When the concept of introducing ISO 9001 to the hospital setting first arose, concerns popped up that the quality management system would be a tough sell for the healthcare industry. As more hospitals look into using ISO 9001, however, it has become clear that hospital leadership—who often come from non-healthcare backgrounds—have frequently encountered the concept, with positive results.
St. Luke's Hospital in Maumee, OH, has been ISO-certified since 2004. The hospital is Joint Commission- and DNV-accredited, and expects to continue DNV-NIAHO accreditation in the next few months with a DNV deemed status survey.
Cheryl Roush, CPHQ, organizational quality manager at St. Luke's, has become the hospital's resident ISO expert—a learning experience that has sold her on the concept as an important one for healthcare organizations to pursue. It's not easy to take the first step, however.
"It's a little intimidating," says Roush.
Coincidentally, a local community college near the hospital offered an ISO-based quality assurance program, offering classes that provided background and basics on ISO concepts.
"Even the terminology is a little scary, but everyone is doing a really good job inter-relating the concepts," says Roush.
Darrel J. Scott, senior vice president of regulatory and legal affairs with DNV Healthcare Inc., points out that thus far, ISO certification has been handled by certified hospitals using existing staff.
"It should be noted that every hospital accredited by DNV (large and small) has become ISO 9001-compliant within its first year in the DNV program and has done so without the addition of any new staff," says Scott.
ISO concepts
The ISO 9001 process targets certain areas to a more intense degree than facilities may have encountered in the past (e.g., calibration of equipment and documentation control).
"Your document control is going to be a big [change]," says Roush. "Joint Commission requires that clinical processes are written, but a lot of other areas, like finance, didn't have documentation [requirements]."
Updating and tightening document control has been an ongoing process. A central location on the hospital's intranet site has been developed to house all documentation, and each department has a section where it now stores its own policies.
A numbering system is now in place to help keep forms current and cycle out older versions. This was developed by a committee that established a specific sequence: the first three numbers identify whether the document is organizational, patient care, forms, etc., and the second three numbers are department specific, using cost center numbers. Beyond that, departments are allowed to customize their numbering system to meet their needs.
"I recommend hospitals have one repository for documents," says Roush. "We have a procedure on document control, highlighting the approval process, the numbering system…everything is controlled on the intranet."
This is also a tightly controlled repository—only Roush is able to go in and make changes, though staff can access the documents for printing and distribution.
CVS Caremark Corp., parent company of the national's largest pharmacy chain, has implemented a chain-wide shredding program in light of the $2.25 million fine handed down in February by the Department of Health and Human Services (HHS) and the Federal Trade Commission (FTC) for potential breaches of millions of patient records.
In its 2008 annual report released May 5 called Improving Outcomes: 2008 Corporate Social Responsibility Report, CVS says, "We are committed to being an industry leader in privacy matters and place a high priority on protecting our customers' private information."
Officials at CVS declined to speak when contacted by HealthLeaders Media, but the report outlines a shredding program that critics said should have prevented the February breach.
"We have comprehensive policies and procedures in place to effectively manage the proper disposal of confidential waste and have instituted a chain-wide shredding program for confidential waste," the report says.
The fine represented a settlement between the HHS Office for Civil Rights (OCR), the FTC, and CVS. An investigation into the pharmacy's practices began with media reports that CVS used industrial trash containers to dispose of patient information outside selected stores. The containers weren't secured and were publicly accessible, according to a February 18 HHS press release.
CVS also settled potential violations of the FTC Act with the FTC in February.
According to HHS, CVS Caremark Corp., violated the privacy of millions of its customers when it improperly disposed of patient information, such as pill bottle labels. According to HHS, CVS:
• Failed to implement adequate policies and procedures to appropriately safeguard patient information during the disposal process
• Failed to adequately train employees on how to dispose of such information properly
CVS also reports it is working with the Health Information Trust Alliance (HITRUST) to develop tools and services "aimed at protecting sensitive health information and reducing the risk of security and privacy breaches."
HITRUST, a collaboration of information security and healthcare leaders, released in March its "Common Security Framework (CSF)," or material on IT security controls for healthcare information based on existing regulations and standards.
CVS, an executive council member of the alliance, says it helped develop the Framework, a first of its kind.
Chris Hourihan, manager, Strategy and Operations, for HITRUST, says the Framework is "essentially the authoritative reference guide for information security in healthcare." The company is working on the second version of the Framework with industry leaders now to include additional regulatory requirements, including the HITECH Act and others from CMS.
Hourihan says company like CVS deals with multiple lines of service, making it difficult to comply with federal regulations across the board. With CSF, "CVS can scale their compliance scope to focus on one or more specific business areas at a time," Hourihan told HealthLeaders Media.
