Government and Regulations

Thousands of Michigan residents will have a better chance of avoiding readmission to the hospital thanks to a groundbreaking new collaboration between three of the state’s healthcare leaders.

Based on SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) model, the collaborative program will be managed by the University of Michigan in collaboration with Blue Cross Blue Shield of Michigan. The Michigan Blues provide and administer health benefits to 4.7 million Michigan residents.

Project BOOST helps hospitals reduce readmission rates by providing them with proven resources and expert mentoring to optimize the discharge transition process, enhance patient and family education practices, and improve the flow of information between inpatient and outpatient providers. Project BOOST was developed through a grant from the John A. Hartford Foundation. Earlier in the year, the program recruited 15 Michigan sites to participate. Training begins in May.

Each improvement team will be assigned a mentor to coach them through the process of planning, implementing, and evaluating Project BOOST at their site. Program participants will receive face-to-face training, monthly coaching sessions with their mentors, and a comprehensive toolkit to implement Project BOOST. Sites also participate in an online peer learning and collaboration network.

“This kind of innovative, targeted program benefits both the patient and the healthcare provider by establishing better communication between all parties,” says Scott Flanders, MD, FHM, associate professor and director of hospital medicine at the University of Michigan in Ann Arbor, and SHM president.

To Flanders, it’s no coincidence that hospitalists are taking the lead in improving hospital discharges. “Readmissions are a pervasive but preventable problem,” he says. “Hospitalists are uniquely positioned to provide leadership within the hospital, to promote positive, system-based changes that improve patient satisfaction, and promote collaboration between hospitalists and primary-care physicians.”

In addition to being preventable, readmissions are costly, draining the resources, time, and energy of the patient, PCPs, and hospitals. Research in the April 2009 New England Journal of Medicine indicates that 20% of hospitalized patients are readmitted to the hospital within a month of their discharge.1 Nationally, readmissions cost Medicare $17.4 billion each year.1

Collaborative Partnerships

Prior to the program’s launch in Michigan, SHM recruited and mentored Project BOOST sites independently. However, like many productive relationships in a hospital, Project BOOST in Michigan depends on collaboration between experts.

“Blue Cross Blue Shield of Michigan is confident that this project, like our other Value Partnership programs that focus on robust, statewide, data-driven quality-improvement (QI) partnerships, will have a positive impact on thousands of Michigan lives,” says David Share, MD, MPH, BCBS Michigan’s senior associate medical director of Healthcare Quality. “We look forward to helping hospitals, physicians, and patients work together to assure smooth transitions between inpatient and outpatient care, and to reduce readmissions and improve the patient experience.”

For University of Michigan hospitalist Christopher Kim, MD, MBA, FHM, Project BOOST is a chance to work with a diverse set of groups. “We are grateful for the opportunity to work with not just Blue Cross Blue Shield of Michigan, but also with the other physician organizations across our state to implement and share best-practice ideas in transitions of care,” says Kim, director of the statewide collaborative program on transitions of care.

Results and Reports

Having launched six pilot sites just two years ago, adding 24 additional sites in 2009, Project BOOST is still a relatively young QI program, which makes reliable quantitative data about its effectiveness tough to come by. The expansion into Michigan gives SHM and others the prospect of programwide measurement of how Project BOOST affects discharge and reduces readmissions.

“This is a tremendous opportunity to improve patient safety, reduce readmissions, and study the impact of Project BOOST interventions through patient-level data,” says Mark Williams, MD, FHM, Journal of Hospital Medicine editor, principal investigator for Project BOOST, and former SHM president. “We’re thrilled to be working with the state’s healthcare leaders to implement this critical program.”

Nonetheless, in the absence of comprehensive data, the early reports from Project BOOST sites are promising. At Piedmont Hospital in the Atlanta area, the rate of readmission among patients under the age of 70 participating in BOOST is 8.5%, compared with 25.5% among nonparticipants. The readmission rate among BOOST participants at Piedmont over the age of 70 was 22%, compared with 26% of nonparticipants. When SSM St. Mary’s Medical Center in St. Louis implemented BOOST at its 33-bed hospitalist unit, 30-day readmissions dropped to 7% from 12% within three months.

Patient satisfaction rates also increased markedly, to 68% from 52%. And in 2009, the University of Pennsylvania Health System awarded its annual Operational Quality and Safety Award to the Project BOOST implementation team at the hospital.

BOOST’s Reach Expands

Project BOOST leaders are planning an aggressive expansion in the near future. In addition to the potential for new program sites, SHM has made materials available to hospitalists through the Project BOOST Resource Room at SHM’s newly redesigned Web site (see “The New Face of HospitalMedicine.org,” p. 12), www.hospitalmedicine.org/boost.

In addition to free resources, new BOOST materials are for sale through SHM’s online store. The Project BOOST Implementation Guide—available electronically for free through the resource room—is now available for sale as a hard copy. The online store also features a new Project BOOST instructional DVD for hospitalists, “Using Teach Back to Improve Communication with Patients.” TH

Brendon Shank is a freelance writer based in Philadelphia.

Reference

1. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14): 1418-1428.

Chapter Updates

The Historic Main Street Trolley in Memphis, Tenn.

Memphis

The Memphis chapter held its quarterly meeting Feb. 4 at Erling Jensen in Memphis, Tenn. Dr. William Edmonson of the North Mississippi Medical Center in Tupelo, Miss., discussed “Updates on COPD.” Boehringer Engelheim sponsored the dinner meeting, which was attended by hospitalists and physicians in the area as well as hospital nurses and administration.

Milwaukee/Southeast Wisconsin

The Milwaukee/Southeast Wisconsin chapter’s Feb. 27 meeting in the Columbia Hospital Auditorium brought together hospitalists, nurse practitioners, pharmacists, and others from the Milwaukee area. Attendees were able to obtain CME credit on topics including acute coronary syndrome, hyponatremia, and sepsis. The meeting highlight was a presentation from Dr. Alpesh Amin, interim chair of the Department of Medicine at the University of California at Irvine. Dr. Amin discussed how to start up a local SHM chapter. Sponsorship from CME University helped make the chapter’s first HM symposium a success.

Nebraska Area

Lincoln HM group Bryan LGH hosted the Nebraska Area chapter quarterly meeting Feb. 23. Dr. Tamer Mahrous gave an overview of coding issues for hospitalists. A copy of the presentation will be sent to all of the chapter members.

The chapter elected officers to serve terms through 2012. They include: Dr. Eric Rice, president; Russ Cowles, vice president; Alissa Clough, secretary; and Jay Snow, officer at large.

Several additional items were discussed, including topics for upcoming meetings, how the chapter can best take advantage of opportunities at HM10, the possibility of launching a chapter newsletter, and organizational issues.

Thousands of Michigan residents will have a better chance of avoiding readmission to the hospital thanks to a groundbreaking new collaboration between three of the state’s healthcare leaders.

Based on SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) model, the collaborative program will be managed by the University of Michigan in collaboration with Blue Cross Blue Shield of Michigan. The Michigan Blues provide and administer health benefits to 4.7 million Michigan residents.

Project BOOST helps hospitals reduce readmission rates by providing them with proven resources and expert mentoring to optimize the discharge transition process, enhance patient and family education practices, and improve the flow of information between inpatient and outpatient providers. Project BOOST was developed through a grant from the John A. Hartford Foundation. Earlier in the year, the program recruited 15 Michigan sites to participate. Training begins in May.

Each improvement team will be assigned a mentor to coach them through the process of planning, implementing, and evaluating Project BOOST at their site. Program participants will receive face-to-face training, monthly coaching sessions with their mentors, and a comprehensive toolkit to implement Project BOOST. Sites also participate in an online peer learning and collaboration network.

“This kind of innovative, targeted program benefits both the patient and the healthcare provider by establishing better communication between all parties,” says Scott Flanders, MD, FHM, associate professor and director of hospital medicine at the University of Michigan in Ann Arbor, and SHM president.

To Flanders, it’s no coincidence that hospitalists are taking the lead in improving hospital discharges. “Readmissions are a pervasive but preventable problem,” he says. “Hospitalists are uniquely positioned to provide leadership within the hospital, to promote positive, system-based changes that improve patient satisfaction, and promote collaboration between hospitalists and primary-care physicians.”

In addition to being preventable, readmissions are costly, draining the resources, time, and energy of the patient, PCPs, and hospitals. Research in the April 2009 New England Journal of Medicine indicates that 20% of hospitalized patients are readmitted to the hospital within a month of their discharge.1 Nationally, readmissions cost Medicare $17.4 billion each year.1

Collaborative Partnerships

Prior to the program’s launch in Michigan, SHM recruited and mentored Project BOOST sites independently. However, like many productive relationships in a hospital, Project BOOST in Michigan depends on collaboration between experts.

“Blue Cross Blue Shield of Michigan is confident that this project, like our other Value Partnership programs that focus on robust, statewide, data-driven quality-improvement (QI) partnerships, will have a positive impact on thousands of Michigan lives,” says David Share, MD, MPH, BCBS Michigan’s senior associate medical director of Healthcare Quality. “We look forward to helping hospitals, physicians, and patients work together to assure smooth transitions between inpatient and outpatient care, and to reduce readmissions and improve the patient experience.”

For University of Michigan hospitalist Christopher Kim, MD, MBA, FHM, Project BOOST is a chance to work with a diverse set of groups. “We are grateful for the opportunity to work with not just Blue Cross Blue Shield of Michigan, but also with the other physician organizations across our state to implement and share best-practice ideas in transitions of care,” says Kim, director of the statewide collaborative program on transitions of care.

