Baltimore won one of the 31 national Tech Hub federal grants from the Biden Administration to create a partnership of several organizations (led by the Greater Baltimore Committee) to create opportunities for diverse organizations.  At this session, representatives from the Greater Baltimore Committee, Fearless, UpSurge Baltimore Conscious Venture Partners, LLC, and Coppin State University.  They are now preparing the Phase 2 applications for $70 million.  Equity is embedded as a core concept in these programs.  What is exciting is that they won the first grant – out of hundreds of applications.  This go-round will be able to feature the accomplishments of the first grant and how this funding will continue the efforts.  Listening to Ron Williams, PhD, Director of the Center for Strategic Entrepreneurship, speak about the goals of these grants – to move away from the “big organizations” and move to more grassroots development — was inspiring.

Then hearing about the “thinking” within the Maryland Department of Health was informative and lent a very different approach to how the Department is working to identify disparity gaps that often not considered at the depth needed to make a difference. This was a forward-thinking discussion with meaty points and challenges being faced.

My bottom line was partly disappointment.  The information given in this April 18^th meeting was so much more than I expected (realizing I wasn’t sure what to expect) but the number of hospitals participating was too low – meaning that many will not be knowledgeable about what is happening in Maryland.  Let’s see if we can broaden the number of attendees for next year!

This blog post was created and shared by: Charlotte L. Kohler, President.

So, I’ll start with Roderick King, MD, MPH, SVP, Chief Equity, Diversity & Inclusion Officer for UMMS.  Yes, he had a lot to say about diversity.  Yes, I already know that the diversity with Kohler HealthCare provides me with personal and professional enjoyment and enrichment.  Through this diversity I have learned about an entirely different approach to strangers than what I grew up with.  The greetings and acknowledgement that others are “seen” and spoken to.   But he didn’t talk about that – it could be because he already knows and is part of that cultural difference.  What I found fascinating was how he challenges each member of the diversity work at UMMS, at each hospital, about whether their assumptions are correct.  Yes, he expects assumptions to be backed up with real data for the specific hospital.  The approach is not that whatever is going on with the downtown UMMS hospital should be applied to every other hospital.  It needs to be thought through to describe the impact on the community and to the cost of care.  What I heard was that diversity is important, but it should be meaningful and measurable.    It made me think about news articles that tell us that the “diversity officer” position in hospitals are being eliminated.  And, I think “why” – but with Dr. King’s approach, it must be that the “diversity” itself was the only goal rather than the many requirements found in Dr. King’s approach.

I have to admit that Dr. King came to this position with a lot of background and experience.  Not many organizations could be so fortunate to have some lead this goal of inclusion and diversity and understand the financial measurement as well as the theoretical (and well meaning) concept of a balanced work force.  (Ok, remember I’m A CPA, too.)

On another BLOG, I will talk about some of the other speakers and what I learned, but I want to make a few comments about our last speaker, Antionette Williams, Founder & CEO of Williams Consulting, who provides a lot of innovative AI work with the federal government and in particular with CMS.  I have noticed for years that the investigation of health providers has become much more focused on using real data from billing records.  I have had the belief that every health care provider should do their own analytics and “know themselves”.  Now I know that Williams Consulting has been instrumental in upping the government’s ability to see the data for potential fraud and abuse.  Ms. Williams started out as a nurse.  She has a passion for doing “right” – billing for the services actually provided.  This is the future, and it’s needed.

This blog post was created and shared by: Charlotte L. Kohler, President.

That doesn’t mean that every practice will or should be ready to be acquired.  But is also means that the acquiror needs to have a much better understanding of: (1) how do medical practices really work (and its often not as you believe); (2) how will the transition really happen easily (depends on…); and (3) what are you really acquiring?

Medical practices for the most part have been running on their own -often with far less formality than larger organizations.  More often a practice will measure success in terms of dollars in the bank and if the physicians are earning fair wages.  The sophistication that larger (investor) organizations use to measure financial performance is often not measured at all, even if their management software can support it.

So, bottom line: learn about the practice before you buy it.   It doesn’t just magically happen or work. The financial analysis generally used is important, but the really important part is the way the practice functions:  the culture will stay – will it fit your expectations?

