Blog and Helpful Articles

Principal Care Management

Although chronic care management has been a CMS-covered care model for managing patients with multiple chronic conditions, this year, codes for a similar program were created.  Principal care management (PCM) is a “sister” model – if you will – geared to patients with only one chronic medical condition.  The goal of this program is two-fold:  improving the patient’s quality of life & medical status, and avoiding costly decompensations in the patient’s health. 

PCM is for patients who have had a recent hospitalization, an acute risk of death, exacerbation or functional decline, or require management that’s unusually complex due to comorbidities. 

The first step is for the provider to create a disease-specific care plan.  As the provider implements the plan, adjustments may be necessary in order to stabilize the patient’s condition.  This medical dance involves not only the medical provider but clinical staff members who continue the program by communicating regularly with the patient to monitor his/her condition and coordinate additional care.

It’s important to keep in mind these parameters in order to incorporate PCM successfully into your practice:

  • PCM is for patients with a complex chronic condition that is expected to last at least three months.
  • It’s for patients at high risk for hospitalization, exacerbation, decline or death.
  • The condition requires a specific care plan that is often subject to revision or tweaking.
  • The condition requires frequent adjustments in medication, or the complexity of care is complicated by the patient’s comorbidities.

At least 30 minutes of care per month must be provided by the medical practitioner (CPT code 99424; use 99425 for each additional 30 mins of provider time).  Staff may also provide services as they implement and manage the patient’s care plan (CPT code 99436 for the first 30 mins; use 99427 for each additional 30 mins of staff time as directed by the medical provider).

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The 2022 Florida Hurricane Season Is Here

Hurricane Season started June 1st. Our first tropical weather system crossed South Florida on June 4th and 5th. The National Oceanic and Atmospheric Administration predicts an average of 14 named storms and seven hurricanes for the Atlantic hurricane season. The average for major hurricanes is three. NOAA is calling this year’s season “above-normal” with 14-21 named storms expected.” Although most of us Floridians have been lucky through the past several hurricane seasons, trusting that luck is not a good plan.

The first part of a plan is to assess the risk most likely to affect your region. As with the first topical weather system that crossed South Florida earlier this month, wind was not the worst threat or eventuality; flooding was the issue. When dispatching caregivers to clients’ and patients’ homes, Administrators need to be aware of the conditions surrounding a client’s residence and avoid sending workers into dangerous areas. FloridaDisaster.org provides resources to identify flood-prone areas. By identifying, in advance, where your clients or patients reside, you can be much more efficient in evaluating whether it is safe to send a worker to a particular location. Further, this process will be necessary while assisting your clients and patients in developing their individual disaster plans.

During the development of your patients’ and your organization’s emergency management plans, consideration must be given to evacuation. Again, FloridaDisaster.org provides maps and other information for Evacuation zones where the likelihood of storm surge and flooding is the highest.   

Finally, as we’ve written in past blog posts on this topic, initial preparation should include the following:

1. Survey your direct care staff to determine their plans to remain available for work or whether they will evacuate. Plans always change, but having people think about it may solidify your staffing levels. Make an analysis of the number of confirmed staff who indicate they will remain available for patient assignments compared with the number of clients/patients who will continue to need care. Categorize the patients according to acuity of their medical condition and needs relative to your skilled providers.

2. Contact your mutual assistance partners – organizations with which you may have understanding regarding assisting one another in an emergency – to determine their continued availability to assist with staffing, etc. if needed.

3. Re-assess your clients’ or patients’ plans to evacuate or remain in their homes because their plans, too, are subject to re-evaluation as personal circumstances change. If they will evacuate, be sure to obtain the contact information for their destination and confirm Special Needs Registry patients have the most updated medication, supplies and equipment list.  If they do not, make arrangements to get the updated list to them

If you spend some time right now, working through these steps – while you can do so thoughtfully and carefully – you will be better able to keep your patients served and staff safe when a hurricane is on the radar, aiming at your area!

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Pitfalls in Chart Reviews: It’s not only about the Bottom Line

In this last blog in our four-part series on pitfalls, we thought we’d discuss the culture of your MRA department and how it guides the work.  Our almost-20 years in this field have brought us into contact with practices and reviewers who span a long continuum.  On one side is the practice whose directive is to increase MRA scores at all costs; reviewers who constantly identify new conditions are lauded.  This, however, can be a slippery slope.  We’ve lost track of the “creative” conditions suggested by some coders and how they strain credulity or are downright incorrect. 

