At $25 BILLION annually, the pre term birth crisis is roughly equal in cost to the Avoidable Readmissions problem. The solution is to utilize post acute providers like home health nursing to care for expectant mothers in the community.
The emergence of health care "ecosystems" -- that operate efficiently and coordinate care effectively among providers -- provides signifcant new opportnities for post acute providers. Home Health Nursing, HME / DME companies, physical therapy agencies, Private Duty Home Care agencies and others have opportunities before them to partner with health systems and Accoutable Care Organizations, or ACOs, to develop new revenue while simultaneously improving patient care in the community. As more care is delivered outside of hospitals, post acute providers will serve as the primary delivery channel.
Ankota is often asked for guidance to help post acute care providers identify new opportuities and new programs to leverage. Here is one tremendously valuable opportunity to improve care and reduce costs for an expensive, high risk population. Post acute providers should partner with local health systems to address the pre term birth crisis.
Ankota's Chief Medical Officer, Dr. J. Hunter Young, points out that premature births in the US cost the healthcare system $25 Billion annually. Additionally, the "cost tail" is a long one, where pre-term babies who consume expensive care at birth tend to consume a disporportionate share of healthcare services for the rest of their lives. This is an entirely addressible problem during pregnancy, but is best suited to be addressed in the community using post acute providers and community based staff as the delivery channel.
Dr. Young is Ankota's Chief Medical Officer, and serves jointly as Assistant Professor of Medicine at the Welch Center for Prevention, Epidemiology, and Clinical Research, and Core Faculty of Johns Hopkins Bloomberg School of Public Health. In these roles, Dr. Young is involved in population health programs and community based initiatives that are aimed at decreasing readmissions and lowering the overall cost of care.
Nearly 500,000 babies are born too early in the US every year.1 As the leading cause of infant mortality and long-term disability in children, the preterm birth rate between 12 and 13% extracts a very high cost on infants and families. This burden is not equally shared. In 2007, the preterm infant mortality was almost 3.5 times higher among infants of African American mothers compared to white mothers.1 In addition, the societal cost of preterm birth is considerable, estimated at more than $26 billion per year.2 Approximately $17 billion of this total goes to the medical care of the infant, accounting for approximately 50% of birth-related spending.2 A significant proportion of this cost supports the frequent admission of the preterm infant to the neonatal intensive care unit.
The good news is that we know many of the risk factors for preterm birth3 and, therefore, we can identify women in time to intervene. Just as important, we have an intervention that has been proven effective in preventing preterm birth among women with certain risk factors.4 Progesterone is a naturally occurring hormone that is involved in maintaining pregnancy. There is very strong evidence that progesterone administration significantly reduces the risk of preterm birth in women who have had a preterm birth in the past.5 There is also very good evidence that progesterone reduces the risk of preterm birth in women who have evidence of a shortened cervix on ultrasound.4 Given this evidence, progesterone administration has become the standard of care in the prevention of preterm birth in women with a history of preterm birth.
The use of progesterone has the potential to significantly reduce the burden of infant mortality and disability in children. In addition, its use has the potential to significantly reduce health care costs. In a paper published in 2007, the authors found that the universal treatment of eligible women with progesterone would save approximately $2 billion in annual direct medical expenses.6 The financial data is old and, therefore, this is likely a significant underestimate of the true cost savings.
Despite the proven benefit, progesterone is still underutilized. The data is sparse but a survey of Maternal-Fetal Medicine specialists in 2005 found that only 67% used progesterone to prevent preterm birth.7 The rate of use by non-specialists is likely substantially lower. Furthermore, progesterone administration is inconvenient, requiring weekly injection or daily vaginal suppositories. Therefore, adherence among women prescribed progesterone is likely low.
Given the proven benefit of progesterone treatment on birth outcomes and costs, it is important that health systems improve the process of identifying, treating, and supporting women at risk for preterm birth. Approaches to improve adherence to progesterone treatment include education of care providers, facilitation of progesterone compounding and delivery, the administration of progesterone in the patient’s home, periodic assessment of adherence, and patient support through education and other efforts such as motivational interviewing. Once implemented, a systematic approach to the care of women at risk for preterm birth could have a substantial impact on birth outcomes and costs. Given the very high direct medical cost for an infant born early, approximately $33,000 by one estimate,2 a small decrease in the rate of preterm birth can have a substantial impact on birth-related expenses.