Kohler HealthCare Consulting performs many due diligence reviews every year.  Beyond the Income Statement and Balance sheet – the culture, the compliance, the functioning.

Are there different rules for different types of providers and different protections for different consumers? YES. Is it easy to figure out which rules apply to which scenarios? NO.

There are many healthcare representatives who have been following the regulations as they’ve unfolded and been updated and been challenged and changed over the past year. I have provided many informational webinars on the topics and I always attend every webinar I can find – from CMS, healthcare finance and advocacy associations, attorneys, anybody who knows anything and is willing to share! I read every article that comes across my desk and have schooled my personal providers as well as clients and friends in the industry on all things NSA. Do I know everything? NO… but I do try to keep abreast of all developments and am constantly seeking information from any and every resource.

Last week, I paid to virtually attend a webinar presented by a National healthcare finance organization. The presentation was fast-paced and full of great information on implementation of the NSA requirements. There was a Q&A session at the end and many participants asked thoughtful questions that pertained to their specific situations. This legislation can be very confusing as there are many moving parts — some only apply to certain providers and consumers. Therefore, it’s easy to mix things up and we look to the presenter to keep everything straight.

For example, the balance billing rules protect individuals with private or commercial health plans from balance billing and out-of-network cost-sharing with respect to emergency services, non-emergency services furnished by out-of-network (OON) providers at in-network facilities, and air ambulance services. The distinguishing factor is whether or not the facility/provider is in the plan’s network or OON. Bottom line: if an insured patient seeks emergency services (and some non-emergency ancillary services) at an in-network facility, that patient will only be required to pay their in-network cost-sharing portion of the medical bill. If an out-of-network provider treats the patient at an in-network facility, they may not balance bill the patient for the portion of their bill that is not covered. There are other factors at play here, but I’m going to stay at a high-level for this post or we’ll be here all day!

The Good Faith Estimate (GFE) requirements of the NSA currently only apply to uninsured (or self-pay) patients. An important note: a patient is considered “uninsured” under the NSA when seeking a service which is not covered by their health plan. In- and out-of-network designations do not apply in these situations. If the service is never covered (e.g., cosmetic procedures), the patient is self-pay for the service and a claim is not filed with the health plan.

Back to the webinar I attended. Right from the start, I was thrown off by the speaker’s explanation of the agenda! The speaker explained that they were going to discuss NSA responsibilities including “providing Good Faith Estimates to patients whose insurance is out-of-network.” As stated, that is NOT a provider responsibility under the NSA and, in my opinion, it plants the seed for further misinterpretation of the regulations.

During the presentation, the speaker stated that the GFE must be signed by the patient. That is news to me! In fact, during the Q&A session, I asked when the Departments stipulated this requirement as it was not part of the initial rules. The answer I was given was, “in October.” I still haven’t been able to find this information… anywhere… and the speaker did not provide the needed citation.

Another participant asked, “Self-pay patients in the ER [absolutely no insurance] – are we allowed to bill?” The speaker replied, “With no insurance, you have to give them a Good Faith Estimate. And they have to sign the notice and consent form.” This response is completely incorrect! GFEs are only required for services that are scheduled at least three days in advance (or upon request). ER visits by definition are not scheduled! The Notice and Consent form applies to balance billing scenarios under the NSA – for insured patients!

Don’t get me wrong – the speaker provided vital information and answered most questions correctly. No matter how well you understand the rules, it can get jumbled in your head, especially during the Q&A session where there’s no structure to the conversation. I know this from experience. This is the kind of bad information that perpetuates the confusion that many providers and facilities have with the NSA regulations. I am left shaking my head and yelling at my computer!

On December 2^nd, I presented a quick NSA overview and moderated a panel discussion for a local healthcare finance association chapter. We mostly discussed the all-inclusive GFE requirement that was set to be “enforced” as of January 1, 2023. Later that day, the Departments issued guidance extending their enforcement discretion in situations where GFEs do not include expected charges from co-providers/facilities…pending further rulemaking. This is great news for providers and facilities struggling to operationalize this requirement.

