Day's Pearls

More Pearls are always on the way...... .
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Better practice ideas to ensure Inpt only surgeries are done correctly --surgery scheduler joins the UR team!
Also, who is validating the CPT code that is being scheduled? That is the biggest challenge as we cannot ‘trust’ that the office who is scheduling the procedure to have the correct CPT codes as the hospital is 100% at risk for incorrect CPTs.
HIM should join the daily process of all ‘inpt only procedures’ to ensure that the CPTs are validated. Then UR compares against the Inpt only list – present? Scheduling is also the eyes of surgeries that are routinely done as an outpt being requested as an inpt. With UR ‘joined at the hip’ with surgery, this should be treated as an uncommon event/add ons. It takes a team to ensure there is not risk with inpt surgeries. Denials/self denials/recoupments result in huge losses to the hospital.
ICD -10 readiness includes testing with every payer to ensure they are ready to accept BOTH ICD-9 and ICD -10 claims post live. The big areas of impact will likely be the ER and inpt surgery claims.
New ICD –codes = new potential edits and rejections. It is important to have HIM designate a ICD -10 ‘cleaner uper’ to research all rejected ICD 10 claims and help the organization learn what needs changed internally or to help challenge the payers if inappropriate denials. Strong internal partnerships – with using the medical record to find the variances- HIM can work closely with PFS to reduce denials and rejections. Track and trend patterns and share them rapidly to prevent repeat rejections.
It is a brave new ICD -10 world.

ICD -10’s roll out must include payer testing. The healthcare industry needs to continue to work closely, demand testing, watch for all new edits as we move from 15,000 to over 70,000 new dx codes –including a major change to the coding of an inpt surgical case. The case mix index should be watched as each sample is tested – look for the reasons the case mix is lessened – are more specific codes missing? The surgical coding combinations should be re-grouped and closely monitored.
The payer’s may or may not be willing to test all patient types – ask for the hospital association to help if they refuse. Think Y2 K – why was it so ‘transparent?”

Watch closely for the potential change with Medicare’s definition o f an inpt. But just as importantly, the non-Medicare payers are continuing to create their own ‘highly questionable’ process for determining inpt and then doing post payment denials. As much as we ‘cuss and discuss Medicare’ – their regulations are at least in print with a formal appeal process.. What about Aetna’s new directive- after 24 hrs in obs, must call for a new pre-cert and they will determine if inpt or obs. United –must meet both clinical guidelines and 2 MN.. Part C Medicare. Humana is coming out of the woodwork—post payment denials after approved thru phone authorization. Telling a much more complete patient story with WHY AN INPT – will help support all type of payer audits. Stay tuned
Continue watching for CMS to clarify any changes to the 2 MN rule –especially if there is a HUGE change to ‘rare and unusual.’ We will see with the final OPPS regs – effective 1-1-15.
Also we have new auditors for the 0-1 MN stays – the QIOs. The goal is to have more physician review and only refer to RACs for high frequency of 0-1 MN stays. We will see how all this plays out but the best policy is to document WHY AN INPT and WHAT IS THE PLAN? This is missing from almost every audit we do and it has been required since Oct 2013. THE probe and educate findings continue to find approx 50% error rate with these missing elements which would clearly outline the rationale behind the Inpt admission. Tell the pt story!
ICD 10 IS HERE—READY OR NOT! As healthcare providers prepare the biggest change in payer communication- new DX codes – it is important to ensure there are ‘humans’ overseeing all the payment activity, especially with many Medicaid state agencies stating they are not ready and will just change 10 back to 9 and pay… SCAREY! Contracts needed revised, payment scheduled that are impacted by dx codes need closely monitored as well as new dx code combination with CPT code rejections. Medically necessary edits just got a new hit. Keep your internal team on their toes – involve PFS, operations, HIM, CDI, and all aspects of payer denials. Here we go!