In addition, misunderstandings about the actual criteria of medical conditions can abound.  We mean no disrespect when we say that sometimes that misunderstanding comes from providers themselves.   They follow guidance from the coder in reporting diagnoses they are not convinced are valid.  (Don’t scoff… we’ve seen and heard it first-hand!)  One condition making its way around coding circles – to the future financial peril of medical practices – is the substance induced disorder.  Scenario:  the patient has insomnia.  The patient drinks coffee.  Coffee is a stimulant.  Hence, the insomnia is due to the coffee drinking.  Uhhhhh not so fast…. Read this blog on how that diagnosis category really works.

On the other end of the MRA department continuum is the team of reviewers that look for the basics:  chronic conditions reported last year that are missing this year.  That’s really just the bottom of the barrel in MRA work.  There must be a balance between assuring long-standing, stable conditions are assessed and reported, and mining new documents to catch new conditions as they’re diagnosed.

Our company has occupied the risk adjustment space since 2004, its very early days, and we completely understand the financial implications of leaving money behind.  We also know the pain of CMS recoveries that strip years of funding from a practice that reported unfounded conditions.  The best philosophy for your MRA department is to identify all the conditions that are clinically indicated for your MA plan member and to assure that every risk adjusted condition you report is valid and properly documented.  This is quite different from the objective of increasing MRA scores that has been management’s directive to more than one coder. 

Increasing MRA scores is a finite exercise because although more than 10,000 codes are risk adjusted, the number of chronic conditions found in primary care is not ever-growing.  Report all you know to be valid and make sure it’s well defended by the provider, both clinically and coding-wise. That’s the true key to success in MRA!

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Pitfalls in Chart Reviews: Specialist Notes

In this four-part series, we’ve explored so far, the use of suspect reports and issues related to prior medical records.  In this installment, we’ll look at what can make specialist notes a little challenging to the chart reviewer.

Although the scope of primary care is broad, it’s obviously not as deep as that for a provider who receives additional training in a subspecialty, resulting in greater expertise.  Of course, PCPs diagnose conditions that fall under subspecialties like cardiology, pulmonary and gastroenterology, all the time, but in some cases, the standard of primary care includes referral to a specialist.

Specialist reports can contain a wealth of MRA information that is helpful to the reviewer.  However, over the years, we’ve learned to take those notes with a grain of salt for the reasons below.

Sometimes providers list diagnoses that are differential – meaning they’re not yet confirmed – as the justification for ordering and/or performing tests.  It’s important for the reviewer to carefully read the specialist’s note and evaluate whether the “breadcrumbs” for the diagnosis are spelled out in the note.  An example that we encounter with great regularity is the diagnosis of angina.  When a cardiologist diagnoses this condition in the absence of any documented findings from the HPI, ROS or exam, it’s suspect for us.  In addition, if the only things documented in the plan are orders for testing, this is usually not a valid diagnosis.  We can’t take a specialist’s note at face value without reading for the context to assure the condition is valid and active.  As non-coders, clinicians may not be cognizant of the differences between inpatient and outpatient coding, and report working diagnoses in error.

Another example is the oncologist visit where the provider codes a cancer diagnosis.  However, the rest of the note goes into great length about the treatment the patient received in the past, often a decade earlier, and mentions there’s been no recurrence.  Sometimes, the oncologist also writes “no evidence of disease” yet he or she does not use the personal history of cancer code.  Again, these are red flags that just because a specialist said it in a note doesn’t make it code-able.

The last example is the specialist who lists conditions that are not under his/her medical specialty.  An example is the gastroenterologist who lists in the assessment Crohn’s disease (a GI condition) along with heart failure and COPD, which are not under the GI specialty. It would be incorrect to use the GI note as evidence of heart failure and COPD. The reviewer must look for other proof – especially from a specialist in that field – to corroborate the condition.

Join us for the final installment of this four-part series where we’ll discuss the bottom line.

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Top Home Health Agency Survey Deficiencies: The POC

In this blog series, we’ll explore the most common survey deficiencies of skilled home health agencies as reported by the Accreditation Commission for Health Care (ACHC), one of three accrediting organizations for home health agencies (among others) with deemed status from CMS to assure compliance.  As we all know, health care is highly regulated and agencies are subject to Florida laws as well as CMS regulations. 

