New Year’s Resolutions

2014–The New Year– Some familiar challenges, and some new ones created by changing health care regulations and policies.  Because the change is so rapid, information we provide may be outdated by the time this newsletter reaches you.  We thought it might be helpful to share ideas for New Year’s Resolutions to help staff manage the pace and nature of change even as “specifics” change:

  1. RECOUPMENTS AND AUDITS WILL CONTINUE TO ACCELERATE SO PREPARE FOR INCREASED AUDITING ACTIVITY.  The MACs are conducting probe audits on short stays (0-1 midnight stays after the inpatient order) and in general, RACs will not be reviewing these same stays until after March 31, 2014. Some have interpreted the “pause” in RAC auditing of short stays as a reprieve. Do not believe those who advise that you have until the second quarter to get policies in order.  The MACs will start with 10-25 cases, and may continue to scrutinize short stays after the initial probe and education period.  Auditing may move from a retrospective basis to a prepayment basis but CMS stated in the commentary to 1599 that these stays would be the focus of CMS short stay audits so take the probe audits seriously, and understand that it is important to have a culture that focuses on IMMEDIACY of compliance.
  2. GET THE APPROPRIATE ORDER IN THE CHART ON A TIMELY BASIS.  The timing of the inpatient order is critical.  If the patient actually stays two midnights AFTER an appropriate inpatient order, the stay will not be subject to the probe audits and will not be subject to other short stay audits for patient status analysis in the absence of evidence of gaming or systemic delays.  Delays in appropriate orders can subject the hospital to unnecessary auditing and recoupments, and even though the hospital may ultimately prevail, the hospital loses valuable time, money and resources defending claims which would have some protection from auditing if the orders were timely filed.  The inpatient stay begins with an appropriate order and initiation of services, so do not be lulled into thinking it is appropriate to delay an inpatient order when inpatient services are appropriate.
  3. EXAMINE PROCESSES TO FACILITATE OBTAINING APPROPRIATE DOCUMENTATION.  When a surgical procedure is scheduled, make certain that office notes or other medical records are obtained to support the patient status determinations and where necessary, to show the surgical procedure meets local or national coverage determination guidelines.  When a patient presents in the emergency department and a determination is made that the patient needs to remain in the facility overnight, make certain that the physician addresses “why” the patient must be hospitalized.  Scrutinize processes, forms and order sets to make certain that the sets facilitate appropriate documentation.  Get appropriate physician advisor input on the front end.
  4. MEET ALL OF THE CERTIFICATION REQUIREMENTS.    Because no specific form is required and because CMS has issued some guidance that seems to suggest that CMS will take a “soft” approach to certification compliance, DO NOT be lulled into weak certification documentation. (Click here to view a document from Palmetto GBA detailing the documentation to be sent when responding to its medical record request.)  THE CERTIFICATION REQUIREMENTS ARE IN THE FEDERAL REGULATIONS.  It is the law that the certification elements be in the record, and signed by the physician prior to discharge.  COMPLY and do not listen to advice that certain elements are not important.
  5. EDUCATION MUST BE ONGOING.  Change is hard, and there is much misdirection and miscommunication about the two midnight rule.  Plan at least quarterly education with your leadership team.  Include examples of documentation issues, audit results, and share newsletters and information that is important to your team.  Pay attention to issues unique to your facility and use these sessions as an opportunity to listen and to address issues.
  6. ENGAGEMENT WITH PHYSICIANS IS IMPERATIVE.  Physicians are critical to the success of each compliance initiative.  Peer to peer communication on both a concurrent basis (as decisions are made) and a retrospective basis (through feedback) is an opportunity to take a collaborative approach to compliance.  Some MACs are beginning to deny professional fees for procedures, and physicians have always been subject to medical necessity reviews.  A collaborative program of education to support systemic compliance is an opportunity to enhance communication and cooperation, improving compliance initiatives, quality of care and overall working relationships.
  7. SELF-AUDIT.  The change in the rebilling rules means that it is imperative for you to conduct self-audits to ensure that the certification and documentation requirements are met.  In addition, self-auditing will be critical to supporting compliance initiatives.
  8. EXAMINE PROCESSES AND STAFFING TO ADDRESS CRITICAL NEEDS.  Case management and administrative staffing requirements are affected by changes in the rules.  For example, midnight is a critical time for billing and compliance purposes.  Hospitals may want to consider shifting staff (or using outsourced resources) to ensure that appropriate decisions and documentation are entered before midnight.  Similarly, determine which functions must be conducted by case managers and which can be handled by administrative support so that licensed personnel can be used effectively for functions only licensed personnel can perform.
  9. CREATE A HEALTHY ENVIRONMENT WHERE COMPLIANCE AND QUALITY GOALS ARE PART OF THE FABRIC OF THE ORGANIZATION.  The auditing and recoupment environment often feels hostile and oppressive to staff.  Make certain to recognize staff efforts to carry out the mission and values of the organization.  Listen and respond to staff concerns.  Keep the focus on what can be done to support compliance and quality rather than the unfairness of the auditing process.
  10. UTILIZE RESOURCES.  There are some efforts to achieve relief to some of the auditing burdens.  MedManagement provides physicians for both concurrent review and retrospective review, and also provides educational materials and programs.  Other professional organizations such as the Health Care Compliance Association, Healthcare Financial Management Association, State Hospital Associations, the American Hospital Association and your law firms offer outstanding educational materials and resources.  Let us know what you need, and we will help get information to you.

2014 is a new year with new challenges and new opportunities.  Let us know how we can help you as you prepare to face the year.

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