Results and Reports

Having launched six pilot sites just two years ago, adding 24 additional sites in 2009, Project BOOST is still a relatively young QI program, which makes reliable quantitative data about its effectiveness tough to come by. The expansion into Michigan gives SHM and others the prospect of programwide measurement of how Project BOOST affects discharge and reduces readmissions.

“This is a tremendous opportunity to improve patient safety, reduce readmissions, and study the impact of Project BOOST interventions through patient-level data,” says Mark Williams, MD, FHM, Journal of Hospital Medicine editor, principal investigator for Project BOOST, and former SHM president. “We’re thrilled to be working with the state’s healthcare leaders to implement this critical program.”

Nonetheless, in the absence of comprehensive data, the early reports from Project BOOST sites are promising. At Piedmont Hospital in the Atlanta area, the rate of readmission among patients under the age of 70 participating in BOOST is 8.5%, compared with 25.5% among nonparticipants. The readmission rate among BOOST participants at Piedmont over the age of 70 was 22%, compared with 26% of nonparticipants. When SSM St. Mary’s Medical Center in St. Louis implemented BOOST at its 33-bed hospitalist unit, 30-day readmissions dropped to 7% from 12% within three months.

Patient satisfaction rates also increased markedly, to 68% from 52%. And in 2009, the University of Pennsylvania Health System awarded its annual Operational Quality and Safety Award to the Project BOOST implementation team at the hospital.

BOOST’s Reach Expands

Project BOOST leaders are planning an aggressive expansion in the near future. In addition to the potential for new program sites, SHM has made materials available to hospitalists through the Project BOOST Resource Room at SHM’s newly redesigned Web site (see “The New Face of HospitalMedicine.org,” p. 12), www.hospitalmedicine.org/boost.

In addition to free resources, new BOOST materials are for sale through SHM’s online store. The Project BOOST Implementation Guide—available electronically for free through the resource room—is now available for sale as a hard copy. The online store also features a new Project BOOST instructional DVD for hospitalists, “Using Teach Back to Improve Communication with Patients.” TH

Brendon Shank is a freelance writer based in Philadelphia.

Reference

1. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14): 1418-1428.

Chapter Updates

The Historic Main Street Trolley in Memphis, Tenn.

Memphis

The Memphis chapter held its quarterly meeting Feb. 4 at Erling Jensen in Memphis, Tenn. Dr. William Edmonson of the North Mississippi Medical Center in Tupelo, Miss., discussed “Updates on COPD.” Boehringer Engelheim sponsored the dinner meeting, which was attended by hospitalists and physicians in the area as well as hospital nurses and administration.

Milwaukee/Southeast Wisconsin

The Milwaukee/Southeast Wisconsin chapter’s Feb. 27 meeting in the Columbia Hospital Auditorium brought together hospitalists, nurse practitioners, pharmacists, and others from the Milwaukee area. Attendees were able to obtain CME credit on topics including acute coronary syndrome, hyponatremia, and sepsis. The meeting highlight was a presentation from Dr. Alpesh Amin, interim chair of the Department of Medicine at the University of California at Irvine. Dr. Amin discussed how to start up a local SHM chapter. Sponsorship from CME University helped make the chapter’s first HM symposium a success.

Nebraska Area

Lincoln HM group Bryan LGH hosted the Nebraska Area chapter quarterly meeting Feb. 23. Dr. Tamer Mahrous gave an overview of coding issues for hospitalists. A copy of the presentation will be sent to all of the chapter members.

The chapter elected officers to serve terms through 2012. They include: Dr. Eric Rice, president; Russ Cowles, vice president; Alissa Clough, secretary; and Jay Snow, officer at large.

Several additional items were discussed, including topics for upcoming meetings, how the chapter can best take advantage of opportunities at HM10, the possibility of launching a chapter newsletter, and organizational issues.

Thousands of Michigan residents will have a better chance of avoiding readmission to the hospital thanks to a groundbreaking new collaboration between three of the state’s healthcare leaders.

Based on SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) model, the collaborative program will be managed by the University of Michigan in collaboration with Blue Cross Blue Shield of Michigan. The Michigan Blues provide and administer health benefits to 4.7 million Michigan residents.

Project BOOST helps hospitals reduce readmission rates by providing them with proven resources and expert mentoring to optimize the discharge transition process, enhance patient and family education practices, and improve the flow of information between inpatient and outpatient providers. Project BOOST was developed through a grant from the John A. Hartford Foundation. Earlier in the year, the program recruited 15 Michigan sites to participate. Training begins in May.

Each improvement team will be assigned a mentor to coach them through the process of planning, implementing, and evaluating Project BOOST at their site. Program participants will receive face-to-face training, monthly coaching sessions with their mentors, and a comprehensive toolkit to implement Project BOOST. Sites also participate in an online peer learning and collaboration network.

“This kind of innovative, targeted program benefits both the patient and the healthcare provider by establishing better communication between all parties,” says Scott Flanders, MD, FHM, associate professor and director of hospital medicine at the University of Michigan in Ann Arbor, and SHM president.

To Flanders, it’s no coincidence that hospitalists are taking the lead in improving hospital discharges. “Readmissions are a pervasive but preventable problem,” he says. “Hospitalists are uniquely positioned to provide leadership within the hospital, to promote positive, system-based changes that improve patient satisfaction, and promote collaboration between hospitalists and primary-care physicians.”

In addition to being preventable, readmissions are costly, draining the resources, time, and energy of the patient, PCPs, and hospitals. Research in the April 2009 New England Journal of Medicine indicates that 20% of hospitalized patients are readmitted to the hospital within a month of their discharge.1 Nationally, readmissions cost Medicare $17.4 billion each year.1

Collaborative Partnerships

Prior to the program’s launch in Michigan, SHM recruited and mentored Project BOOST sites independently. However, like many productive relationships in a hospital, Project BOOST in Michigan depends on collaboration between experts.

“Blue Cross Blue Shield of Michigan is confident that this project, like our other Value Partnership programs that focus on robust, statewide, data-driven quality-improvement (QI) partnerships, will have a positive impact on thousands of Michigan lives,” says David Share, MD, MPH, BCBS Michigan’s senior associate medical director of Healthcare Quality. “We look forward to helping hospitals, physicians, and patients work together to assure smooth transitions between inpatient and outpatient care, and to reduce readmissions and improve the patient experience.”

For University of Michigan hospitalist Christopher Kim, MD, MBA, FHM, Project BOOST is a chance to work with a diverse set of groups. “We are grateful for the opportunity to work with not just Blue Cross Blue Shield of Michigan, but also with the other physician organizations across our state to implement and share best-practice ideas in transitions of care,” says Kim, director of the statewide collaborative program on transitions of care.

Results and Reports

Having launched six pilot sites just two years ago, adding 24 additional sites in 2009, Project BOOST is still a relatively young QI program, which makes reliable quantitative data about its effectiveness tough to come by. The expansion into Michigan gives SHM and others the prospect of programwide measurement of how Project BOOST affects discharge and reduces readmissions.

“This is a tremendous opportunity to improve patient safety, reduce readmissions, and study the impact of Project BOOST interventions through patient-level data,” says Mark Williams, MD, FHM, Journal of Hospital Medicine editor, principal investigator for Project BOOST, and former SHM president. “We’re thrilled to be working with the state’s healthcare leaders to implement this critical program.”

Nonetheless, in the absence of comprehensive data, the early reports from Project BOOST sites are promising. At Piedmont Hospital in the Atlanta area, the rate of readmission among patients under the age of 70 participating in BOOST is 8.5%, compared with 25.5% among nonparticipants. The readmission rate among BOOST participants at Piedmont over the age of 70 was 22%, compared with 26% of nonparticipants. When SSM St. Mary’s Medical Center in St. Louis implemented BOOST at its 33-bed hospitalist unit, 30-day readmissions dropped to 7% from 12% within three months.

Patient satisfaction rates also increased markedly, to 68% from 52%. And in 2009, the University of Pennsylvania Health System awarded its annual Operational Quality and Safety Award to the Project BOOST implementation team at the hospital.

BOOST’s Reach Expands

Project BOOST leaders are planning an aggressive expansion in the near future. In addition to the potential for new program sites, SHM has made materials available to hospitalists through the Project BOOST Resource Room at SHM’s newly redesigned Web site (see “The New Face of HospitalMedicine.org,” p. 12), www.hospitalmedicine.org/boost.

In addition to free resources, new BOOST materials are for sale through SHM’s online store. The Project BOOST Implementation Guide—available electronically for free through the resource room—is now available for sale as a hard copy. The online store also features a new Project BOOST instructional DVD for hospitalists, “Using Teach Back to Improve Communication with Patients.” TH

Brendon Shank is a freelance writer based in Philadelphia.

Reference

1. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14): 1418-1428.

Chapter Updates

The Historic Main Street Trolley in Memphis, Tenn.

Memphis

The Memphis chapter held its quarterly meeting Feb. 4 at Erling Jensen in Memphis, Tenn. Dr. William Edmonson of the North Mississippi Medical Center in Tupelo, Miss., discussed “Updates on COPD.” Boehringer Engelheim sponsored the dinner meeting, which was attended by hospitalists and physicians in the area as well as hospital nurses and administration.