1. Preterm Birth. 2012; www.cdc.gov/reproductivehealth/maternalinfanthealth/PretermBirth.htm. Accessed March 11, 2013, 2013.
2. Behrman R, Butler A. Preterm birth: causes, consequences, and prevention. Nataional Academy Press. Washington DC: Institute of Medicine; 2006.
3. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet. Jan 5 2008;371(9606):75-84.
4. Ransom CE, Murtha AP. Progesterone for preterm birth prevention. Obstetrics and gynecology clinics of North America. Mar 2012;39(1):1-16, vii.
5. Dodd JM, Flenady VJ, Cincotta R, Crowther CA. Progesterone for the prevention of preterm birth: a systematic review. Obstet Gynecol. Jul 2008;112(1):127-134.
6. Bailit JL, Votruba ME. Medical cost savings associated with 17 alpha-hydroxyprogesterone caproate. American journal of obstetrics and gynecology. Mar 2007;196(3):219 e211-217.
7. Ness A, Dias T, Damus K, Burd I, Berghella V. Impact of the recent randomized trials on the use of progesterone to prevent preterm birth: a 2005 follow-up survey. American journal of obstetrics and gynecology. Oct 2006;195(4):1174-1179.
"We will need to find ways to do more with less."
Phillips Health Care Letter to the HME Industry
Philips Healthcare: "Along with you, we are disappointed by the recent CMS Competitive Bidding Round 2 Reimbursement Cuts announcement."
March 5, 2013
Dear Homecare Provider:
Along with you, we are disappointed by the recent CMS Competitive Bidding Round 2 Reimbursement Cuts announcement. Knowing the provision of many life-saving homecare products and services is so critical to the success and even to the survival of providers like you, we are also disappointed by the extent of those cuts and the lack of transparency demonstrated throughout Round 2 of the Competitive Bidding process. At this crucial time, we remain committed to working as your ally to find viable solutions for these changing times. We will continue our efforts to drive innovative solutions and to provide added value opportunities for you and your business, while also continuing our efforts in Washington to influence policy in a way that will benefit all in the long term.
Faced with this unfortunate development, the number one priority for all of us must be to preserve the integrity of patient care. We will need to find ways to do more with less. Fortunately, ongoing collaboration with you has enabled us to introduce meaningful technologies and programs that may help reduce some of the sting. Tools like EncoreAnywhere were developed with input from providers like you and quickly became an invaluable resource to care teams who need efficient, remote access to vital patient information.
Today, patients are now able to manage more of their own care through feedback, troubleshooting and motivation with the use of SleepMapper, a new-to-the-industry innovation that was, again, inspired by our customers. Ideas such as the innovative Fit for Life program which offers resupply services with the purchase of a mask were developed for the changing industry model and are there to encourage long-term patient compliance, and to help you deliver practical ongoing care with less strain on your resources. REMstar Pro with Auto-Trial/CPAP-Check can provide efficient patient management as it helps to optimize pressure settings for home sleep testing patients, while providing them the long-term benefits of fixed pressure. Homecare provider focused retail programs and merchandising tools help to expand your offerings into new solutions beyond managed care. And our robust education and Partner Programs will be further bolstered to help you stay informed and stay a step ahead.
We approach our pledge to homecare providers like you with more resolve than ever. We will continue to lead the drive toward healthier patients, healthier practices and healthier businesses. And you can be sure we will be working even more closely with you to improve the likelihood of ongoing success. In the coming weeks and months, our team will be reaching out to you regularly to discuss your needs and present specific, real-world solutions that can help you immediately and set the stage for your future success.
The Competitive Bidding Round 2 Reimbursement Cuts is just the latest evidence that our industry is changing. Undoubtedly, we will face countless new challenges on our journey ahead. But through a concerted and collaborative effort, we will find optimal solutions and emerge stronger. Those who are open minded, willing to adapt and able to make the transition will be the ones who will ultimately realize success. As your allies, all of us at Philips Respironics are committed to help you make that transition.
We look forward to working with you through this latest challenge. In the interim, we want to hear from you. Share your thoughts and ideas by contacting us at firstname.lastname@example.org.
Philips Home Healthcare Solutions
Sr. VP/GM, Sleep and Respiratory Care
Philips Home Healthcare Solutions
We see it all the time, and perhaps you even catch yourself doing it in your practice. As the president of one of our new physical therapy customers said to me,
"Sometimes we get so focused on the clinical side
of providing care that we forget we're
running a business, too."
