Continuing Care Insite

Earthquake Victims Have Long Term Needs

2010-01-17T05:29:00.000-08:00

My career in health care has bridged both acute care and long term care. As I watch the rescue and emergency care efforts on TV in Haiti, my perspective on care across the continuum causes me to anticipate what the long term care needs of the survivors will be. With the crushing injuries that are evident with survivors, and the resulting amputations, there will be need for prosethetics and for rehabilitation.

The health care needs of the earthquake victims will be tremendous and ongoing. When we see a person pulled from the rubble on the cable news, that's just the beginning of the rescue mission. Next comes the need to address their injuries with IV fluids, surgery, medication, and lots of nursing care. Then comes rehabilitation. If they are debilitated or have suffered the loss of a limb, they need to strengthened and taught to adapt to their new reality.

A search of the web reveals a center for rehabiliation in Deyang City specifically for earthquake victims in the Sichuan region of China. This may serve as a model for what will be needed in future months and years. Read more about the Hong Kong Red Cross Centre for Rehab and Prosthetics and Orthotics.

Added to the physical needs of these victims are the enormous emotional consequences of living through such a disaster. The social fabric of many family units and neighborhoods have been torn apart, and will need to be replaced by new support systems. The work is just beginning. Unfortunately, the road to recovery will be long-- for the victims, and for the country. It is important that once the news cycle of the urgent needs passes, that attention continue to be paid to the continued needs of those we began to help. We need to see it through...

Improving Payer Mix

2009-11-22T05:12:00.000-08:00

Facility revenue levels depend directly upon the mix of reimbursement for resident care that you achieve through the admissions process. In most states, Medicare reimbursement represents the optimum payer. But optimum payer class is not always so obvious. For example, if your state bases it's Medicaid reimbursement on case mix of your Medicaid patients only, then admitting Medicaid patients who need rehab or subacute care might not pay off on the short term, but can greatly help to improve your facility case mix and overall Medicaid reimbursement. So the right mix of payers requires some careful analysis.

Once you arive at your optimum payor mix, then add your actual payor mix to your dashboard and monitor it weekly. Based on your data, you should redirect your marketing activities to target the particular payor class you need to improve on. You certainly won't turn away patients who are not in your targeted group, but you will focus your marketing and outreach activities to reach patients of your targeted payor group.

Finally, don't be caught in the trap of looking only at what a payor class reimburses you for care without also looking at what it costs you to provide the care. Careful and ongoing monitoring of expenses per payor class is critical, and also should be dashboard. Categories for close monitoring include pharmacy costs, rehab staffing expenses, and co-pay receivables.

Successful operation of long term care facilities is a complex challenge in today's fiscal environment. For more information on these strategies, contact Joseph Tomaino at joseph.tomaino@rsmi.com or 212-372-1640.

New York State Medicare Crossovers

2009-11-19T06:17:00.001-08:00

According to CSC presentation at NYHSFA Fall Conference today, it was announced that nursing homes are being carved out of the crossover payment process. This process would have automatically crossed over claims to Medicaid after processing by Medicare for the amount not covered by Medicare. This would have created issues for skilled nursing facilities that are subject to Part B carve outs.

Health Care Reform Brings Heightened Provider Scrutiny

2009-11-13T17:59:00.001-08:00

The proposed House and Senate plans for health care reform vary considerably, but the one common element of both, give or take a few billion, is that they are very expensive. The Office of Management and Budget discusses on their website the various sources of revenue that will be used to finance this expenditure. One category they point to is the billions of dollars that are lost each year to Medicare fraud and abuse. This means that the already active revenue recovery efforts by federal and state agencies will intensify over the coming years.

Despite their best intentions, providers can find themselves facing an Office of Inspector General or State Office of Medicaid Inspector General audit, and be surprised to find out that they have been submitting claims for reimbursement that are not supported properly. It may be that the wrong procedure or E&M code was selected; or the right code was selected for what was done, but the documentation doesn't support it; or the visit was not justified medically. Nursing home providers may find that MDS completion was not based on the true condition of a resident,or that the resident experienced quality of care issues while being covered by Medicare. A home care agency may find that the ICD-9 codes they selected for prospective payment were not appropriate for the client's medical diagnoses, or a hospice provider may find that they inadvertently billed for days after a patient died because of a breakdown in communication.