Even though there was no way for me to know this was going to be announced, I sent an email to all registered participants describing the update with a link to the official notification. I do not like to leave misinformation out there!   That means that reading our free monthly newsletter and our weekly Top Five can help you stay up to date. Sign up for both at https://mailchi.mp/kohlerhc.com/0oma58sv9t.  Hoping to hear from you!

So how do we navigate this new landscape?  Financial markets, hospitals, and the hospitality industry have been hardest hit with some of the most radical disruptions we have seen in decades. How can we continue to find innovation and opportunity in this extremely difficult environment?

Learn How to Digital Partner Differently

What exactly is the meaning of to digital partner differently? This means going all in.  Grab the cameras, set up the lights, it’s GO time!  People have been learning very rapidly how to digital partner better.  Years ago, interviews were constrained to being in person and in the same room.  Businesses spent millions of dollars traveling to meet clients and today we are holding these same meeting from our phones and tablets from our home office.  Now is the time to innovate around the pandemic to create those much-needed digital partnerships.  Offer things that no one else in the industry is offering perhaps by adding some flair to your training offerings.  Create a new service that is even more digitally driven than your competitors.  Automate your customer ending processes and show them what you know.  Partner with a company that offers something exciting like introductory videos or adds soothing background music to your virtual webinars.  We could all use it.  Make your company stand out with digital partnerships that are different.

Launch Now

Great companies can be born as a result of disruptive events, for example, Uber, Groupon, and Slack, that fall into this category.  Look at the changes in the real estate marketplace where a prospective buyer can access a completely virtual tour of a home and meet with their client  over a Zoom meeting.  The need no longer exists to even step foot into the home.  Many transactions are occurring without ever visiting the property and thus becoming a completely virtual experience.

Where do we get the confidence to trust these services?  I think that it is from knowing that someone smarter than us innovated and created a process around something that assists in our life progression.  We hope that they have thought out all of the bugs and errors along the way.

This means that we have the potential opportunity to find those bugs and address those errors in a way that is more meaningful today than perhaps previously thought.  Can you find the gaps?  Today, some might say we have a bigger voice because everyone has been upgraded or downgraded (depending how you look at it) to the same video-enabled internet platform.  Here, in the digital arena, we are on a level playing field and as we approach the issues.  There is no better time than now to humbly innovate in the industries most impacted by the crisis. Spend the time now!  Launch something that the future will need and thank you for it!

Do More with Less

Can we increase operational efficiency without spending another $10,000-$20,000 on a product or service for the year?  I’m sure we can do this.  Drill down into your existing team and focus on the technologies that are already in use.  Help everyone become more efficient. For example, have your administrative support team member or Excel Analyst host a virtual training class and invite the entire team.  Have your analyst guru instruct everyone how to addresses problems in Excel and perhaps how to model data to answer specific questions about their projects.  Share this information far and wide.   Repeat, repeat, repeat and hope that the team recalls some specifics of the training and brings that learning into their own processes.

Are you utilizing Microsoft Teams or Slack?  Are you actually using Teams for the complete project setup and project management or are you just using Team to communicate like Skype?  Microsoft Teams is a very powerful collaboration tool and integrates many facets of a solid project management or workflow foundation.  Having colleagues working within those boundaries, although difficult, allows for a more fluid and easier project administration.  It fosters centralization and conversations around the work product which makes things easy to find and reference later.

Balance Your Short-Term Versus Long-Term Needs

As we continue to search for solutions to the problems that a company encounters, we should always consider the ways in which we can reduce risk without adding additional overhead and ensure that our team adapt to the ever-changing needs of the crisis.  Setting goals for the business, much like setting personal goals, requires strategy, tactics and communication in order to make it a reality.  Set your sights for a one-year goal on business operations. How do we envision our organization to be operating one year from now?  At first, this question may seem nuanced and this question should be asked every year as part of a progress check to determine the reasonableness of that future vision.

What must be kept in mind is how we can change the current state which involves thinking about the systems that are currently in place. Those systems may have been flushed out and work really well or they might not be working well.  The job of innovators on the team is to determine how things can work better.

