The CMS (Centers for Medicare and Medicaid Services) employs HCC (Hierarchical Condition Category) for determining payment level for Medicare Advantage Plans. The difference in diagnosis of patients and outcome of their health makes for the risk- adjusted payment. Patients suffering multiple chronic conditions are prone to greater risk scores. For physicians practice accurate HCC coding becomes an important element for managing the revenue cycle.
These risk scores are derived by HCC which are annually assigned to the members. HCCs are completely based on claims data which is collected from the providers. This information further gets annually validated through an audit, which is referred as RADV audit (risk adjustment data validation).
For tackling this situation in a better manner, many payers have started education initiatives for guiding their medical staff and physicians to document complete and accurate medical records. Your medical records determine risk scores of all the members. Here we will tell you how professional support can be a holistic approach for reaping greatest benefits and further upgrading your HCC revenue cycle management:
Let’s begin with have a brief insight into HCC codes:
Under HCC codes, your reimbursement depends on diagnosis of the patients. The risk score is higher with the patient having severe diagnosis. HCC codes are also referred as “payment multipliers” by CMS. All the guidelines are to choose a primary diagnosis under risk adjustment.
Describing the main reason for the encounter.
Adding codes which describes coexisting conditions.
Now, let’s start with the importance of professional support in order to upgrade our HCC Revenue Cycle Management:
Staying Updated with Guidelines
We recommend you to look for a partner who have expertise working in the HCC risk adjustment, encounter data submission, preparation of audits(RADV) and can have a retrospective review of records. Regulations which are implemented by ACA can change anytime and that too abruptly. For staying up-to-date, many vendors have established a body of governance, guidance and memoranda. As soon as the changes are announced, this body of governance informs and updates the affected department.
This governance body is liable for evaluating new requirements. Any single department or an individual can’t anticipate the impacts of modified conditions. Expert of each department collectively takes the decision of selecting the best way for responding the new guidelines.
A professional support have its own body of governance for dealing with new guidelines in a better way.
Implementing Audit and Quality Assurance Program
A quality assurance program will lead you to meet RADV audits and improve the accuracy of your data. For reaping the benefits of this you need to hire a third party. Your third party will substantiate the HCCs which are documented and are based on medical records.
The IVA (initial validation audit) has to verify the enrollment which is included in the sample of the member. After this whole process gets completed, a second validation of audit (SVA) is conducted by HCC. This focuses on the sub sample of the member whose evaluation of record is done in the IVA.
In case SVA finds huge amount of errors, HHS will confirm that whether payer is having an effective program for quality assurance. This program focuses to ensure that the data is complete, accurate and formatted properly. A solid assurance quality program is an important defense in the cases of False Claim Act.
As part of an ongoing effort to ensure compliance with the HIPAA Privacy, Security, and Breach Notification Rules, the HHS Office for Civil Rights (OCR) has begun the second phase of audits for HIPAA covered entities. The first phase of the audits was conducted in 2011 and 2012 and evaluated the controls and processes implemented by 115 covered entities in order to comply with HIPAA’s requirements. This second phase of audits builds upon the findings of that first audit, and will address compliance efforts by both covered entities and their business associates.
The second phase of the OCR audits is focused primarily on compliance with HIPAA directives related to privacy, security, and breach notifications. Currently, details about the specific documentation that will be required is unavailable, but the OCR has noted that the audit will only deal with compliance with federal guidelines. Compliance with state regulations will not be addressed at all. Still, even though the specifics of the audit are still under wraps, now is a great time to review your own compliance with HIPAA rules and begin gathering documentation.
The HIPAA Audit Process: An Overview
Earlier this summer, the OCR sent notification to all HIPAA-covered entities requiring them to confirm the contact details for their organization and all business associates that handle protected data by the end of July. Once contact details are confirmed, the OCR will send out preliminary surveys to gather more information about specific organizations and their data protection protocols. From those survey responses, several hundred organizations will be chosen for desk audits, which means that they will be required to submit specific, requested documentation as instructed.
While the Phase 2 audits have many health care executives concerned, the OCR has noted that only several hundred entities will be selected for an audit, and of those, a very small percentage (only about 25 to 50 organizations total) are expected to move on to a full, on-site audit. Still, because there is no way of knowing whether your organization will be selected for audit, you need to prepare and be ready to go should that be the case.
