Many others are taking on the burden themselves and utilizing their inhouse team of Regulatory, Finance, and IT staff.

For you, KHC can help in the following areas:

• Answering questions regarding the rules and their specific application.
• Performing a review of your results – as a quality check.
• Help you handle certain portions of the updates needed – you define and you control.
• Training staff on ways to facilitate the data burdens and the Hospital Price Transparency rules.

If these or other areas of assistance are needed, please contact Sara Rivenburgh (srivenburgh@kohlerhc.com) or Linker Mills (lmills@kohlerhc.com).

Many hospitals have implemented clinical documentation improvement programs over the past few years. Some are successful; others are not. Most are not meeting the full potential.

ICD-10 is a game changer.

The best CDI practices, software, and staff cannot be successful without physician support. If you are not seeing consistently excellent documentation, there is high risk of substantial denials post ICD-10. Even high functioning programs need to make adjustments.

We can help you make the crucial documentation shift to ICD-10 and for current improvement.

Why KHC?

• Our approach was developed by and is led by some of the most experienced CDI people in the industry. It is not a “one size fits all” approach.
• We build on your existing foundation providing what you need when you need it. For example, as you expand to a new specialty or service line we can provide the analytics and training for just that specialty or service line (i.e., Obstetrics).
• We utilize data mining to provide comprehensive, yet inexpensive, opportunity identification using your claims data. This approach is significantly faster than typical medical records-based assessments and provides a variety of data “slices”– i.e., departmental as well as service line.
• We employ a denial prevention mindset using data from a variety of internal data to solve the right problems.
• Physician-led physician education.
• Custom CDIS education focused on your specific opportunities. We use your medical records to make training relevant and effective.
• It is a “speed to value” approach that generates results fast.

• Anesthesia Compliance Audits to Ensure Adherence To
  • The 7 Steps of Medical Direction
  • Hospital Conditions of Participation
  • Concurrency
• Ensure Optimal Reimbursement
  • Capture All Ancillary Services-A-line, CVP, Swans-Ganz
  • Correct Coding and Billing of Post-Operative Pain Services
  • Qualifying Circumstances
  • Proper Obstetrics Policies
• Billing Nuances of Anesthesia Services

• • Anesthesia Modifiers
  • Rounding of Minutes
  • Physical Status Modifiers
  • Cancelled Services
• Coding and Medical Record Documentation
  • Review Surgical Reports to Validate ASA Coding
  • Diagnostic and Medical Necessity Coding Review
• Compliance and Regulatory Matters
  • Op-Out State Regulation
  • Broken Medical Direction

Further, we can add our clinical background in improving an Ambulatory Surgery Center’s operational and regulatory reviews with our Registered Nurses and Credentialed Coders.

Federally Qualified Health Centers (FQHCs) include all organizations (public entity or private non-profit) receiving grants under Section 330 of the Public Health Service Act, certain tribal organizations, and FQHC Look-Alikes. FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits. FQHCs must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality assurance program, and have a governing board of directors.

Funded Health programs include Community Health Centers; Migrant Health Centers; Health Care for the Homeless Programs and Public Housing Primary Care Programs. FQHCs are community-based organizations providing both primary care and preventive care, including health, oral, and mental health/substance abuse services to persons of all ages, regardless of their ability to pay. Requirements can be complex — Indian Health Service funded FQHCs may differ from the requirements for FQHCs receiving Section 330 grants and for FQHC Look-Alikes.

How We Can Assist

KHC has extensive and varied experience working with FQHCs in the following areas:

• Operational assessments, including all facets of Practice management:
  • Best business practices, accounts receivables management, reimbursement, coding, billing, compliance, and regulations.
• Physician compensation and provider productivity analysis and development.
• Strategic plan development, business planning, and feasibility studies.
• Successfully written several grants to HRSA on behalf of FQHCs on new service and site expansion.
• Providing training consisting of design, curriculum formulation and presentation that is specific to FQHCs.

Hospitals now face financial penalties when patients are readmitted and it’s deemed to be an “avoidable admission.” Many patients discharged after a hospital admission, are readmitted due to many situations. Many readmissions are avoidable and create opportunities to improve and better coordinate care for the patient. Hospitalizations are an expensive and ineffective form of managing health care and often cause further deterioration of a patient’s health status, including safety and infection risks. Reducing avoidable hospital readmissions leads to improving quality, reducing unnecessary health care costs, and promoting patient-centered care.

Our Approach

Being prospective and creative is the key. There are basic steps to achieve process improvement and one critical element is to develop a systemic team approach to reach the desired goals and outcomes. Although there are challenges in our health care delivery system, interventions to address readmissions would include:

• An assessment of current practices
• Develop baseline dataset for admission and readmission causes
• Develop a multidisciplinary team with appropriate stakeholders
• Institute a Community-Based Case Management Program ®
• Develop processes to address the reasons for readmissions
• Implement and follow-up to determine realization of goals

Our goal is to provide our clients with quality services to address issues that affect how patients are managed in the health care climate and improve the effectiveness of hospital and community systems.

Mandatory compliance programs, ever-changing regulations and heighted scrutiny requires Home Care executives to proactively focus on the OIG’s seven pillars of compliance — and the priority elements of documentation, coding, billing and reimbursement for the Agency. The OIG believes compliance risks exist in delivering medically unnecessary services, insufficient OASIS and visit documentation, inadequate supervision, billing for services not actually rendered, and duplicate billing.