One of the top deficiencies reported is about the Plan of Care (POC), specifically, that there is a written POC for each patient accepted to services.  Once the agency conducts the comprehensive assessment, the information obtained – in addition to orders from the medical practitioner, which must be received before care is provided to the patient – must be incorporated into the POC.  The POC will contain specific treatment orders and measurable goals and objectives for the care that is to be provided with the purpose of the patient’s eventual discharge back to community-based care.

Honestly, we’ve never seen an agency that doesn’t have a POC for each patient.  We have, though, seen issues with the quality of the information on the POC.  Remember that it all has to tie together from the orders and assessment. Some issues we’ve encountered are missing frequencies for the services.  The standard is that duration, frequency and amount of service has to be spelled out in the POC.  Therapy services, in particular, must include the specific modalities and procedures that will be used.  When your therapist completes his/her therapy assessment, make sure those modalities are explained so that you can include them in the POC.

Another issue concerns medications.  First, they must all be listed and also, must match the medications on a medication profile.  For the most part, agencies using electronic systems enter info into a medication section that then populates a med profile and POC, but we’ve seen differing doses and medication names so employ your eagle-eye to avoid any problems.  PRN medications and treatments need parameters or indications (e.g., for pain, when systolic pressure is > X).

POCs are not one-size-fits-all documents although, admittedly, a good bit of templated language may be contained in each plan.  However, this language must be appropriate for the conditions being treated and the care ordered by the provider. For example, many diabetic patients may have similar goals:  to keep their blood sugars within a specified range, to adhere to a diabetic diet, to be able to administer their own insulin, etc. 

The quality assurance aspect of reviewing admission documents can’t be overemphasized.  Spend time on the front-end, reviewing admission information and making sure your POC is a good blueprint for the care that will be provided and that it meets all accrediting standards and CMS regulations.

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What We’re Reading: Problem People & Employee Discipline

“The reality is that most employers don’t like terminations.”  This statement from a valuable whitepaper about “problem people” set the tone for some valuable suggestions when an employee just isn’t cutting it. To begin, the author – who is an employment attorney – describes problem people as those who create drama, are never happy and spend an inordinate amount of time complaining.  No one wants to deal with them and frankly, they’re exhausting.  Moreover, they poison the well, so to speak.  However, the point of the article is that sometimes other issues are at play and as managers, we need to know what the goal is.  Is it to improve performance?  Or is it to work the steps and cover our company’s backside on the road to termination?

While to us, the author seems to dance on the fine line of hand-holding & Kumbaya versus corrective action plans, she does put forth some excellent suggestions.  The progressive discipline process can create more angst and drama, especially if the employee (or manager) isn’t clear on what improvement looks like or if there are other factors aggravating the situation.  Ideally, the correction process is about helping the employee meet the company’s standards for the work, but in honesty, we’ve seen managers who really aren’t clear on that, or who tolerate substandard work from others but seem to be on a crusade against one team member.  Putting that aside, though, let’s acknowledge that people’s personal baggage comes to work with them.

Someone’s sick.  A bad breakup.  A health issue.  These can certainly affect work product and may not be readily visible.  Do we know what’s going on with the employee? In a culture of trust, the worker might touch on some personal factors aggravating the work situation; in other companies, it may be tantamount to handing HR the noose with which to hang him.  That question requires more of a corporate self-assessment than we can accomplish in a simple blog, but it’s worth considering.  The bottom line is to ask if we’re seeing the actual problem or symptoms of something else.

Assuming the employee wants to remain in the position – a big assumption, as that may not be the case – the article puts forth Five Ts to try before termination: 

  • Offer time off.  Managers should be knowledgeable of the company’s PTO policy and try some creativity to see if the worker just needs a short break in order to regroup.
  • Offer treatment.  Perhaps the employee needs to talk things out with someone.  Checking into your EAP program or health insurance coverage may result in a needed lifeline for your worker.
  • Consider training.  Sometimes people think they know and managers think the employee knows.  And the longer someone’s been employed, the harder it might be to ask foundational questions.  Retraining can be an opportunity to fine-tune some points, fill in knowledge gaps or just reinforce certain concepts, and get the worker back on a good path. 
  • Transfer.  While we certainly don’t want to foist a challenging employee on another manager, a different role could be the breath of fresh air the employee needs to rise to the work needed. 
  • Trust.  This last point is about giving employees more control over their work-day and trusting them to get the work done. A very rigid system can be stifling, so allowing for more autonomy may be just the balm to improve engagement and productivity.