Don’t Make Small Problems Bigger Than They Are

Finally, do not make problems bigger than they need to be.  Solve for the immediate need of the client or supervisor and make sure not to put the task off until it is too late which could result in a missed deadline.  Ask those tough questions now while you have the time to solve the problem. Think about what you are doing and don’t forget to be present in the problem solving.  Sometimes the only thing stopping us from solving the problem is being fully present in the moment of solving that problem.  Be a good team member by being the change agent that you would want to see in others.

References

1. The Digital Transformation Playbook: Rethink Your Business for the Digital Age By. David L. Rogers.
2. Scaling New Heights: A Toolkit for SME’s Preparing for Post-COVID-19 Business By. Craig

The HIPAA Right of Access Initiative was created to support patients’ rights to timely and affordable access to their health records.

The HIPAA Privacy Rule protects individual’s rights to access their health information under 45 CFR §164.524.  Generally, the HIPAA Privacy Rule requires:

“HIPAA covered entities (health plans and most health care providers) to provide individuals, upon request, with access to the protected health information (PHI) about them in one or more “designated record sets” maintained by or for the covered entity.”¹

The “designated record set” is defined at 45 CFR §164.501 to include:

“…a group of records maintained by or for a covered entity” that includes medical and billing records; enrollment, payment, and claims adjudication data; and case or medical management record systems data.²

HIPAA generally requires covered entities to provide access to medical records within 30 days of a patient’s request and also specifies what fees providers can charge.³

 OCR Enforcement

Department of Health and Human Services (HHS) Office of Civil Rights’ (OCR) enforcement of this initiative began in 2019.  Bayfront Health St. Petersburg paid $85,000 to the HHS OCR after failing to provide records to a mother for her minor daughter in a timely manner.⁴

In September of this year, the OCR resolved its 20^th enforcement with an $80,000 settlement.

Children’s Hospital & Medical Center (CHMC) failed to provide a mother:

“with timely access to her minor daughter’s medical records. CHMC provided some records but did not provide all of the requested records to the parent’s multiple follow-up requests.”⁵

The OCR also recently announced four additional enforcements totaling $232,000 in settlements in addition to corrective action plans, and one civil money penalty of $100,000.⁶  These we not related to a parent/minor relationship.

 The OCR Not Backing Down

In the HHS press release, OCR Director Lisa J. Pino is quoted as saying:

“OCR will continue its enforcement actions by holding covered entities responsible for their HIPAA compliance and pursue civil money penalties for violations that are not addressed.” ⁷

The most recent enforcements include individual doctors, medical groups, and specialty treatment centers.   As patients file complaints, if they feel they have not been given timely access, enforcements will not be limited to large organizations.  Individual providers and small groups alike are subject to the Privacy Rule.

All providers should have a plan to ensure they meet the 30-day limit to provide the medical records to ensure they are in compliance with the HIPAA Right of Access Initiative.

Resources:

1. https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html
2. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.501
3. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.524
4. https://www.healthcareitnews.com/news/first-hipaa-right-access-case-gets-settled-ocr
5. https://www.hhs.gov/about/news/2021/09/10/ocr-resolves-twentieth-investigation-in-hipaa-right-of-access-initiative-with-settlement.html
6. https://www.hhs.gov/about/news/2021/11/30/five-enforcement-actions-hold-healthcare-providers-accountable-for-hipaa-right-of-access.html
7. https://www.hhs.gov/about/news/2021/11/30/five-enforcement-actions-hold-healthcare-providers-accountable-for-hipaa-right-of-access.html

Data problem? Analytics? Regulations? Data privacy? Humanity? Coffee and talk?  You can reach me at jleventhal@kohlerhc.com or 312.933.2752.

Josh Leventhal is an expert in healthcare data and analytics and is Managing Director with Kohler HealthCare. He has over 15 years of hands-on experience in healthcare data and analytics solving problems for providers, payers, and life science organizations.  Josh started his career in management consulting analyzing data for the largest joint defense litigations in the country before applying his skills and expertise at local startups to assist the Medicaid a managed care organization and medical research industries.  His experiences as a consultant, product manager and developer allow him to work effectively with both business and technology stakeholders.