In its annual report, CVS says it is also effectively protecting patient privacy in the areas of:
With a deteriorating cash position, Ivinson Memorial Hospital in Laramie, WY, recently completed an overhaul of its revenue cycle, dropping its net AR from 90 to 61 days
Reimbursement investigations will likely be pursued in numbers and with a tenacity not previously seen in the Part B Medicare program. Hospital-based physicians should therefore take steps today to ensure that their practices will be ready if and when a RAC investigation is launched.
As an exclusive HealthLeaders Media audio feature demonstrates, RAC investigative results will be subject to the existing Medicare appeals process. Therefore, it is important that organizations be ready and willing to pursue timely appeals through the five-stage Medicare process in the event an investigation finds for recovery against the physician group.
According to CMS data, only 14% of providers in the RAC demonstration project appealed adverse RAC findings. However, of the groups that did appeal, 33% received rulings in their favor. Significantly, a provider win at any level in the appeal process reduces the RAC contractor contingency payment to zero. A win also prevents the RAC from coming back at a later date to scrutinize the same set of claims. An aggressive appeals stance on the part of providers, therefore, will likely emerge as a significant deterrent against marginal investigations as the program matures. However, knowing the appeals process is only the first step to effectively and successfully tackling a RAC investigation.
Self-assessment is a key step
It is important to have a program in place that can review a physician group's claims for a specific period of time to identify potential outlier situations in much the same fashion that RAC contractors assess claims. From this information, physician groups can then determine the nature and extent of potential problems and begin working to mitigate them before a RAC investigation is launched.
According to CMS, groups can take other steps to prepare for the RAC rollout:
Identify where improper payments have been persistent by reviewing the RAC’s Web sites.
Keep track of denied claims and corrections of previous errors.
Determine what corrective actions need to be taken to ensure compliance and avoid submitting incorrect claims in the future.
CMS plans to work closely with national and state medical, hospital, and nursing home associations to strengthen relationships and to anticipate the needs and concerns of healthcare providers. Before the program roll-out, town hall-type meetings will be held in each state and will include representatives from the regional RAC contractor, CMS, and provider organizations. Physicians can obtain information about these meetings and the date the program will begin in their states by checking the CMS RAC Web site.
RAC response strategies
Providers should prepare themselves by putting strategic processes in place should a RAC investigation be launched. In a RAC investigation, RAC medical record requests are in writing and providers have 45 days to respond. Providers should first know that a failure to respond leads to a determination of overpayment. Once a response is submitted, the RAC must notify the provider of the result within 60 days of their response. RAC demand letters must also explain reasons overpayment was ruled and appeal rights available to providers.
Providers should know their rights in responding to the RAC, which includes agreeing with determination whereby the Carrier/MAC may be offset or payment may be demanded by the RAC. That’s when the rebuttal letter can be written by the provider within 15 days specifying reasons against the overpayment demand, to which the RAC then has an additional 60 days to respond. Appeals should be prepared with a rebuttal letter.
Personalize your RAC action plan
Providers should first perform their own internal "outlier" analysis before the RAC audit letter is received. In other words, be proactive! Second, coding and documentation practices should be checked thoroughly, and corrective action should be taken if needed. Part of this process involves constructing existing compliance programs which are continually updated to ensure that documentation, coding, and claims procedures conform with both the letter and spirit of Medicare payment rules.
The creation of the RAC mechanism, however, introduces a major wild card into the Medicare enforcement mix. Given the financial incentives that exist for RAC contractors to identify and recover improper payments, there is no guarantee that even the most conservative compliance philosophy will preclude a future RAC investigation. That's why it is essential for provider organizations to conduct self-assessments to gauge areas of potential vulnerability and then implement policies to reduce or eliminate that risk.
Providers must also create policies to ensure that all inquiries from RAC contractors are immediately acknowledged and addressed. Finally, they need to be ready to aggressively fight adverse claims through the Medicare appeals process, both to reduce potential financial exposure and to limit the likelihood of repeat investigations.
Hospital-based physician groups should waste little time in preparing for the changes to come. For most providers, it isn't a question of if they'll be audited by a RAC contractor, but when.
Edward Gaines is the vice president and chief compliance officer of Medical Management Professionals, he can be reached at egaines@cbizmmp.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Millions of dollars go into customer service programs to help healthcare organizations treat their customers like their neighbors. Healthcare providers have come a long way in enhancing the patient care experience in certain parts of the healthcare continuum such as the doctor's visit or the hospital stay. However, there is still a lot of drag when it comes time to collect payment.
For all the new billing systems and consultants focused on helping hospitals manage the revenue cycle more efficiently, industry folks I talk to tell me that a lot of bills still go out to third-party collection. We can all agree that this is a necessary part of doing business for a small percentage of bills coming through the back office. But, I wonder if a large percentage of organizations send out to third-party collection because it is easier and less costly than finding the resources to change systems, train staff and implement programs that enable better segmenting of patients on the front end of the visit. This in turn, of course, makes it easier to move patients onto an appropriate payment plan or into charity care. We all know that third-party collections have a terrible ROI that in the future will offer less and less value as hospitals see increasing numbers of self-pay patients who are uninsured, underinsured or who have high-deductible health plans. Plus, they are just plain bad for the brand.
