitz
Laurie Hurwitz

Research indicates that happy patients are also patients who pay their bills; in fact, research from Conance suggests that they are twice as likely to pay their bills in full versus their less satisfied counterparts. In the age of rising deductibles and patient responsibility, this statistic underscores the importance of patient satisfaction.  Healthcare CEO’s are feeling the pressure; in a recent ACHE study, patient satisfaction was a top 5 concern for this group of healthcare leaders. Patient financial experience is an area of focus as it links directly to satisfaction and loyalty.

Though providers are motivated to improve satisfaction, real-life application is another issue. Influenced by best practices in retail, travel and other verticals, consumer expectations and a provider’s patient financial experience are typically quite different.  Providers who have mitigated this mismatch have been able to achieve above-average results for patient satisfaction, payments and even staff utilization.

At Gundersen Health System, we have used the patient financial experience as a winning differentiator across our five-hospital integrated health network and more than one million encounters across Wisconsin, Iowa and Minnesota. I tend to be conservative in execution of my duties as executive director of revenue cycle at Gundersen, but I also knew that some major shifts would be necessary to align our patient financial experience to patient expectations. We believed that optimizing post-service billing engagement would improve patient satisfaction which in turn would improve our rate of collections.

We felt passionately that hospitals oftentimes create a vicious cycle of poor bill payment experiences with their patients. If only half as many patients paid their bills in full because they did not understand their statements, and if patients were half as likely to return for service if they weren’t satisfied with their billing experience, we were losing revenues and market share due to a totally preventable problem. Happier patients are more likely to pay; as such we needed to ensure that our patients were happy with our billing experience. As a result and in partnership with Simplee, we took inventory of best practices in bill pay and payments cross-industry and explored how to bring these best-in-class experiences to Gundersen’s patient financial experience.

It was obvious that retail payment experiences are designed to make the payment easy, a fundamental difference from health care. Retail facilitates secure guest payment experiences, which eliminated login hurdles. Bills are clear and avoid technical speak, which is practically the antithesis of a typical healthcare experience. Installment plans are flexible and self-service made it incredibly easy for users to stay committed to a payment plan. Retailers also wisely survey clients almost immediately post-transaction, mitigating issues like survey response bias and transaction-survey match confusion.

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