What Will Patients Do When They See Your Prices?

Two trends are forcing greater consumerism and price sensitivity in health care. One is that Medicare, Medicaid, and some commercial insurance carriers, are starting to show patients and employers the prices facilities charge for common procedures. Another factor is that patients with high-deductible health and account-based plans have an incentive to consider cost when choosing services and providers.

How consumer-savvy are patients? They can search for providers by quality measures on a number of websites including HealthGrades.com and QualityCheck.org. But it’s not as easy to find out what providers charge for, say, an MRI or sinus surgery and compare prices to quality measures. Continue reading

A Gift from the OIG That Could Be Worth Millions

Not convinced of the importance of administrative and financial data integrity in health care? Consider – both OIG and OCR (Office of Civil Rights) are monitoring healthcare provider’s (facility and professional) compliance patterns. Whether it is a HIPAA violation or claim error, they are able to determine if the problem is due to a simple mistake or emblematic of larger systems issues. Repeated non compliance patterns are revealed in monitored data.

On June 5, 2014 the OIG released results of an audit performed on a large medical center for calendar years 2010 and 2011. Unfortunately, the medical center was found to be in non compliance with about 50 percent of the claims reviewed. The OIG’s data monitoring efforts identify areas of concern – even when an organization believes it is compliant. Just like banking and other regulated industries, data integrity is crucial to both providers and monitors. Every aspect of compliance – especially those that are most complicated – becomes critical. Continue reading

Price Shopping and Narrow Networks

Making available hospital prices – amounts paid to hospitals – has historically been handled with a great deal of caution by policy makers. Fear that hospitals will use posted prices to coordinate negotiated rates with insurers has evolved into numerous legal arrangements shielding payments from scrutiny. Moreover, the hospitals that would be seen to gain, if we accept this viewpoint, are concerned that the public will misinterpret price information. The result has been a payment system that is to a large extent shielded from daylight. There are signs that this is changing. While there seems to be increasing support for, and attempts to deliver, hospital price transparency, there remains little consistency among proponents on how to define transparency and what it should achieve. Continue reading

Live from HFMA: Will data fix our broken health care system?

At the 2014 HFMA conference here in Las Vegas, Dr. Atul Gawande delivered the keynote address and outlined four emerging lessons about U.S. health care:

  1. The debate about whether to provide health care coverage to Americans is over.
  2. The delivery system is still broken.
  3. Understanding the sickest is how we fix our health care system.
  4. Success requires making data the most important resource to clinicians and patients for improving care.

So, what does this really mean and what is missing from this picture? Continue reading

Toss Those Pebbles Carefully…The Ripple Effect of CDI and Coding on Quality Outcomes

I have never been able to skip a stone, but I do enjoy watching the ripples expand until they disappear. Or do they?

Clinical documentation improvement (CDI) has been around for quite a while and the function has changed throughout the years. Initially, the focus was on appropriate financial reimbursement for resources provided to patients. As quality of care became more transparent, the scope expanded into accurate reflection of severity of illness and risk of mortality. Today, the role of clinical documentation has grown far beyond these two functions. Continue reading

ICD-10 Coders Climb Mountains

The small nation of Papua New Guinea was an early adopter of ICD-10, inspired by its neighbor Australia. In the remote provinces of New Guinea, an ICD-10 codebook is considered a precious object. One codebook is granted to each village and entrusted to the care of the village coder, who is held in the highest esteem by the people. The account that follows gives us yet another example of the quiet heroism of the ICD-10 coder.*

There were two warring tribes deep in the hinterlands of Papua New Guinea, one that lived in the valley and the other high in the mountains. One day, the mountain people invaded the valley, and as part of their plundering of the people, they kidnapped an ICD-10 book from one of the villages and took the codebook with them back up into the mountains. Continue reading

HIMagine That! Highlights from the AHIMA Clinical Coding Meeting

Donna: Hey, Sue – what were your takeaways from the AHIMA Clinical Coding meeting held in New Orleans?

Sue: I really enjoyed the presentation by Dr. Jon Elion. He offered great clinical perspective on some of the diseases that can cause the most difficult documentation and coding conundrums – you know, like malnutrition, encephalopathy, CHF, malignant hypertension . . .

Donna: So interesting! He noted that there is no specific code for hypertensive urgency. If this is documented and there is no current or impending organ failure, one should not query for malignant hypertension in this scenario – instead, it is just reported as unspecified hypertension.

Sue: Which presentation piqued your interest? Continue reading

Why Are We Complaining about ICD 10? The Cost of Non-Compliance (Again)

In my May blog, I talked about the cost of non-compliance versus the cost of implementing ICD-10. My hypothesis: human nature is the real cost driver in health care – not code set changes. A recently released study by OIG revealed that physicians increased the billing of all E/M (Evaluation and Management) services from 2001 to 2010 (the years studied). The higher the level of E/M codes assigned, the greater the reimbursement. CMS found that E/M services are 50 percent more likely to be paid in error than other Part B services. Why? Because they are coded to a higher level which results in more money paid to the provider – physician and non physician alike. CMS identified the root cause of the overpayments – no surprise here, coding error and poor documentation. Continue reading

Quality Reviews: Delivering Constructive Feedback

To many healthcare documentation specialists (HDS), the QA process can feel like being scored for an academic grade. This is because a medical transcriptionist’s performance review, and sometimes even their compensation, is affected by her quality scores. But as I have discussed in previous posts, quality in documentation is a team sport in which the dictator, HDS, QA reviewer, and final authenticator(s) are all expected to contribute their best efforts to the document. Although it is important to ensure that each individual is doing her part to generate complete and accurate documentation, quality reviews should be treated as an opportunity to provide education and feedback toward continuous quality improvement. Continue reading

Three Reasons Not to Model Health Care after Trader Joe’s

The AHIP conference in Seattle this month includes three consumer retail executives on the agenda. In leading up to the event, the media cited one of the speakers, the former president of Trader Joe’s, and suggested that health care should take some cues from the retail grocer.

Stop right there. Health care should not imitate the business model of Trader Joe’s, known for its folksy story-telling and unique selection of private label foodstuffs. The healthcare market is significantly different from grocery stores in ways that make it difficult to be consumer friendly: Continue reading