Milwaukee/Southeast Wisconsin

The Milwaukee/Southeast Wisconsin chapter’s Feb. 27 meeting in the Columbia Hospital Auditorium brought together hospitalists, nurse practitioners, pharmacists, and others from the Milwaukee area. Attendees were able to obtain CME credit on topics including acute coronary syndrome, hyponatremia, and sepsis. The meeting highlight was a presentation from Dr. Alpesh Amin, interim chair of the Department of Medicine at the University of California at Irvine. Dr. Amin discussed how to start up a local SHM chapter. Sponsorship from CME University helped make the chapter’s first HM symposium a success.

Nebraska Area

Lincoln HM group Bryan LGH hosted the Nebraska Area chapter quarterly meeting Feb. 23. Dr. Tamer Mahrous gave an overview of coding issues for hospitalists. A copy of the presentation will be sent to all of the chapter members.

The chapter elected officers to serve terms through 2012. They include: Dr. Eric Rice, president; Russ Cowles, vice president; Alissa Clough, secretary; and Jay Snow, officer at large.

Several additional items were discussed, including topics for upcoming meetings, how the chapter can best take advantage of opportunities at HM10, the possibility of launching a chapter newsletter, and organizational issues.

Hospitalists will be essential players in helping their institutions prepare for the Recovery Audit Contractor (RAC) program, now being rolled out nationwide by the Centers for Medicare & Medicaid Services (CMS). The program is part of CMS’ arsenal to ferret out improper payments and prevent fraud, waste, and abuse in the Medicare system.

All providers who bill Medicare fee-for-service are fair game for an RAC audit, which scrutinizes medical records to validate diagnosis-related groups (DRGs), coding, and the necessity of care provided by hospitals. Hospitalists are being asked to document their diagnosis and treatment decisions more precisely and thoroughly than ever, ensuring that DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery.

Specificity of documentation is the hospitalist’s most potent weapon against this new layer of federal audits.

In a three-year demonstration of the RAC program that ended in March 2008, one-third of all medical records audited resulted in an overpayment finding and collection. RACs collected more than $900 million in overpayments and returned nearly $38 million in underpayments. One-third of provider appeals (physician, hospital, and other providers) were successful during the demo program, according to a June 2008 CMS evaluation report. (Download a copy of the report at www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf.)

How the Audits Work

Coding rules and terminology often don’t match what we’re used to writing in the record. So hospitalists need to learn what these connections are and use them in their medical record documentation. This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.—Richard D. Pinson, MD, FACP, CCS, principal, HCQ Consulting, Nashville, Tenn.

Listen to an interview with Dr. Pinson

Out of concern that the Medicare Trust Fund might not be adequately protected against improper payments by existing error detection and prevention efforts, Congress directed CMS to use RACs to identify and recoup Medicare overpayments under Section 306 of the Medicare Modernization Act of 2003, and directed CMS to make the program permanent by 2010 under Section 302 of the Tax Relief and Health Care Act of 2006. According to CMS, RACs were implemented so that physicians and other providers could avoid submitting claims that do not comply with Medicare rules, CMS could lower its error rate, and taxpayers and future Medicare beneficiaries would be protected.1

CMS has contracted with four regional RACs for the national program, and each will use proprietary auditing software to review paid claims from Medicare Part A and Part B providers to ensure that they meet Medicare’s statutory, regulatory, and policy requirements and regulations.

The RACs use automated review for claims that clearly contain errors that resulted in improper payments (e.g., claims for duplicate or uncovered services, claims that violate a written Medicare policy or sanctioned coding guideline), in which case the RAC notifies the provider of the overpayment. For cases in which there is a high probability—but not certainty—that the claim contains an overpayment, the RAC requests medical records from the provider (including imaged medical records on CD or DVD) to conduct a complex review and make a determination as to whether payment of the claim was correct, or whether there was an over- or underpayment.

CMS uses a Web-based data warehouse to ensure that RACs do not review claims that have previously been reviewed by another entity, such as a Medicare carrier, fiscal intermediary, the Office of Inspector General, or a quality-improvement organization (QIO).

Connie Leonard

The four regional RACs are ramping up their claim review activities in all states, says Connie Leonard, director of CMS’ Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding providers to repay their Medicare carrier or intermediary within 30 days. For confirmed underpayments, RACs inform the provider’s Medicare contractor or fiscal intermediary, which then forwards the additional payment, Leonard says.

Providers can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. The Medicare contractors use recoupment—reducing present or future Medicare payments—on day 41. Providers who wish to dispute overpayment charges can take their case through the usual Medicare claims appeal process. RACs also offer a “discussion period”—from the date the provider gets a “Detailed Review Results” letter until the date of recoupment—to discuss with the RAC an improper payment determination outside the normal appeal process, Leonard says.

RACs are targeting confusion between septicemia and urosepsis.

—Kathy DeVault, RHIA, CCS, CCS-P, manager, Professional Practice Resources, American Health Information Management Association, Chicago

If providers disagree with the RAC’s determination, Leonard says, they should either 1) pay by check by day 30 and file for appeal by day 120 of the demand letter; 2) allow recoupment on day 41 and file for appeal by day 120; 3) stop the recoupment by filing an appeal by day 30; or 4) request an extended payment plan and appeal by day 120.

Some physicians in the demonstration project regarded the third-party RAC companies as “bounty hunters” operating without sufficient CMS oversight, imposing undue administrative burdens on physician practices, and lacking the clinical expertise to adjudicate claims appropriately, according to Michael Schweitz, MD, a rheumatologist from West Palm Beach, Fla., who testified before a Congressional committee in 2008 about RAC activities.

In response, CMS has modified the program (see “Refinements in Permanent RAC Program,” p. 8) in several ways to address those flaws and ensure a fair and smooth auditing process, Leonard says. (Listen to an audio interview with Ms. Leonard)

Connie Leonard

All About the Details

Because RACs focus on coding and documentation that fails to support DRG designations, hospitalists who focus on accurate and precise documentation that can be coded properly will greatly help their hospitals defend against RAC audits, as well as yield better payment and improved quality scores, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Nashville, Tenn. Pinson will present “Documentation Tips Your Hospital Will Love You For” at HM10 in Washington, D.C., this month. A video/audio download of the presentation will be available on SHM’s Web site in May.

“Coding rules and terminology often don’t match what we’re used to writing in the record, so hospitalists need to learn what these connections are and use them in their medical record documentation,” Pinson says. “This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.”

For example, if a hospitalist sees that a pre-operative patient has severe congestive heart failure, that condition cannot be coded as a complication of the patient’s care or considered as such in the DRG assignment, Pinson explains. If the hospitalist says the patient has an acute exacerbation of systolic heart failure, then that is a major comorbidity and ought to be documented as such. The average value of a major comorbidity in a surgical case could be as much as $20,000 per case, Pinson notes. If the DRG assignment included acute exacerbation but the medical chart only said severe congestive heart failure, the hospital would face recoupment of payment from an RAC audit.

“If we’re inconsistent or ambiguous in how we apply our terms, we can end up inadvertently upcoding. The key is: Learn to use the right terms that correspond to the right codes, based on what your patient actually has, and then be consistent throughout the record in your use of those terms,” Pinson says. For example, “we may admit a patient and say at the very beginning that the patient probably has aspiration pneumonia. We then treat the patient for aspiration pneumonia but leave it out of the discharge summary. The coder may code aspiration pneumonia, but the RAC auditor may point out that it was only mentioned in the patient’s record once, as possible, and may recoup any payment for treatment beyond simple pneumonia.”

Level of care and symptom-based DRG designations are red flags for RAC recovery, Pinson says. When the auditor sees a DRG based on symptoms rather than diagnoses (e.g., chest pain, syncope, transient ischemic attack, dehydration) and it is billed as inpatient status instead of observation status, that’s a target. Those symptoms, he says, often don’t meet the medical necessity criteria for inpatient status.

Pinson advises hospitalists to ask their institution’s case-management department, or hire an external consultant, to abstract key criteria for patient status designation, and to consider starting a patient as observation status until a precise diagnosis can be made that warrants hospital admission. Hospitalists should then describe the patient’s situation more precisely in the medical record as a diagnosis, not just as symptoms—e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina.

“For inpatient billing, those uncertain diagnoses, described that way, count as if they were established conditions. They don’t go into symptom DRGs,” Pinson says. “If you’re doing these things to protect the validity of you hospital’s billing, you’ll be protecting yourself at the same time, and it’s unlikely that RACs will single you out at all for auditing.”

Hospitalists can be valuable participants on their institutions’ RAC response team, providing clinical clarification on cases and helping to draft appeal letters.

There are several other red flags that RACs zero in on and hospitalists should watch out for, says Kathy DeVault, RHIA, CCS, CCS-P, manager of Professional Practice Resources for the American Health Information Management Association (AHIMA). Specificity in the medical record makes all the difference. For example, by identifying incorrect coding for excisional debridement (removal of infected tissue), RACs collected nearly $18 million in overpayments in fiscal-year 2006 because medical record documentation omitted such details as the word “excisional” (e.g., sharp debridement coded as excisional debridement), whether it was performed in the operating room or not, instruments used, the extent and depth of the procedure, and if the cutting of tissue was outside or beyond the wound margin.

