“Hospitals are absorbing new penalties from the Centers for Medicare & Medicaid Services for “excessive readmissions” as part of the Hospital Readmissions Reduction Program created by the Affordable Care Act.

In Part 1 of this article, posted on April 25, 2013, we described the long-term implications of the readmissions reduction program and recommended that…

READ Hospital Readmissions: How to Stop the Pain – Part 2.”

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There is good reason for this approach. According to the American Hospital Association, “About 60 cents of every dollar spent by hospitals goes to pay for wages and benefits for those who directly care for patients or support their care in some manner.”

An efficient staffing management program is an imperative component of cost containment; however, its implementation is not as simple as picking a labor benchmark for hours per patient day and using it as a basis of the new annual budget. Approaching staffing in this manner often results in budget overages instead of cost reduction, distrust in administration, and staff frustration.

Involve the Stakeholders

Before senior leaders set out to develop new staffing plans, they should first consider who needs to be involved in the project. Having the primary stakeholders involved in the project from the beginning will help gain their understanding and support.

Determine the Objectives

There are several questions that should be addressed before starting the plan. First, develop a common understanding of your objectives or what you are trying to accomplish. Every hospital wants to provide quality care to their patients, but what does that really mean? What else are you trying to accomplish? What model of care do you want to utilize? Is there availability of personnel to match the preferred staffing model? Can you recruit staff to support this model? Do you need your staffing to meet a predetermined number of FTEs to achieve a non-negotiable financial target? Are you trying to obtain Magnet status or some other certification?

Choose Benchmarks Carefully

Benchmarks should be carefully chosen based upon the objectives you are trying to accomplish. Using benchmarking data to set staffing targets can be dangerous if you don’t understand the peer group you have chosen. A comprehension of the types of organizations included in the benchmarking system (size, community, teaching, critical access, quality ratings, Magnet, etc.) will inform your decision on which peer group to choose and how closely you would like to match their numbers. Once benchmarks are chosen, the staffing objectives and the method for choosing the benchmarks should be communicated to the staff in a transparent manner to help allay staff fears and give credibility to the benchmarks chosen.

Another thing to consider is whether you have adequate resources to implement the new plan. While it’s “macho” to believe that staff can do “more with less,” the fact is that they can only do “less with less” unless support structures and processes change. Planning should consider which systems will have to change to meet the new benchmarks, who will drive the changes, and how the changes can be accomplished. Don’t overlook the fact that taking people away from normal work to work on projects means you need to backfill their project time.

Enroll and Support the Frontline Staff

Whenever possible, enroll the frontline staff in development of the plan to achieve the benchmarks. They know the work better than anyone and will have a wealth of knowledge and ideas on how to do the work more efficiently and, ultimately, better. Establish work teams and provide them with training in continuous process improvement processes. Assign a facilitator or coach to the teams to keep them focused on the project, provide ongoing support in performance improvement methodologies, and assist in data collection and analysis if needed.

Be aware that during the redesign process and transition, productivity is likely to drop as it takes time for the staff to learn and adapt to the new processes or flow. During this phase, support from the leaders is imperative.

Recruit and Train New Staff if Needed

If you do not currently employ the right skill mix for the staffing model you have chosen, recruitment will be necessary. This may simply involve a recruitment plan if trained personnel are available within the organization or the community. If not, you may need to collaborate with local colleges or universities to train staff, and a more long-range transition plan will be needed.

Capital Expenditures May be Necessary

Some system changes require capital. The purchase of equipment to automate processes formerly done manually may be necessary to achieve the goal. For example, implementation of bar codes in medication administration can reduce manual documentation steps but requires new equipment and software. If equipment has to be purchased, implementation of the project may need to be delayed until appropriate capital can be obtained and the equipment is installed and ready for use.

Deciding to modify staffing levels may seem like an obvious and simple undertaking. But developing and implementing a staffing system that will meet the organization’s needs requires consideration of many complex issues, as well as a plan to move from the present state to the future state. Failing to consider all the issues and not providing adequate resources can lead to much effort but no results. Successful implementation, on the other hand, can lead to sustainable labor cost reductions and set the stage for future productivity improvements.

Image credit: Brand X Pictures / Thinkstock

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The Center for Medicare and Medicaid Services (CMS) states that medical necessity, related to patient care activities, must be justified as reasonable, necessary, and appropriate based upon clinical standards of care that are evidence-based. This requires attention to detail in documentation and should provide clarity to the overall plan of care for patients.