"I think I know why," I replied, "that's easier to do and it's more interesting." His smile said it all, and he agreed, "It's what we already know and what our people are trained to do."
Indeed, providers tend to focus on what they know: providing care. Therapists focus on therapies and rehabilitating patients, infusion nurses focus on administering antibiotics and chemotherapy drugs, and HME businesses focus on the delivery and set up of home medical equipment (while losing sleep over how to navigate the competitive bidding nightmare!).
The business stuff should take care of itself, or "we're not a business," says conventional health care wisdom. Not so. That's just an excuse to justify focusing on the most comfortable and certainly more interesting things like taking care of patients. People get into the "business" of healthcare because they care about taking care of patients. They're forced into marketing the business and developing referral sources to stay alive, yet the business operations are often assumed or even neglected. It's the way they've always done things, but the inefficiency becomes especially obvious when compared to other industries. This neglect is fundamentally an issue of attitude. If you choose to focus on what you know best, you won't improve on the things where you are weakest. It's a mindset. Choose to focus where your business needs it and where you can improve, where you are least comfortable, in addition to the areas where you are more comfortable.
Am I saying that business owners have a bad atttude? Not at all! I'm saying that it's easy to focus and what you already know, where you're already good. Likewise, it's easy NOT to focus where you're uncomfortable.
Agencies of all types simply must decide to tackle the issues they may not know much about. Set aside discomfort, and simply decide to act. Focus. Redirect. Change your attitude. And enlist the help of others. Leverage technology as much as possible to improve both and challenge technology providers to show you how you can run your business more productively. We see literally hundreds of operations every year, and have tremendous expertise in business performance management and optimization of people and resources. The vendors you talk to can be a tremendous asset if you take advantage of them.
Even if it means you may not be good at what you're now focusing on, just change your attitude. Study after study shows that attitude triumphs and is a larger contributor to success than anything else. Take a look at this piece by Dan Waldschmidt
in the Business Insider, which discusses attitude as the primary factor of success. "Your Attitude Determines Whether Or Not You'll Succeed"
Think this is a problem only for smaller home health and therapy agencies? think you're too big to suffer some of the operational problems that many providers experience? Think you're too small for change to matter or for technology to help?
Think again. Many of the very largest, publicly traded home health agencies still run on paper at the point of care. Existing scheduling tools are basic and don't optimize for concerns such as time, travel, skills, or availability. That's ridiculous and providers know it. Reporting takes forever. Billing takes days or even weeks in some instances. They waste millions of dollars each year processing time sheets when technology at the point of care would automate such things and render time & attendance reporting obsolete. One large home care agency we studied spends more than $3 million annually processing time sheets alone. Technology from Ankota can eliminate this expense entirely.
Why do they do it this way? Because that's how they've always done it. That's the attitude that costs them $3M each and every year. It seems to be changing, but it first requires a change in attitude to acknowledge that there may be better ways and seek them out.
Think your agency is too small for automation to make a biug difference? Consider this: A typical home health agency may support roughly 20-25 care givers with a single scheduler using existing technology. Using more powerful (and often less expensive) technology from Ankota, the same scheduler may support 2-3 times as many caregivers. When you're a smaller agency, the cost of hiring new bodies to scale operations is tremendously expensive. Rather than assuming that the only option is to hire more, turn to your software vendors and demand that they show you how to accomplish more with the resources you already have. Expect your partners to act as your advocates to help make you better at what you do, no matter how small your business is.
We're seeing numerous programs emerging among hospitals and Accountable Care Organizations (ACOs) that are intended to improve the cost and quality of care for populations, but are repeating old mistakes. They're taking a "safe" route and building new programs on old technologies and sometimes even using paper documentation. The attitude shift that is needed here is to assume that existing ways are not safe, not productive, and not in compliance. Assume that there are better ways to design and manage community based and population health programs and find tecchnologies to make them better. Change your attitude.
That's why Ankota built software solutions that scale for organizations of all sizes, small to very large. To solve some of these problems of managing care delivery, to make it easy to Plan, Coordinate and Deliver care and to do it efficiently across virtually any healthcare setting.
You've probably heard a thousand "-isms" about attitude driving success, about perspiration, inspiration, and more. All you need to do is make a choice to change your attitude, change your focus, and make it so.