While these types of events are most often not intentional, they can happen very easily from a variety of factors:
1. Staff can become so absorbed in meeting the tremendous needs of patients that they don't pay enough attention to the "paperwork".
2. Interfaces between clinical and financial information systems can have glitches that remain unknown for months.
3. Providers become accustomed to doing things a certain way for years without being told it is not a proper procedure that they assume it is proper.
4. Staff can identify an issue as not being correct, but because of workplace politics, power structures, etc., nothing happens about it, so they stop bringing it up.

So what is a provider to do to prepare for the increased scrutiny of their claim submissions? Every provider organization should have a compliance plan where the principles of revenue integrity are spelled out for all staff to see, and the expectations for how that integrity will be monitored and what a staff member should do if he or she sees something they don't think is right, is laid out. This compliance plan should include ongoing monitoring of revenue cycle processes to make certain that claims submitted are based on proper coding and are supported with the appropriate clinical documentation. Staff who show a pattern of non-compliance should be given feedback and if they do not improve, should be subject to disciplinary action. It also is valuable to have both the compliance plan, as well as a sample of claims submissions for a period of time, reviewed by an outside consultant who will be objective and provide the perspective of external scrutiny.

For more information on this topic, or to discuss how a diagnostic assessment of how effective your organization's compliance and revenue integrity processes are, contact Joseph Tomaino at 212-372-1640, or joseph.tomaino@rsmi.com .

Patient Safety Across the Continuum of Care

2009-11-11T06:38:00.000-08:00

Multi-drug reistant organisms are a major challenge for healthcare organizations today. Whether we are dealing with MRSA, or drug resistant strains of C-diff, the care of these patients is expensive and time consuming, and can have a significant impact on morbitity and mortality. Controlling these organisms when patients move between different levels of care in the continuum is complicated by the lack of understanding and communication that often exists. While providers in a hospital setting would never dream of transferring a patient between one unit and another without giving the receiving unit a full report, the same is not true when patients are transferred to a nursing home from a hospital or vice-versa.

On Friday, November 13, 2009, I will be presenting about efforts to control the spread of multi-drup resistant organisms between hospitals and nursing facilities at the Patient Safety Across the Continuum of Care 2009 Conference sponsored by the Southeastern Pennslyvania Association for Healthcare Quality in Plymouth Meeting, PA. For more information about the conference, or to register, go to http://www.spahq.org. The focus of my presentation will be on building bridges of understanding and cooperation between care settings in the infection control arena, and several best practice examples will be presented.

If you are not able to attend this presentation and would like more information, or if your organization needs assistance with performance improvement in this area, you can contact me at joseph.tomaino@rsmi.com.

Long Term Care Included in House Plan?

2009-11-10T09:13:00.000-08:00

A report in last week's Wall Street Journal mentioned that long term care coverage is being included in the House plan for national health care. I have not been able to find many details on the proposal. The idea is exciting, but at the same time terrifying. It's exciting because with the aging of our population and the range of needs growing daily, such coverage would offer payment for services which right now often go undelivered. On the other hand, with such massive need, it's difficult to imagine how it would be paid for. What are your thoughts?

It's Not Just About the Census Anymore...

2009-07-31T14:19:00.001-07:00

Measuring success has changed as the continuing care market has changed. For example, managed care reimbursement has created new challenges. Just because your nursing home beds are filled, it does not automatically mean you are being profitable. I recently made a presentation at the Spring Institute at the New Yew York Association of Homes and Services for the Aging in June. Mike Martin, from the Springfield office of RSM McGladrey and I will be presenting another version at the Illinois Health Care Association conference in Peoria on September 16, 2009. For more information on the conference, go to the Illinois Health Care Association website I hope to see you there!