Palomar Medical Center in Escondido, CA, has filed a lawsuit against HHS claiming that RACs violate CMS' rules.
CMS requires "good cause" for reopening and reviewing claims more than one year after payment, but RACs regularly reopened claims between one and four years old during the demonstration project without just cause.
Palomar is continuing its fight against this practice; it filed a complaint against HHS in U.S. District Court Southern District of California March 24.
Palomar's fight began in 2007 when PRG-Schultz—the RAC for California during the demonstration project—denied a 2005 claim. Palomar appealed the denial to the Administrative Law Judge level. In October 2008, the ALJ decided in Palomar's favor. The ALJ also found that PRG-Shultz "had not shown ‘good cause' to reopen the claim more than one year after payment, as required by Medicare regulations," according to the complaint Palomar filed in March. The ALJ also determined it had jurisdiction to determine whether the RAC properly reopened the claim.
However, the Medicare Appeals Counsel reversed the ALJ's decision that the reopening was improper and "held that the ALJ lacked jurisdiction to determine whether the RAC had lawfully reopened the claim," according to a February 13 letter to Palomar.
The complaint Palomar filed in March asserts the decision to overturn the ALJ ruling violates Palomar's right to due process and that the RAC violated Medicare rules for reopening claims in effect during the demonstration project.
Per 42 CFR § 405.980(b)(1), a contractor can reopen a claim for any reason within one year of payment, however to open a claim between one and four years post-payment, contractors must have "good cause" to do so per 42 CFR § 405.980(b)(2).
This has been a long-standing concern—many healthcare organizations believe the RACs bent CMS' own rules during the demonstration project.
The decision whether RACs can reopen claims more than one year after payment is important to many healthcare organizations with small operating margins.
Andrea Kraynak, CPC-A, is managing editor of The RAC Report, the Coding Educator, and for HCPro's Revenue Cycle Institute. She may be reached at akraynak@hcpro.com.
Researchers at Brigham and Women's Hospital (BWH) and Massachusetts General Hospital (MGH) in Boston have found that the use of a better-integrated computer system and process redesign could reduce the number of potential medication errors present in the medication reconciliation process.
The study, published in the April 27 Archives of Internal Medicine, took place during May and June 2006, and focused on using existing technology to compare patients' medication lists to prevent adverse events.
"We know that good medication reconciliation is not occurring," says Jeffrey Schnipper, MD, MPH, senior author on the study and hospitalist at BWH.
There are usually 1.44 errors with potential for medication harm, says Schnipper, and his team's randomized controlled clinical trial lowered that number to 1.05 during the course of their study.
Of the 322 total patients who were part of the study, 160 patients in the control group receiving the hospital's normal medication reconciliation processes could have suffered 230 potential adverse events; the 162 patients who were part of the intervention could have suffered 170 potential adverse events.
The Joint Commission's National Patient Safety Goals have contained a goal concerning medication reconciliation since 2005. The Joint Commission is currently reviewing that goal to determine how to better use it to prevent medical errors, as many hospitals have struggled to effectively reconcile medications across the continuum of care and comply with the goal.
Both BWH and MGH were using computer physician order entry (CPOE) systems already, so researchers designed the study around using the existing system and workflow. The study took the existing system and made it easier for staff members to compare a patient's preadmission medication list with both their inpatient and discharge medication lists. This is one area where many hospitals create their own medication reconciliation problems, says Schnipper.
"In many hospitals, a lot of people take a patient's medication history, but it's done in silos—all of these people keeping separate, different lists," says Schnipper, who gave examples of various entry points, such as an emergency room nurse, inpatient nurse, or pharmacist.
The goal of this study, he says, was to reduce redundancy; create only one in-hospital medication list that staff members could refine, but with increased attention on verification and communication among caregivers.
Since the study ended, BWH and MGH staff members have worked on further refining the computer application so that it can detect even more detailed differences in the three medication lists, down to distinctions in the class and dose of medications, says Schnipper. The application alerts caregivers to any of these differences, which could help in preventing adverse drug events.
Process Redesign
Another part of the study involved redefining the roles that certain caregivers play in reconciling medications, specifically the home and the discharge medication lists. Pharmacists and nurses were given a larger role in checking to be sure that patients' preadmission medication lists were accurate.
"Pharmacists get this, and they were thrilled to be involved," says Schnipper.
