Blog and Helpful Articles

What We’re Reading – Three ways healthcare facilities are rebounding from COVID-19

The pandemic has been stressful for every industry but healthcare has been hard hit for a few reasons: providers still need to treat patients, but some of those patients may be scared to go to the doctor’s office or visit a hospital; medical staff, who want and need to be there for patients not only have the same worries but also the added stress of possibly losing their jobs.  In the midst of their own health worries, providers need to balance their patients’ and employees’ needs with concerns about the viability of their practices too.

This article showed three ways healthcare is rebounding from COVID-19 and gives us reason to be optimistic.

  1. Telehealth: This is the about one of the only “positive” things to come out of the pandemic. Normally, telehealth was only utilized for rural areas but with the public health emergency (PHE) it has become the most common type of visit. Not only can the patient be treated for medical conditions while staying safe, but the clinician and staff can be protected and still provide care, albeit virtually. Hopefully, expanded telehealth services will continue after this crisis is over.
  2. Regaining public trust: It’s important to find ways to let patients know it is safe to come back to your office or visit the hospital, as most are now resuming elective surgeries. Communication is always challenging but, in this day and age, social media is a savior. Posting on these platforms is one way to let patients know what they can expect when visiting the office/hospital and what precautions are being taken to keep everyone as safe as possible. Some providers are even purchasing television ads to let everyone know about their COVID-19 safety measures.
  3. Better employee engagement: Here, too, communication is key. With the rise in unemployment, keeping an open and strong dialogue with employees is paramount. Not only does this show how you are keeping patients safe but the communication reinforces that we are in this together and that you have your employees’ safety in mind as well. Where possible, providers are allowing more flexibility to staff as we all deal with school closures, etc. Last but not least, asking for and listening to employee suggestions reassures them of your concern; even something as simple as checking in with your employees and expressing interest in how they are coping through all of this shows them they are not alone.

The most important take-away from this article is that “communication” is key with patients as well as staff to keep everyone on the same page.

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CMS Makes Changes to Telehealth Billing

This is a follow-up to an earlier blog about the Centers for Medicare and Medicaid Services’ (CMS) expanded provisions for coverage of telehealth (TH) visits for Medicare beneficiaries. CMS recently added additional billing codes to its approved list, and clarified the codes used for audio-only vs. audio/video.  The attached summary contains some frequently asked questions we have received from clients regarding the billing of TH services.  If you have a question that is not listed, please feel free to call the office (954-578-3331) or email us at info@askCCG.com.

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The DOJ Targets MA Plans

The Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) reported that a study conducted in 2019 revealed, “Unsupported risk adjusted payments are a major driver of improper payments in the Medicare Advantage (MA) program.”  The study stems from the OIG’s mission to prevent, detect, and deter fraud, waste, and abuse; hold wrongdoers accountable; and recover misspent public funds.

In 2020, the Department of Justice initiated two lawsuits against Medicare Advantage plans Anthem and Cigna.  Although the facts differ between the two, the root is the same: alleged improper payments resulting from gaming the system.  We hate to say we’re not surprised.

The trend we’ve observed in our risk adjusted reimbursement activities since 2004 is a growth in what we call creative diagnosing. In the early days of MRA, the majority of clinicians were not well-versed on the particulars of this payment paradigm. Patient medical charts contained numerous conditions that mapped to hierarchical condition categories (HCCs) but were not reported by the provider despite their management.  Our company’s first priority became to educate providers on the conditions in the CMS-HCC model and remind them to assess and report the diagnoses since they were already treating them  – and maybe even financially responsible for the cost of claims related to these conditions.

Over time, we saw improvement in this regard and turned our attention to the quality of the medical  documentation and coding specificity.  While risk adjusted conditions may have indeed been evident for the patient, clinician documentation was woefully inadequate in reflecting the evidence and management of these diagnoses.  This road has been long and treacherous.  EMRs have become a double-edged sword:  making it easier for providers to click and include the required elements of the visit, but facilitating the copy/paste of templated information from one visit note to another, leading to suspicion of the documented details.