"If you don't run the business like a business,
you'll be out of business."
"If you continue to do what you've always done, you always get what you've always gotten."
Change your organization's attitude by leading with your own. And ask Ankota to help!
How do you manage operations when disaster strikes? Technology and good planning should be your allies.
Storms threaten patient safety and the delivery of post acute care, but a little planning and some good technology can help hospitals, ACOs and post acute providers of all types to keep things running smoothly. Making sure the right patients continue to get the right care at the right time should be easy with the right business practices and technology--even during a weather emergency.
click here to see images from Sandy
A myriad of providers must cooperate to deliver services to patients in their homes and other residential settings. Home Care Agencies, Physical Therapy providers, infusion nurses, and HME delivery organizations are some of the more common ones, but hurricanes like Sandy threaten to disrupt operations and may even threaten the lives of patients.
We're in the throes of hurricane season now and Sandy is beating on my door in Baltimore as I type this. Readers may recall a similar post when Hurricane Isaac struck the Gulf region in early September. That article remains one of the most popular posts we've ever run and it seems fitting to share some pieces of it again here.
Once we emerge from hurricane season in November, much of the country will face the snowy winter months and the risk to care continuity that presents. Then, tornadoes and extreme thunderstorms of spring and the extreme heat of summer... and so on. Storm Happens. It's incumbent on providers to have a contingency plan, communicate it, and activate it when the weather turns extreme.
One of the most read articles ever on Ankota's blog discussed ways to better manage home care when catastrophes hit. "Managing Home Care in a Storm," was originally written by Ankota's CTO, Ken Accardi, and the same lessons apply to hospitals, ACOs and post-acute providers that provide services including DME delivery, Physical Therapy, Infusion Nursing, and more.
The challenges of delivering care outside of hospitals on any kind of mobile basis are exacerbated when weather disrupts operations, as we just witnessed again with Hurricane Isaac. How are patients prioritized and rescheduled? Which ones require critical care regardless of the weather? Which ones can wait? Which care plans are affected? How do you communicate changes in schedules and care plans with staff, patients, family, and support networks? Hospitals, ACOs, and post acute care providers of all types must implement strategies to deal with weather-related emergencies and utilize technology that enables care, rather than inhibits it. Dangerous and life threatening conditions can be avoided with some simple planning.
From Managing Home Care in a Storm:
Here are some best practices that we've observed home care organizations follow to manage their operations in the midst of a snow emergency (and some things that Ankota's software does to help):
Move Appointments to Avoid the Times when travel is most inhibited: Ankota's scheduling board (screenshot below) shows you all of the planned jobs for the week on a drag and drop interface. so moving jobs forward or back is simple.
Make Sure that the jobs with critical timing are dealt with at the appropriate time: Visits such as "chemo finish" visits for a 48-hour chemo infusion have a very specific time frame for completion. Ankota's scheduling board let's you know if you've by attempting to move a visit you've violated a scheduling constraint.
Communicate the Changes to the Care-Givers: Ankota's software changes the visits to a different color when you manually reschedule, allowing you to tell your care workers what changed and what stayed the same.
Plan for Two people per car (in the event that it will be impossible to park and one person will need to hover): Although the Ankota software doesn't specifically have a feature for scheduling two people in the same vehicle, we have the ability to change the work shifts easily for the emergency workers and mark the others as unavailable (and to make sure that all of the time sheets come out right).
Keep non-essential personnel at home: Ankota's web-based software allows your office staff to operate from their home via their internet connection.
Communicate to the Loved-Ones of Your Patients: Ankota's FamilyConnect allows you to send a message out to family members of the people you care for. By proactively sending a message to all of the families, you can save time for your critical staff. Also, you can send messages to the families of individual patients/clients using the quick connect feature. FamilyConnect messages are received by email and/or text message (as selected by the family member)
Below is a screen shot of the Ankota Drag and Drop Schedule Board that allows you to see status and resolve issues at a glance.
We thank you for all you do to provide outstanding home care, even during the thoughest conditions! If rescheduling was tougher for you than what's described above, please contact us so we can try to help.
Ankota provides software to improve the delivery of care outside the hospital. Today Ankota services hospitals, ACOs, home health, private duty care, DME Delivery, RT, Physical Therapy and Home Infusion organizations, and is interested in helping to efficiently manage other forms of care. To learn more, please contact Ankota by clicking on this cool orange button!