This is well evidenced by the actions of the Department of Justice (DOJ).  In 2017, the DOJ created a specific Data Analytics Team within their Health Care Fraud Unit.¹  In addition to analyzing trends within healthcare, the Data Analytics Team also provides the offices of the U.S. Attorney with analytics support, including case specific support.  Furthermore, the DOJ leadership has continued to express how the role of data analytics in developing cases.

The DOJ has expressly said that it analyzes data submitted to Medicare to identify fraud.  Acting Assistant Attorney General Brian M. Boynton explained in his remarks to the Federal Bar Association that the DOJ “has increasing been undertaking sophisticated analysis of Medicare data to uncover potential fraud schemes that have not been identified by whistleblower lawsuits, as well as help analyze and support the allegations that we do receive from such suits.” ² (emphasis added)

Identifying Potential Fraud with Data

Government agencies have access to a trove of data submitted by providers and pharmaceutical and device manufacturers and are comparing these disparate data sets to identify potential fraud, with a focus on outliers.

1. Medicare Parts A, B, C, and D, including DME, home health, SNF and hospice.
2. Medicaid data, including prescription claims.
3. Medicare and Medicaid provider and beneficiary information.
4. Open Payments.

These data can be utilized to identify potential fraud both within a dataset and across data sets.  Over the past few years, I have seen an increase in the sophistication of the analytics by governmental agencies and which often times results in larger cases.

Some recent examples from my experience, as well as cases announced by the DOJ:

1. Physicians that bill an uncommon code more often than normal, including unusually high amounts of a particular DME or drug, can be identified using claims data.
2. Ancillary service providers (e.g., labs, pharmacies) that receive a large portion of referrals form certain physicians or set of physicians can be identified using claims data and provider information.
3. Providers that provide care to patients that do not live geographically close by and providers that do not practice close to a frequently used lab can be identified using claims, provider and beneficiary information.
4. Providers that diagnose and prescribe differently from other providers for the same patient can be identified using claims data.

Recently, the DOJ announced criminal charges against 14 defendants for alleged participation in a COVID-19 exploitation scheme involving telehealth and laboratory testing.³  You can view a simple infographic about the scheme here: https://oig.hhs.gov/documents/root/368/covid-takedown-2021-scheme-508.pdf.

Having experience with these types of allegations, specifically in analyzing claims and other data as it relates to lab referrals for testing, I understand how claims, beneficiary and provider data likely played a role in identifying outliers.  Further, unrelated data was likely used to identity the flow of money between the various parties.

What this means for the Compliance Department?

As part of an effective compliance program, compliance programs should leverage the data they have to proactively identify potential fraud. The DOJ’s Evaluation of Corporate Compliance Programs Guidance (ECCP) provides guidance to prosecutors on evaluating compliance programs.  Imporantly, the guidance includes evaluating “Data Resources and Access” to ensure that the Compliance Departments “have sufficient direct or indirect access to relevant sources of data.” ⁴

Compliance programs can leverage analytics to sift through their own claims data to identify high-risk areas.  The Office of Inspector General’s (OIG) Audit Work Plan is an good place to start for high-risk areas identified by the Government.⁵  Compliance programs should review the targets of the Audit Work Plan and dig into the relevant regulations to determine how data can be mined in order to be proactive.

Dashboards with KPIs can be developed that measure and identify risk. Investing in an analytics project that utilized modern technology will streamline this process so that the Compliance Department can focus on investigating and mitigating the risk instead of focusing on data challenges.  Scripts can be developed to pull new data in as it becomes available, cleanse it, and then harmonize it with other data.  Data visualization tools provides quick dashboarding and an opportunity for further analysis to determine what might be driving risk for further investigation.

I also believe that with an effective analytics program measuring the correct KPIs and resources focused on investigating and mitigating risk, the Compliance Department transitions from a cost-center to a revenue generator through the protection of past and future revenue.

