SUNY NY B OARD M EET ETING NG A UGUST 3, 2015
C ONCERN CERNS /I /I SSUE TO B E A DD UES TO DDRESSED RESSED Provide an explanation of why the Downstate CMI is low compared to Upstate and Stony Brook Clarify, specifically, what has been accomplished (with Pitts guidance and assistance) to correct coding and billing problems and highlight that the problems identified a few years ago are not the same as UHB is faced with today Effort/status to fill key leadership vacancies in the organization Transition plan prior to PMA’s departure 1
C ASE SE M IX IX B ACK CKGROUND OUND Case mix index (CMI) is a relative value assigned to a diagnosis-related group of patients in a medical care environment. The CMI value is used in determining the allocation of hospital resources to care for and/or treat the patients in the group plus to determine relative weights by government payors for payment rates. Patient 1 Patient 2 Patient Diagnosis Heart Failure and Shock Artificial Lung/Trach Code in ICD-9 System 428.33 440.24 Medicare DRG 291 003 Medicare Weight 1.5031 17.6369 Case Mix can be quoted differently for two reasons: First, all payors do not use the same weighting system Second, all patients are not included in some CMI reporting requirements; in particular, case mix is often reported without newborn nursery 2
C ORREC OF UHB B C ASE SE M IX IX I NDE DEX N UMBER BER P RESE RRECTI TION ON OF ESENTE NTED ON ON J UNE 15, 2015 FY12 FY13 FY14 FY14 FY15 FY15 Actual Actual Actual Projected Budget As Disclosed 1.4175 1.2435 1.2853 1.2264 1.2300 1.2264 (Projected) June 15, 2015 As Corrected 1.2478 1.2435 1.2853 1.2264 1.2347 1.2264 (Actual) And Updated 3 Medicare weights with Nursery
C OMPARIS ON W ITH O THER ER A CAD MIC M EDI CAL C ENTER RISON ADEMIC DICAL NTERS H OSPIT AL C ASE SE M IX IX I NDICES BY P RIMA IMARY P AYOR PITAL DICES BY OR Overall Hospital Case Mix Index Mean 1.745 Minimum 1.259 UHB has the lowest CMI 25 th 1.602 among all AMCs Median 1.753 75 th 1.907 Maximum 2.430 Function of patient population and competitors: • Stony Brook and Upstate SUNY Downstate 1.259* are Level I Trauma Centers SUNY Stony Brook 1.774* and UHB is not • SUNY Upstate 1.619* UHB has a Level I Trauma Center competitor across the street * Case Mix Index has been calculated using Medicare DRG weights 4 Source: COTH Annual Survey of Operations & Financial Performance – Autumn, 2014
W HILE LE THE CMI HAS REMA ABLE , , OTHER CHANGES IN UHB’ S MAIN INED STABLE NGES IN ON CMI SERVICE VICE MIX OF OF PATIENTS TIENTS HAVE VE HAD A NEGATI TIVE VE IMPACT CT ON The service mix has shifted away from higher-CMI services such as Surgery and Neonatal to lower- CMI services such as Medicine 5
W HILE LE THE CMI HAS REMA ABLE , , OTHER CHANGES IN UHB’ S MAIN INED STABLE NGES IN ON CMI SERVICE VICE MIX OF OF PATIENTS TIENTS HAVE VE HAD A NEGATI TIVE VE IMPACT CT ON Similarly, the intensity of inpatient surgeries has moved from higher-CMI specialties such as Cardiothoracic to lower- CMI specialties such as Otolaryngology 6
UHB B C ASE SE M IX IX S UMMA MARY Negative Influencing UHB’s Counteracting Factors Initiatives • More discharges with lower • Improved clinical resource utilization documentation by faculty physicians and residents • More surgical discharges with lower resource utilization • Improved coding quantity and quality • Continuing Medicare weighting reductions • Improved billing policies, procedures, monitoring and staff productivity 7
C LINICA INICAL D OCUME TION I MPROVEM IN T WO WO P HASE UMENT NTATION VEMENT ENTS IN ASES Phase I The UHB documentation improvement program was completed in February 2013 with a focus on acute Medicare cases only and included physician and CDI staff education. 8
CDI F INANCIAL NANCIAL I MPROVEM VEMENT ENT (12/1 /1/12 /12 TO TO 11/30/1 /14) 4) (millions) Exceeded plan by over $2M 9
C LINICA INICAL D OCUME TION I MPROVEM IN T WO WO P HASE UMENT NTATION VEMENT ENTS IN ASES Phase II Documentation improvement expanded to include not only Medicare cases, but also other acute cases paid on a DRG basis; targeted are about 1/3 of total cases; full implementation is expected in September 2015 6.3% actual improvement 3.1% actual improvement 3.5% targeted 3.5% targeted Excludes psyc, rehab, OB/newborns, one-day stays, Medicaid and Medicaid HMO. 10
