Friday, April 13, 2007
OIG: DME ordered with surrogate UPINs - Updata - durable medical equipment; unique physician indentification numbers - Brief Article
The OIG's report on suppliers' billing and documentation practices for durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) found that 61 percent of services were ordered using surrogate unique physician identification numbers (UPINs) rather than permanent UPINs. According to the OIG, the ordering physicians have had permanent UPINs for at least five years, when one-third of these services were ordered. For 17 percent of these services, the ordering physicians had individual permanent UPINs for at least 10 years before the dates of these services.
In addition, the OIG reported that supporting documentation was missing for 45 percent of services ordered using surrogate UPINs. The OIG recommended that CMS perform a targeted review of claims for medical equipment ordered with surrogate UPINs and continue to educate suppliers and physicians about the need to use accurate UPINs on claims. In addition, the OIG recommended that CMS advise physicians to stop using surrogate UPINs when they have a permanent UPIN. To read the report, go to http://oig.hhs.gov/oei/reports/oei-03-01-00270.pdf.
Medical Center may step in when King/Drew steps out
The plan to close in about 90 days, announced to howls of protests last week by the L.A. County Board of Supervisors, has breathed new life into an effort by California Hospital Medical Center to open its own trauma unit. In July, the downtown L.A. facility failed to reach agreement with the county on how many patients would be sent there.
"This whole thing has made people more responsive," said Katreena Salgado, the hospital's director of public affairs. "We are at the point where we are ready to move forward."
The previous discussions foundered when the county only wanted to guarantee $1.6 million in annual funding for 600 projected trauma victims. The hospital projected it would receive 1,000 patients.
But with King/Drew being taken out of the 13-hospital trauma network, the county appears open to new discussions on the matter. The hospital had been projected to treat 1,800 trauma patients next year.
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California Medical Center, which is owned by Catholic Healthcare West, the San Francisco-based non-profit, has increased staffing and made a host of emergency-room improvements in preparation for what officials thought would be a summer agreement on the trauma unit. "We are ready and waiting," Salgado said.
Tenet Billing Impact
Just how responsible might Tenet Healthcare Corp. be for the high premiums paid by Los Angeles County employers? Possibly a lot, according to a recent study conducted for the California Nurses Association.
The study found that 14 area hospitals owned by Tenet were among the top 50 most costly nationally as measured by their charge-to-cost ratio (the amount of their gross charges for services compared to the actual cost).
The hospitals ranged from Midway Hospital Medical Center, which ranked No. 4 nationally and charged nearly 10 times more than its costs, to Queen of Angels/Hollywood Presbyterian Medical Center, which ranked No. 50 and charged nearly seven times its costs, according to the study by the Institute for Health and Socio-Economic Policy.
"They are fighting lot their bottom line. There is a war among the major players in this industry. The market demands and encourages this kind of behavior," said Don DeMoro, executive director of the institute.
Jan Emerson, a spokeswoman for the California Healthcare Association, a hospital trade group, derided the study as unreliable, noting that DeMoro is the husband of Rose Ann DeMoro, executive director of the nurses association.
Medical expenditures during the last year of life: findings from the 1992-1996 Medicare Current Beneficiary Survey - Cost of Care
Inpatient hospital expenditures constitute a large portion of end-of-life expenses, but use of this service by terminally ill patients declined in the late 1980s and early 1990s (Temkin-Greener et al. 1992; Lubitz and Riley 1993; Scitovsky 1994; Garber MaCurdy, and McClellan 1999). Still, Garber et al. (1999) observed that hospital inpatient Medicare expenditures in the last year of life among the 20 percent Medicare sample grew from 1989-1995, although perhaps not as rapidly as did expenditures for other services during this time period. Recent initiatives to promote the use of home health care, hospice, and advanced directives might be expected to curtail "unnecessary" or unwanted inpatient hospital and other end-of-life services, but these services are difficult to target without also reducing valuable services (Emanuel and Emanuel 1994).
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The continuing growth of population in the oldest age groups in the United States could also change the portion of medical expenditures spent on the last year of life either through larger numbers of elderly deaths or different medical spending patterns for those dying at the oldest ages. Medicare expenditures during the last 12 months of life decline with age at death (McCall 1984; Scitovsky 1984; Lubitz and Riley 1993). Reasons suggested for this include shorter intervals between illness and death and decreased use of acute care, hospitals, and other services with older age at death (Gaumer and Stavins 1992; Scitovsky 1994), as well as less desire among the oldest individuals or their health care providers to use advanced (and expensive) technological methods to prolong their lives (Kramer 1995). By contrast, endof-life non-Medicare expenses are higher among those with older age at death. Three studies observed rising non-Medicare expenditures with older age at death during the last 90 days of life (Temkin- Greener et al. 1992), last year of life (Scitovsky 1984), and last two years of life (Spillman and Lubitz 2000). This increase in terminal year non-Medicare expenditures with older age at death was largely from greater long-term care facility expenditures for older decedents.