Prior to the study, Schnipper's team found that pharmacists were spending more time finding and questioning discrepancies between patients' preadmission medication lists and the inpatient medication lists. However, it turned out that a bigger problem existed with the creation of the home medication, which was often inaccurate.
Now, pharmacists at BWH and MGH are doing whatever they can to make sure a correct and up-to-date home medication list is created when a patient enters the hospital. That might mean making an extra effort to find and speak with family members or call a patient's home pharmacy to discover his or her most recent home medications, says Schnipper.
Additionally, nurses, who often are in charge of educating patients about their medication regimens after discharge, have found that because there is one concise list to refer to, they can do a better job with discharge counseling.
:“Any hospital with CPOE should strongly consider having an integrated EMR," says Schnipper.
A computer system that can compare lists and serve as one place for medication data can be a good starting point to cut down on potential adverse events.
Also important is the allocation of personnel. Schnipper says hospitals should evaluate if they need to hire more pharmacists, or if they could use pharmacy techs for some of the tasks associated with a more integrated CPOE system.
Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.
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That is, the news you just read about the world-wide outbreak of swine flu is already out of date. More cases have occurred, and in many other states and countries. This morning (April 29) it was even renamed: H1N1 Flu, and termed "pre-pandemic."
Public health officials from the Centers for Disease Control and Prevention in Atlanta to the California Department of Public Health are using terms like "fluid," "evolving," and "rapidly" to describe the pace and path of this virus while at the same time trying to reassure health providers everywhere to stay calm, that things are under control.
These experts believe that enough supplies, antiviral drugs and support are securely stockpiled and quickly deliverable because of thoughtful and long-standing disaster planning. They express confidence that practitioners from counselors to surgeons and hospital executives across the country are well-braced for whatever might come from this hybridized virus.
But there is considerable nervousness in their voices.
"We are wary that it could get worse, in the severity of illness, as time goes on," said Bonnie Sorensen, MD, chief deputy director of the Department of Public Health in California, where case counts are increasing.
Richard Besser, MD, CDC acting director said at a news conference yesterday, "People are concerned. And we're concerned. Concern is a good thing if it drives planning and action." However, he cautioned, "As we continue to investigate cases here, I expect that we will see deaths in this country."
There's an awful lot about the current outbreak that just isn't yet known, he and other health officials acknowledge. Just how far will H1N1 flu spread? Why did so many Mexicans die from what appears to be a nearly identical strain, while only one death has been attributed to the virus so far in the U.S.? Perhaps those cases now recognized among Mexicans were just the worst, and there are many more patients in that country with milder ailments who didn't seek care, or who did but were not diagnosed.
Why are so many younger people getting sick rather than older people, the traditional victims of seasonal flu which kills an average of 36,000 people in the U.S. each year?
CDC officials yesterday said they would rename the virus because the calling it "swine" implies it is transmitted by eating pork products or touching pigs, when it is not.
"Predominantly, it's the fact that young healthy people are getting sick that scares people," says Nancy Pratt, senior vice president of clinical effectiveness for Sharp HealthCare, a five-hospital system along the California-Mexico border, where so far 10 of the state's 11 confirmed and four unconfirmed patients reside.
Pratt also says that providers need guidance from the CDC on when to give antiviral medication. Do you hold off, because the patient is not that sick and you know there's a limited supply? We know most patients will recover without it. Or do you pull the trigger because the patient may have co-morbidities (and be a higher risk of complications)? That's a big question for us right now."
Chris Van Gorder, CEO of Scripps Health, a San Diego regional healthcare network where some of the first H1N1 patients were seen, advised hospitals and physicians to be proactive in getting information and distributing it.
Van Gorder also advises hospitals to check supplies and order more. "Contact vendors to make sure they are prepared to increase supply delivery if necessary. Most hospitals use 'just-in-time' inventories now so they don't maintain excess stock." Having extra lab test kits and N95 masks are critical, he adds.
Think ahead with other community hospitals to maximize healthcare resources. Most of the time, county public health officials coordinate this activity, but if they can't or don't, hospitals will have to step in, he says. "Monitor patient capacity, isolation capacity, and equipment respiratory disease capacity," he says.
Also, he says, review plans for how to manage employees as well as their families. Providers may have family members who are ill at home and may have to stay at home to help them. "Pandemic plans must incorporate consideration of family members," he says.
