Welcome to the July issue of the Indidge Advantage newsletter.
You may be familiar with cross training at the gym but what about in our hospitals? Our first article suggests hospital department leaders must remain flexible in a difficult economy.
Are you ready for a RAC investigation? The second article talks about successfully tackling a RAC investigation.
Next is news from Methodist Hospital in Southern California.
And finally regarding Health Insurance Options you won't know whether to laugh or cry.
The Indidge Advantage is produced by Indidge Systems, a healthcare software solutions company specializing in Compliance and Risk Management solutions.
Dom Nicastro
Sometimes, your health information managers need to code. And your patient access managers need to register patients.
In these tough economic times, your hospital staff members should be ready for different roles on any given day. No one is immune to change.
At Albany (NY) Medical Center, managers in the patient access department are prepared to handle staff shortages.
During a recent string of illnesses and consecutives days with short staffs, department leaders took off their managers' hats and got on the frontline to register patients.
"The leadership team are working managers, much like any other patient access area," says Cathy Pallozzi, CHAM, patient access director at Albany Medical, noting the staff recently experienced colds and GI, which sprang the managers to action. "So the managers are on the front end, as well as the associate director. If I am needed, I will be on the front end as well." Albany plays the game of position musical chairs well because the facility prepares, Pallozzi says.
"I have always been from the school of thought that you need to maximize your resource always," Pallozzi says. "In times such as these, it is no different then when you are so busy you do not have enough resources."
Pallozzi says "cross training" is the key. Managers are ready to register patients, obtain authorizations, place patients, and collect copayments and balances.
"Cross training has been and will always be a primary focus for my leadership team," Pallozzi says.
Albany's patient access team created a spreadsheet of tasks and chores-no matter how small-to help move it forward. The medical center called them "re-engineering/efficiency" opportunities, and staff must answer four questions for each task:
- What is the added value in performing this task?
- What does it cost in resources (FTE or hours)?
- Is there a cross training opportunity?
- Is there a redundant process that you are aware of?
Its goal is to gain efficiency, maximize their resources, and "assure that we are working together to problem-solve staffing concern, volume influx, and meeting our patients' needs," Pallozzi says.
Albany's copayment collection remains strong, Pallozzi says, and its pre-encounter telephone calls assist in ensuring the patient knows what is expected. While it has had a dip in its elective surgeries, the medical center's ED and outpatient volume remain strong, Pallozzi adds.
It helps that Albany's managers are always ready for the next challenge, Pallozzi says.
"They are acting as a staff member-the full scope of the registrar responsibilities," she says.
Edward Gaines
Reimbursement investigations will likely be pursued in numbers and with a tenacity not previously seen in the Part B Medicare program. Hospital-based physicians should therefore take steps today to ensure that their practices will be ready if and when a RAC investigation is launched.
RAC investigative results will be subject to the existing Medicare appeals process. Therefore, it is important that organizations be ready and willing to pursue timely appeals through the five-stage Medicare process in the event an investigation finds for recovery against the physician group.
According to CMS data, only 14% of providers in the RAC demonstration project appealed adverse RAC findings. However, of the groups that did appeal, 33% received rulings in their favor. Significantly, a provider win at any level in the appeal process reduces the RAC contractor contingency payment to zero. A win also prevents the RAC from coming back at a later date to scrutinize the same set of claims. An aggressive appeals stance on the part of providers, therefore, will likely emerge as a significant deterrent against marginal investigations as the program matures. However, knowing the appeals process is only the first step to effectively and successfully tackling a RAC investigation.
Self-assessment is a key step
It is important to have a program in place that can review a physician group's claims for a specific period of time to identify potential outlier situations in much the same fashion that RAC contractors assess claims. From this information, physician groups can then determine the nature and extent of potential problems and begin working to mitigate them before a RAC investigation is launched.
According to CMS, groups can take other steps to prepare for the RAC rollout:
- Identify where improper payments have been persistent by reviewing the RAC's Web sites.
- Keep track of denied claims and corrections of previous errors.
- Determine what corrective actions need to be taken to ensure compliance and avoid submitting incorrect claims in the future.
CMS plans to work closely with national and state medical, hospital, and nursing home associations to strengthen relationships and to anticipate the needs and concerns of healthcare providers. Before the program roll-out, town hall-type meetings will be held in each state and will include representatives from the regional RAC contractor, CMS, and provider organizations. Physicians can obtain information about these meetings and the date the program will begin in their states by checking the CMS RAC Web site.
RAC response strategies
Providers should prepare themselves by putting strategic processes in place should a RAC investigation be launched. In a RAC investigation, RAC medical record requests are in writing and providers have 45 days to respond. Providers should first know that a failure to respond leads to a determination of overpayment. Once a response is submitted, the RAC must notify the provider of the result within 60 days of their response. RAC demand letters must also explain reasons overpayment was ruled and appeal rights available to providers.