Reflections

As one who has been known to “geek out” in data from time to time, I enjoy seeing analytics continue to play a major role in compliance.  I also appreciate that analytic tools have become robust enough that the analysis of disparate data sets is becoming more accessible.

While data is a good foundation to help prove a hypothesis, one must recognize that data does not provide context.  It does not inherently explain why there is an outlier or why there is a trend.  The context within the industry is important in order to understand if the outlier really is an outlier.  A good example is trending and identifying outliers related to COVID-19.  Normal curves and averages do not exist as benchmarks, therefore, what might seem like average could be considered high, even though not an outlier.

Providers may not be well-positioned to act on their data.  Although tools are better, analyzing disparate data is a challenge within itself.  By linking disparate data together, one can derive more meaning from the analytics.  The most time-consuming part of any data project is data engineering, which I lovingly call the art of cleansing, harmonizing and herding data cats.  However, this is a rabbit hole to be explored in a future article.

Resources

1. DOJ Fraud Section Year in Review 2017: https://www.justice.gov/criminal-fraud/file/1026996/download
2. Acting Assistant Attorney General Brian M. Boynton Delivers Remarks at the Federal Bar Association Qui Tam Conference https://www.justice.gov/opa/speech/acting-assistant-attorney-general-brian-m-boynton-delivers-remarks-federal-bar
3. DOJ Announces Coordinated Law Enforcement Action to Combat Health Care Fraud Related to COVID-19: https://www.justice.gov/opa/pr/doj-announces-coordinated-law-enforcement-action-combat-health-care-fraud-related-covid-19
4. U.S. DOJ ECCP: https://www.justice.gov/criminal-fraud/page/file/937501/download
5. OIG Audit Work Plan Fiscal Year 2021: https://oig.ssa.gov/audits-and-investigations/audit-work-plans/audit-work-plan-fiscal-year-2021

Data problem?  Analytics?  Regulations?  Data privacy?  Humanity?  Coffee and talk?  You can reach me at jleventhal@kohlerhc.com or 312.933.2752.

Josh Leventhal is an expert in healthcare data and analytics and is Managing Director with Kohler HealthCare.  He has over 15 years of hands-on experience in healthcare data and analytics solving problems for providers, payers and life science organizations.  Josh started his career in management consulting analyzing data for the largest joint defense litigations in the country before applying his skills and expertise at local startups to assist the Medicaid a managed care organization and medical research industries.  His experiences as a consultant, product manager and developer allow him to work effectively with both business and technology stakeholders.

A recent Office of Inspector General (OIG) review of Medicare Advantage (MA) companies found that during 2016, the 162 MA organizations received $9.2 billion “from diagnoses that were reported only on chart reviews and HRAs, and on no other service records.”¹  Of these 162 organizations, 20 received 54% ($5 billion) of the payments while accounting for only 31% of MA beneficiaries.

The Centers for Medicare and Medicaid Services (CMS) risk-adjusts capitated payments based on beneficiaries’ diagnosis codes.  MA organizations report beneficiaries’ diagnosis codes based on service provided to the beneficiary to CMS’ MA encounter data system and the Risk Adjustment Processing System.  There are two primary sources for MA organizations to identify diagnoses used for risk adjustment:

1. Chart reviews are an MA organization’s review of a medical record to identify diagnosis codes that a provider did not submit or submitted in error.
2. Health Risk Assessments (HRAs) occur when a health care professional collects information from the beneficiary about their health in order to diagnose a beneficiary and identify gaps in care.

The diagnosis codes are then translated into HCCs that are used for the basis of payments to MA organizations.

The OIG found that the HCCs based on chart reviews and HRAs were not always supported by services documented in the medical record:

HCCs generated by diagnoses reported only on chart reviews and HRAs included serious illnesses, such as diabetes and heart disease. However, there were no service records directly demonstrating that beneficiaries who had a chart review and/or HRA received treatment for these serious health diagnoses.

The OIG further identified that for the 20 companies, $3.4 billion (68%) of their total $5 billion in payments on HCCs based only on chart reviews and HRAS were on 12 of the 101 possible HCCs, as identified in the chart from their report as displayed below.