Detailed notes on the patient condition and plan of care, both in the office record as well as the hospital records, is essential to maximize reimbursement and to avoid issues of noncompliance with billing rules.  Because physicians document in medical terms, not in coding terms, a highly skilled coder is required to ensure that all possible documentation-supported codes are selected. Use certified coders, who are up-to-date with the new ICD-10-CM codes, to ensure coding integrity.

Relevant information in the medical record should include reason for the visit (or admission), history and physical examination, any contributing prior diagnosis or test results, complete assessment, initial impressions and/or diagnosis, and plan for care. Entries must carry the prescriber’s signature and dates of aforementioned record entries. The rationale for tests, procedures, or ancillary services should be clearly articulated or easily inferred from the notes. Concurrent audits (performed by internal coders) to ensure that appropriate medical necessity is being documented are recommended but not always practical.

Times have changed. Remember, you are writing for external record reviewers, not as personal reminders.

There are a myriad of federal policies that provide focus (as well as confusion!) as to what the medical record should include to ensure compliance of these regulations. The National Coverage Determinations (NCDs) as well as Local Coverage Determinations (LCDs) describe the criteria needed to ensure a complete and comprehensive medical record that supports provider claims for payment. The Medicare Coverage Database provides a quick search function to all the NCDs and LCDs necessary to assure appropriate coding, and coverage guidance for to support providers in filing claims.

There are limitations to some coverage provided by the Medicare program based upon some diagnosis, frequency, and utilization, and whether the service has proven clinical efficacy. For example, a physician orders a second screening test (e.g., mammogram, colonoscopy) twice in one calendar year without clinical decision support. To receive payment, the provider must include additional documentation that supports his/her reasons for prescribing. Even with additional information, the claim may be rejected.  It is therefore recommended that questionable medications and/or procedures be vetted prior to ordering.  A patient may be asked to sign an advance beneficiary notice (ABN) that enables the provider to bill the patient should Medicare deny the submission.

Being compliant is a simple matter of adopting these public policy requirements.  This means providing the pertinent education and instructions to providers so that they understand the expectations and conduct periodic monitoring to ensure compliance. If done effectively, documentation and coding practices enhance reimbursements, limit risks, and provide an atmosphere of professional compliance.

Of course, compliance is not simple. Although the necessary information is available through public sources, some practices may find it laborious to gather the information, develop a compliance plan, and then educate physicians and office staff on the details, as they also have to run the practices. The fact is that the details are the problem. Practices that recognize their vulnerability should consider getting help from experienced compliance experts who have the time to master the details.

Image credit: Comstock/Thinkstock

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Indeed, CMS treats provision of substandard care as potential fraud, the thought being that offering one product—safe care—and delivering something less—substandard care as defined by the Conditions of Participation—is a form of fraud. And trends indicate that CMS is becoming less and less tolerant of the provision of substandard care.

How should a hospital leader respond to a CMS inquiry, complaint survey, or finding of Immediate Jeopardy?

First, don’t just delegate and then forget about the issue. Too many organizations have had ugly surprises when passing an inquiry or request for information to an isolated compliance department and moving precious attention back to pressing operations. Compliance is becoming extremely delicate business; as such, tracking and reviewing responses should be a senior executive responsibility, with progress shared with all senior leadership, including the Board.

Secondly, don’t travel this road alone. The rules and regulations of CMS compliance are complex and, at times, obscure. Get serious help, even if only to double-check your organization’s work. There is a language associated with CoP compliance. Make sure the response reflects that lingua franca; any organization that can’t parse “credible allegation of compliance” needs a consultant who can do so.

Too frequently, leaders seek assistance when it is too late in the process for anything more than an emergency response. If you are in receipt of a complaint survey, get assistance before it becomes a finding of Immediate Jeopardy (IJ). Obtain seasoned, experienced help reviewing your IJ response, and certainly have the experts on speed dial if a 23-day notice of termination is received. Again – don’t try to do this alone.

Finally, if possible, don’t get into the hole if at all. It’s easier said than done, but the effort is worth it. Construct a CMS Survey Preparation Plan, know what vulnerabilities are present, and address them in terms of priority for vulnerability. Drill the organization for response to a survey by implementing dry runs and critiquing results. Monitor patient and practitioner complaints, and address revealed concerns if reasonable.  Recall the adage that chance favors the prepared mind—similarly, CMS success favors the prepared organization.