Timothy Uyeki, MD, medical epidemiologist with the CDC's influenza division, said today. The virus "can be assumed to be transmitted similarly to influenza A and B viruses, but research is needed. There are many unanswered questions about this virus that CDC scientists and others are working to address."
For example, he says, "It is too early to determine the most affected age groups."
Officials at other state health organizations and providers are worried too.
Ernie Schmid, director of policy analysis for the Texas Hospital Association, the state which yesterday had six confirmed cases of H1N1, calls the infection "the number one public health problem of interest right now."
The media's "24/7 coverage has leant an air of seriousness. Hospitals know how to deal with these issues, but it's the fear of a pandemic that's got everyone's attention," he says.
Will public officials be able to forge an effective vaccine in time? The rapid influenza test commonly used is reliably accurate, but is it also accurate to determine if a patient has H1N1? Now, most states must send their saliva samples to the CDC for confirmation, which may take as long as a week.
In the first days of the outbreak, it was unclear whether H1N virus particles could be transmitted through aerosolized mists, which must survive an indefinite period of time while hovering in the air. At some point CDC officials changed the information to suggest the virus is carried through droplets from coughing or sneezing, or through contact such as touching something recently touched an elevator button recently touched by an infected finger.
Besser and Sorenson say that over the next several weeks, health officials should look for many adjustments in various guidelines as more is learned.
For health providers in hospitals and other clinical settings, knowing which patients to worry about, and what to advise them, remains unclear. In many affected regions of the country, patients seeking routine care in their physician's offices appeared wearing simple paper masks. They were there for routine care, but feared others might be coughing or sneezing infectious viral particles.
CDC and other experts want health providers to tell their patients not to come into healthcare settings if they have respiratory symptoms. Instead, they advise, call a physician first to discuss symptoms, rather than risk infecting others. Health providers too should not come to work if they are sick. Infection control experts also advise those working in hospitals and other healthcare settings to separate those with respiratory symptoms away from other patients.
"You don't want to put patients with respiratory infections in the same area as patients with chest pain or broken bones," says Pratt.
In San Diego County, which saw some of the first confirmed cases, some schools have been closed and border officials are looking carefully at those crossing the border for signs of illness. Physicians' offices are filled with routine patients wearing masks as a precaution.
On the good news front, Uyeki said, "Efforts are underway utilizing multiple strategies to develop candidate vaccines against this new virus." Other advisories are listed at CDC's Web site.
The Senate on Tuesday approved the Fraud Enforcement and Recovery Act of 2009, which would give additional resources to law enforcement for fighting fraud and abuse, and strengthens fraud laws and statutes.
Although the bill's primary function it to prevent the growing number of mortgage fraud cases, it also broadens the scope of claims that fall under the False Claims Act, which can affect any organization that submits claims to the government for payment, including healthcare providers.
Specifically, the bill would extend the reach of the False Claims Act to include any false or fraudulent claim for government money or property, regardless of whether:
The claim is presented to a government official or employee
The U.S. government has physical custody of the money
The defendant specifically intended to defraud the U.S. government
"If the bill becomes law, it's easier for the government and private whistleblowers to succeed in false claims act cases," says Claire Turcotte, a healthcare attorney with Bricker & Ecker LLP in West Chester, OH.
Not that False Claims cases have been particularly unsuccessful. In a press release, the bill's co-author, Sen. Patrick Leahy (D-VT), called the False Claims Act "one of the best civil tools available to root out fraud in government." Leahy also said the Justice Department recovered more than $15 billion in fraud using the False Claims Act from 2000-2008.
According to Leahy, the bill redefines terms in the False Claims Act to more accurately reflect the intention of the law. In particular, the term "knowingly" has been redefined to in a way that overturns the Allison Engine Supreme Court decision of 2008, which required prosecutors to prove specific intent to defraud the government.
The new language specifically states intent is not a requirement of the False Claims Act and the prosecution only needs to show the violator did one of the following, in regards to information:
Had actual knowledge of the information
Acted in deliberate ignorance of the truth or falsity of the informationbr
Acted in reckless disregard of the truth or falsity of the information.
Turcotte says this change would take away a key tool organizations use to fight false claims allegations because now the government is not burdened with the difficult task of proving intent. But the new question is how can an organization show that it acted without "deliberate ignorance" or "reckless disregard"
Turcotte says time will tell how the courts will interpret these terms. However, she believes those terms could refer to compliance programs.
