In our recent blogs, we’ve highlighted how Business Intelligence (BI) can help providers more effectively tell their stories to stakeholders, investors, and referral sources. However, providers have another key audience to whom they could effectively present data-driven demonstrations of value and quality – ACOs. In an article published by Healthcare IT News, the author identifies, among other critical success factors, that ACOs need to align the payment model with value and to develop the data model, IT infrastructure, and tools to support reporting and analytics.

Aligning value with payment models

One of my co-workers likes to use the cliché, “Keep it real. In that spirit, because payment model and value alignment are important to ACOs, providers need to understand ACO requirements and to tie their quality improvement initiatives to that payment model. BI can help providers identify and share the results of these initiatives with ACOs, demonstrating payment model-relevant value and service quality.

Developing the data model, IT infrastructure, and tools to support reporting and analytics

Key to successful ACO participation is a dynamic BI tool, the backbone of which is readily interoperable with other systems. Being able to integrate data from various data sources into one common data warehouse will help open lines of communication and care coordination within the payment model parameters. To the extent that LTC providers, with ambitions to participate as a valued and contributing ACO member, have the infrastructure in place, they will be able to more readily integrate their data into the ACO’s existing platform.  

Let me add our two cents – talking the talk; walking the walk

In marketing, we use the term “buyer persona”, which means that for us to effectively communicate, we need to understand who our targeted audience is, their concerns, their interests, etc., and to tailor our communication and engagement efforts accordingly. Likewise, providers need to understand the ACO stakeholder persona(s) and to craft their interactions with those stakeholders by talking their talk and walking their walk. Addressing their concerns with relevant information goes a long way.

Summary

Within the last couple of years, ACOs have begun to recognize that the inclusion of post-acute care providers can contribute to major cost savings and quality care improvement. LTC providers who have BI and data integration technology in place are better positioned to solicit and participate as viable ACO members. Are you one of them? Is ACO participation on your strategic radar screen? If so, having BI and analytics tools to help you demonstrate value in harmony with ACO payment models will help you to stand out among the crowd of ACO membership “wannabees”.

Periodically, you will read about out-of-court settlements or court decisions rendered for False Claims Act violations. Claims may be subject to false claims accusations for treatments or services provided that are not deemed to be medically necessary, do not meet the coverage qualifications, or the medical record indicates they were not provided as ordered.

To take the side of an honest mistake, providers can find themselves inadvertently on the wrong side of the False Claims Act if medical record documentation does not support the following:

• A medically necessary admission to a SNF within 30 days of a covered inpatient hospital stay lasting no less than three days,
• That the resident/patient is receiving services and treatments for the condition or injury treated during the qualifying inpatient hospital stay,
• The physician’s certification and subsequent recertification that the services ordered meet each of the qualifying requirements, and
• The documentation identifies that the physician-ordered services were provided as ordered

Further, in an article written in April 2013, Amy E. McCracken wrote that providers must safeguard that claims filed do not include “worthless services” or “implied false certifications,” the two primary theories for the basis of liability. Worthless services suggests deficient services provided inconsistent with physician orders. Implied false certification infers the violation of Medicare or Medicaid regulations.

What are the potential damages? The False Claims Act provides for three times the actual damages and an $11,000 per-claim fine. This can add up quickly. In a recent McKnight’s article, a large provider agreed to pay $600K to resolve False Claims Act allegations. In this case, the facility in question failed to “provide patient care activities as recorded in the resident medical record of a patient and not providing certain care activities consistent with a physician order for more than a month.”

Also, in the case above, the provider has to “pay for a transition consultant to assist the new operator of the skilled nursing facility for a year. This consultant will help ‘identify risks and opportunities for improvement in providing skilled nursing services to residents at the facility.’”

What must providers do to minimize the risk of falling afoul of the False Claims Act?

1. Confirm that the attending physician certifies and then appropriately recertifies the need for skilled care under the definition of skilled services within the SNF.
2. Make sure the care plan is consistent with physician orders.
3. Follow the care plan.
4. Validate that the clinical documentation supports the services provided consistent with the care plan.
5. Reconcile the clinical notes to make sure all disciplines, for example, nursing and rehabilitation, accurately and collaboratively support the resident’s/patient’s condition absent conflict or inconsistencies.
6. Verify that the charges claimed are consistent with the documented physician-ordered services.
7. Take advantage of the triple check process to confirm consistency of charges on the claim with the medical record, care plan, and physician orders. A mere typo can trip you up.
8. Consider self-reporting. If you discover serious billing problems, voluntarily reporting the violation within 30 days of discovery may reduce and damages and penalties significantly.

Violating the False Claims Act carries with it heavy penalties to your hard-fought-for reputation and your finances. Take appropriate steps to minimize the risks. To do nothing would be cents-less.