Sometimes the relationship isn’t salvageable and both parties have to be okay with that.  The biggest takeaway is that here too, creativity can make this a more positive outcome for all.  Allowing flexibility while the employee searches for a new job or even offering severance pay can be a win-win:  the employer needn’t worry about claims or lawsuits and the worker receives a cushion while she evaluates her next step.

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Pitfalls in Chart Reviews: Prior PCP Records

In Part 2 of this series on the challenges encountered in chart reviewing for risk adjusted conditions, we’ll discuss the prior PCP.  Every single primary care practice has a mechanism for requesting and obtaining records from the patient’s prior primary care provider.  Of course, there is great variability in the processes, follow through and success in obtaining records. 

Additionally, every practice has different guidelines for what it will release. Some PCP offices release only their created medical visit notes, while others release PCP notes and labs.  Still others release the whole chart, or every document for the last two years.  You really don’t know what you’ll receive although your medical records request form should state what you want (which should be all documents for X period of time).

When receiving prior PCP records, it’s important to review them with a critical eye.  We’ve blogged before about providers who report conditions that have no evidence to support them and so, incorporating a condition into your new patient’s chart because “the prior PCP said so” is a recipe for recoupments. 

To be honest, when we review charts, we take a cautious approach with old PCP notes, relying on them only to provide clues that will be validated elsewhere in the record.  For example, the prior PCP says the patient has pulmonary hypertension and cites an echo result.  We use that to track down the actual echocardiogram report and would never suggest the condition to our client based on only hearsay.  Some might take that as evidence, but what if the PCP did not adhere to the proper medical criteria for diagnosing this condition?  Or what if the PCP’s note contains a typographical error? You would be perpetuating erroneous information for your company. If you’re lucky enough to receive lab and imaging reports, you’re close to a goldmine of information that can bolster your work as an MRA reviewer.

In Part 3 of this series, we’ll explore specialists’ notes.  If you missed Part 1 of this series on suspect reports, here’s the link.

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Pitfalls in Chart Reviews: Suspect Reports

Our company began working with risk adjusted payments in 2004, shortly after the CMS-HCC model was implemented, and as you can imagine, we’ve reviewed thousands of medical charts.  Over the years, as providers from all specialties have become more versed in medical coding and MRA, we’ve seen an evolution in the pitfalls that reviewers can encounter when auditing charts. This series will explore four common issues and our suggestions for avoiding mistakes. In Part 1, we’ll discuss suspect reports.

Suspect reports are lists of risk adjusted medical conditions that health plans believe may apply to specific patients.  The plans provide these lists to provider offices and request the staff “work” the lists.  This means chart reviewers should determine whether the suspected conditions are valid (e.g., there is evidence to support them) and then suggest that providers assess and report them at the next visit.  At first blush, this sounds like a great help to provider offices in making sure no valid conditions are being overlooked.  Reality, however, doesn’t bear this out.  (Our health plan colleagues will probably cringe, but we’ve got to share our honest perspective with you.)

Suspected conditions are pulled from many sources:  hospitalizations, lab and other provider data, medication use and even plan algorithms that supposedly can pinpoint possible medical conditions.  What results is, essentially, a wild goose chase, assuming the practice has a process for reviewing documents from any provider who sees the member and determining whether there are new conditions to assess.  Suspect reports rarely contain the name of the provider source or date of service, which makes this an even more frustrating and time-consuming exercise with little return on investment.

In addition, let’s not forget that hospitals, for example, are subject to different coding rules than medical professionals in outpatient settings.  Inpatient claims may contain codes for differential diagnoses or rule-out conditions that can ultimately find their way into suspect reports.  Consequently, taking them at face value can result in errors for the practice.

A better source of potential conditions is a report of claims paid on behalf of your patients, if it’s possible to obtain that from your plan.  A claims report will provide a date of service and ICD-10-CM codes reported for your patient.  The practice can then request specific records from the provider source and determine whether the conditions are valid for the patient.  It may be valuable to work both types of reports and track success rates in validating new conditions. This will give you data with which to reassure your MA plan rep that you’re doing the work, just a little differently.

In the next installment of this blog series, we’ll discuss the value and hazard of prior PCP records.

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Do I Really Need Billing Policies?