Turcotte says government representatives have said they are looking more closely at whether an organization has a prudent compliance program, and based on the severity of the violation, the government will likely offer more leniency to an organization that can prove it properly educated educate employees on claim submissions.
The bill is headed to the House of Representatives.
Ben Amirault is an editorial assistant for the revenue cycle division of HCPro. He manages the Compliance Monitor e-newsletter and has developed a number of online learning modules. He can be reached at bamirault@hcpro.com.
There are many ways that social media tools can benefit a hospital, says hospital Web manager and blogger Ed Bennett. In this posting, Bennett provides some success stories.
The value of hospitals conducting face-to-face visits with referring physicians in order to increase or maintain referrals can't be overstated—showing docs that your organization cares about them and educating them about the benefits of sending patients to your hospital for care is mission-critical.
Meanwhile, it's become increasingly difficult to secure that one-on-one time with physicians, who are busier than ever these days. Add to the stresses on hospitals' physician relations departments the cost of travel, tightening budgets, staff reductions, and competition for docs' time from pharmaceutical reps and competing hospitals.
But hospital physician sales reps or liaisons might take a lesson from a recent study of a tactic that pharma reps use to supplement face-to-face visits with physicians.
Although it's a rare hospital salesperson who would consider pharma reps to be role models, ePromotion might help alleviate some of the stresses on doctors' time and hospital physician relations program resources.
ePromotion includes a variety of technology-powered initiatives, including technology-enabled promotions that do not include live communication, online live promotion or telephone-assisted Internet browsing in which participants can see and/or speak with an activity conductor, and virtual events including seminars, continuing medical education events, opinion leader events, Web conferences, and group discussions.
And physicians love it. According to a study released on April 27 by healthcare analytics firm SDI, more than two-thirds (67%) of US physicians have a positive attitude toward electronic promotion by pharmaceutical companies. And nearly three-fourths (73%) say they think ePromotion is equal or superior to face-to-face communication from drug sales reps.
"Every year we have conducted this survey, we have seen acceptance toward ePromotion among physicians increase," Jason Fox, associate director at SDI, said in a release. "Given how busy most doctors are and how expensive and challenging it has become for pharmaceutical companies to reach them, the results of this survey underscore a growing opportunity for the two groups to interact more regularly."
Other key findings:
Sixty-nine percent of surveyed physicians participate in electronic promotional activities after office hours, in the evenings.
In 2008, the average time spent by a physician on a single ePromotion activity was 18 minutes.
Among the criticisms against consumer-directed health plans (CDHP) is that they are merely a way to transfer costs onto patients, don't create more educated healthcare consumers, and force patients to delay preventive care.
It's up to health plans to prove those assumptions wrong. Aetna took a step in that direction by releasing a six-year study of its consumer-directed plan, called HealthFund. Aetna found that HealthFund members did not put off chronic and preventive care—and the plan actually helped make members better healthcare consumers.
Aetna is making that claim because HealthFund members used generic drugs, didn't utilize emergency rooms for basic care, and accessed online tools and information more often than Aetna's PPO members. The study also found sustained savings in the CDHP over that time period.
"What we were able to find is that we were able to sustain control of costs over time without sacrificing care," says Kathy Campbell, director of consumer-directed health plans for Aetna in Hartford, CT.
CDHPs often enjoy a first-year savings for employers when the new plan is offered, but Campbell says the study showed that the savings continued in succeeding years. Aetna, similar to many insurers, doesn't charge members for preventive care, which Campbell says removes cost barriers so members get the care they need to ward off future health problems.
The study found that Aetna HealthFund members accessed the same or higher levels of preventive, diabetes-related, and chronic care. Researchers also discovered that emergency room usage decreased for HealthFund members, which resulted in 5% to 10% lower emergency room use than the control group. Aetna said this shows members are not using the emergency room for non-urgent care and are getting the necessary preventive services.
Critics of CDHPs will surely point to the results and say it's simply a large insurer promoting its product. Regardless, health plans and employers can learn from Aetna's experience.
For instance, to find the employers that are effectively implementing consumerism practices, Aetna looked at 11 best-in-class customers, which included more than 144,000 employees.