The OIG recommended that CMS should provide oversight to these 20 MA organizations and perform “periodic monitoring to identify MA companies that had a disproportionate share of risk-adjusted payments from chart reviews and HRAs.”

Providers and MA organizations should pay close attention to the findings and establish procedures to ensure that risk-adjusted diagnosis codes are supported by services documented in the encounter notes.

At KHC, we advise our clients to establish and HCC coding workflow that integrates the doctor and an HCC coder, in order to ensure that all diagnoses are supported and that HCCs are appropriately captured.  This workflow is supported by data mining and analytics to identify high risk areas and monitor the success of the HCC program.  We recommend our clients consider the following:

1. Analyzing data available from the Medicare Advantage (MA) plans, such as Open HCC Lists and MA websites, to calculate and monitor HCC recapture rates.  This data can also be used to identify and schedule patients with open HCCs.
2. Monitoring volumes of frequently miscoded diagnosis codes/HCCs (e.g., heart attack or active stroke within office), especially those on the OIG’s list above.
3. Monitor diagnosis codes submitted on encounters by providers that cannot assign risk adjusted diagnosis codes.
4. Monitor the volume of diagnosis codes that are unspecified, as the medical record may support a higher level of specificity.
5. Use patient measurements taken during an office visit and recorded in the medical record, such as body mass index (BMI), to identify inappropriate diagnosis codes (e.g., cannot be morbidly obese if BMI is low).

Resources

1. Office of Inspector General report, “Some Medicare Advantage Companies Leveraged Chart Reviews and Health Risk Assessments To Disproportionately Drive Payments”: https://oig.hhs.gov/oei/reports/OEI-03-17-00474.pdf

Data problem? Analytics? Regulations? Data privacy? Humanity? Coffee and talk?  You can reach me at jleventhal@kohlerhc.com or 312.933.2752.

Josh Leventhal is an expert in healthcare data and analytics and is Managing Director with Kohler HealthCare. He has over 15 years of hands-on experience in healthcare data and analytics solving problems for providers, payers, and life science organizations. Josh started his career in management consulting analyzing data for the largest joint defense litigations in the country before applying his skills and expertise at local startups to assist the Medicaid a managed care organization and medical research industries. His experiences as a consultant, product manager and developer allow him to work effectively with both business and technology stakeholders.

It’s not that our leaders were ignoring the power of data, however, the pandemic has revealed the truly meaningful benefits of investing in the resources and the infrastructure that is required for a strong data analytics team.  We have leveraged data analytics in the healthcare world in the following ways:

Patient Engagement

The modern model of patient engagement consists of utilizing a patient portal for scheduling visits, messaging the doctor, prescription refills and virtual visits.  One aspect of technology that has notably improved in recent months is the amount of real-time data being passed between the patient and doctor through the patient portal.  Because at times, in-person results and updates were  not possible, the importance of utilizing and engaging with the patient portal were critical for patient care.

Corporate Agility

Last year, some healthcare providers learnt lessons the hard way when COVID hit the nation. Pivoting quickly by learning and implementing  strategies from other the organizations was essential in providing patient care.  From a workforce perspective,  internally transitioning into more collaborative tools like Microsoft Teams and video conferencing solutions provided the platform for sharing information for decision-making.

Leverage Technology

As the organization’s employee needs change in collaboration with the ever-changing needs of the patient, we have always been faced with addressing these challenges by using the technology we have around us. The fundamental directives moving forward should be to understand how we can leverage technology further and reshuffle priorities well into 2022. Knowing and harnessing the power and understanding the technology we implement allows us to answer question:  “Can we do this?” with a Yes answer.  The  answer of “Let me go check.” should no longer applies in the environment of today. e

Dynamic Strategies

Are your leaders making decision on whims and their gut feelings? What if you knew the facts before making those assumptions?  Things change and so should our business strategies. Strategies should align with the organizations plans but also be open enough to adjust and consolidate those decisions and commitments in a way that is flexible and dynamic.

It’s as important as ever to make sure your business is optimized and structured according to your improved decision-making processes.  Make sure the structures are clear and streamlined in an effort to expedite the process and resolve issues that need to be addressed.