DeVault warns that “RACs are targeting confusion between septicemia and urosepsis.” According to CMS, if the hospital reports a patient’s principal diagnosis as septicemia (03.89) but the medical record indicates the diagnosis of urosepsis, the RAC will bump the diagnosis code down to urinary tract infection (599.0), a lower-payment DRG, and demand recoupment.1

Urosepsis does not have a specific ICD-9-CM diagnosis code, and defaults to a simple UTI code, as referenced in ICD-9-CM. Unless the physician states in his or her documentation that the patient’s condition was systemic sepsis or septicemia, urosepsis would be coded as a UTI. RACS also denied some respiratory-failure claims for incorrect sequencing of principal diagnosis (e.g., respiratory failure vs. sepsis). The American Hospital Association has issued a regulatory advisory about these issues (web.mhanet.com/userdocs/articles/RAC/AHA_RAC_Coding Advisory_071608.pdf).

DeVault highlights three additional RAC targets that might impact HM:

• Documentation for transbronchial biopsy (a surgical DRG) in which the medical record only shows pathology of bronchus tissue (which RACs regard as nonsurgical);
• Failure to document the severity of a patient’s anemia as such to meet the medical necessity requirement of a blood transfusion (e.g., a chronic blood loss anemia or a pernicious anemia); and
• Documentation of treatments performed by intensivists in an ICU. By the time a patient’s attending physician sees their patient out of the ICU, DeVault says, their acute renal failure could be turned around but the attending might not document what happened in the ICU. The intensivist must see to it that the documentation allows the appropriate DRG assignment for the level of care the patient received.

AHIMA has published a 65-page RAC Audit Toolkit that describes the audit process, outlines preparations and procedures, and offers concrete guidance for appeals. Download a copy at www.ahima.org/infocenter/documents/RACToolkitFINAL.pdf. TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

Reference

1. The Medicare Recovery Audit Contractor (RAC) program: an evaluation of the 3-year demonstration. CMS Web site. Available at: www.cms.hhs.gov/RAC/Downloads/RACEvaluationReport.pdf. Accessed March 3, 2010.

Refinements in CMS’ Permanent RAC Program

Connie Leonard

Based on lessons learned from demonstration programs, CMS has made a number of changes to the permanent Recovery Audit Contractor (RAC) program.

Among the changes are:

• RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
• For physicians, RACs are limited to requesting 10 medical records per 45 days from a single physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15, and 50 from a large group of more than 16 physicians;
• For hospitals, RACs are limited to requesting 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days;
• RACs must send a “Detailed Review Results” letter within 60 calendar days of receipt of the medical records they request for review;
• Each RAC must hire a physician medical director and certified coders, and providers may request the credentials of their auditor and request to speak to their RAC’s medical director regarding a claim denial;
• All new issues that an RAC wishes to pursue for overpayments must be validated by CMS or an independent RAC validation contractor, and posted to the RAC’s Web site before widespread review;
• RACS must have a Web-based “Claim Status” platform that will allow providers to track the status of medical record submissions to RACs;
• RACs must pay back contingency fees when an improper payment determination is overturned at any level in the appeals process (demo RACs were allowed to retain them on determinations overturned on second- and third-level appeal); and
• RAC validation contractors will conduct a third-party review of RAC claims determinations and provide annual accuracy scores for each RAC.—CG

Hospitalists will be essential players in helping their institutions prepare for the Recovery Audit Contractor (RAC) program, now being rolled out nationwide by the Centers for Medicare & Medicaid Services (CMS). The program is part of CMS’ arsenal to ferret out improper payments and prevent fraud, waste, and abuse in the Medicare system.

All providers who bill Medicare fee-for-service are fair game for an RAC audit, which scrutinizes medical records to validate diagnosis-related groups (DRGs), coding, and the necessity of care provided by hospitals. Hospitalists are being asked to document their diagnosis and treatment decisions more precisely and thoroughly than ever, ensuring that DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery.

Specificity of documentation is the hospitalist’s most potent weapon against this new layer of federal audits.

In a three-year demonstration of the RAC program that ended in March 2008, one-third of all medical records audited resulted in an overpayment finding and collection. RACs collected more than $900 million in overpayments and returned nearly $38 million in underpayments. One-third of provider appeals (physician, hospital, and other providers) were successful during the demo program, according to a June 2008 CMS evaluation report. (Download a copy of the report at www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf.)

How the Audits Work

Coding rules and terminology often don’t match what we’re used to writing in the record. So hospitalists need to learn what these connections are and use them in their medical record documentation. This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.—Richard D. Pinson, MD, FACP, CCS, principal, HCQ Consulting, Nashville, Tenn.

Listen to an interview with Dr. Pinson

Out of concern that the Medicare Trust Fund might not be adequately protected against improper payments by existing error detection and prevention efforts, Congress directed CMS to use RACs to identify and recoup Medicare overpayments under Section 306 of the Medicare Modernization Act of 2003, and directed CMS to make the program permanent by 2010 under Section 302 of the Tax Relief and Health Care Act of 2006. According to CMS, RACs were implemented so that physicians and other providers could avoid submitting claims that do not comply with Medicare rules, CMS could lower its error rate, and taxpayers and future Medicare beneficiaries would be protected.1

CMS has contracted with four regional RACs for the national program, and each will use proprietary auditing software to review paid claims from Medicare Part A and Part B providers to ensure that they meet Medicare’s statutory, regulatory, and policy requirements and regulations.

The RACs use automated review for claims that clearly contain errors that resulted in improper payments (e.g., claims for duplicate or uncovered services, claims that violate a written Medicare policy or sanctioned coding guideline), in which case the RAC notifies the provider of the overpayment. For cases in which there is a high probability—but not certainty—that the claim contains an overpayment, the RAC requests medical records from the provider (including imaged medical records on CD or DVD) to conduct a complex review and make a determination as to whether payment of the claim was correct, or whether there was an over- or underpayment.

CMS uses a Web-based data warehouse to ensure that RACs do not review claims that have previously been reviewed by another entity, such as a Medicare carrier, fiscal intermediary, the Office of Inspector General, or a quality-improvement organization (QIO).

Connie Leonard

The four regional RACs are ramping up their claim review activities in all states, says Connie Leonard, director of CMS’ Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding providers to repay their Medicare carrier or intermediary within 30 days. For confirmed underpayments, RACs inform the provider’s Medicare contractor or fiscal intermediary, which then forwards the additional payment, Leonard says.

Providers can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. The Medicare contractors use recoupment—reducing present or future Medicare payments—on day 41. Providers who wish to dispute overpayment charges can take their case through the usual Medicare claims appeal process. RACs also offer a “discussion period”—from the date the provider gets a “Detailed Review Results” letter until the date of recoupment—to discuss with the RAC an improper payment determination outside the normal appeal process, Leonard says.

RACs are targeting confusion between septicemia and urosepsis.

—Kathy DeVault, RHIA, CCS, CCS-P, manager, Professional Practice Resources, American Health Information Management Association, Chicago

If providers disagree with the RAC’s determination, Leonard says, they should either 1) pay by check by day 30 and file for appeal by day 120 of the demand letter; 2) allow recoupment on day 41 and file for appeal by day 120; 3) stop the recoupment by filing an appeal by day 30; or 4) request an extended payment plan and appeal by day 120.

Some physicians in the demonstration project regarded the third-party RAC companies as “bounty hunters” operating without sufficient CMS oversight, imposing undue administrative burdens on physician practices, and lacking the clinical expertise to adjudicate claims appropriately, according to Michael Schweitz, MD, a rheumatologist from West Palm Beach, Fla., who testified before a Congressional committee in 2008 about RAC activities.

In response, CMS has modified the program (see “Refinements in Permanent RAC Program,” p. 8) in several ways to address those flaws and ensure a fair and smooth auditing process, Leonard says. (Listen to an audio interview with Ms. Leonard)

Connie Leonard

All About the Details

Because RACs focus on coding and documentation that fails to support DRG designations, hospitalists who focus on accurate and precise documentation that can be coded properly will greatly help their hospitals defend against RAC audits, as well as yield better payment and improved quality scores, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Nashville, Tenn. Pinson will present “Documentation Tips Your Hospital Will Love You For” at HM10 in Washington, D.C., this month. A video/audio download of the presentation will be available on SHM’s Web site in May.

“Coding rules and terminology often don’t match what we’re used to writing in the record, so hospitalists need to learn what these connections are and use them in their medical record documentation,” Pinson says. “This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.”

For example, if a hospitalist sees that a pre-operative patient has severe congestive heart failure, that condition cannot be coded as a complication of the patient’s care or considered as such in the DRG assignment, Pinson explains. If the hospitalist says the patient has an acute exacerbation of systolic heart failure, then that is a major comorbidity and ought to be documented as such. The average value of a major comorbidity in a surgical case could be as much as $20,000 per case, Pinson notes. If the DRG assignment included acute exacerbation but the medical chart only said severe congestive heart failure, the hospital would face recoupment of payment from an RAC audit.

“If we’re inconsistent or ambiguous in how we apply our terms, we can end up inadvertently upcoding. The key is: Learn to use the right terms that correspond to the right codes, based on what your patient actually has, and then be consistent throughout the record in your use of those terms,” Pinson says. For example, “we may admit a patient and say at the very beginning that the patient probably has aspiration pneumonia. We then treat the patient for aspiration pneumonia but leave it out of the discharge summary. The coder may code aspiration pneumonia, but the RAC auditor may point out that it was only mentioned in the patient’s record once, as possible, and may recoup any payment for treatment beyond simple pneumonia.”