These days, creativity reigns supreme.  We have observed increased “shopping through the HCC list” in an attempt to shoehorn a risk adjusted condition into bits and pieces of the member’s health factors when other, non-risk adjusted medical codes are more appropriate. Rare conditions are reported in droves, defying prevalence statistics from across the U.S.  As providers and coding staff move among medical groups, they can bring a few bad habits and dubious creativity to new workplaces, which further exacerbates the issue.

This seems to be the substance behind the Cigna lawsuit: improper diagnostic codes for health conditions that its members did not have, were not recorded in medical records and were not based on clinically reliable information.  The Anthem lawsuit is centered on the reporting of diagnoses that were known to be false, and not removing erroneously reported conditions from the patient’s medical profile when they were discovered.

Health plans and medical groups undoubtedly have significant MRA infrastructure, but proper auditing includes three key concepts:

  1. Knowledge of proper medical coding, documentation and clinical guidelines;
  2. Independence from real or perceived pressure to overlook inaccurate codes or faulty documentation;
  3. Neutrality by having an auditor who is not associated with the individual who initially performed the work.

The federal government’s history has been one of “pay & pursue.”  Claims are paid and oversight is conducted retrospectively, usually very long after the fact.  The same is true in the Medicare Advantage sphere with a significant difference: in fee-for-service payments, recoveries are date of service-specific.  For MA plans, who receive monthly payments based on risk scores, the recoupment is retroactive, and CMS’s lookback period is six years from the payment year.

We predict increased scrutiny, with these two MA Plan lawsuits representing the tip of the iceberg in potential recoveries.  Not only do we believe that more plans will be the focus of external review, but the providers themselves, who received erroneous payments, are sure to be the next group of targets.  For this reason, we strongly encourage every entity that receives federal funds to assure strict adherence to its Compliance Plan and to retain an experienced and external organization to validate its risk adjusted coding.

This Pandora’s Box is open and providers must act quickly to assess their coding, remediate erroneous coding behavior and mitigate recoveries.

 

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MACs Resume Medical Review on a Post-Payment Basis

To protect the Medicare Trust Fund against inappropriate payments, Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities. Beginning August 17, the MACs are resuming with post-payment reviews of items/services provided before March 1, 2020. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.

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CMS Approves COVID-19 Counseling

When patients are tested for COVID and are awaiting results – or if they’ve tested positive – research shows virus transmission is reduced by 86% if these patients self-isolate early.  For this reason, CMS recently clarified that counseling, which includes the activities listed below, can impact the evaluation and management (E/M) visit level if they comprise more than 50% of the visit.  This is valid for telehealth visits as well.

  • Signs & symptoms of COVID
  • Immediate need to separate themselves from others while waiting for results
  • Informing close contacts to also separate from the patient while results are pending
  • The patient’s cooperation with the health department if the test is positive
  • Any services available to the patient while quarantining at home

Remember, to follow the rules when counseling services are more than 50 percent of the visit length: The time spent and counseling topics need to be documented, and the E/M guidelines apply. Keep in mind that part of the counseling can also include contact tracing.

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What We’re Reading- How effective and important are one-on-one discussions with direct reports

What can you accomplish by conducting one-on-one meetings and making them a standard practice in your organization? This article delves into the positive impact these interactions can have on helping your team to thrive. Utilizing this practice becomes a great tool in improving employee performance and productivity, employee engagement and creating effective teamwork.

The author gives us five best practices for ensuring that your one-on-one meetings are productive:

  1. Don’t wing it. Come prepared with plan and desired outcome of the meeting.
  2. Don’t put it all on your direct report. Have ideas and feedback ready.
  3. Focus on the most important priorities.
  4. Be engaged and attentive.
  5. Don’t substitute. Stay on schedule with your one-on-ones to yield maximum results.