How do you mamage risk during storms? We'd love to hear from you in the comments section below.
Are HMEs surviving competitive bidding? Funny you'd ask...As Theresa Flaherty's September 7th piece in HME News shows, more than 450 HME providers have closed locations, sold their businesses or gone out of business due to the program. Further, VGM estimates that more than 100,000 jobs will be lost. Download the VGM report here
Subcommittee Scrutinzes Competitive Bidding Program
from HME News, September 7, 2012
WASHINGTON – When industry stakeholders give testimony during a congressional hearing tomorrow, one of the things they plan to do is paint the competitive bidding program as a job killer.
Stakeholders are scheduled to testify at a hearing titled "Medicare's Durable Medical Equipment Competitive Bidding Program: How are Small Suppliers Faring?" before the House Small Business Subcommittee on Healthcare and Technology.
"Lawmakers want to know what the impact is on small businesses," said John Gallagher, vice president of government relations for The VGM Group.
VGM has commissioned several studies on the economic impact of competitive bidding, and AAHomecare in July provided the House Ways and Means Committee with a list of more than 450 HME providers who have closed locations, sold their businesses or gone out of business due to the program.
Boosting the industry's message: a weak jobs report, released last week by the Labor Department, that showed U.S. employers added only 96,000 jobs last month—far less then anticipated. That means preserving the jobs of providers and their employees—rather then forcing them out of business—will be front of mind for lawmakers at the hearing.
"We are trying to make sure they've got our reports on jobs," said Gallagher. "And we want them to ask CMS, 'What is the impact of this and what are the jobs that are going to be impacted?'"
With lawmakers returning to the Hill this week, stakeholders say the hearing will provide momentum to move the market-pricing program (MPP) forward. In August, Rep. Tom Price, R-Ga., agreed to introduce a bill for MPP.
"Everybody understands the issue, now it's just a matter of keeping it in the forefront," said Joel Marx, chairman of AAHomecare chairman and Cleveland-based Medical Service Co.
Scheduled to testify at the hearing: Laurence Wilson, director of the Chronic Care Policy Group for CMS; Peter Cramton, an economics professor and critic of the bidding program as currently designed; Tammy Zelenko, president/CEO of Bridgeville, Pa.-based Advacare Home Services, who will testify on behalf of AAHomecare; and Randy Mire, owner of Reserve, La.-based Gem Drugs, who will testify on behalf of the National Community Pharmacists Association.
click here for the full article on HME News
Related article Home Care Magazine "Bidding Will Cost Jobs"
When faced with an audit, documentation and technology can save the day
Health care providers of all types face increasing scrutiny from public and private payers alike to operate in a totally above-board, compliant fashion. Simply doing things the right way is no longer enough, you have to prove that you are compliant, and have systems and processes in place to assure that you will continue to operate that way with every patient, every day.
This helpful piece, written by Wayne van Halem, CFE, AHFI, President of The van Halem Group, LLC, originally ran in Home Care Magazine and is intended to help HME providers to better prepare for and respond to Medicare audits. The lessons are applicable to many of Ankota's customers and are definitely not limited to just HME companies (or CMS), so we decided to share it here on the Ankota blog. Whether you are an HME, a home health agency, a physical therapy providerer, infusion nursing, or even non-medical private duty home care -- read on!
If you are a hospital or Accountable Care Organization (ACO), or involved in Care Transitions Initiatives, then you should also read on. You should anticipate that your organization will become increasingly responsible for the care and services that take place outside of the hospital--whether by your organization or one to which you refer or subcontract services. As more care is delivered outside of hospital settings, hospitals and ACOs need to take steps to assure that 3rd party providers follow the rules.
The biggest problem concerning audits, without question, is physician documentation being deemed insufficient. Recent changes to the Medicare Program Integrity Manual, which guides audit contractors, have reflected what we are noticing in these audits. The Centers for Medicare & Medicaid Services (CMS) wants to see that the physician documentation specifically addresses the criteria listed in the Indications and Limitations of Coverage section of the Local Coverage Determinations, and that it is documented in their notes as well as in the normal format that they document their own services. This seems reasonable, in theory, except for the fact that CMS does not fund the DME MACs to educate physicians and the Part B MACs are not funded to educate physicians on DME policies. So physicians do not know what they are supposed to document—it’s up to you to educate them.