Level of care and symptom-based DRG designations are red flags for RAC recovery, Pinson says. When the auditor sees a DRG based on symptoms rather than diagnoses (e.g., chest pain, syncope, transient ischemic attack, dehydration) and it is billed as inpatient status instead of observation status, that’s a target. Those symptoms, he says, often don’t meet the medical necessity criteria for inpatient status.

Pinson advises hospitalists to ask their institution’s case-management department, or hire an external consultant, to abstract key criteria for patient status designation, and to consider starting a patient as observation status until a precise diagnosis can be made that warrants hospital admission. Hospitalists should then describe the patient’s situation more precisely in the medical record as a diagnosis, not just as symptoms—e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina.

“For inpatient billing, those uncertain diagnoses, described that way, count as if they were established conditions. They don’t go into symptom DRGs,” Pinson says. “If you’re doing these things to protect the validity of you hospital’s billing, you’ll be protecting yourself at the same time, and it’s unlikely that RACs will single you out at all for auditing.”

Hospitalists can be valuable participants on their institutions’ RAC response team, providing clinical clarification on cases and helping to draft appeal letters.

There are several other red flags that RACs zero in on and hospitalists should watch out for, says Kathy DeVault, RHIA, CCS, CCS-P, manager of Professional Practice Resources for the American Health Information Management Association (AHIMA). Specificity in the medical record makes all the difference. For example, by identifying incorrect coding for excisional debridement (removal of infected tissue), RACs collected nearly $18 million in overpayments in fiscal-year 2006 because medical record documentation omitted such details as the word “excisional” (e.g., sharp debridement coded as excisional debridement), whether it was performed in the operating room or not, instruments used, the extent and depth of the procedure, and if the cutting of tissue was outside or beyond the wound margin.

DeVault warns that “RACs are targeting confusion between septicemia and urosepsis.” According to CMS, if the hospital reports a patient’s principal diagnosis as septicemia (03.89) but the medical record indicates the diagnosis of urosepsis, the RAC will bump the diagnosis code down to urinary tract infection (599.0), a lower-payment DRG, and demand recoupment.1

Urosepsis does not have a specific ICD-9-CM diagnosis code, and defaults to a simple UTI code, as referenced in ICD-9-CM. Unless the physician states in his or her documentation that the patient’s condition was systemic sepsis or septicemia, urosepsis would be coded as a UTI. RACS also denied some respiratory-failure claims for incorrect sequencing of principal diagnosis (e.g., respiratory failure vs. sepsis). The American Hospital Association has issued a regulatory advisory about these issues (web.mhanet.com/userdocs/articles/RAC/AHA_RAC_Coding Advisory_071608.pdf).

DeVault highlights three additional RAC targets that might impact HM:

• Documentation for transbronchial biopsy (a surgical DRG) in which the medical record only shows pathology of bronchus tissue (which RACs regard as nonsurgical);
• Failure to document the severity of a patient’s anemia as such to meet the medical necessity requirement of a blood transfusion (e.g., a chronic blood loss anemia or a pernicious anemia); and
• Documentation of treatments performed by intensivists in an ICU. By the time a patient’s attending physician sees their patient out of the ICU, DeVault says, their acute renal failure could be turned around but the attending might not document what happened in the ICU. The intensivist must see to it that the documentation allows the appropriate DRG assignment for the level of care the patient received.

AHIMA has published a 65-page RAC Audit Toolkit that describes the audit process, outlines preparations and procedures, and offers concrete guidance for appeals. Download a copy at www.ahima.org/infocenter/documents/RACToolkitFINAL.pdf. TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

Reference

1. The Medicare Recovery Audit Contractor (RAC) program: an evaluation of the 3-year demonstration. CMS Web site. Available at: www.cms.hhs.gov/RAC/Downloads/RACEvaluationReport.pdf. Accessed March 3, 2010.

Refinements in CMS’ Permanent RAC Program

Connie Leonard

Based on lessons learned from demonstration programs, CMS has made a number of changes to the permanent Recovery Audit Contractor (RAC) program.

Among the changes are:

• RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
• For physicians, RACs are limited to requesting 10 medical records per 45 days from a single physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15, and 50 from a large group of more than 16 physicians;
• For hospitals, RACs are limited to requesting 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days;
• RACs must send a “Detailed Review Results” letter within 60 calendar days of receipt of the medical records they request for review;
• Each RAC must hire a physician medical director and certified coders, and providers may request the credentials of their auditor and request to speak to their RAC’s medical director regarding a claim denial;
• All new issues that an RAC wishes to pursue for overpayments must be validated by CMS or an independent RAC validation contractor, and posted to the RAC’s Web site before widespread review;
• RACS must have a Web-based “Claim Status” platform that will allow providers to track the status of medical record submissions to RACs;
• RACs must pay back contingency fees when an improper payment determination is overturned at any level in the appeals process (demo RACs were allowed to retain them on determinations overturned on second- and third-level appeal); and
• RAC validation contractors will conduct a third-party review of RAC claims determinations and provide annual accuracy scores for each RAC.—CG

Hospitalists will be essential players in helping their institutions prepare for the Recovery Audit Contractor (RAC) program, now being rolled out nationwide by the Centers for Medicare & Medicaid Services (CMS). The program is part of CMS’ arsenal to ferret out improper payments and prevent fraud, waste, and abuse in the Medicare system.

All providers who bill Medicare fee-for-service are fair game for an RAC audit, which scrutinizes medical records to validate diagnosis-related groups (DRGs), coding, and the necessity of care provided by hospitals. Hospitalists are being asked to document their diagnosis and treatment decisions more precisely and thoroughly than ever, ensuring that DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery.

Specificity of documentation is the hospitalist’s most potent weapon against this new layer of federal audits.

In a three-year demonstration of the RAC program that ended in March 2008, one-third of all medical records audited resulted in an overpayment finding and collection. RACs collected more than $900 million in overpayments and returned nearly $38 million in underpayments. One-third of provider appeals (physician, hospital, and other providers) were successful during the demo program, according to a June 2008 CMS evaluation report. (Download a copy of the report at www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf.)

How the Audits Work

Coding rules and terminology often don’t match what we’re used to writing in the record. So hospitalists need to learn what these connections are and use them in their medical record documentation. This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.—Richard D. Pinson, MD, FACP, CCS, principal, HCQ Consulting, Nashville, Tenn.

Listen to an interview with Dr. Pinson

Out of concern that the Medicare Trust Fund might not be adequately protected against improper payments by existing error detection and prevention efforts, Congress directed CMS to use RACs to identify and recoup Medicare overpayments under Section 306 of the Medicare Modernization Act of 2003, and directed CMS to make the program permanent by 2010 under Section 302 of the Tax Relief and Health Care Act of 2006. According to CMS, RACs were implemented so that physicians and other providers could avoid submitting claims that do not comply with Medicare rules, CMS could lower its error rate, and taxpayers and future Medicare beneficiaries would be protected.1

CMS has contracted with four regional RACs for the national program, and each will use proprietary auditing software to review paid claims from Medicare Part A and Part B providers to ensure that they meet Medicare’s statutory, regulatory, and policy requirements and regulations.

The RACs use automated review for claims that clearly contain errors that resulted in improper payments (e.g., claims for duplicate or uncovered services, claims that violate a written Medicare policy or sanctioned coding guideline), in which case the RAC notifies the provider of the overpayment. For cases in which there is a high probability—but not certainty—that the claim contains an overpayment, the RAC requests medical records from the provider (including imaged medical records on CD or DVD) to conduct a complex review and make a determination as to whether payment of the claim was correct, or whether there was an over- or underpayment.

CMS uses a Web-based data warehouse to ensure that RACs do not review claims that have previously been reviewed by another entity, such as a Medicare carrier, fiscal intermediary, the Office of Inspector General, or a quality-improvement organization (QIO).

Connie Leonard

The four regional RACs are ramping up their claim review activities in all states, says Connie Leonard, director of CMS’ Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding providers to repay their Medicare carrier or intermediary within 30 days. For confirmed underpayments, RACs inform the provider’s Medicare contractor or fiscal intermediary, which then forwards the additional payment, Leonard says.

Providers can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. The Medicare contractors use recoupment—reducing present or future Medicare payments—on day 41. Providers who wish to dispute overpayment charges can take their case through the usual Medicare claims appeal process. RACs also offer a “discussion period”—from the date the provider gets a “Detailed Review Results” letter until the date of recoupment—to discuss with the RAC an improper payment determination outside the normal appeal process, Leonard says.

RACs are targeting confusion between septicemia and urosepsis.

—Kathy DeVault, RHIA, CCS, CCS-P, manager, Professional Practice Resources, American Health Information Management Association, Chicago

If providers disagree with the RAC’s determination, Leonard says, they should either 1) pay by check by day 30 and file for appeal by day 120 of the demand letter; 2) allow recoupment on day 41 and file for appeal by day 120; 3) stop the recoupment by filing an appeal by day 30; or 4) request an extended payment plan and appeal by day 120.

Some physicians in the demonstration project regarded the third-party RAC companies as “bounty hunters” operating without sufficient CMS oversight, imposing undue administrative burdens on physician practices, and lacking the clinical expertise to adjudicate claims appropriately, according to Michael Schweitz, MD, a rheumatologist from West Palm Beach, Fla., who testified before a Congressional committee in 2008 about RAC activities.