Effective one-on-ones will provide your team with a mutual understanding of individual and organizational goals, and allow your direct reports to feel like they’re “a part of the plan.”

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COVID & the Home Health Industry

It’s no understatement to say that COVID has wreaked havoc with every aspect of our lives:  families, jobs, school, and health care.  However, the home health industry has been hard hit and will continue to feel the effects of COVID for the foreseeable future. Many provider segments have weathered the storm – or still are – thanks to various relief programs and flexibilities such as telehealth.  Home health has not been so lucky.

More than 82% of home health providers experienced decreased revenue due to two major factors: fewer new patient admissions (largely resulting from canceled surgeries) and patients refusing care out of fear of catching COVID – even skilled care ordered by a physician.  A study by the National Association for Home Care & Hospice reported that 87.4% of agencies had patients who refused care.  Reductions in physician ordered visits triggers payment reductions as high as 75% over the 30-day period payment.  Yet agencies’ costs have increased during the pandemic:  personal protective equipment (PPE), overtime, hazard pay and more acutely ill patients all further reduced agencies’ profitability.

Workers are also concerned about the possibility of being infected with COVID, and some show reluctance in working in home care and being assigned new patients.  The widespread shortages of PPE don’t help instill confidence in workers and patients. How does an agency safely deploy staff and also reassure both important constituents?

Some suggestions from the field include:

  • Heightened adherence to the infection control program. Certain elements being discussed for COVID should be part of every agency’s policies.  Observing standard precautions protects workers from patient infections;  the infection control program should have policies related to employee illness and caring for immune compromised patients, all of which are relevant for COVID-infected patients. The new component to this list is temperature and COVID symptom checks.
  • Making every effort to obtain PPE and zealously assuring appropriate utilization. Supervisors can make random, unannounced video calls to staff members to check use of PPE.
  • Cutting down on in-person visits, where possible, and conducting telehealth checks. Keep in mind that telehealth cannot replace in-person visits but can be used as a means for patient monitoring.  Read here about the strict guidelines for telehealth in home care.
  • Where possible, limiting the number of staff members caring for COVID patients. Some agencies are assigning a small cadre of staff to COVID patients, where possible, to minimize exposures.  If this is not feasible, it may be possible to schedule visits to COVID patients for late in the day – last appointment, so to speak – so the staff member can go home afterward and implement home disinfection procedures.  Most if not all healthcare workers have developed their own protocols when arriving home, such as: removing their shoes, disinfecting footwear, leaving shoes on the porch and/or wrapping them in plastic bags; promptly removing and laundering clothes worn during the day; thorough handwashing upon arrival, or showering; disinfecting all work supplies and equipment while wearing gloves as well as surfaces in the car and home; severely limiting contact with family members, especially the elderly or infirm, or even living apart for a time, etc.
  • Observing strict social distancing for any services that don’t involve touching the patient.
  • One of the biggest tools to reassure patients and staff is communication. In this situation, you can’t communicate too much.  Many agencies are posting and distributing their COVID action plans, and telephonically explaining them to patients.  If a staff member is not caring for a COVID patient, he or she can mention this to the patient in an effort to further reassure him. You can incorporate this into a process where you call the patient the day before, inquire about any possible COVID symptoms or exposure, confirm the appointment and reassure her about your staff’s safety.
  • Some agencies provide patients with a laminated sheet of COVID symptoms so they can perform their own symptoms check, and give instructions on who to call if any are positive. Staff members visiting the patient can inquire about an accessible thermometer and sufficient supply of soap, toilet paper and hand sanitizer.
  • As an added measure, staff should stay aware of the number of surfaces they touch in the patient’s home and minimize contact as much as possible. Staff can use a disinfecting wipe on the way out and wipe down any surfaces they touched.
  • Lastly….. communicate once again. Regularly informing patients of all the aspects of your agency’s program will go a long way in minimizing potential exposures and reassuring them of the safety of receiving home heath services from your agency.