How We Can Help You Succeed

Our experience proves that periodic reviews of compliance program elements result in the most effective programs. Effective compliance programs eliminate, reduce or mitigate an organization’s risk, and build awareness of compliance efforts, and ensure income is captured, billed and kept. KHC and Client personnel work together as a team to plan and perform the compliance programs reviews, resulting in an effort that is cooperative, as well as efficient. Risk exposure is assessed based on known areas of potential fraud and payment risk trending in the Home Care industry.

Our Home Care review can be customized to your specific needs including:

• Review of the OIG’s seven elements of an effective compliance program to identify and prioritize compliance and non-compliance risk.
• Provide targeted medical record and process reviews to focus exclusively on HOME CARE HOTSPOTS:
  • Home Health Certification/ Plan of Care/ CMS485
  • Referrals/ Authorizations
  • Validity of Physician Order and Homebound Status
  • Oasis Content and Reporting
  • Face-To-Face Documentation
  • Visit Cycles/ Frequency/ Duration/ Lupas
  • Skilled Care Assessment
  • Therapy Assessment / Reassessment
  • On-Going Clinical Progress Documentation To Support Service
  • Supervision of Care Delivered By Aides
  • Billing and Coding Review
  • ICD-10 Transition: Training/ Implementation

• Improve and develop internal compliance controls and standards.
• Create and implement necessary policies and procedures for the Home Care Agency’s compliance program.
• Provide assistance in the development and implementation of the Agency’s operational action plan for improvement.

The implementation of ICD-10 and implementation of the “2 Midnight Rule” has hospitals anticipating skyrocketing denials, plus the fact that the RAC moratorium for audits on most one-day stays ended on March 31, 2014. The RACs are ready to target one-day stays. Getting patient status right is a financial imperative for both your financial wellbeing as well as the patient’s.

The current MAC “probe and educate” audits are neither robust enough nor timely enough to fully identify risks on your behalf. It is up to you to implement an effective observation model, including protocols with appropriate clinical documentation. Physician reluctance or confusion about utilizing observation status must be addressed now.

One costly consequence for Medicare patients may be not meeting the 3 day inpatient stay requirement for eligibility for admission to skilled nursing facilities. Beneficiaries’ copays are often significantly higher as an outpatient in observation than when admitted as an inpatient, as well.

So what can you do? First, assess your process and vulnerabilities. Second, make the process changes and take corrective action. Third, educate your physicians, clinical documentation specialists, case managers and coders. Fourth, audit the process and the results.

Helping You Get it Right

Use the questions below to evaluate your preparedness. Remember, KHC can provide the clinical, CDI, and revenue cycle experience to get you to a “yes” on all of them.

• Are your patients paying too much because they are in Observation too long?
• Are you auditing one day stays beyond the mandated MAC “probe and educate” samples?
• Are your inpatient admission and Observation orders and other physician certification requirements entered timely?
• Have you assessed your current process for assigning patient status?
• Do your physicians generally follow your Observation protocols?
• Do your protocols comply with the “2 Midnight Rule” and other regulations?
• Is your clinical documentation specific, clear and compliant?
• Are you aware of the alternative models for providing Observation care?
• Is your case management staffing patterns aligned with operational needs?
• Have you verified that Observation hours are being documented correctly and that the correct hours flow through appropriately for billing?
• Do you utilize Condition Code 44 appropriately?
• Have your updated your policies and procedures and educated your staff on the proper use of Occurrence Code 72 in accordance with the “2 Midnight Rule”?

For many reasons—managed care, compliance, third-party payers, regulators and declining reimbursements—the need to conduct a careful and comprehensive assessment of practice operations and financial management is necessary. Like any business, if a medical practice is going to succeed, it must continually assess its operations and monitor performance.

Approach to Improvements

KHC’s assessment is designed to respond directly to a Practice’s specific needs, goals and objectives. We begin with on-site observation and evaluation of the provider and staff in action, focusing on improved work flow in the office – making employees’ work time more productive by eliminating unnecessary tasks and improving process. We follow with a detailed analysis of your data and provide clear, useful practice management information, tools and benchmarks to measure and monitor practice performance.

Our Assessment can be comprehensive or focused exclusively on selected areas. Some areas we can assist you with:

• Evaluate Practice productivity/profitability
• Improve appointment scheduling and patient flow
• Financial review
• Evaluate billing and collection policies
• Review fee structure
• Compliance review
• Analyze accounts receivable level
• Coding/Documentation Training
• Evaluate marketing and expansion plans
• Assist in HMO/PPO contract negotiations
• Personnel management review and staffing analysis
• Assist in physician contract negotiations
• Evaluate logistical and operational aspects for improved profitability

KHC offers consulting services from Nurse Executives who have lived on the front line and became successful career leaders through hands—on experience, practical knowledge, and professional development. We offer an array of services and a comprehensive approach to target your specific needs:

Leadership

• Interim Position Fill for Nursing Manager or Director
• Patient Care Area Performance Assessment, Stabilization and Upgrade
• Enhanced Manager Skill + Effectiveness
• One-on-One Manager Coaching

Operations

• Operational Assessment and Process Improvements
• Departmental Turn-Around Assessment and Action Plans
• HCAHPS Score Improvement

Financial

• Nursing Staffing Examinations and Labor Costs Management
• Reduction of Non-Productive Time/Overtime

Human Resources

• Clinical Job Descriptions, Competencies and Performance Management Systems
• Recruitment and Retention Strategies
• Strategic Employee-Based Action Plans