ICD 10 is live! And the real hit is now to a) protect case mix index with ensuring all complications are identified and coded correctly and b) payer accuracy with new DRG assignments.
The ongoing unknown of new denials with the new codes is still to come. Stay tuned for Nov!
Watch for the case mix hit from DRGs being impacted by ICD-10.
It is the next issue --ensuring that all specific dx are present. Do a comparison of the pre-ICD 10 higher intensity inpt and then compare a similar case in Icd-10. Same level of DRG?
Watch as not all payers are on the same DRG version. Case Mix Index is at risk if we are not closely monitoring the payments from the payers. Little goodies but overall, more smooth of a conversion than anticipated.

Mgd care plans are the new audit challenge. Traditional Medicare Part A is totally separate from Mgd Care Part C Medicare. Each Part C plan establishes their own areas of coverage including the definition of an inpt. Ensure the contracts with ALL payers clearly identify a) how an inpt will be determined, b) how to address disputed pt status issues and c) how to rebill post discharge disputes? Many claims are being erroneously down coded to obs even with an excellent inpt order and a dynamic plan. No contract? Fully at the mercy of the payer. Get your attorneys ready! Track and trend patterns and abuses. The road is going to be hard as the ‘rules’ are not well known by the UR Team. Contract Mgt and revenue cycle leaders need to join UR in the new mgd care/payer challenges.
Mgd care denials are hitting the hospitals at an increasing alarming speed. The Mgd Care Medicare plans are the most concerning as the facilities are unprepared for the constantly changing ‘interrupts’ from the plans with the UR staff unprepared to deal with the payers. The contracts need immediately evaluated with language to protect the site: What is an inpt? Part C does not follow Traditional Medicare’s rules.
Time to closely align the denials, contracting and UR first point of contact team. Here we go again!
Watch for continuing updates on the change to the QIO for all 2 MN audits. There is still uncertainty as to what will constitute ‘referrals to RAC for additional auditing.’ However a RI hospital, in conversation with their QIO, indicated that after 3 failed audits/major concerns the referral would happen.
Hot news as this is not clearly identified in writing by CMS. Patterns should be identified to prevent repeat ‘at risk.’ ALWAYS HAVE A PLAN for why 2 MNs..
As the QIOs continue to audit short stays, the 2 MN rule should be well documented to avoid any potential denials. Laying out a plan for why 2 MN /presumption or why the 2nd MN after the 1st outpt MN/benchmark is essential to prevent the auditors from ‘hunting.’ The brave, new world is full of auditors from all payers. Telling the pt story and why an inpt will help with Traditional Medicare plus all the mgd care plans.
QIO is on pause. But that doesn’t mean that all documentation education to support 2 MN is on ‘pause.’ Bring your CDI team, your internal physician advisors, your utilization management team ==all together and coordinate an integrated clinical documentation improvement effort. You will be amazed at the consistency of the message with the provider community…and the depth of education internally.
Dr Maria Johar, Super Physician Advisor for Promedia in Toledo, Ohio recently gave us 2 pearls:
Look for the MEAT: Monitor, evaluate, assess Treat= excellent documentation. Plan for the day, Plan for the stay, Plan for the way and Plan for the pay.
Another gem!
Medicare Part C/Medicare Advantage is not Traditional/Original Medicare… all aspects are contract driven. There is significant confusion with treating everyone the ‘same’ but MA plans are very different. Take a look at this month’s Info Line as we will continue to share the huge issues providers are dealing with. PLUS the 2017 Boot camp…it will take a village!

CMS is continuing to look for ways to get a handle on the appeal backlog. Remember that Part C Medicare DOES have an appeal process that mirrors Part A unless the facility signs a contract that says otherwise…which no one should do –right? Ensure denial mgt, UM/Care mgt and other revenue cycle leaders are closely working with contracting to address the many areas of Mgd Care disputes and denials – beyond rates. Have a great one
THE NEW RACS ARE HERE! The RACs are still not allowed to identify short stay inpts for initiation of audit but with the new contracts, the handoffs between the QIO and the RAC will begin… time to beef up your documentation of –why an inpt!
