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Healthcare industry recovers amid ongoing public health emergency. AAPC’s 2021 Salary Survey shows that our members are resilient, forward-thinking leaders in the business of healthcare who persevere in difficult times through certification, education, and networking. Nearly every industry has felt the effects of the COVID-19 pandemic, possibly none more than the healthcare industry. While hospitals […]
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In August, Ontario, Calif.- based Prime Healthcare Services paid $ 65 million to settle assertions it disregarded the False Claims Act by conceding patients who just required outpatient mind and participating in upcoding.
The post $ 65M False Claims Act Lawsuit Shows Need To Improve Coding & CDI Compliance appeared first on The Coding Network.
The 2018 quality payment program (QPP) Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provides several new incentives for providers to use remote monitoring and patient-generated data. According to FierceHealthcare, the final rule includes reimbursement changes suggested by the App Association’s Connected Health Initiative. A new improvement activity performance loop encourages devices that have […]
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Health related TV shows like “House,” “ER,” and “Grey’s Anatomy” can all have a negative impact on our health. People who watch too many TV medical dramas have less general satisfaction than those who do not watch health related shows. A study conducted in the United States showed that watching TV can cause people to become more conscientious of health risks. People build up this perceptiveness because watching TV leads them to think they have a greater chance of being at a health risk. TV also can lead people to think these health risks are much more severe than they are in reality.
In this recently conducted study, 274 students in the College of Communications took a survey on their TV viewing and their life satisfaction. The students were not informed on the purpose of the survey. The students were between 18 and 31 years old. The group surveyed showed a high rate of dissatisfaction. It is thought that if a more varied group was surveyed the dissatisfaction would be higher. Other research and studies showed that TV viewing can cause a lower satisfaction because those watching TV become more materialistic.
Hypochondria is defined as excessive worrying over having a serious health illness. People who submerge themselves in medical related topics on a daily basis are more likely to become hypochondriacs. Medical students are the most common hypochondriacs as they are immersing themselves in new disorders every day, but anyone can be a hypochondriac. When watching health related shows often you have an increased risk of developing hypochondriac symptoms. Millions of people watch health shows and dramas, and even if you can avoid this you still see heath updates everyday on the news. When obtaining new health knowledge, people are more likely to think they suffer from the illnesses and conditions they hear about.
The best way to stop these TV related health problems is by limiting the time spent in front of the screen.
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Commonwealth Fund study shows insurance gaps remain
Learning objective
At the completion of this educational activity, the learner will be able to:
While some 26 million Americans have gained insurance since the Affordable Care Act (ACA) became effective in 2010, another 24 million U.S. adults are still living without coverage, according to a new report by the Commonwealth Fund, a private, nonprofit organization that supports health policy research and reform.
This is a concern because not only are uninsured adults likely to skip needed health services due to the cost, but a lack of insurance is also a risk factor for preventable hospitalizations and health declines due to chronic diseases, according to the Henry J. Kaiser Family Foundation (http://ow.ly/Bs3a304bJR7).
So who are these uninsured Americans? According to The Commonwealth Fund survey (http://ow.ly/I8uZ304cB2b), 88% are Latinos under the age of 35 who earn less than $ 16,243 and/or work for a small business. "Half (51%) of the remaining uninsured live in one of the 20 states that had not yet expanded Medicaid at the time of the survey," states a press release issued by the Commonwealth Fund (http://ow.ly/gqsB304bJZk).
Case managers should take note of the survey findings.
"The Commonwealth Fund analysis is beneficial to all case managers, because the uninsured population compromises our most at high-risk groups of patients," says June Stark, RN, BSN, Med, director of care coordination at St. Elizabeth’s Medical Center in Boston. "Most hospitals today seem to be the primary source of healthcare provision to the patients in their communities. Expanding the case manager’s understanding of this population can contribute to the development of successful strategies for managing this group."
About the study
The study, called The Commonwealth Fund Affordable Care Act Tracking Survey, consisted of 15-minute telephone interviews. Interviewers conducted the interviews in two languages, either English or Spanish, between February and April 2016. The data was collected by calling a random, nationally representative sample of nearly 5,000 adults ages 19?64.
