Blog and Helpful Articles

WWR – Kaiser agrees to pay $6.4 million to settle claims it received inflated Medicare Advantage payments

Kaiser joins the undignified ranks of the companies investigated for committing fraud.  This timely article from Healthcare Finance News doesn’t use that word, but it describes the finding that Kaiser “knowingly submitted” false diagnoses to inflate its payments, which is the definition of fraud.  It’s certainly a sad day for a healthcare giant to be guilty of this conduct but it’s not surprising.

Since our company started working in risk adjusted reimbursement in 2004, and more so today, we have seen the upcoding that regularly occurs for medical conditions.  Our chart reviews never fail to find conditions that have been mis-coded as risk-adjusted when the proper code is not weighted.  Sometimes it happens through ignorance of the guidelines, but many times, we encounter provider groups where clinicians defend their actions as appropriate.

One true example occurred to us this year when a cardiologist who was versed in risk adjustment told us that if he codes ischemic cardiomyopathy, there will be no risk adjusted payment because this condition is not weighted. But he “knows” how sick the patient is so he codes cardiomyopathy, unspecified which does risk adjust. It is improper and fraudulent for a provider to know for a fact that a patient has one condition and mis-characterize it as another for payment purposes.

We can’t stress enough to every client, consider a compliance audit.  Hire someone external to your organization to objectively review a sample of your providers’ charts and validate the codes you’re submitting to Medicare Advantage plans.  If you’re concerned about what they’ll find, consider that you have the opportunity to remediate improper coding behavior and show a government regulator your intent to run a lawful organization.  Not knowing and not even being curious to know will be no defense during a payment audit.

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What We’re Reading – Employees are eager to get back to the workplace—if it’s safe

We were a little surprised to read a recent article stating that more than half the respondents to a survey are ready to return to the workplace.  It seems they miss interacting with co-workers (55%) while another 43% look forward to having a personal workspace.  It seems “death by Zoom” is the motivation for 32% who want less video-conferencing.  However, the return isn’t all or nothing: most want a hybrid arrangement with 67% of workers preferring flexible hours and staggered on-site work times.

The workplace area of greatest concern to returning staff members is meeting and conference rooms, cited by 58%.  Common areas worry 53% of workers while bathrooms and work stations were cited by slightly less than half of the survey’s respondents.  As the author summarized, transparency is a key factor in restoring employee confidence in embracing on-site work.  Employers should over-communicate (if that’s even possible) the preventive measures they are taking to minimize the spread of COVID and other communicable conditions.  Managers should explain any new workplace policies as well as how sanitizing practices have been enhanced and how compliance is being monitored.

Many employers anticipate transitioning workers to some on-site work beginning in January.  HR managers should consider which workplace policies they will implement to lessen the amount of employee traffic, streamline operations to continue allowing remote work, and how they will get the word out (loudly and frequently) of the steps being taken to keep everyone safe. Who knows… maybe the new normal will revert to the old normal sometime soon.

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What We’re Reading – During COVID, holiday gift-giving can be HR’s ‘time to shine’

This year has rocked the workplace like no other, and although we’re probably all glad to see 2020 end, the issue of holiday traditions looms large.  Many companies of all sizes are foregoing expensive holiday parties this year for many reasons:  social distancing requirements, economic slowdowns, and sensitivity that many workers may not be feeling particularly festive.  And so, many employers have turned their attention to employee gifts; advice from industry gurus suggests: Think caring. Think cozy. Think creative.

This article we read cites one online corporate gift-giving company representative who has seen corporate budgets climb because of holiday party savings.  “The average spend per gift by employers with more than 500 employees falls between $25 and $35; 100 to 500 employees is $50 to $70; and small companies, under 100 employees, exceeds $100.”

While a cash gift may be the easiest to accomplish on a grand scale, the author states that this is a time where HR can shine.  These front-line advocates have their pulse on the workforce’s mindset and the challenges they’ve faced with adjusting to remote working, daily child schooling, stress from the pandemic and economic uncertainty.  So while cash may seem to fill most needs, a little more thought can convey how much you care about your employees with an end-of-year token of appreciation.