The post When CMS is On the Doorstep: Strategies for Successfully Preparing for Increased Clinical Scrutiny appeared first on BETTER HOSPITALS.

If you are interested in scheduling time to meet with our Compass executives at the Congress, please call our office at 800.241.0142 or visit our website.

The 2013 Congress on Healthcare Leadership, which takes place March 11-14 in Chicago, will focus on the theme of “Changing Healthcare by Design.”

About 2013 ACHE Congress on Healthcare Leadership

The Congress on Healthcare Leadership is ACHE’s largest national event, with more than 100 seminars, numerous career development programs, and unparalleled networking opportunities.

Learn more about the 2013 Congress on Healthcare Leadership by visiting ACHE’s website.

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With increasing compliance requirements of government guidelines and laws, organizations need individuals and committees to organize and manage the multiple functions of corporate compliance departments. Although the program is currently still voluntary, the Patient Protection and Affordable Care Act of 2010 proposes that compliance programs become mandatory for enrollment in any federal healthcare program. Therefore, preparation and immediate implementation are necessary.

A robust hospital corporate compliance program measures, articulates, and demonstrates an organization’s commitment to ethical and legal practices. A baseline assessment is paramount to developing a value-based compliance program.

The seven-step initial assessment of organizational systems will be multifaceted:

1. Development of standards of conduct and operational policies.  Review of appropriate policies and procedures that support ethical business practices is a cornerstone of a vibrant compliance program.

2. Oversight requirements to ensure compliance. Claims and billing practices must be reviewed and monitored to ensure that adequate internal controls and audits are in place.  Audits must be defined and scheduled in order to minimize unsupported claims and billings, as well as focused to reduce/eliminate exposure to criminal and civil penalties. Procedures that encourage reporting and investigation of potential billing misconduct are vital. Medical necessity documentation, standing orders, protocol use, patient safety, and recovery audits (RAC) are all integral parts of a balanced corporate compliance program.

3. Creation of compliance training throughout the organization. Educational programs that explain the benefits and purpose of a well-defined compliance program should be required of all staff, the board of directors, and affiliated agencies. The programs should include familiarity of Federal Fraud and Abuse laws—namely, Stark, False Claims Act, Fraud Enforcement and Recovery Act, and Patient Protection and Affordable Care Act.  A detailed log of what was communicated and who took the course is important.

4. Monitoring and auditing. Although time and resource consuming, monitoring and auditing will ensure the overall success of the program. Review of medical records for appropriate documentation that supports coding/billing practices must occur regularly, and the results should be published and distributed to the entire organization, including members of the medical staff.

5. Consistent and timely communications to all staff of the organization.  The rules and regulations are difficult and plentiful.  Frequent Q&A memos will keep the program front and center.  When it comes to compliance, there is no such thing as over-communication.

6. Disciplinary actions (one of the more difficult components of the program). Unethical or intentional misconduct of compliance rules must have consequences.  Each organization must develop actions that are commensurate with the event.  Self-reporting to the OIG, while uncomfortable, is necessary but must be measured against the infraction. Not all events are reportable.

7. The organization’s response to detected offenses.  A Root Cause Analysis (RCA) performed to determine the genesis is required. Revision of policies, re-tooled audit trails, and re-education must all occur once the root of the issue has been determined. Follow-up reviews and oversight must continue until there is assurance that the offense cannot be repeated.

Ensuring compliance is a lot of work, but ignoring compliance can have devastating consequences if the OIG finds that your organization is not in compliance. The financial consequence of compliance failures is usually measured in the millions or even hundreds of millions. The consequences to an organization’s reputation can result in a major loss of patient volume. Hospitals that have been cited have needed to be sold to prevent closure.

The best guidance we have is to assess your organization’s current compliance program to determine how ready you are if federal investigation begins.

Learn more about how Compass Clinical Consulting’s Corporate Compliance services can help your organizational.

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Most organizations experience a negative compliance finding from the Centers for Medicare and Medicaid Services (CMS) as an injury to organizational self-esteem and reputation. When this occurs, nursing is frequently the target of that assault or, at the minimum, heavily involved in the Corrective Action Plan that is the result. This article addresses the reason for such extensive and frequent nursing involvement and provides strategies for preventing a noncompliance finding. More…

Read the complete article at Nurse Leader Magazine.

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