Since the ACA went into effect, the uninsured population shifted from mostly white adults to Latinos, according to the Commonwealth Fund press release. Results also show that renewed efforts to help uninsured individuals gain coverage might also be in order.
"The ACA held promise for many, especially those with incomes that could bear new market sticker prices, and as can be seen from the study, diverse populations benefitted from targeted reform marketing efforts," says Shawna Grossman Kates, MSW, MBA, LSW, CMA, the director of case management and bed management for RWJBarnabas Health in Toms River, New Jersey. "Yet it is very apparent that while there has been success with some at-risk populations, those with the lowest incomes who do not qualify for Medicaid are still struggling."
This study, she says, shows it may be time for a revival of the initial efforts to enroll Americans in health plans, which have become less prominent over time. There may also be a role for case managers and social workers to help guide uninsured patients they encounter in the hospital to seek coverage.
"The case manager has an active role in helping patients acquire insurance coverage," says Stark. "A mainstay of the traditional case manager role is, during the admission assessment, to determine if the patient has insurance and if so, to validate if it is correct and active. This is accomplished by interviewing the patient, viewing their insurance card, and checking further with the help of the hospital’s financial counselors."
If a patient is uninsured, case managers should refer him or her to financial counselors to determine the patient’s eligibility and to help him or her secure insurance during the hospital stay, she adds.
"The case manager’s efforts to secure insurance is essential, as the specific insurance benefits drive what discharge options are available for the patient, and therefore, helps secure a safe discharge plan," says Stark.
Social workers, too, play a role.
"It is often the social work partner in a case management relationship who provides the under-insured and uninsured the counseling, available tools and resources, and sometimes the hands-on, step-by-step training to explore with patients and families their income/assets/spending and eligibility for entitlement programs or market products," says Kates. "It is a continuous conversation that has been rooted in a long history of patient intervention by social work. Possessing expert knowledge in federal and state eligibility requirements, financial/social access limits, and having strong relationships with county and state providers, the social worker will connect services with patients."
In their role as patient advocates, case managers and social workers can help to break down cultural and social barriers, such as language and access based on geography, she adds.
Action points from the Commonwealth Fund
The Commonwealth Fund study authors agree with Kates that enhancing efforts to reach the uninsured and help them enroll in health plans should be a goal based on these findings. Only 62% of people without insurance said they knew about insurance marketplaces.
They also recommend a number of other steps that they say could help more of these uninsured individuals gain coverage. Their recommendations are as follows:
Ultimately, using a combination of local and federal interventions can help the U.S. move closer to its goal of helping get coverage for all its citizens.
One year of ICD-10: First half 2016 data shows coding trends and impacts
by Eileen Dano Tkacik
One year following the official implementation of ICD-10, the coding industry is beginning to report valid results regarding accuracy, productivity, and denial trends. While some of these facts and figures are self-reported by HIM directors and anecdotal in nature, other findings are grounded in hard, fast coding performance data. Such is the case with the results from Central Learning (www.centrallearning.com), a web-based system that electronically assesses coder knowledge using real medical record cases and expert-verified answer keys.
This article summarizes coder performance data as measured across 50 health systems and 300 coders as of June 30, 2016. It compares these findings with other industry reports and extrapolates key findings for HIM directors and revenue cycle executives. Since coding and diagnosis-related group (DRG) assignment are the major drivers behind health system revenue streams, consistent data analysis helps to ensure accurate coding and reimbursement.
ICD-10 coding accuracy on the rise
According to Central Learning data, coding accuracy is slightly increasing after nine months under ICD-10 for both experienced coders and coders-in-training. While the industry overall still lags behind the 95% accuracy benchmark achieved in ICD-9, we’re getting closer in all three major patient types: inpatient, outpatient, and emergency services.
Fifty health systems are represented in the data, providing a broad-based assessment. We compared coder accuracy from Q1 (January 1?March 31) with Q2 (April 1?June 30) to identify recent, timely trends in code quality. The figure on p. 13 lists the most current benchmark of our status through June 30, 2016.