While a number of hospitals and health systems are implementing pressure-free and patient friendly payment programs to try to improve billing and collection practices, do they pass the small-town test? One of the most important aspects of running a business—providing good customer service—I learned in my home town, population 2,000. During high school, I worked the soda fountain and cash register at the local drug store, the place that tourists and locals congregated in a no-stoplight town. Here I learned that you can never live down bad service because the odds are stacked against you that you will run into the recipient of that service at the deli or the gas station, or they will tell your mother.
They will also tell their friends and their friends and their friends. The effect is immediate there, but it takes longer, for example, if you are a hospital in a community of a half million, like Nashville, where I live today.
Hannibal Regional Hospital in Missouri, a community hospital with 105 beds, uses a few billing and collection practices from which we can all learn. I have to admit that when I spoke to Steve Keppner, group director of patient financial services, I identified with his approach because it was based less on implementing new programs, and focused more on being a good citizen in a small community. Five years ago, the hospital's business office invited community members to a forum to talk about the hospital's billing practices. "We learned from them that it wasn't about what the bill looked like as much as how we managed that bill," recalls Keppner.
What has unfolded in the last several years is an operation front to back that doesn't see much in third party collections, says Keppner. The hospital maintains 45 AR days, down from 80 a decade ago. "Maybe 5% or 10% of hospitals can maintain days this low," says Keppner, noting that the hospital implemented a QuadraMed system in 2003 to help manage several areas, including patient registration, accounting, and scheduling.
Another important investment for the hospital has been its back-office staff of 18, he says, which has seen very little turnover. Three of the 18 are financial counselors, a number he says may be higher than "most facilities."
Here are three practices that have worked well for the hospital in being a good neighbor and employer:
Help patients with low benefits understand their bills: Patients know what their portion of the bill will be at the time of their visit. "There is kind of a peace of mind in knowing I have a $5,000 bill coming and my insurance will pay all but $1,000 vs. just going through the normal process and saying you owe $1,000 at the tail end," says Keppner. Financial counselors also help patients sign up for Medicaid and other programs to help pay their bills, or when appropriate they are moved into charity care.
Keep it in-house: "I believe we should be doing everything in house because these are our patients," says Keppner, referring to the practice of sending out different parts of accounts receivable management to third parties. "We are in a little community in northeast Missouri where some of these people are our neighbors and families. I don't want to send their bill to a firm when I should manage their accounts to the best of my ability."
Create an environment where people will want to stay: Hannibal Regional is invested heavily in helping registration and billing employees improve their skills. "Most of our employees have received national certifications," says Keppner. He notes that as part of their job description employees are expected to obtain certification from either AAHAM or NAHAM. "We have had real good success and it helps them develop extraordinary skills," says Keppner. "Instead of 'I just do this,' now they understand the whole revenue cycle, including what happens before them and after them."
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Online advertised vacancies rose 250,000 to 3,367,000 in May, according to The Conference Board Help-Wanted Online Data Series. The May gain was the first since the modest gain of 21,000 in October 2008, and the largest since October 2006. But even with the increase, online advertised vacancies remained down 1,152,000, or 25%, since last year.
The Sisters of Mercy Health System named Lynne Mitchell to serve as Regional CFO for its three care divisions in Arkansas—St. Joseph’s Mercy Health System in Hot Springs, St. Edward Mercy Health System in Fort Smith and Mercy Health System of Northwest Arkansas in Rogers. Mitchell, an Alma, AR, native with more than 24 years of experience in the healthcare industry, is based out of a Hot Springs office at St. Joseph’s Mercy Health Center.
J. Fred Earley, II has been elected president of Mountain State Blue Cross Blue Shield, effective July 1. Earley succeeds Gregory K. Smith, who is retiring as president and CEO. Earley joined Blue Cross Blue Shield in 1989.
Kathy A. Howell has been appointed CEO of Saint Luke's South in Overland Park, KS, effective immediately. She assumes the role vacated by Julie Quirin, who became CEO of Saint Luke's Hospital of Kansas City in December. Howell has served as vice president and CNO at Saint Luke's South since 2001 and additionally as Saint Luke's Health System vice president of women's and children's services since 2005. Saint Luke's South opened in 1998 and has 125 licensed beds and more than 550 physicians on its medical staff.
Jackson Healthcare announced the appointment of Kerry Teel as President of Premier Anesthesia, a national anesthesia management company based in Atlanta. Kerry served as president and CEO of 526-bed Twelve Oaks Medical Center in Houston from 2000 to 2006.