Evaluating Medicare and non-Medicare expenditures among the elderly near the end of life remains important as the American population ages. But end-of-life non-Medicare and total elderly medical expenditures have not been studied or compared to non-end-of-life expenditures in a national sample. We, therefore, study 1992-1996 Medicare and non-Medicare expenditures during the last 12 months of life (referred to as "terminal year expenditures") as compared to expenditures before the last 12 months of life (referred to as "nonterminal year expenditures") using data from the Medicare Beneficiary Survey (MCBS). Expenses are subdivided according to service, payer, and person's age. Implications of the findings with respect to current and future health care costs and efforts to reduce medical expenditures are discussed.
METHODS
Study Population and Expenditure Data
The 1992-1996 MOBS is a weighted, stratified, multistage, area probability sample of Medicare enrollees (community and facility dwellers) drawn from the Medicare enrollment file maintained by the Health Care Financing Administration (HCFA). This sample is supplemented annually to add newly enrolled individuals and replace attrition from death. The MCBS interviews participants/proxies every four months, reviewing all health care encounters with the assistance of calendars, along with explanation of benefits from all payers. To improve accuracy of data, respondents record medical events/ procedures on special calendars, and bring receipts, statements, and medication containers to the interview. In computing Medicare expenditures, MCBS cross-checks and supplements the survey with Medicare claims information. For facility residents, billing office workers are asked to provide data on charges and payments. However, only total health care expenditures for a calendar year (or the portion of the year a person survive s) are recorded and non-Medicare costs cannot be subdivided further from available information on dates of service. More details on the MCBS are given elsewhere (Olin, Liu, and Merriman 1996; Eppig and Chulis 1997). This analysis includes full-year Medicare enrollees aged 65 and older on January 1 of the MCBS calendar year.
Recovering buried revenue potential: New Hampshire medical center deploys document management solution that attracts at-home coders and enables reduct
Decreasing the number of unbilled days, or the time it takes to generate and mail a bill and get it into the hands of a discharged patient, by just several days can reduce a hospital's weekly cost of unrealized revenue from delayed payments by millions of dollars. That's the kind of bottom-line fact that cannot be ignored as healthcare providers continuously strive for financial security.
Stuck in Coding Limbo
Concord Hospital, a regional medical center based in Concord, N.H., is the second busiest acute care hospital in New Hampshire, with 205 licensed beds and more than 15,000 admissions in 2004. It provides traditional acute care services in 50 medical specialties and subspecialties, and offers individual centers dedicated to cancer, trauma, orthopedics, cardiology and urgent care.
Last year, Concord Hospital's Walk-in Urgent Care Center was in urgent need of three additional coders to prepare and process invoices. Like many healthcare providers, Concord Hospital had always relied on paper-based patient invoices and records to drive the billing process, but mounting cost pressures and compliance with federal regulations such as HIPAA forced the medical center to seek out a better coding method.
according to Concord Hospital's coding manager, Dottie Poudrier, her department could not keep up with the backlog of paper claims waiting to be coded because of a lack of staff. There was a limited supply of coders looking for jobs, and enticing new hires was an issue, since most candidates wanted to work from their homes. "We needed to offer something special as an incentive to make coders jump ship, since most of them generally stay in one place," she says.
Poudrier's goal was to facilitate the hiring of more coders that would ultimately shave two days off Concord Hospital's average number of unbilled days, which was 14. The problem, though, was clear: How do you keep patient records secure and adhere to HIPAA's strict requirements while attracting quality coders who require the freedom to work at home?
Expediting the Workflow
In addition to addressing the coding staff shortage, Poudrier and her team aspired to eliminate paper completely from the billing process. With this in mind, they mapped out a plan to move to a data entry solution through specialized network devices and customized electronic forms processed by Concord Hospital's mainframe system. To accomplish this, the medical center needed a method of converting existing paper records into electronic documents while the hospital's infrastructure and applications were being revamped.