The Aetna study found that best-in-class performers used five strategies for success:
Promote a strategy where employers are engaged healthcare consumers
Build a benefits package with appropriate member responsibility
Engage employees
Emphasize wellness and healthy behaviors
Steer enrollment toward the Aetna HealthFund plan option
The best-in-class performers introduced coordinated strategies in the areas of benefit structure, information and tools, and a culture that fostered engagement, such as getting management to lead the effort through example.
"If the management team—and this is from the top-down— understands how important this is, it makes a difference. Also, engaging people so they enroll in the plans—that made a difference in the results," says Campbell.
The best in class also helped employees and their families make informed decisions to better manage their health, spending, and overall wellness through providing cost of care, benefits information, and the Aetna Navigator member Web site. Those employers also reduced employee premium contributions for those in HealthFund.
As employers search for ways to cut healthcare costs, CDHPs will remain a viable option. But employers and health plans must not look at CDHPs as merely a way to transfer costs onto the individual. That does not work and will only force members to put off vital care, both preventive and chronic.
Instead, health plans and employers should view CDHPs as a way to change the dynamic. This will take time as members have become accustomed to insurers taking on much of the decision-making responsibility.
Consumerism means member empowerment, but health plans and employers need to actually educate the individual. They can't merely create a Web site with a glossary of healthcare terms and set up an HSA. These stakeholders must also invest in member outreach and conduct lengthy education campaigns.
Health insurers view CDHPs as a cost-saving, patient-empowering movement, as was evident in the health plan portion of the HealthLeaders Media Industry Survey 2009, but the percentage of employees enrolled in a CDHP is still often in the single digits in the small employer market. Large employers that have invested in CDHPs, however, are finding more interest.
The percentage of employees in CDHPs is important because getting more employees enrolled in those plans correlates with lower costs. In looking at cost trends and basic costs, Ted Nussbaum, group and healthcare practice leader at Watson Wyatt in Stamford, CT, says companies need 15% enrollment to begin seeing ROI that is required for building CDHP infrastructure. Companies with at least half of their employees enrolled in a CDHP have a two-year cost trend that is 25% lower than non-CDHP sponsors, according to the survey.
"We're starting to reach that [15%] threshold. Companies are working very hard to address the health status of their population and get their employees to get involved in the process themselves," he says.
Inching closer to that 15% threshold is a positive step, but health plans and employers cannot celebrate the milestone. They must continue to push to create more educated consumers and just as importantly invest in programs like waiving preventive care costs and implementing value-based insurance design so preventive care is free and those suffering from chronic disease don't face cost barriers to care and life-saving medications.
Rather than improving health and creating better consumers, plans that simply shift costs will result in sicker members down the road—and that will cost the healthcare system even more.
Emergency Health Centre (EHC) in the competitive Houston market wanted to be the go-to medical facility for minor and major medical emergencies. This campaign strove to highlight the patient experience at the organization, featuring its caring staff, individual exam rooms, convenient online check-in, and short waiting times.
However, even while differentiating the organization as a high-end experience, the campaign needed to make it clear that the organization accepts most insurance plans. The marketing team did not want people to think of EHC as too expensive.
The campaign, which took home a platinum award in the integrated category at the 2008 HealthLeaders Media Marketing Awards, had two main objectives: to increase visibility and awareness of the facility before its fall 2007 opening and to ensure patient flow after the opening.
EHC has almost reached its volume goal, and attendance at the opening and other events met expectations. Another sign of success: Three new branches are in the works.
This well-integrated campaign used a variety of media, including online, direct mail, print, and outdoor. "Overall, the campaign has a nice, clean look," one judge said. "Good use of the various forms of media chosen, and it has a clear, integrated brand message."
This Campaign Spotlight was excerpted from Hospital Campaigns That Work, featuring the winners of the 2008 HealthLeaders Media Marketing Awards. Don't forget, the deadline to enter the 2009 awards is May 29.
Over two-thirds of U.S. physicians have a positive attitude toward electronic promotion by pharmaceutical companies, and nearly three-fourths (73%) say they think ePromotion is equal or superior to face-to-face communication from drug sales reps, according to an annual study on ePromotion from SDI.
Facebook and Twitter have joined the repertoire of technologies being used by St. Louis healthcare organizations to pursue the "better, faster, cheaper" mantra driving the industry. In February, for example, SSM Health Care decided to make Twitter a part of its external communication strategy.