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What We’re Reading – What COVID means for voluntary benefits might surprise you

In an earlier blog, we explained that, despite the economic uncertainty, a large number of employers are expanding employee benefits.  As discussed in this article, they are also tweaking voluntary benefit offerings in response to a change in demand.

It’s an understatement to say that the COVID-19 crisis has gotten everyone’s attention, but there is evidence to show that, “Employees have a heightened sense of mortality and morbidity” that didn’t exist before the pandemic. So benefits like critical illness coverage and hospital indemnity insurance that were not attractive to a younger workforce are now of interest.

Some other voluntary benefits that are on the rise include: pet insurance because pet adoptions are climbing and some Millennials are replacing kids with pets; identity theft insurance, especially since more of us are working remotely and carrying out more activities online; and even legal insurance with industry experts predicting a rise in divorces.

Approximately 12% of employers have enhanced voluntary benefits in the post-COVID world, striving to add value to their employees and perhaps lower their stress.

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Top 3 Home Health Agency Survey Deficiencies

The Agency for Healthcare Administration (AHCA) publishes an annual list of survey deficiencies for all license types and the most recent available analyzes 2018 surveys.  Of the 10 citations listed, the top three merit some review.

The most common survey deficiency concerned treatment orders. As a reminder, treatment orders from the attending physician, physician assistant (PA) or nurse practitioner (ARNP) are required for all patients receiving skilled care. The orders must be signed by the clinicians and contain the legible name and credential of the signer.

Treatment orders must be followed exactly and if they cannot be followed, they must be revised.  Agencies can request the revised order from the clinician, or write the revised order and ask the clinician to sign and return, indicating approval.  Any verbal order must be transcribed by an authorized professional, sent to the clinician for signature/approval and filed in the record.

The second most common survey gig had to do with the Background Screening Clearinghouse. AHCA developed a web-based repository for the criminal history checks of home health agency employees and potential employees. The home health agency must enter the information of all employees, as well as changes in status, within 10 business days.

The last of the top-three home health deficiencies was related to the Emergency Plan Review. Statutes require all agencies to send their Comprehensive Emergency Management Plan form to the Department of Health (DOH) for review and approval by the state and/or county health department and also the review their plans annually.  Agencies should maintain proof that the initial plan, and any revisions to contact information, were sent to the DOH and their county, if required. The related tag also requires agency patients to have a list of their specific medications in case they are evacuated from their homes.

Thorough understanding of and compliance with state regulations will help you avoid corrective action plans and possibly fines.

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What We’re Reading – PPP Loans Have Helped Save More Than 160K US Home-Based Care Jobs

The Paycheck Protection Program (PPP) was created by the CARES Act and provided a mechanism for businesses to receive funds to cover two months of payroll and other approved expenses, such as rent, utilities and health insurance premiums.  If the use of funds meets certain criteria, PPP loans are forgivable up to 100%.  Needless to say – despite some program quirks – these loans delivered welcome relief to businesses, especially small homecare companies.

This article summarized an analysis of PPP loan proceeds and concluded that 15,000 homecare agencies, who each received less than $150,000 in loans, were able to salvage 160,175 jobs.  Texas, California and Florida, saw the largest number of retained homecare jobs, saving 21,541, 19,186 and 11,039 jobs, respectively.  This is not surprising as 5,400 agencies in these three states received $224 million.

On the other hand, Idaho – which the author termed an ‘unlikely suspect’ – retained the most employees, on average, at about 20 for each of its 60 homecare agencies. The article concluded that although the PPP benefited homecare agencies, these companies also experienced higher costs for PPE, overtime, hazard pay and decreased utilization, which impacted their profitability.  The end result may have been more of a band-aid than pathway to sustainability.

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