Department heads can be instrumental in identifying gifts that will touch their employees’ lives.  Consider empowering them with a budget and allowing them to customize gift-giving, if possible. Some companies are focusing on wellness, giving items that promote healthy eating, exercise and stress reduction.  Others may look to gadgets that facilitate more comfortable remote work. Whatever the gift – and this article is full of good ideas – the central message is, “We care about you.”  And really, isn’t that what the holidays are all about?

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E/M Codes Are A-Changin’ for 2021

Evaluation & Management codes, which have long been the bane of physicians and billers, determine the payment for the most common outpatient medical services.  Each E/M code level corresponds to an expected fee, and historically, code selection has depended on many factors.  You can read our blogs on this topic here.  In a nutshell, a number of visit elements are required and three [history of present illness (HPI), physical examination, and medical decision-making (MDM)] determine the visit level.  Payments increase with the complexity of the visit so the higher the level, the greater the payment.

In an effort to reduce administrative burden and update codes to reflect current medical practice, the Centers for Medicare and Medicaid Services (CMS) and the AMA have made significant changes to the code selection process.  And these changes will definitely impact provider documentation.

Five big changes include:

  • Deleting 99201, which was deemed redundant to 99202.
  • Removing the HPI and examination as key components to determining the visit level. The rationale is that because the HPI and other elements of the history may be documented by someone else (e.g., a medical assistant), this component of E/M selection may not involve the provider beyond merely reviewing and accepting what was documented. In addition, given the widespread use of EMR templates, it’s questionable whether the 100% of the documented exam was actually performed.  (Remember, we’re just the messengers!)
  • New definitions for MDM. Code selection will be largely determined by MDM and this element has undergone vast changes for 2021.  Although on their faces, the components of MDM (diagnoses, data and risk) are the same, the definitions and requirements have been modified a great deal.  There are precise definitions for what is a problem vs. a minimal problem, to what is an acute illness with systemic symptoms and what it really means to “monitor drug therapy.”
  • Modifying time-based billing. Time has been a component of E/M if the provider spent more than 50% of the visit providing counseling or coordination.  But similar to the Daylight Savings Time change, time will mean something new in 2021.  Providers can be paid for preparing to see the patient and even for documenting information in the EMR, but there are specific guidelines for the activities that qualify under time and when they can be done.  If clinicians believe this aspect will simplify things, consider that a 99213 visit requires documented time of 20 to 29 minutes – of the provider’s time!
  • New guidelines sections within E/M with definitions. These may be more effective than Ambien for the sleep-deprived 😉

Remember the transition to ICD-10?  If you lived through that, you will make it through this change too, but we strongly suggest you begin focusing on the changes and assessing the readiness of your documentation.  All in all, this change will be beneficial but with all such changes, education and adaptation are the keys.

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What We’re Reading – The Average Cost of Hospital Care for COVID-19

Wide variations in hospital costs for COVID-19 patients were discussed in an article from Healthcare Finance News.  The author cited claims research from February through August and revealed the average cost of hospital care varied by age and length of stay.  Here are some mind-blowing figures from the article:

For patients without insurance or who received out-of-network care, average costs ranged:

  • From $51,389 for patients between 21- and 40-years-old
  • To $78,569 for patients between 41 and 60 years of age

Hospitalization charges for patients under 20-years-old without insurance averaged about $68,261. For people over 60-years-old, that figure was about $77,323.

For insured patients,

  • the highest average amount paid to the provider was $40,208 for people over 60, and
  • the lowest average amount paid for patients from age 21 to 40 was $26,152.

As expected, the average hospital charge increased the longer patients were there and costs continued to vary by age group.  For those with stays beyond 15 days, hospitalizations averaged $980,821 for patients between 21 and 40 years of age and $460,989 for those over 60 years old.

The cost of hospitalizations, on top of any other required treatments for COVID-19, could total $546.6 billion for payers.

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Independent Contractor Guidelines are Changing

The Fair Labor Standards Act, enacted in 1938, requires – among other things – employers to pay their employees overtime for every hour worked over 40 in a workweek; this rule does not apply to individuals who work as independent contractors (IC). Over time, the guidelines for distinguishing between employees and ICs have been tweaked, adapted and interpreted, resulting in many gray areas that can have costly repercussions for employers.

In trying to remove the gray, the Department of Labor (DOL) has proposed revisions to the “tests” the employer can apply to a working relationship to more accurately determine the status of the worker.  Comments were solicited on the proposed rule and the comment period expired on October 26, 2020, so we expect a final decision on the IC guidelines in the coming months.