With the massive uncertainty of healthcare reform and the new administration, it is imperative that each healthcare worker realizes the unique role they have to stay educated and teach – their family, their peers, along with their immediate circle of influence. It is going to be a bumpy road with many changes and a potential for a profound change in healthcare…with lots of confused patients … Stay tuned.
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2017 will be full of healthcare chaos with many patients more confused, anguish, and even angry as Congress continues to make changes to possibly the very basic of coverage - Medicare. Stay informed, be prepared to be a leader with knowledge and integrity. Our patients need us as their advocates more than ever.
Healthcare reform is yet again an issue for the country. Promises were made by President Trump that will be extremely difficult to keep -especially as it relates to low cost, healthcare for everyone. If the proposed changes are adopted -even some of them – huge changes to employer coverage, individual coverage, low income, self-employed, chronic illnesses/loss of job, and Sec HHS & Rep Ryan’s desire to move from traditional Medicare/coverage regardless of health status or ability to pay – to an insurance market driven voucher . WOW! Which Insurance plan is ready to offer a 77 yr old with 2 chronic conditions the same premium they have now with the same out of pocket.. Part A Medicare = NO PREMIUM monthly. Hold on! VERY BUMPY ROAD!
Huge concern over the GOP’s repeal and replace of a basic healthcare option for the under 50 employers, self-employed, retires with no insurance and not 65 yet –not to mention Medicaid. Did I mention 130,000 with pre-existing conditions that are at risk? Why is it that we mandate car insurance but not our ‘body ‘ insurance? Essential benefits – maternity, mental health and birth control – are all on the chopping block. Who knows better than healthcare workers the true reason we have insurance? Speak up and educate your family and friends. Healthcare professionals – all levels – see what healthcare really is! Not the political battle.
As we watch the multiple Medicare Advantage insurance plans being investigated for potential fraud in the billing for the management of Medicare patients thru the whistleblower case -we need to be diligent to monitor and report any areas of abuse and concern. We will always be looking for ways to streamline the very labor intensive process of working with the Medicare Mgd care plans. Plus remember – if you have a Medicare pt who is covered by a payer/insurance plan you do not have a contract with – then Traditional Medicare applies. Time to buckle down and track and trend concerns. Happy summer
2018 will create more challenges than we have seen for many years. The changes with the inpt only procedures; bundle initiatives are eliminated or reduced after years of costs to get ready and begin; plus more ‘back and forth’ with regulatory changes – specifically the GOP leadership stating they want to ‘target entitlements’ – which include Medicare, Medicaid and Social Security. The loss of the individual mandate will dramatically affect bad debt…again. Turbulent times…keep the faith.
Watch very closely as the total knee is now off the inpt only list for Traditional Medicare.
What are the rules for inpt coverage for the Medicare Advantage plans? And how do you justify inpt for TK as now justification must be present? Think co-morbid conditions, think living alone/at risk/no one to provide care, think limitations for safe discharge. All need documented every time, each patient. The audits will be starting but remember – patterns are being developed. UG!
Brave new world for contracting. Brave and bold enough to say ‘no’ and realize there has to be a win-win at some level. Unfortunately, the payer/provider conflicts continue and spiral when trying to get inpt coverage or readmission within 30 days for the mysterious ‘related’ denial or disallowing diagnosis codes when they impact a higher DRG payment. Stay diligent and complain loudly. Use the CMS payer-specific complaint process. Providers need to squeak.
Total knees are no longer on the inpt only list.
Therefore, the 2 MN rule applies when ‘defending’ the need for the pt to be an inpt. It is not acceptable to have all 1 MN stays as inpt – that is not the exception. It is important to a) document the medically necessity of the total knee replacement/this is not new and then b) why this pt needs 2 MN – either presumption or benchmark. We should anticipate extensive audits after the 2 yr period ‘to get it right.”