We expect the uptick in coder accuracy to continue as coders and health systems engage in more targeted education and training for ICD-10. Actively monitoring code quality through monthly coding audits, combined with coder knowledge assessments, helps prevent denials and mitigates compliance risk. This two-pronged approach to coding management is critical, as payer denials and Recovery Auditor audits are expected to increase later in 2016.
Education and communication are the keys to making continued improvements in coder accuracy over time. This is especially true for the five identified areas of coding accuracy concern.
Five areas of coding accuracy concern
A closer look at Central Learning data from June 30, 2016, identified five coding categories where accuracy remains below acceptable levels (ranging between 65%?75% accuracy). With concentrated training efforts in these specific areas, coders can see a marked improvement in the quality of their work. For example, the coding of injury, poisoning, and other external causes ranked third lowest in Q1, but only sixth worst for coding quality in Q2 with a 12.6% improvement in coding quality following focused educational efforts.
HIM directors and coding managers can use these nationwide benchmarks to compare coding quality across internal teams and identify specific areas for coding risk.
Other ICD-10 coding quality data results
Alongside these specific Central Learning data reports, AHIMA recently conducted interviews to benchmark coding accuracy and productivity in ICD-10. The survey was conducted by the AHIMA Foundation in May 2016 (http://journal.ahima.org/2016/06/13/survey-coding-productivity-dipped-after-icd-10-implementation). In the self-reported survey results, "respondents noted they experienced a 14.15% decrease in productivity, yet only a 0.65% decrease in accuracy."
With such a dramatic variation between AHIMA’s self-reported results and system-generated data from Central Learning, it is evident that continued coder assessments and monitoring are essential. Solid coding data drives performance transparency?a critical component of revenue cycle preparation and denial prevention in ICD-10.
Putting ICD-10 coding data to work
Practices and health systems are smart to flag specific areas of coding concern based on their areas of challenge to introduce targeted education and training. This is especially true for specific diagnoses and procedures frequently used by providers.
Coding performance data analysis is also a first step to develop follow-up performance measures for coding teams, coding audits, and coding compliance programs. Positive trends in high coding quality should be accelerated, while poor performance areas should be targeted for risk mitigation.
A great starting place is to identify your coding team’s top five most and least accurate code categories during coding audits or coder knowledge assessments. This will bring your strengths and weaknesses to the forefront so you can conduct appropriate training.
Once you’ve identified these categories, use your data to answer these five important questions:
1.How accurate is the code assignment methodology used for high-risk service lines within these code categories?
2.What are the specific coder knowledge gaps by diagnosis, procedure, and coder?
3.Is clinical documentation accurate, complete, and as specific as possible?
4.Are payers paying high-risk service lines correctly?
5.How much revenue, if any, is lost due to incorrect coding?
Coders are using training tools, such as AHIMA seminars and the Central Learning training tool, to enhance their knowledge and experience with ICD-10. The result should be continual improvement in coding accuracy. The impact of accurate coding on the revenue cycle, compliance, and accurate reimbursement becomes more obvious as we get further down the ICD-10 road.
Correlation between coding and revenue stream
High levels of coding accuracy are essential in both fee-for-service and value-based reimbursement models. So far, the payment trends under ICD-10, to the surprise of many, have been positive. There has been a steady decrease in claims processing and payment velocity. Also, the deluge of claims denials has not yet happened?but may occur after October 2016 when the one-year grace period for code specificity concludes.
The following data was collected in a recent year-over-year six-month period (October 1, 2015?March 31, 2016), compared to the same six-month period from a year ago (October 1, 2014?March 31, 2015) according to RemitDATA, a healthcare claims clearinghouse company:
Coding certainly has played a big role in this trend. Precise coder accuracy measurement and analysis of coding data are the first steps to making this transition.
Editor’s note
With over 30 years of combined expertise in audit, information technology, and revenue cycle operations, Tkacik is the director of operations and information of Aviance Suite, Inc. She last served as the Interim Director, Revenue Cycle at Lehigh Valley Physicians Group (LVPG). Prior to LVPG, she served as the Vice President of Information Technology and Patient Accounting. It was Tkacik’s combination of revenue cycle operations and information technology that led her to Aviance Suite. Aviance Suite is an integrated platform of web-based software applications that helps hospitals and health systems make better revenue cycle and clinical coding decisions.