While it may not be feasible to request documentation up front in all instances, CMS and its contractors seem to believe it is. I’m not sure what to do to resolve that issue, but what I can recommend are some ways to encourage cooperation from physicians by touting the term “compliance.” It’s not an option for physicians to comply, it’s the law. Unfortunately, CMS has put the responsibility on you to educate the physicians, and there has been little—if any—liability placed on physicians who do not comply.
Recently, however, we have seen an increase in additional documentation requests (ADRs) because contractors are auditing the physicians, so perhaps they will be more aware and willing to cooperate. We must come together and hold physicians accountable, so begin educating your physicians of their legal obligation. It’s not your requirement that you provide documentation, it’s Medicare’s requirement, and in order for you to be in compliance with federal regulations you need the documentation. As a result, the physicians may become the target of an audit because their documentation is not being deemed sufficient, so why not work with a company that is taking the extra effort to be compliant? It’s a great marketing tool in an environment of intense regulatory oversight that is now affecting other health-care providers, including physicians.
Another important topic to address is holding your patients more accountable. If you get the patients involved in their treatment and care, and educate them under what circumstances Medicare will cover the equipment that was ordered for them, it helps them understand what is needed to get their claim reimbursed accordingly so they are not liable. If you explain to patients that their physician has failed to comply with the request for documentation, and as a result they may be responsible for payment of the services, they will naturally be motivated to contact their physician.
While most physicians may not be concerned over your claims getting paid, they would likely be concerned if the patients call to complain. A successful practice must keep their patients content. While I advocate for the use of Advance Beneficiary Notices (ABNs), I also think it is extremely important that you fully explain the document to the patients so they understand what they are signing. The form should be specific and unique to that patient’s situation. It’s a fine line the provider must walk between alienating referral sources and patients, but both of these groups must take an active role in the care you provide.
In my opinion, I think suppliers should develop a process to request documentation for each patient knowing that you won’t always get a response. However, it’s an opportunity to educate your physicians on what the coverage policies are. We recommend drafting cover letters to use when faxing orders to be signed by physicians that explain under what circumstances the items are reimbursed by Medicare, as well as the documentation requirements. Explain that the patients’ progress notes must support that the criteria are met or coverage can be denied and the patient may be held liable for payment. Ask them to review, sign and date the attached order and return it with the most recent progress note which supports that your patient meets the criteria for coverage. While they may not send the progress note in return, they may take notice of what needs to be documented. By asking for the most recent progress note, you are alerting them to the fact that you’re not asking for hundreds of pages of records and they may be more willing to comply. The more often they get the letter, the more quickly it may sink in. It certainly increases your chances above not requesting anything at all, and it’s worth the minor extra effort if they do comply. Of course, following up if they don’t respond is highly recommended, as well.
Quality, Not Quantity
Many providers think that the more records they send in, the higher the likelihood the claim will be approved. There is just no truth to that, and it’s really quite the contrary. Patients’ conditions may worsen, but the physician may not adequately document it in their records. Therefore, sending in additional records may raise concerns with the reviewer that the patient does not qualify for coverage, when they do indeed.
Additionally, the reviewers at Medicare have strict timelines and performance standards related to their workload that must be met. They could be reviewing thousands of pages of records each day. The more records that you send in, the harder it is for the reviewer to find the necessary elements in order to approve the claims. Be precise and simple in your documentation requests, and try to automate the process as much as possible to manage the workload associated with doing so. If your system allows you to export intake data to Excel, it could be as simple as performing a mail merge to complete cover letters.
Some providers have created forms to document medical necessity, or have added this information to their orders. However, if you have this information on your order, Medicare is clear that the order is not part of the “clinical record” for purposes of an audit. Therefore, under no circumstances would a claim in which this is the only supporting documentation get approved upon initial review. There is a similar issue with forms. Unless it is a CMS-approved form required by policy—such as a Certificate of Medical Necessity or a Statement of Certifying Physician—an auditor would not consider it as part of their review. The supporting documentation must be present in the clinical record and in the normal format that the practitioner uses in documenting their notes. If you are relying solely on forms, then the physician completes the form and assumes that their work is done. This actually makes it less likely that the physician will document the need for the equipment in the notes.