The OCR is quick to point out that the Phase 2 auditing process is not intended to be punitive, and that the purpose is rather to identify best practices and potential weaknesses as a means to provide better guidance to covered entities on how to more effectively comply with HIPAA regulations. That being said, regulators do note that should there be serious deficiencies discovered during the process, then there could be sanctions or other corrective actions taken.
Obviously, the health care providers in your facility do great work every day. You might even argue that miracles are a common occurrence. But when we talk about halos in health care, we aren’t talking about health care in a spiritual sense. When we refer to a halo, we’re talking about the overall impression that patients and their families have of your hospital, and how it can influence your patient satisfaction scores. Because as it turns out, your HCAHPS scores aren’t always based entirely on the actual patient experience.
Understanding the Halo Effect
In 1920, psychologist Edward Thorndike coined the term halo effect to refer to the cognitive bias that influences our impressions of others. According to Thorndike, the overall impression that we have of someone influences the assessment of their character. When someone rates another person highly in one trait, for example, leadership, they are more likely to carry those positive impressions over to other traits, and consider that person more intelligent and dependable as well. We see the halo effect often in our ratings of celebrities: Because celebrities are often attractive and successful, we are more likely to evaluate them with other positive associations as well, such as being kind or intelligent, despite not having any evidence to support that impression.
The halo effect does not only apply to individuals, though. When asked to rate businesses or services — including healthcare — people who have a positive experience in one or more areas are more likely to rate the entire experience as being a good one. What constitutes a positive experience depends on the individual; for example, someone who values tidiness might be upset that their room is not cleaned and straightened up often enough, and thus rate the entire experience more negatively because their experience in one area clouded the entire stay.
The Halo Effect and Satisfaction Surveys
Often, hospital administrators approach patient satisfaction surveys and scores literally. That is, they look at the areas where they are perhaps not up to snuff and focus on improving those specific aspects of the patient experience. While that’s undoubtedly important, by improving the overall experience that patients have with your hospital you can also see an uptick in your overall satisfaction scores. In other words, patients who have a generally extraordinary experience with you are going to rate you higher on the HCAHPS even if every aspect of the experience wasn’t perfect, then a patient who had a less than ideal experience. If the room wasn’t cleaned enough and the food was subpar then those experiences will influence their responses on questions relating to other areas, which may have been excellent.
So how do you “polish your halo,” so to speak? By focusing on the entire patient experience, and identifying the factors that most strongly influence how patients respond to patient satisfaction survey questions, and developing plans to improve in those specific areas. Healthcare administrators are well served to follow the lead of facilities like the Cleveland Clinic, which went so far as to develop an entire department devoted to patient experience and operates under the notion that patients view service as synonymous with quality in healthcare.
Ask anyone involved in the world of clinical trials about the biggest trend facing the industry, undoubtedly they will say “BYOD.” The idea of allowing patients to use their own mobile devices to report data related to their trial participation isn’t necessarily a new one, but with more people using smartphones and tablets than ever before, it’s moved to the forefront of discussions about the best way to manage eCOA data collection.
Why BYOD Is Gaining Traction
On the surface, incorporating BYOD into eCOA seems like a perfect, and obvious, solution. Using dedicated applications on devices that they already own and are familiar with — and most likely have on them most of the time — they can enter data easily, and in real time. The benefits don’t end there, either.
Cost — One of the most significant cost centers for clinical trials, accounting for about a third of the costs of clinical trials, is reporting. More specifically, those costs are incurred in the provisioning of devices for study participants to use in reporting their data. With BYOD, those costs are reduced significantly.
Improved Engagement and Compliance — BYOD in clinical trials removes some of the learning curve inherent in providing devices to participants. Patients are already familiar with how to work their devices, and generally use them on a regular basis, which has the effect of increasing their engagement with the study, and more likely to record the data when and how they are supposed to. There’s no need to carry or learn about a second device, or go to any extra effort, which has the potential effect of improving the accuracy of study results.
Improved Access — Some experts argue that allowing patients to use their own devices for data collection can help increase access to clinical trials for patients living in remote areas. Currently, patients in those areas cannot participate in trials due to limited broadband, but reporting via cellular connections may open new opportunities.
Clearly, there are some significant benefits to using BYOD for clinical trials, and the potential for improved outcomes cannot be ignored. However, there are some concerns about BYOD in this capacity — concerns that have significantly affected adoption rates.