As an initial step in 2004, Poudrier upgraded the department's photocopier to a digital Canon imageRUNNER equipped with eCopy software from Nashua, N.H.-based eCopy Inc. In the fall of 2004, her staff began scanning paper generated by the Urgent Care Center into the department's computer system. The new process required minimal training. In four hours, the staff learned to scan emergency room records and ancillary claims, including laboratory results, and assign them to a secure network folder that both on-site and off-site coders could access through a virtual private network (VPN).
This procedural evolution allowed Poudrier to entice prospective coders with the option of working remotely; she hired the three at-home coders that she needed. Training them, installing and configuring additional PCs, and setting up VPN access took approximately three months, however. "Coder training and scanning training were minimal. It generally took the remote coders about a week to get comfortable," Poudrier says. Best of all, the remote coders were committed to learning the new process because of the benefits and flexibility of being able to work from home.
Remote Coders to the Rescue
The document management software, coupled with the high-speed scanning capabilities of a digital copier, enabled Concord Hospital to convert paper documents into electronic information that was easily integrated into commonly used business applications, including the existing Novell GroupWise collaboration and communications system and other networked enterprise applications. The result was low-cost, easy and instantaneous distribution and management of electronic copies of paper documents.
Using the new software allowed Concord Hospital to offer a digital document workflow that could accommodate teleworkers. The at-home coders who Poudrier hired have been 25 percent more productive than those coders who work in-house, she says. Overall, Concord Hospital's coding department has experienced an almost 50 percent decrease in the average number of unbilled days, from 14 days to 8 days. No one anticipated the results would be so dramatic, particularly not the medical center's administrative department. By hiring the at-home coders and decreasing the number of unbilled days, Concord Hospital reduced its weekly cost of unbilled days by an average of about $3.6 million, according to Poudrier.
Peer comparisons promote improved billing practices - Data Trends - hospitals should compare billing patterns among peer hospitals - Illustration
Focus 1: Practice Patterns
The analysis of differences in practice patterns, should begin with a comparison of the actual services performed. Simply looking at a charge description master (CDM) alone would not provide evidence of such differences. A hospital in a major Midwestern metropolitan area, for example, compared primary and secondary services delivered in association with echocardiograms with such services delivered by peer hospitals in its market. The peer hospitals had different practice patterns in the type and volume of services. Upon analyzing secondary services, the hospital found that its peers perform a number of additional examinations for a small percentage of patients that it typically does not perform or performs at a much lower rate. For example, the peer hospitals perform cardiovascular stress tests and nuclear medicine exams of the heart in conjunction with echocardiograms 1 to 4 percent of the time, whereas the hospital generally did not perform these exams. The analysis raised the question of whether all hospit als should be performing these studies, and alerted the hospital to a practice pattern that might need to be reviewed.
Focus 2: Internal Procedures
Comparing billing patterns of two or more hospitals also can allow a hospital to identify missed charges caused by deficient internal procedures. For example, upon comparing its MRI services with those of its peers, a large urban hospital found that it was not reporting MRIs in conjunction with emergency department services, whereas its peers were routinely reporting such MRIs. When hospital managers investigated this finding, they discovered that patients' charge tickets were not being updated following MRIs. As a result, billing information for the MRI was not being captured. A CDM review would not have identified this operational problem.
Focus 3: CDM
Following such an analysis, it is critical that the hospital update and maintain its CDM to account for all such secondary codes, as well as recent changes in factors such as HCPCS codes, APCs, and Medicare's rules for coverage. Failure to perform this step will likely lead to missed charges and denied claims.
Billing Alert
A: The amount of protected health information (PHI) your staff is using, disclosing, or requesting is subject to the minimum necessary provision of the HIPAA regulations. Based on this provision, your facility must determine what PHI is necessary for your staff to carry out their job functions. Use common sense. For example, if someone on your staff is responsible for determining the appropriate ICD-9 codes for billing claims, that staff member will need access to the resident's complete medical record to accomplish that task. Your collections staff should never have access to medical records because their tasks only require the information typically found on the resident's admission paperwork, commonly called the resident face sheet. This data includes the responsible party, addresses, phone numbers, and insurance information. Determine by job function what PHI your staff need to know to carry out their duties. Make a reasonable effort to limit PHI access to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request.
From Billing Alert for Long-Term Care by Lee Heinbaugh, consultant, PMG, LLC (Cleveland), published by HCPro, Inc. (www.hcpro.com). Nursing Homes/Long Term Care Management bears no responsibility for the opinions/advice contained herein
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