Call us nerds but we’re fans of having policies & procedures.  They’re not a magic bullet by any means, but they do provide a framework for operating that accomplishes two things:  P&P force practice leaders to consider and document business standards and processes and they guide and remind employees about those workplace standards and processes.  So, although they can be the bane of a manager’s work existence, P&Ps are our friends.  The billing department is one place where we believe you really need robust P&P.  Why?  Because it’s the heart of the office. 

We can’t tell you how many billing assessments we’ve done only to find out that Sally does things this way and on these days, and Henry does them that way and on a different timetable. These differences can impact the financial wellbeing of the practice because so many billing tasks are time-based.  For those of you who tremble at the thought of writing stuff, P&P don’t need to be fancy.  They just need to put forth the steps and guidelines of a process.  Here’s a list of subjects you can cover in your policies:

  • The steps in the billing process for your practice – No need to get too nitty-gritty on the how-tos with screenshots (although that would be helpful in a training handbook), but cover the basics:  when is billing done (preferably daily), how is it done (is the note reviewed? Do you use a superbill?), how frequent is claims f/u, what is the process and timeframe for denials, etc.
  • Financial hardships, courtesies and discounts – How do you handle these?  Who can receive a discount? What can a biller or billing manager discount without authorization?  What needs approval?
  • Payment plans – How do they work?  Who can establish them?  What size balance can be paid off in this manner?  Will you collect a credit card and process payments automatically?  Who is responsible for monitoring payment plans? How will that be done and on what timetable?
  • Delinquent accounts – How do you define this?  What do you do with delinquent accounts?  Will you refer a delinquent patient to collections?  When does that happen – after how many collection attempts?
  • Refunds – Define when a refund may be due and to whom.  Who can process refunds? Is authorization needed for any refund or only those over a certain dollar amount? What documentation is made in the system?
  • Patient statements – How often are they sent? How many statements are sent before an account is deemed uncollectable?
  • Write-offs and adjustments – Define these terms so their distinctions are clear.  When are adjustments made?  Are adjustments for contractual allowances, for example, done automatically?  When is a write-off done?  What can be written off automatically?  Do write-offs require authorization?  From whom?

Billing policies are not for the specific steps in performing the process but for the standards and rules of the department and practice.  The more you spell out for your billers, the more effectively they can work because the parameters for using their judgment are clear.  Think about the issues you cover with a newly hired biller and we bet you’ll have the topics for a basic billing policy manual in no time!

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The Balanced MRA Approach

Like grandparents who pepper conversations with comments like, “Back in the day…” we’ve been around the risk adjusted payment methodology since its birth in 2003.  Back in the day LOL the provider community was largely in the dark about many aspects of this huge payment shift.  Remember that in the early aughts, MA payments were based on factors beyond the provider’s control, namely demographics, and documentation was deliberately sparse in prepaid circles because it wasn’t believed to matter to the payment. (That’s the subject of another discussion.)  Additionally, the majority of providers were documenting visits on paper.  Raise your hand if you remember the blue paper problem list filed on the left side of the chart!

So much of our work in early MRA was educating providers and identifying risk adjusted conditions buried in the chart – conditions which had not been previously coded or reported.  That’s perhaps the “fun” part of MRA work: unearthing conditions that may add to the provider’s (or Plan’s) funding.  With time, things shifted and providers were more informed on the conditions under the CMS-HCC model and better at coding them. In time, regulators stepped up their scrutiny of reported conditions and documentation to assure proper compliance with all guidelines, coding and medical. Cue the OIG.  As we’ve reported many times over the years, the Office of the Inspector General (OIG) has commissioned numerous audits of MA plans, questioning the validity of submitted conditions and even making serious accusations of fraudulent activities and “upcoding.”   That’s the non-fun part. 

The balanced MRA approach, therefore, has to embrace the two: identifying new conditions that fall in the CMS-HCC model which have not been reported and assuring that the submitted codes are valid.  Valid encompasses:  using the most specific ICD-10-CM code possible; making sure the evidence supporting the condition is clear, documented and accurate; and requiring comprehensive documentation of a proper assessment of the condition on the date of service for which it is reported. 

In our work, we get to see the MRA activities of many practices, large and small.  Some are heavily slanted toward identifying new conditions – however creatively – but they disregard the validation aspect at their own peril. A few are exclusively archaeologically inclined!  We urge every single provider operating under this payment method to assure your MRA department’s activities are equally split between identifying unreported conditions and making sure what has been submitted will pass muster. 

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