In response, CMS has modified the program (see “Refinements in Permanent RAC Program,” p. 8) in several ways to address those flaws and ensure a fair and smooth auditing process, Leonard says. (Listen to an audio interview with Ms. Leonard)

Connie Leonard

All About the Details

Because RACs focus on coding and documentation that fails to support DRG designations, hospitalists who focus on accurate and precise documentation that can be coded properly will greatly help their hospitals defend against RAC audits, as well as yield better payment and improved quality scores, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Nashville, Tenn. Pinson will present “Documentation Tips Your Hospital Will Love You For” at HM10 in Washington, D.C., this month. A video/audio download of the presentation will be available on SHM’s Web site in May.

“Coding rules and terminology often don’t match what we’re used to writing in the record, so hospitalists need to learn what these connections are and use them in their medical record documentation,” Pinson says. “This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.”

For example, if a hospitalist sees that a pre-operative patient has severe congestive heart failure, that condition cannot be coded as a complication of the patient’s care or considered as such in the DRG assignment, Pinson explains. If the hospitalist says the patient has an acute exacerbation of systolic heart failure, then that is a major comorbidity and ought to be documented as such. The average value of a major comorbidity in a surgical case could be as much as $20,000 per case, Pinson notes. If the DRG assignment included acute exacerbation but the medical chart only said severe congestive heart failure, the hospital would face recoupment of payment from an RAC audit.

“If we’re inconsistent or ambiguous in how we apply our terms, we can end up inadvertently upcoding. The key is: Learn to use the right terms that correspond to the right codes, based on what your patient actually has, and then be consistent throughout the record in your use of those terms,” Pinson says. For example, “we may admit a patient and say at the very beginning that the patient probably has aspiration pneumonia. We then treat the patient for aspiration pneumonia but leave it out of the discharge summary. The coder may code aspiration pneumonia, but the RAC auditor may point out that it was only mentioned in the patient’s record once, as possible, and may recoup any payment for treatment beyond simple pneumonia.”

Level of care and symptom-based DRG designations are red flags for RAC recovery, Pinson says. When the auditor sees a DRG based on symptoms rather than diagnoses (e.g., chest pain, syncope, transient ischemic attack, dehydration) and it is billed as inpatient status instead of observation status, that’s a target. Those symptoms, he says, often don’t meet the medical necessity criteria for inpatient status.

Pinson advises hospitalists to ask their institution’s case-management department, or hire an external consultant, to abstract key criteria for patient status designation, and to consider starting a patient as observation status until a precise diagnosis can be made that warrants hospital admission. Hospitalists should then describe the patient’s situation more precisely in the medical record as a diagnosis, not just as symptoms—e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina.

“For inpatient billing, those uncertain diagnoses, described that way, count as if they were established conditions. They don’t go into symptom DRGs,” Pinson says. “If you’re doing these things to protect the validity of you hospital’s billing, you’ll be protecting yourself at the same time, and it’s unlikely that RACs will single you out at all for auditing.”

Hospitalists can be valuable participants on their institutions’ RAC response team, providing clinical clarification on cases and helping to draft appeal letters.

There are several other red flags that RACs zero in on and hospitalists should watch out for, says Kathy DeVault, RHIA, CCS, CCS-P, manager of Professional Practice Resources for the American Health Information Management Association (AHIMA). Specificity in the medical record makes all the difference. For example, by identifying incorrect coding for excisional debridement (removal of infected tissue), RACs collected nearly $18 million in overpayments in fiscal-year 2006 because medical record documentation omitted such details as the word “excisional” (e.g., sharp debridement coded as excisional debridement), whether it was performed in the operating room or not, instruments used, the extent and depth of the procedure, and if the cutting of tissue was outside or beyond the wound margin.

DeVault warns that “RACs are targeting confusion between septicemia and urosepsis.” According to CMS, if the hospital reports a patient’s principal diagnosis as septicemia (03.89) but the medical record indicates the diagnosis of urosepsis, the RAC will bump the diagnosis code down to urinary tract infection (599.0), a lower-payment DRG, and demand recoupment.1

Urosepsis does not have a specific ICD-9-CM diagnosis code, and defaults to a simple UTI code, as referenced in ICD-9-CM. Unless the physician states in his or her documentation that the patient’s condition was systemic sepsis or septicemia, urosepsis would be coded as a UTI. RACS also denied some respiratory-failure claims for incorrect sequencing of principal diagnosis (e.g., respiratory failure vs. sepsis). The American Hospital Association has issued a regulatory advisory about these issues (web.mhanet.com/userdocs/articles/RAC/AHA_RAC_Coding Advisory_071608.pdf).

DeVault highlights three additional RAC targets that might impact HM:

• Documentation for transbronchial biopsy (a surgical DRG) in which the medical record only shows pathology of bronchus tissue (which RACs regard as nonsurgical);
• Failure to document the severity of a patient’s anemia as such to meet the medical necessity requirement of a blood transfusion (e.g., a chronic blood loss anemia or a pernicious anemia); and
• Documentation of treatments performed by intensivists in an ICU. By the time a patient’s attending physician sees their patient out of the ICU, DeVault says, their acute renal failure could be turned around but the attending might not document what happened in the ICU. The intensivist must see to it that the documentation allows the appropriate DRG assignment for the level of care the patient received.

AHIMA has published a 65-page RAC Audit Toolkit that describes the audit process, outlines preparations and procedures, and offers concrete guidance for appeals. Download a copy at www.ahima.org/infocenter/documents/RACToolkitFINAL.pdf. TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

Reference

1. The Medicare Recovery Audit Contractor (RAC) program: an evaluation of the 3-year demonstration. CMS Web site. Available at: www.cms.hhs.gov/RAC/Downloads/RACEvaluationReport.pdf. Accessed March 3, 2010.

Refinements in CMS’ Permanent RAC Program

Connie Leonard

Based on lessons learned from demonstration programs, CMS has made a number of changes to the permanent Recovery Audit Contractor (RAC) program.

Among the changes are:

• RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
• For physicians, RACs are limited to requesting 10 medical records per 45 days from a single physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15, and 50 from a large group of more than 16 physicians;
• For hospitals, RACs are limited to requesting 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days;
• RACs must send a “Detailed Review Results” letter within 60 calendar days of receipt of the medical records they request for review;
• Each RAC must hire a physician medical director and certified coders, and providers may request the credentials of their auditor and request to speak to their RAC’s medical director regarding a claim denial;
• All new issues that an RAC wishes to pursue for overpayments must be validated by CMS or an independent RAC validation contractor, and posted to the RAC’s Web site before widespread review;
• RACS must have a Web-based “Claim Status” platform that will allow providers to track the status of medical record submissions to RACs;
• RACs must pay back contingency fees when an improper payment determination is overturned at any level in the appeals process (demo RACs were allowed to retain them on determinations overturned on second- and third-level appeal); and
• RAC validation contractors will conduct a third-party review of RAC claims determinations and provide annual accuracy scores for each RAC.—CG

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.

In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.

Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.

What is Quality?

As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:

• Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
• Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
• Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
• Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?

We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.

New Ways to Deliver Care

The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.

While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.

The good news is we aren’t alone in our efforts to change the culture, even the mission, of our hospitals. In a time of healthcarewide workforce shortages, there are increasing demands for direct inpatient care, coupled with the added time needed to document current performance and train and implement needed improvements. The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

All-Star Teams

High-performing organizations are composed of high-performance teams and a set of operating principles that create a widespread culture of motivated individuals who are focused on metrics, are execution-driven, and are committed to continual improvement and rapid adaptation.

The characteristics of high-performance teams are that they:

• Self-correct and reallocate resources;
• Have clear roles and responsibilities;
• Have clear, valued, and shared visions;
• Have strong team leadership;
• Develop a strong sense of “collective” trust and confidence; and
• Manage and optimize performance outcomes.

SHM has taken the lead at a national level in helping to organize the Hospital Care Collaborative (HCC), which is made up of CEOs and leaders in nursing, pharmacy, case management, social workers, and respiratory therapy. The HCC has published a set of “Common Principles” (see “Common Principles for the Hospital Care Collaborative”) and is planning to develop practical strategies for building high-performance teams at our nation’s hospitals.

SHM recently received support from Ortho-McNeil and has created a partnership with the American Hospital Association, American Organization of Nurse Executives, and American College of Physician Executives to develop principles and strategies to implement high-performance teams and to use this as a springboard to look at hospital care in the broadest sense (including transfers with medical home and accountable-care organizations). To start, SHM has convened a blue-ribbon group of hospital CMOs, CQOs, nursing executives, and other leaders in the hospital C-suite. Former SHM president Pat Cawley, MD, MBA, FHM, assistant professor and executive medical officer at the Medical University of South Carolina in Charleston, will chair this effort.

In these two initiatives, SHM and national hospital leaders are providing direction and innovation at two entry points—the C-suite and executive team—as well as on the front lines with the other healthcare professionals who care for our nation’s hospitalized patients.

More to Come

HM has had an interesting decade, growing to more than 30,000 hospitalists now practicing in 75% of our nation’s hospitals. We’ve taken on comanagement and are providing real success as change agents. But the decade to come will see the reinvention of our nation’s hospitals and distinct changes in workflow and responsibilities. We are moving from care based on the unit of the visit or the procedure to episodes of care. We are moving from a system that rewards just doing something to one that rewards doing the correct thing and doing it well. We are moving our hospitals from a swap meet where each physician has a booth and everyone supports those individual efforts to an institution with a culture that is patient-centered, based on quality measurement and performance, and provides care delivered by teams of health professionals working in concert.