The Meaning of Modifiers
The last—but probably most important—item that I want to discuss is the KX modifier. I believe the government is building this up as a tool to implement false claim violations. Recently, and often, the “meaning” of these modifiers has been revised and changed in various policies. In some instances the KX modifier added to a claim indicates that the supplier has clinical notes in their possession supporting that criteria for coverage has been met. Yes, some policies now have a mandatory documentation requirement. If you add the modifier indicating this and you get audited, and if they determine you don’t have it, you’ve potentially submitted a false claim, which carries significant monetary penalties. I cannot stress enough the importance of knowing and understanding the specific meaning of this modifier for all the products you bill that require it.
Too many times I’ve asked billing staff why they added the KX modifier when conducting our compliance assessments, and the response was that it will not be paid without it. While this is true, that is not why it is added to the claim, and there is a significant amount of risk associated with this modifier for our industry. I’m afraid that in the future, auditors and investigators will target suppliers using this modifier. In fact, for the second year in a row the improper use of modifiers has been identified as an issue in the Office of Inspector General Workplan. Suppliers should take heed of this advice in order to avoid future issues.
As I’ve previously stated, documentation is your only defense in an audit. You must come up with innovative and streamlined processes to obtain as much documentation as possible, and review it before putting it in your files. Conduct risk assessments with your referral sources to determine which physicians are not cooperating, which need more education, and which ones seem to understand. You can then decide which ones you no longer want to do business with, and which you may feel comfortable can provide you with the necessary documentation if you choose to not request it every time for every claim.
Don’t accept liability without holding those other interested parties more accountable. Stated simply, it’s just a sound business decision.
Physician, Heal Thyself!
Lack of physician documentation complicates audits. Here are some points you should make to the physicians in your referral network:
- CMS doesn’t fund physician education, so it’s up to you to educate them. Help physicians understand the challenges you face and ask for their help.
- Encourage cooperation from physicians by touting the term “compliance.” It’s not an option for physicians to comply, it’s the law.
- Emphasize that it’s not your requirement to provide documentation, but Medicare’s, and in order for you to be in compliance you need the documentation.
- Physicians may become the target of an audit when their documentation isn’t deemed sufficient, so market yourself as a company that will help them to comply.
- Point out that the current environment of intense regulatory oversight is affecting a wide variety of health-care providers, including physicians.
Maybe you don't want to give a copy of Fifty Shades of Gray to your elderly home care patients, but you might just learn some valuable things from the block-buster novel. If you are a physical therapist, you might not want to read from it while your client rehabs with you from a fall. And, if you are an infusion nurse, as tempting as it might be, your oncology patient might not be the best one to share the book with (or maybe she is!!). Either way, here's an interesting twist on the book: 6 business lessons you can apply to any post acute care operation.
Have you heard that it's a little dirty? You HAVE heard about Fifty Shades of Gray -- right?!?
In the American Express Open Forum, Rieva Lesonsky writes, "If not, either you’re a guy who has no woman in his life, you’re living in a cave or you’re a guy living alone in a cave. Women everywhere are buzzing about this bestselling erotic novel, which tells the story of a wealthy entrepreneur’s affair with an innocent college student. First-time author E.L. James has been mobbed at book signings, interviewed on TV and given a seven-figure contract with Vintage Books. Ellen DeGeneres read snippets from the novel aloud on her talk show, Barbara Walters discussed it on The View and Time magazine named James one of its 100 Most Influential People of 2012."
Lesonsky explains that, as she read Fifty Shades, she kept drawing lessons from the book that applied to business. Despite my healthy skepticism that anyone can read this book and think about how it might apply to their business, I am a guy, I do have a "cave" of sorts in my basement, and I will defer to someone who has actually read the book. So, I share these with Ankota's readers here along with my disclaimer that says "I don't know much more about this book...though I don't live alone in a cave."
So, what do you think? What can home health care and other providers of post acute care learn from Fifty Shades of Gray? There must be something smart you can say about Physical Therapy or Infusion, at least.
I think it's time for me to go back into my cave.
The Six Lessons can be read in its entirety here
By David Kopf Apr 26, 2012
Testimony to Senate Finance Committee says DME/HME's anti-fraud measures are pushing fraudsters into other areas.
Efforts to push fraud out of the durable medical equipment sector have been successful, according to testimony made by HHS Inspector General Daniel Levinson to Senate Finance Committee this week.