As the reimbursement world changes from fee-for-service to pay-for-performance models, demonstrating value is key. To be able to compellingly demonstrate value compliant with payment model expectations, providers need to be able to know how well their facilities are performing today. The technology needed to effectively identify and communicate such value is available through business intelligence (BI). As mentioned in a previous post, BI can also be useful in helping providers share information with stakeholders, investors, and even referrals sources.

Let’s assume you’ve identified a particular hospital which shows considerable potential as a referral source to one of your facilities for patients requiring the kinds of services that facility specializes in. With BI, you can effectively tell your story with data-driven information, easily retrieved and configured for presentation. You can bring demonstrated improvement trends in rehospitalization rates tied to clinical best practices and specific diagnoses. Statistically, you can also show how competently your facility treats in-house as well as community-acquired pressure ulcers, physical restraints, falls/accidents, significant weight loss, medications, infections, etc.

You can confidently share with the hospital’s executives discharge information length-of-stay and admissions/discharges information, Five Star ratings compared to peers, and inspection results, such as fines and deficiencies, and quality measures you can present in chart or graph form with trends and benchmarks to state averages. A further indicator of quality within the context of Five Star ratings is labor. BI gives you the opportunity to compare your staffing to 5-Star, 4-Star, and 3-Star requirements.

If your clinical software enables your clinicians to uniquely identify hospitals, you can specifically demonstrate to your audience how well you serve the patients they have discharged to your facility.

What’s most useful is that BI already generates this information for you automatically. You can export it and reconfigure it to meet your audience’s needs. So, what’s required? A BI tool tailored to your organization’s mission, objectives, and best practices, and the opportunity to share your story, to demonstrate your value to the community and the care continuum you serve.

Present on Admission, handling rejections, and shortening the revenue cycle topped this month’s key claims management blogs. Here are the key topics for this month:

To get paid or not, the answer could be a simple “Yes” or “No” – POA

Some SNF providers strongly assert that HAC-POA (Hospital Acquired Condition-Present on Admission) indicators do not apply to claims submitted to SNFs. Yet, recently an entire batch of claims submitted to a large insurance carrier was rejected, because the SNF provider’s billers had not included the POA indicator.

• What is a Present on Admission Indicator?
• Why POA could be important to SNFs
• How should billers use the POA?

No pain, no gain–not true. 4 ways to deal with claims rejections pain

One of the pervasive and overlooked pains in claims management involves claims rejections. Claims rejections require the billing staff to review the claims, address whatever is missing or in error and resubmit the claims in order to get paid. In some cases, payers reject specific claims over and over again. What’s even more painful is that billers, with the best of intentions, sometimes will put the rejected claims in a file folder which, if not dealt with immediately, can collect dust. Are you feeling the throb?

• Pay attention to rejections
• Discover the issue and if it is something you can control, address and fix it quickly.
• Check the contracts.
• You may have to stop accepting certain insurances/payers.

3 unique ways to shorten revenue cycles

LTPAC CFOs in the 21st century have to be concerned about many things. But in reality, much of what CFOs do revolves around getting paid on time in the amounts anticipated. Perhaps paying attention to the not-so-obvious factors influencing payment may be worth investigating.

Three ways to shorten the revenue cycle by “developing and leading the finance team to maximum productivity and responsiveness”:

• Improve A/R team job satisfaction
• Address claims processing costs
• Pay attention to Medicare Secondary Payer (MSP) claims

Nothing tells a good story better than relevancy, accuracy, and timeliness. When it comes to seeking investments on the best of terms, there’s no better way to tell the story than through the use of BI-generated Key Performance Indicators (KPIs). In the past, we have identified how BI can help you more effectively monitor and manage your operations.  But, did you know that BI can also serve as a great resource for communicating your market dominance and strengths? It’s transparent. It’s current information delivered when and how you need it – automatically.

Ray Tyler, Health Services Management’s COO, reports that “one of the biggest advantages to Business Intelligence is our ability to…quickly prepare and submit reports to key stakeholders, such as REITs. We can view and report on actual-to-budget (performance).”

Along with demonstrating company background and experience, uniqueness, and business model effectiveness, providers have to know their numbers. BI helps them significantly by automating reports and KPI views. Because they don’t have to prepare reports manually, executives have more time to conveniently familiarize themselves with those numbers. They can know the “what’s” and “why’s” quickly.

As Dean Kiklis, CFO for Frontline Management, stated recently, “The dashboard helps us to know what is happening in each of our buildings every single day….(Because) it’s up to date…, we don’t have to wait for someone to create reports for us.”

Further, BI makes it easy for executives to trend and report their companies’ performance year over year. BI can also help prospective investors evaluate provider revenue streams and other critical cash flow information.

Creating context? BI can help there as well. NIC’s Skilled Nursing Data Initiative is one way participating providers can compare their operations against national benchmarks. Thus, they are able to demonstrate their strengths and dominance within the markets they serve.

How has BI helped you in managing and promoting your company to investors?