The DOL has proposed five factors, or tests, based on “the economic realities” of the relationship. The first two tests, characterized Core Factors, have more weight than the remaining three factors.  Below is a brief discussion of the five factors but keep in mind that additional, important detail is contained in the 40-page Federal Register summary.

The Core Factors are:

  • The nature and degree of the individual’s control over the work performed. When a worker “exercises substantial control over key aspects of the performance of the work,” he or she may be properly categorized as an IC. This can include aspects of work, such as determining the work schedule, choosing assignments, working with little or no supervision, and being able to work for others, including an employer’s competitors. Additionally, if the means, or instruments or implements, by which the worker completes the tasks are determined by the worker, the worker would tend to be classified as an IC.
  • The worker’s opportunity for profit or loss. The DOL is proposing a revision to its approach which analyzes, primarily, the worker’s investment in capital, such as tools, trucks or other equipment, as well as training or professional education, as part of the opportunity for profit or loss. Another aspect, which cannot be considered alone, is whether the worker exercises personal initiative, including managerial skill or business acumen.

The gist of these two Core Factors is whether, as a matter of economic reality, the individual is economically dependent on the potential employer for work. The remaining three factors below can serve as additional guidance for employer analysis but are secondary to the two Core Factors.

  • The “Skill Required” Factor. The proposed new rule would require that if the work at issue requires specialized training or skill that the employer does not provide, this weighs in favor of IC classification.
  • The ‘‘Permanence of the Working Relationship’’ Factor. ‘The degree of permanence of the working relationship between the individual and the employer is an economic reality factor under the proposed new rule.

‘Permanence of the relationship’ speaks to the continuity and duration of the relationship or length of time that a worker works for a single employer.  Relationships with defined duration lean toward IC status since employment relationships are, by design, indefinite in duration or continuous. An important side-note is that the seasonal nature of some jobs does not necessarily suggest IC status, especially where the worker’s position is permanent for the duration of the relevant season and where the worker has done the same work for multiple seasons.

  • The ‘‘Integrated Unit’’ Factor. If the work performed by a worker is integral to the employer’s business, it is more likely that the worker is economically dependent on the employer and less likely that the worker is in business for himself or herself. Additionally, if a worker’s tasks are the same as, or the worker’s tasks cannot be distinguished from, the tasks of acknowledged employees, that will tend to indicate employee status.

The revised DOL tests have great implications for employers who may have misclassified workers and may be operating outside the wage and hour laws.  We strongly suggest that all employers: 1) read and understand the DOL’s proposed rule changes, 2) begin a review of worker relationships, using CCG’s abbreviated tool, to assess if you have misclassified workers, and 3) consult with a certified Human Resources professional or employment attorney.  Do this now so you can start 2021 on the right foot and not looking over your shoulder.

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Penalty for Delayed RAP Submission in 2021

In an earlier blog, we briefly touched on the challenges for the home health industry this year and the news just keeps getting – er – worse.  For those who may not know, the Request for Anticipated Payment (RAP), which was phasing out in 2020, will be fully retired in 2021.  Kind of.  CMS will still require the submission of a RAP for no pay and penalize agencies for filing it late.

The RAP served a few purposes for agencies.  By making a split percentage payment for new admissions, agencies could even out their cash flow and also establish themselves as the beneficiary’s primary HHA with CMS.  This allowed CMS to reject claims from other providers for the duration of the episode.  Agencies then filed a final claim at the end of the episode, which triggered the balance of the payment.

However, because CMS changed the episode of care to 30 days, it changed the RAP to a zero payment.  Agencies are still required to submit a RAP at the beginning of each 30-day period when 1) the written clinician order that sets out the services for the initial visit has been received and 2) the initial visit has been made and the beneficiary has been admitted to the agency.  This must occur within five days of the start of care.  If the agency does not file the RAP, there will be a “non-timely submission payment reduction” for every day the RAP is late.

CMS provides for a small number of exceptions to the non-timely RAP submission but they are not regularly occurring circumstances.  Coleman Consulting Group does not handle home health billing but we’re fortunate to refer clients to our colleague, Imark Billing.  Here is YouTube video they posted on this subject.  Lynn and her team focus exclusively on home health and hospice billing and can help your agency avoid unnecessary payment reductions, especially at this crucial time.