This is a world that hospitalists can thrive in and, with your help and direction, SHM will provide the tools along the way. TH

Dr. Wellikson is CEO of SHM.

While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.

In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.

Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.

What is Quality?

As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:

• Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
• Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
• Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
• Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?

We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.

New Ways to Deliver Care

The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.

While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.

The good news is we aren’t alone in our efforts to change the culture, even the mission, of our hospitals. In a time of healthcarewide workforce shortages, there are increasing demands for direct inpatient care, coupled with the added time needed to document current performance and train and implement needed improvements. The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

All-Star Teams

High-performing organizations are composed of high-performance teams and a set of operating principles that create a widespread culture of motivated individuals who are focused on metrics, are execution-driven, and are committed to continual improvement and rapid adaptation.

The characteristics of high-performance teams are that they:

• Self-correct and reallocate resources;
• Have clear roles and responsibilities;
• Have clear, valued, and shared visions;
• Have strong team leadership;
• Develop a strong sense of “collective” trust and confidence; and
• Manage and optimize performance outcomes.

SHM has taken the lead at a national level in helping to organize the Hospital Care Collaborative (HCC), which is made up of CEOs and leaders in nursing, pharmacy, case management, social workers, and respiratory therapy. The HCC has published a set of “Common Principles” (see “Common Principles for the Hospital Care Collaborative”) and is planning to develop practical strategies for building high-performance teams at our nation’s hospitals.

SHM recently received support from Ortho-McNeil and has created a partnership with the American Hospital Association, American Organization of Nurse Executives, and American College of Physician Executives to develop principles and strategies to implement high-performance teams and to use this as a springboard to look at hospital care in the broadest sense (including transfers with medical home and accountable-care organizations). To start, SHM has convened a blue-ribbon group of hospital CMOs, CQOs, nursing executives, and other leaders in the hospital C-suite. Former SHM president Pat Cawley, MD, MBA, FHM, assistant professor and executive medical officer at the Medical University of South Carolina in Charleston, will chair this effort.

In these two initiatives, SHM and national hospital leaders are providing direction and innovation at two entry points—the C-suite and executive team—as well as on the front lines with the other healthcare professionals who care for our nation’s hospitalized patients.

More to Come

HM has had an interesting decade, growing to more than 30,000 hospitalists now practicing in 75% of our nation’s hospitals. We’ve taken on comanagement and are providing real success as change agents. But the decade to come will see the reinvention of our nation’s hospitals and distinct changes in workflow and responsibilities. We are moving from care based on the unit of the visit or the procedure to episodes of care. We are moving from a system that rewards just doing something to one that rewards doing the correct thing and doing it well. We are moving our hospitals from a swap meet where each physician has a booth and everyone supports those individual efforts to an institution with a culture that is patient-centered, based on quality measurement and performance, and provides care delivered by teams of health professionals working in concert.

This is a world that hospitalists can thrive in and, with your help and direction, SHM will provide the tools along the way. TH

Dr. Wellikson is CEO of SHM.

While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.

In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.

Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.

What is Quality?

As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:

• Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
• Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
• Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
• Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?

We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.

New Ways to Deliver Care

The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.

While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.

The good news is we aren’t alone in our efforts to change the culture, even the mission, of our hospitals. In a time of healthcarewide workforce shortages, there are increasing demands for direct inpatient care, coupled with the added time needed to document current performance and train and implement needed improvements. The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

All-Star Teams

High-performing organizations are composed of high-performance teams and a set of operating principles that create a widespread culture of motivated individuals who are focused on metrics, are execution-driven, and are committed to continual improvement and rapid adaptation.

The characteristics of high-performance teams are that they:

• Self-correct and reallocate resources;
• Have clear roles and responsibilities;
• Have clear, valued, and shared visions;
• Have strong team leadership;
• Develop a strong sense of “collective” trust and confidence; and
• Manage and optimize performance outcomes.

SHM has taken the lead at a national level in helping to organize the Hospital Care Collaborative (HCC), which is made up of CEOs and leaders in nursing, pharmacy, case management, social workers, and respiratory therapy. The HCC has published a set of “Common Principles” (see “Common Principles for the Hospital Care Collaborative”) and is planning to develop practical strategies for building high-performance teams at our nation’s hospitals.

SHM recently received support from Ortho-McNeil and has created a partnership with the American Hospital Association, American Organization of Nurse Executives, and American College of Physician Executives to develop principles and strategies to implement high-performance teams and to use this as a springboard to look at hospital care in the broadest sense (including transfers with medical home and accountable-care organizations). To start, SHM has convened a blue-ribbon group of hospital CMOs, CQOs, nursing executives, and other leaders in the hospital C-suite. Former SHM president Pat Cawley, MD, MBA, FHM, assistant professor and executive medical officer at the Medical University of South Carolina in Charleston, will chair this effort.

In these two initiatives, SHM and national hospital leaders are providing direction and innovation at two entry points—the C-suite and executive team—as well as on the front lines with the other healthcare professionals who care for our nation’s hospitalized patients.

More to Come

HM has had an interesting decade, growing to more than 30,000 hospitalists now practicing in 75% of our nation’s hospitals. We’ve taken on comanagement and are providing real success as change agents. But the decade to come will see the reinvention of our nation’s hospitals and distinct changes in workflow and responsibilities. We are moving from care based on the unit of the visit or the procedure to episodes of care. We are moving from a system that rewards just doing something to one that rewards doing the correct thing and doing it well. We are moving our hospitals from a swap meet where each physician has a booth and everyone supports those individual efforts to an institution with a culture that is patient-centered, based on quality measurement and performance, and provides care delivered by teams of health professionals working in concert.

This is a world that hospitalists can thrive in and, with your help and direction, SHM will provide the tools along the way. TH

Dr. Wellikson is CEO of SHM.

Just when you thought you had heard the last about the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (HHS) has promulgated new rules for notifying individuals when their protected health information has been breached. These “breach notification” regulations implement provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act (ARRA) of 2009. The regulations became effective in September.

The regulations require covered entities (health plans, healthcare clearing houses, and healthcare providers) to promptly notify individuals affected by a breach, as well as the HHS secretary and the media in cases in which a breach affects more than 500 individuals.  Breaches affecting fewer than 500 individuals must be reported to HHS annually. Notably, breaches will be posted on the HHS Web site. The regulations also require business associates to notify covered entities with whom they work of breaches.

All Breaches Not Equal

Any impermissible acquisition, access, use, or disclosure of unsecured protected health information that compromises the security or privacy of the information triggers the new breach notification requirement. Health information is unsecured only if it is not encrypted or destroyed. Security or privacy is compromised when a breach poses a significant risk of financial, reputational, or other harm. To determine whether a significant risk of harm exists, a covered entity must document a fact-based assessment of the risk involved, including evaluation of:

• What happened to the information (e.g., Was a laptop stolen and never recovered or lost but subsequently found? Was an unauthorized access intentional or accidental?);
• The nature of the information (e.g., Did the information contain Social Security numbers and other data that could lead to identity theft? Did the information involve sensitive health information?);
• Steps that could mitigate the potential harm (e.g., call the recipient and request destruction of the information and confirmation); and
• The number of individual identifiers present in the information (e.g., Did the information have name, birth date, and Social Security number, or only a medical record number?).

Consequently, breaches that do not involve information that can be used to identify a specific individual are not reportable. Moreover, inadvertent breaches to other covered entities pose a low risk of harm. For example, if medical records are inadvertently faxed to the wrong pharmacy or other healthcare provider, there is low risk of harm because the recipient is independently required to comply with HIPAA.

Additionally, the regulations expressly exclude the following events from the definition of a breach:

• Unintentional, good-faith access by an employee or agent if the information has not been redisclosed. An example would be mail sent to or opened by the wrong staff member;
• Inadvertent disclosures among persons otherwise authorized to access protected health information within the same entity, provided the information is not redisclosed; and
• When an unauthorized recipient could not have retained the information (e.g., paperwork given to the wrong patient but returned immediately without being read).

In each of the examples above, a covered entity does not need to provide breach notification because a breach has not occurred under the regulations.

Notification Requirements

Unless law enforcement makes a written request for a covered entity to delay notification, covered entities must provide written notice to each individual affected by a breach as soon as possible but no later than 60 calendar days from discovery of the breach. Importantly, a covered entity is liable for appropriate notification if they know, or should know, of a breach. Moreover, the knowledge of an employee is imputed to an employer. Further, business associates must notify covered entities of any breaches. Thus, policies and procedures should include training of a covered entity’s workforce and ensuring business associates’ compliance.

While there is not a prescribed form for notice, the regulations do require some specific elements, including:

• Description of the breach and the dates, if known;
• Description of the protected health information involved;
• Steps the affected individual should take to protect themselves (e.g., cancel credit cards);
• Description of the steps being taken by the covered entity; and
• Contact information to obtain more information, which must include a toll-free telephone number, e-mail or postal address, or Web site.

If 10 or more individuals are involved for which the entity does not have adequate contact information, notice can be accomplished by a conspicuous posting on the entity’s Web site for at least 90 days, or a posting in print or broadcast media. In either case, an active toll-free telephone number where individuals can find out if they were affected must be available for 90 days.

If a breach involves more than 500 people from any one state, notification must include prominent media outlets. Moreover, the covered entity must notify the HHS secretary at the time notice is provided to affected individuals. Breaches involving fewer than 500 individuals must be reported annually through the Office of Civil Rights Web site.