Medicare Advantage continues to be the new anguish. By 2020, it is anticipated 40% of the Medicare patients will be on a MA plan. There is a great need for the providers to learn more about how the Medicare Advantage plans ‘work’ as well as MA plans learning how the anguish over contracting ‘lack of language’ or disputes are adding to the cost of healthcare while drastically reducing the potential for a positive working relationship. Many providers are also forming MA plans. WOW! Ask for operational addendums to the contracts rather than try to put it all within the standard ‘usually rate focused’ contract language. Stay tuned… the Boot Camps will continue to yield more interactive ideas for moving forward. Stay strong!
Continue to aggressively report all Medicare Advantage/Part C denials,down grades and disputes. The list of CMS contacts are on our webpage. If we don’t report the abuse, there is a ‘sense’ that all is well. The MA plans receive large yearly bonuses based on their client/Medicare patient’s scoring of their services. The MA plans are able to offer more than Traditional Medicare with payment based on per-member, per month payments-all based on the risk to care for the pt/how sick they are = higher payments. Stay tuned as we are all learning how to survive the big push for more MA plans.
Medicare Advantage /Part C Medicare is expected to represent 50% of the Medicare market by 2020. WOW! It is time for healthcare providers to gain a much better understanding of how the plan’s operate, the supplemental benefits they offer pts, the ‘choice issues’ , and the significant impact to the providers as they struggle to get authorizations for care. Watch for the 8th PA & UR Boot camp: “Medicare Advantage- Building blocks of contracts, provider sponsored plans, and the new disruption” Look for July 2019 in DC. Stay tuned…as we all continue to learn together..
Disruption in healthcare means change- pure and simple. The delivery system of care is being re-defined -especially as it relates to outside the walls of a hospital. Care Mgt at home for at risk patients – like diabetes – is now part of population health that is being developed and implemented by hospitals. Medicare Advantage is ahead of the game for extending in-home support to help keep patients healthy but their compensation is much different than traditional Medicare. Still, a great way to look at the future of healthcare. Outreach to help patients with compliant healthy choices..chronic conditions….and patient engagement. All looks a bit different but change is constant. And that is not a bad thing…(said the baby boomer! YES)
Merry Christmas! Happy Holidays! As we approach 2019, let’s pray for acceptance, inclusion, while we practice what we believe: Love thy neighbor as thyself. In healthcare, we are healers—in many different ways. Be a healer in very area you ‘touch’ – professionally and personally. We hear it often but – ‘be the person who you want others to be.” The power of one!


Never a dull moment in healthcare! New daily habit – get connected to ongoing updates – like Becker Report, your professional association, other healthcare news updates/usually all free – and do searches for DC proposed changes. They are constant and usually with big gaps for what they really mean. But stay informed. Be the educational leader in your community. Feel free to use all the classes and other tools on the webpage. It takes a village.
As we continue to bombarded with payer downgrades, disputes and denials – it is important to stay diligent with detailed tracking of all 3 elements – payer specific. Additionally, sharing the 3 D’s information – from back to front and to all in-between – we have an opportunity to challenge and possibly change payer behavior. Squeak!
As we all prepare for even more of the Medicare beneficiaries to move under Medicare Advantage-the question is why? Some plans are offering Zero monthly premiums- WOW! Others are offering ‘outside normal healthcare services ‘ -gym memberships, eye glasses, home food deliveries, care managers/calls, telehealth connections. Why? The MA plan forecasts how much each Medicare pt will ‘cost’ with Medicare /tax payer funds paying the per member/per month amt. Limitations: Only ‘community’ coverage -hospitals, providers. Rest = out of network unless emergency. Stay tuned.