Echoing Levinson's comments was Wifredo Ferrer, from the U.S. Attorney’s office in Southern Florida, who added that criminal activity in Medicare has transitioned “from the DMEs to HIV infusion therapy to home health and now, community mental health,” according to a report from the American Association for Homecare...
click here for full article
Whether you are part of a hospital system like Johns Hopkins Home Care Group in Baltimore or an independent Physical Therapy agency like Rehab Maxx in Chicagoland, Ankota's customers must sometimes face the very difficult task of firing people. As anyone who has mishandled a firing before will tell you: Don't mess it up. (Our customers don't mess it up...we're just sayin').
It's awful and no one ever enjoys it. If you are like most people, you dread firing staff and, let's face it, you're probably not very good at it anyway (don't feel bad: no one is). There are some definite "do's and don'ts" that you MUST follow and this article by Jeff Hayden of Inc. does a good job of synthesizing a lot of concepts into "The 10 Worst Things you Can Say When Firing Someone."
Says Hayden, "Firing someone is hard -- but getting fired is always harder. Don't make it worse by putting your foot in your mouth." Hayden continues, "Never say the following..."
1. "Look, this is really hard for me."
2. "We've decided we need to make a change."
3. "We will work out some of the details later."
4. "You just aren't cutting it compared to Mary."
5. "Okay, let’s talk about that. Here’s why..."
6. "You’ve been a solid employee but we simply have to cut staffing."
7. "We both know you aren't happy here, so down the road you’ll be glad."
8. "I need to walk you to the door."
9. "We have decided to let you go."
10. "If there is anything I can do for you, just let me know."
You can read Hayden's article in its entirety here, including a discussion of each of The 10 Worst Things You Can Say When You Fire Someone
In "How to Improve Delivery Operations Management," Dave Kopf, Editor of HME Business writes, "One of the major elements of HME business overhead is running delivery and repair fleets and their supporting operations. It is a staff-intensive, and involves continuing regular capital expenditure for fuel and repairs, as well as depreciating assets — the vehicles — that need to be regularly replaced."
It's on every HME's mind: How Can I Cut Costs Now?
Kopf points out that the practice of managing deliveries and planning routes consumes a good amount of staff time, which also means more overhead. The HME industry has been grossly underserved with technology until recently, and most HMEs are still in the dark ages when it comes to leveraging technology.
Managing deliveries is both complex and expensive. Kopf and other experts note primary costs to consider, below. Ankota offers additional guidance on how technology can address and reduce these costs directly. I cannot speak for other software companies, but in our experience with Ankota's HME Optimization technology, these results can be achieved in less than one quarter, even making the system self-funding.
It's a matter of survival. With reimbursement cuts, many HMEs are certain to fail. Technology MUST be leveraged immediately to improve profitability and allow providers to survive and grow with fewer staff. It's all about productivity improvement and that is best achieved through automation.
A few more things to consider when choosing a system:
- Get rid of paper now. Does the system provide a "closed loop" electronic process? You can initiate orders, plan and track staff, vehicles and deliveries (including signature capture), generate invoices and payroll -- all electronically. Your billing and payroll should be done instantly as a result, further reducing staff needed to support operations. It is not unusual for an HME to consume .5-.75 FTE filing delivery sheets, or scanning and attaching them in another system. That process can be fully automated, saving a single office several tens of thousands of dollars in direct labor costs per year.
- Scheduling & Route Planning: does the system simply create routes and maps based on the schedule? Or does it utilize optimization technology to schedule deliveries in such a way that the appointments and sequence in which deliveries are made are optimized, resulting in fewer miles traveled and lower fuel expense? You want the latter, for sure. It can reduce your cost per service order by 25-50%.
- Integration with existing systems: Does the system connect with your order entry system so that your staff can avoid time wasting efforts like entering data multiple times? Same should go for integration with your billing and payroll systems (or services you use for these).
- Finally, only use web-based technology that you can pay for on a monthly or quarterly basis. The technology will serve you far longer, will provide greater innovation, and you can always hold the vendor's feet to the fire when issues come up. Good web based products will also support offline use and syrchronize when you have a connection.
Delivery of Home Medical Equipment (HME/DME) is critical to the overall success of the healthcare system. HME Providers must utilize technology to maintain viabillity and survive resimbursement cuts. Technology can be used to improve profitability quickly and put HME providers in position to participate in Coordinated Care and Accountable Care models. Without Care Coordination technology that ties delivery operations to those who plan and authorize care, HMEs will be left out.