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What We’re Reading – Identity theft risk spiking with COVID-19

A very interesting article from Physician Practice discusses scams that have resulted from the pandemic and provides several good sources of additional information.  In a nutshell, identify theft happens every two seconds, has affected 30% of the US population and over 14 million people in 2019.  And… it’s on the rise due to chaos from COVID.  Some areas that scammers have targeted include:

  • Fraudulently obtaining unemployment benefits, receiving PPP loans, hijacking bank accounts and opening new accounts in your name;
  • Fraudulent websites offering PPE and medical supplies with too-good-to-be-true pricing. They either don’t deliver after you pay, deliver counterfeit or expired goods or steal your credit card info.
  • Remote work scams of entities using email to obtain sensitive information or embedding links or attachments to trick the receiver.
  • Impersonating medical or health orgs selling COVID-related products or offering fake services such as contract tracing.

Among the author’s suggestions if you are a victim of any of these scams are:

  • Placing fraud alert on credit cards or freezing your credit report
  • Reporting identity theft to the FTC and police
  • Reviewing your credit reports with all agencies and correcting mistakes
  • Changing your passwords

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What We’re Reading – Employers make ‘remarkable’ pivot to virtual hiring

If we all had to admit it, COVID has ushered in some good changes: more remote work and schedule flexibility; new safety and sanitizing practices that may protect us from even the common cold; Zoom-ing has perhaps made us more thoughtful about the need for a meeting in the first place; and my personal favorite, widespread curbside meal pick-up 😊

The Human Resources sphere has been particularly hit by the pandemic and is responding with innovation, particularly in recruitment and orientation.  This article summarizes businesses’ reliance on virtual technology to more speedily accomplish the stages in the recruitment cycle.  More than 75% of senior managers reported conducting virtual interviews and on-boarding, and many plan to continue the trend. A Robert Half spokesperson called the transition “remarkable.”  But seriously, should we be surprised?  A highly lauded leadership trait is adaptability, which HR takes to heart: we do what we need to do to get the job done.

This adaptability has paid dividends with 60% of the surveyed companies reporting they shortened their hiring process and have been able to recruit from a wider pool of talent.  It’s possible that even after some work returns to brick and mortar locations, several HR functions may retain a virtual aspect.  Either way, quickly filling vacant positions with qualified workers is a win-win for everyone.

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What We’re Reading – Get Ready for these 4 Changes Coming to the Business World in 2021

We believe 2020 will go down as the Year – if not the eon – of Adaptation.  It certainly seems like we’ve lived an eon in just 10 months, doesn’t it?  Not only have employees, children, consumers et al adapted, but small- to medium-sized businesses have had their share of change thrust upon them as well.  This article from Inc. Magazine praises leaders who’ve been able to pivot and survive, and extends their lessons to the rest of us.  Though it may seem trite to say businesses need to anticipate as much as possible the challenges that lie ahead, it’s safe to say that 2021 will build on these changes from 2020.

  1. Working from home. As the author said, the genie is out of the bottle on this one, and the workforce has shown that remote work can be productive, efficient and successful. Although some aspects of work life – innovation, on-boarding, training and maintaining culture – may require the face-to-face connection, leaders need to find the right mix of F2F and remote work that balances myriad needs and meets the company’s business goals.
  2. Physical space. The amount of physical infrastructure most businesses have invested in is quickly being re-imagined.  Some companies are re-visiting the need for large spaces across the board while others are re-configuring space to convey the sense of physical safety employees want with an eye toward that F2F/remote-work hybrid.  Whatever you do for 2021, it will involve some amount of “re-.”
  3. Business travel. The author believes we will not return to the level of pre-pandemic business travel because it’s proven to be just not necessary. Here again, companies would be well advised to study which aspects of the business need F2F connections – maybe critical steps in the sales process? – and which can be continued virtually. We’ve seen some creative conferences that offered familiar convention features in a different manner, and so continued creativity will rule next year, too.
  4. Digital transformation. The article touches on the inadequacy of 2005’s Internet infrastructure and how up-a-creek, pandemically-speaking, we all would have been back then.  The companies that have most successfully weathered COVID are those that have been making inroads on the digital transformation path for a while.

The opportunities for 2021 include embracing and continually adapting the four areas mentioned to better position our companies to fully bounce forward to, well, 2019 levels – only better.

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