Sanctions and Penalties

HHS is required to audit, investigate, and impose civil monetary penalties for offenses resulting from willful neglect. Fortunately, HHS has indicated that it will not be imposing sanctions for unintentional violations of the notification requirements until March. This gives providers some time to implement the necessary processes. Nonetheless, it is important to implement compliance processes now, as the penalties for noncompliance can be severe. Under the new law, penalties are tiered based on knowledge, and are capped at $1.5 million annually.

For more information about HIPAA, visit www.hhs.gov/ocr/privacy. TH

Patrick T. O’Rourke works in the Office of University Counsel at the University of Colorado Denver. Kari Hershey is a public relations consultant with Budman & Hershey, LLC, in Denver.

Just when you thought you had heard the last about the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (HHS) has promulgated new rules for notifying individuals when their protected health information has been breached. These “breach notification” regulations implement provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act (ARRA) of 2009. The regulations became effective in September.

The regulations require covered entities (health plans, healthcare clearing houses, and healthcare providers) to promptly notify individuals affected by a breach, as well as the HHS secretary and the media in cases in which a breach affects more than 500 individuals.  Breaches affecting fewer than 500 individuals must be reported to HHS annually. Notably, breaches will be posted on the HHS Web site. The regulations also require business associates to notify covered entities with whom they work of breaches.

All Breaches Not Equal

Any impermissible acquisition, access, use, or disclosure of unsecured protected health information that compromises the security or privacy of the information triggers the new breach notification requirement. Health information is unsecured only if it is not encrypted or destroyed. Security or privacy is compromised when a breach poses a significant risk of financial, reputational, or other harm. To determine whether a significant risk of harm exists, a covered entity must document a fact-based assessment of the risk involved, including evaluation of:

• What happened to the information (e.g., Was a laptop stolen and never recovered or lost but subsequently found? Was an unauthorized access intentional or accidental?);
• The nature of the information (e.g., Did the information contain Social Security numbers and other data that could lead to identity theft? Did the information involve sensitive health information?);
• Steps that could mitigate the potential harm (e.g., call the recipient and request destruction of the information and confirmation); and
• The number of individual identifiers present in the information (e.g., Did the information have name, birth date, and Social Security number, or only a medical record number?).

Consequently, breaches that do not involve information that can be used to identify a specific individual are not reportable. Moreover, inadvertent breaches to other covered entities pose a low risk of harm. For example, if medical records are inadvertently faxed to the wrong pharmacy or other healthcare provider, there is low risk of harm because the recipient is independently required to comply with HIPAA.

Additionally, the regulations expressly exclude the following events from the definition of a breach:

• Unintentional, good-faith access by an employee or agent if the information has not been redisclosed. An example would be mail sent to or opened by the wrong staff member;
• Inadvertent disclosures among persons otherwise authorized to access protected health information within the same entity, provided the information is not redisclosed; and
• When an unauthorized recipient could not have retained the information (e.g., paperwork given to the wrong patient but returned immediately without being read).

In each of the examples above, a covered entity does not need to provide breach notification because a breach has not occurred under the regulations.

Notification Requirements

Unless law enforcement makes a written request for a covered entity to delay notification, covered entities must provide written notice to each individual affected by a breach as soon as possible but no later than 60 calendar days from discovery of the breach. Importantly, a covered entity is liable for appropriate notification if they know, or should know, of a breach. Moreover, the knowledge of an employee is imputed to an employer. Further, business associates must notify covered entities of any breaches. Thus, policies and procedures should include training of a covered entity’s workforce and ensuring business associates’ compliance.

While there is not a prescribed form for notice, the regulations do require some specific elements, including:

• Description of the breach and the dates, if known;
• Description of the protected health information involved;
• Steps the affected individual should take to protect themselves (e.g., cancel credit cards);
• Description of the steps being taken by the covered entity; and
• Contact information to obtain more information, which must include a toll-free telephone number, e-mail or postal address, or Web site.

If 10 or more individuals are involved for which the entity does not have adequate contact information, notice can be accomplished by a conspicuous posting on the entity’s Web site for at least 90 days, or a posting in print or broadcast media. In either case, an active toll-free telephone number where individuals can find out if they were affected must be available for 90 days.

If a breach involves more than 500 people from any one state, notification must include prominent media outlets. Moreover, the covered entity must notify the HHS secretary at the time notice is provided to affected individuals. Breaches involving fewer than 500 individuals must be reported annually through the Office of Civil Rights Web site.

Sanctions and Penalties

HHS is required to audit, investigate, and impose civil monetary penalties for offenses resulting from willful neglect. Fortunately, HHS has indicated that it will not be imposing sanctions for unintentional violations of the notification requirements until March. This gives providers some time to implement the necessary processes. Nonetheless, it is important to implement compliance processes now, as the penalties for noncompliance can be severe. Under the new law, penalties are tiered based on knowledge, and are capped at $1.5 million annually.

For more information about HIPAA, visit www.hhs.gov/ocr/privacy. TH

Patrick T. O’Rourke works in the Office of University Counsel at the University of Colorado Denver. Kari Hershey is a public relations consultant with Budman & Hershey, LLC, in Denver.

Just when you thought you had heard the last about the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (HHS) has promulgated new rules for notifying individuals when their protected health information has been breached. These “breach notification” regulations implement provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act (ARRA) of 2009. The regulations became effective in September.

The regulations require covered entities (health plans, healthcare clearing houses, and healthcare providers) to promptly notify individuals affected by a breach, as well as the HHS secretary and the media in cases in which a breach affects more than 500 individuals.  Breaches affecting fewer than 500 individuals must be reported to HHS annually. Notably, breaches will be posted on the HHS Web site. The regulations also require business associates to notify covered entities with whom they work of breaches.

All Breaches Not Equal

Any impermissible acquisition, access, use, or disclosure of unsecured protected health information that compromises the security or privacy of the information triggers the new breach notification requirement. Health information is unsecured only if it is not encrypted or destroyed. Security or privacy is compromised when a breach poses a significant risk of financial, reputational, or other harm. To determine whether a significant risk of harm exists, a covered entity must document a fact-based assessment of the risk involved, including evaluation of:

• What happened to the information (e.g., Was a laptop stolen and never recovered or lost but subsequently found? Was an unauthorized access intentional or accidental?);
• The nature of the information (e.g., Did the information contain Social Security numbers and other data that could lead to identity theft? Did the information involve sensitive health information?);
• Steps that could mitigate the potential harm (e.g., call the recipient and request destruction of the information and confirmation); and
• The number of individual identifiers present in the information (e.g., Did the information have name, birth date, and Social Security number, or only a medical record number?).

Consequently, breaches that do not involve information that can be used to identify a specific individual are not reportable. Moreover, inadvertent breaches to other covered entities pose a low risk of harm. For example, if medical records are inadvertently faxed to the wrong pharmacy or other healthcare provider, there is low risk of harm because the recipient is independently required to comply with HIPAA.

Additionally, the regulations expressly exclude the following events from the definition of a breach:

• Unintentional, good-faith access by an employee or agent if the information has not been redisclosed. An example would be mail sent to or opened by the wrong staff member;
• Inadvertent disclosures among persons otherwise authorized to access protected health information within the same entity, provided the information is not redisclosed; and
• When an unauthorized recipient could not have retained the information (e.g., paperwork given to the wrong patient but returned immediately without being read).

In each of the examples above, a covered entity does not need to provide breach notification because a breach has not occurred under the regulations.

Notification Requirements

Unless law enforcement makes a written request for a covered entity to delay notification, covered entities must provide written notice to each individual affected by a breach as soon as possible but no later than 60 calendar days from discovery of the breach. Importantly, a covered entity is liable for appropriate notification if they know, or should know, of a breach. Moreover, the knowledge of an employee is imputed to an employer. Further, business associates must notify covered entities of any breaches. Thus, policies and procedures should include training of a covered entity’s workforce and ensuring business associates’ compliance.

While there is not a prescribed form for notice, the regulations do require some specific elements, including:

• Description of the breach and the dates, if known;
• Description of the protected health information involved;
• Steps the affected individual should take to protect themselves (e.g., cancel credit cards);
• Description of the steps being taken by the covered entity; and
• Contact information to obtain more information, which must include a toll-free telephone number, e-mail or postal address, or Web site.

If 10 or more individuals are involved for which the entity does not have adequate contact information, notice can be accomplished by a conspicuous posting on the entity’s Web site for at least 90 days, or a posting in print or broadcast media. In either case, an active toll-free telephone number where individuals can find out if they were affected must be available for 90 days.

If a breach involves more than 500 people from any one state, notification must include prominent media outlets. Moreover, the covered entity must notify the HHS secretary at the time notice is provided to affected individuals. Breaches involving fewer than 500 individuals must be reported annually through the Office of Civil Rights Web site.

Sanctions and Penalties

HHS is required to audit, investigate, and impose civil monetary penalties for offenses resulting from willful neglect. Fortunately, HHS has indicated that it will not be imposing sanctions for unintentional violations of the notification requirements until March. This gives providers some time to implement the necessary processes. Nonetheless, it is important to implement compliance processes now, as the penalties for noncompliance can be severe. Under the new law, penalties are tiered based on knowledge, and are capped at $1.5 million annually.

For more information about HIPAA, visit www.hhs.gov/ocr/privacy. TH

Patrick T. O’Rourke works in the Office of University Counsel at the University of Colorado Denver. Kari Hershey is a public relations consultant with Budman & Hershey, LLC, in Denver.