When we think we ‘have it’ with the different payer rules – another one jumps up and we start over. Do not dismay! It use to be much more difficult before the internet!! HA Yes, aging myself on that one. Use the power of the internet to search on any topic. You will be amazed at the amount of reference material -especially from CMS. Happy Spring!
Medicare Advantage is fairly new – mostly since 2003. It is primarily insurance companies who offer Part C in addition to their commercial market. MA is NOT Traditional Medicare. The rules are whatever the contract with the payer says it is. But if you are not contracted, Traditional Medicare rules apply. WOW! We need to get our A Game On to be ready to tackle up to 50% of the Medicare market will be MA in 2020. Stay tuned.
Medicare Advantage – do we understand how different it is than Traditional Medicare?
It is hard to get all the team – Utilization Management, Business Office, Denial Management, Contracting = are seldom on the same page when it comes to understanding and coordinating the roll out of MA plans. Contracting =?? Non – Contracting =? It is not Traditional Medicare… It is like a commercial insurance. Have fun!
Prior Authorization! What a nightmare for the healthcare provider community. Although there have been hearings in DC and CMS has said they want ‘patients over paperwork’ and advocated for more electronic submission of required documentation vs faxing – the feedback is – CMS is missing the point. IMA did a recent survey and found that 14 hrs a week is dedicated to trying to get payers to approved medically appropriate care. The conversation continues around why repeat prior auth with ongoing care? What are the true high risk/dx issues versus ALL ? Stay tuned as more and more is continuing to come forward. Happy Oct!

With the 2020 regulations released, we see the anticipated change to move total hip replacements off the Medicare Inpt only list.This will mean that the 2 MN rule will apply, appropriate documentation to support a) medically necessity of having a replacement and b) inpt vs outpt. Check out the inpt vs obs class on our webpage as ‘total knee’ anguish is included. Now just add total hip. Wow! Additionally, CMS is beginning auditing total knee inpts as of 1-20 with dates of service of 1-20. No retro. But don’t give them something to look at! t.
As 2019 comes to a close, it is a good time to reflect on the ‘gifts’ from the Affordable Care Act – as it may well be in jeopardy again. For those of us who have been in healthcare before the ACA -we know how much the ‘protections’ matter – no cap on coverage for long term care or acutely ill, no ability to limit coverage based on pre-existing conditions and the creation of the Exchanges where independent workers, employers and early retirees can still get insurance -some with financial assistance. Healthcare is Personal! Best to you all!
Our world tilted in March. April has been a once-in-a-lifetime event..or so we hope.
Every day I watch and wonder at the internal strength of so many. How we survive when we are scared, when our livelihood is threatened, when our family is apart and when we are challenged in ways we never dreamed we would see. It is a Public Health Emergency. No one asked for this to happen but when I see more than 50,000 known deaths from COVID-19 since the end of March, it is time to put on our best citizen, our best neighbor behavior forward. Stay healthy. Stay safe. Be kind. Getting thru this together means different things to different people. The life challenges are unique to each of us. Humbled..

COVID 2020- As we all work to stay safe, we need to begin to focus on post PHE payer audits.
There were many exceptions made -with each payer making their own – and CMS guiding many plus CARES money = a great potential for errors to be made. Review this week’s Info Line, 6-18-20, as we highlight multiple hot spots for audit. The virus is here for the foreseeable future… let’s be diligent on all fronts.
“Payers gone wild” is a fun line I used recently. It is a little tongue in check but with the many Pandemic ‘rules’ and the exceptional to payer rules with tons of interps – it is incredibly important to create a payer-matrix with all the ‘current rules ‘with appropriate effective dates -and update it constantly. Check every payer’s webpage for changes as this is the most common way for them to share and hopefully you catch it in time. Craziness!”