C LINICA INICAL D OCUME TION I MPROVEM IN T WO WO P HASE UMENT NTATION VEMENT ENTS IN ASES Phase II Continuing Plan includes improving clinical documentation to increase the CMI by 3.5% Financial impact on RAP2 of CDI on CMI projected to be $1.28 to 1.45M UHB CDI issues to achieve these improvements Number of trained and effective Extending contract with outside clinical documentation specialists CDI vendor for additional interim experienced staff Physician and Resident education Additional follow-up training this fall for Physicians and Residents and training Number of cases reviewed Improving processes for expanded case review 11
I MPROVING VING C LINIC AL D OCUME IS N OT OT THE E ND INICAL UMENT NTATI TION IS ND Coding – checking a variety of sources within the patient’s medical record to verify the services provided, abstracting the information from the clinical documentation, assigning the appropriate codes, and creating a claim to be paid Billing (and collecting) – getting an accurate and timely claim out the door, following up on unpaid claims, resubmitting claims when necessary to ultimately get cash in the door 12
C ODI NG P ROBLEM OF A F EW EW Y EARS ARS A GO DING OBLEMS OF GO Staff - Difficulty in securing services of a sufficient number of coders Training - Lack of initial and ongoing training for coders Inefficiencies within the HIM Department - Tracking and working unbilled accounts were not structured, resulting in unbilled accounts exceeding the allowable billing timeframe Inefficiencies outside the HIM Department - High number of unbilled accounts due to delays, i.e., missing medical records, delayed physician query responses, and decision on patient types from Case Management Lack of accountability within and outside the HIM Department 13
C ONTINUI NG A CTION IONS R ELA TO C ODING DING I SSUES TINUING LATE TED TO ES Executed two outside vendor contracts to augment coding staff remotely Achieved HealthBridge (EMR) access for remote coders and made access more efficient The current coding turnaround time blended for Inpatient, Ambulatory Surgery, and ED cases is 2.5 days (uncoded total/average daily gross revenue) Average days in DNFB was 12.1 in March 2013; in May 2015, average days in DNFB was 8.7 Established managerial policy to assign daily tasks to each employee A daily tracking tool was established allowing close monitoring of coded account volume by employee as compared to the newly established productivity goals Medical record receipt by the HIM Department is monitored; UHB is experiencing 100% compliance Paper inpatient and ambulatory surgery records are scanned and available for review within 24-48 hours of discharge In-house coders are receiving training via the American Health Information Management Association’s on -line training program An in-house quality control program to review denials is on-going resulting in substantial decline in denials Recently engaged an outside vendor to perform a medical record review for coding quality On June 12, the pure uncoded backlog for Inpatient, Ambulatory Surgery and ED was $4.2M, the lowest it has ever been. 14
T ODAY ’ S C OD ING I SSUES ODING ES Maintaining the number of coding staff necessary to perform timely coding of medical records, while at the same time training the same staff on ICD-10 effective October 1, 2015 Maintaining the extensive process and efficiency improvements Hiring and training permanent coding staff (a new inpatient coder was hired the week of 7/6/15) Assessing the quality of coding being performed and developing plans for improvement 15
B ILLI NG P ROBLE OF A F EW EW Y EAR ARS A GO LING OBLEMS OF GO Decentralized management structure for Revenue Cycle, in which several components affect “billing” Minimal information technology to automate processes and monitoring of patient accounts operations; most existing reports were manual Inefficient processes for working patient accounts did not conform to industry standards and was not efficient Minimal attention paid to the maintenance of the Charge Description Master No structured denial management program No standards established for late charges, denials, account follow-up, queries, underpayments, and insurance verification No point of service cash collections 16
Recommend
More recommend