Providers should know their rights in responding to the RAC, which includes agreeing with determination whereby the Carrier/MAC may be offset or payment may be demanded by the RAC. That's when the rebuttal letter can be written by the provider within 15 days specifying reasons against the overpayment demand, to which the RAC then has an additional 60 days to respond. Appeals should be prepared with a rebuttal letter.
Personalize your RAC action plan
Providers should first perform their own internal "outlier" analysis before the RAC audit letter is received. In other words, be proactive! Second, coding and documentation practices should be checked thoroughly, and corrective action should be taken if needed. Part of this process involves constructing existing compliance programs which are continually updated to ensure that documentation, coding, and claims procedures conform with both the letter and spirit of Medicare payment rules.
The creation of the RAC mechanism, however, introduces a major wild card into the Medicare enforcement mix. Given the financial incentives that exist for RAC contractors to identify and recover improper payments, there is no guarantee that even the most conservative compliance philosophy will preclude a future RAC investigation. That's why it is essential for provider organizations to conduct self-assessments to gauge areas of potential vulnerability and then implement policies to reduce or eliminate that risk.
Providers must also create policies to ensure that all inquiries from RAC contractors are immediately acknowledged and addressed. Finally, they need to be ready to aggressively fight adverse claims through the Medicare appeals process, both to reduce potential financial exposure and to limit the likelihood of repeat investigations.
Hospital-based physician groups should waste little time in preparing for the changes to come. For most providers, it isn't a question of if they'll be audited by a RAC contractor, but when.
Methodist Hospital of Southern California, in Arcadia, California has announced that it has selected Indidge Systems for its Policy and Procedure Management System. Methodist Hospital of Southern California is a 460-bed standalone community hospital serving the many cities in the San Gabriel Valley.
Kara Marx, Methodist Hospital CIO says, "We looked at several vendors but the Indidge Systems product was clearly superior to the others we viewed and their commitment to serving our needs made idTracks-Docs the obvious choice."
"With their track record and with the options they provided for us, it became obvious that Indidge Systems not only offered the best products and services, but their reputation with their provider client base proved invaluable in our decision. We evaluated the top policy and procedure management vendors and Indidge Systems was the clear choice for Methodist Hospital."
About Indidge Systems
Indidge Systems is an industry leader in providing Policy and Procedure Management Systems, Contract Management Systems, Physician Standing Orders Management, and other cost effective products and services within the healthcare industry, With clients spread across the United States, including hospitals ranging in size from 25 beds to large, multi-hospital organizations, Indidge Systems provides web native applications that are focused on improving the operational efficiencies and profitability for providers of healthcare services. These products include POMA (Physician Standing Orders Management), Cercare (Contract Management), and idTracks-Docs (Policy and Procedure Management). Indidge Systems is committed to serving their customers with integrity and providing excellence in every relationship, always. For more information please call 866.252.4656, ext 101 or visit www.indidge.com.
Join us Monday, July 20, 2009 from 9 AM - 10 AM PDT for a free educational webinar. Just click on the register button below or if this does not fit your schedule, send Tom Reid an email at tom.reid@indidge.com or call him now at (480) 829-0479 Ext. 138 to schedule a web demo that better fits your schedule.
For those of you in a quandary when considering your health insurance options, consider the following Q and A:
Q. What does HMO stand for?
A. This is actually a variation of the phrase, "HEY MOE." Its roots go back to a concept pioneered by Moe of the Three Stooges, who discovered that a patient could be made to forget the pain in his foot if he was poked hard enough in the eye.
Q. I just joined an HMO. How difficult will it be to choose the doctor I want?
A. Just slightly more difficult than choosing your parents. Your insurer will provide you with a book listing all the doctors in the plan. The doctors basically fall into two categories: those who are no longer accepting new patients, and those who will see you but are no longer participating in the plan. But don't worry, the remaining doctor who is still in the plan and accepting new patients has an office just a half-day's drive away.
Q. Do all diagnostic procedures require pre-certification?
A. No. Only those you need.
Q. Can I get coverage for my preexisting conditions?
A. Certainly, as long as they don't require any treatment.
Q. What happens if I want to try alternative forms of medicine?
A. You'll need to find alternative forms of payment.
Q. My pharmacy plan only covers generic drugs, but I need the name brand. I tried the generic medication, but it gave me a stomach ache. What should I do?
A. Poke yourself in the eye.
Q. What if I'm away from home and I get sick?
A. You really shouldn't do that.
Q. I think I need to see a specialist, but my doctor insists he can handle my problem. Can a general practitioner really perform a heart transplant right in his/her office?
A. Hard to say, but considering that all you're risking is the $20 co-payment, there's no harm in giving it a shot.
Q. Will health care be different in the next century?
A. No, but if you call right now, you might get an appointment by then.