COVID -19 and 2020. Both have impacted the history of healthcare and the country. As we work to bring this country together – under science and medicine – please remember the power of the healthcare village. We are all tired; we have loved ones impacted by this horrible virus; our community hospitals are in danger of being overwhelmed and yet, our front line heroes and our back end heroes – our revenue cycle leaders continue to do the right thing for our patients. The regulatory changes keep coming; the payers keep changing the rules and yet, we stay committed to the mission of our careers. I applaud each of you. Continue to lead by example. It matters!
Happy Holidays! Merry Christmas! Best healthy wishes to all. As we look back on 2020, each of us has our own ‘memories’ – all requiring a new type of personal commitment to our community, our families and ourselves. Leading by example, believing in science, and the goodness of others -we will have a spectacular 2021… Be safe and smile. Thank you for being part of our healthcare family. The glass is ½ full..
The vaccination rollout is moving slowly but moving. Be sure to read the Info Line /Feb as there are very important issues regarding billing the patient for any vaccination related charges. Financial navigator is needed with correct, easy to communicate answers. People are frustrated and if they gets bills, it will be very negative for hospitals, pharmacies, etc. Happy healthy thoughts to you all!
As the vaccination plan rolls forward, we are continuing to see a change in payer payment reduction plans. Major plans to attack outpt lab, imaging, procedures and specialty drugs. Wow! Hospitals need to be diligent with their pricing to be competitive -even if it requires a complete re-thinking of outpt revenue. Revenue to Cash is being severely impacted by the payers. With the transparency law (with recent data showing plenty of non-compliance) and the patients new engagement with consumerism – time to put our A game on and tackle the real challenges or our market share will continue to disappear to be only inpts. Double Wow!
Hope your ‘little mutiny’ works out but wow – some people are a bit amazing in their lack of respect or lack of ability to work thru change.. Maybe knowing you are ‘listening’ and helping her understand, might help? Crap – and yes, I don’t miss that part of my job / 20 years with 80 employees in multiple different areas.
Spring 2021. We are beginning to receive all the CMS proposed regs plus ‘pause’ decisions on multiple pieces of legislation that was approved by the Trump administration – especially at the end. CMS has said they will evaluate multiple alternative payment models along with more risk-sharing, working on incentives vs hammer…and maybe a combination of both. I know you weren’t bored, but just in case – ensure you are receiving all the CMS updates.. Happy healthy spring!
Hint – when records are requested, the account is being assessed for recoupment by the payer. It is time to insert a revenue cycle review – why was it requested after the initial service was prior-authorized? This is especially important with Medicare Advantage plans. Take a look at the ‘Attacking Medicare Advantage Denials – Taking your power back’ class as it is full of action ideas. Antennas up!
The revenue cycle continues to be a see-saw of digital innovation and human interaction as we all remember – the patient didn’t ask to get sick, didn’t ask to have their live disrupted and didn’t ask to have their bill be so high and their insurance pay so little. This is our community that we serve.
Time to get our “A Game” on as leaders of the revenue cycle.
The payers continue to challenge us in new ways and yet, the front end/Care Mgt/UM sometimes have little knowledge of what the payers are telling us on the EOBs and denial letters.Time to formally ‘track and trend/TNT’ for patterns with each payer -focusing heavily on MA plans and now Mgd Medicaid. Developing a payer matrix is essential so all can ‘see’ and understand the contract implementation pieces while TNTing to really ‘see’ how it works! Fun! Nope, you weren’t getting bored!
Happy healthy Holiday season! As we approach year 3 of the public health emergency, let's not get 'tired' of this and forget that it takes all of us - our healthcare village - to keep each other healthy and strong.
Praying for a better 2022!
Get Vaccinated and let's stop this -it is all preventable! Crazy as I remember my mother telling us about my big brother who had a mild case of polio and how they were standing in line to get vaccinated...and then all of six of us as we were EXCITED not to get sick or have lifelong impacts of many illnesses- red measles, rubella, mumps, then tetanus and boosters.
Science gave us a gift...many times over. Thank you...