Compliance, Audit, Risk & Ethics (CARE) Issues · 2015. 3. 9. · •Organizational Complexity...
Transcript of Compliance, Audit, Risk & Ethics (CARE) Issues · 2015. 3. 9. · •Organizational Complexity...
Compliance, Audit, Risk & Ethics (CARE) Issues Use of Data in an Effective Compliance Program
Healthcare Financial Management Association (HFMA) NJ Chapter
March 10, 2015
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DISCLAIMERS
The opinions expressed are those of the presenter and are not intended to be
statements or reflections of the opinions or positions of their organizations/
employers
This presentation is general in scope, seeks to provide relevant background and
hopes to assist in the identification of pertinent issues and concerns. The
information is not intended to be, nor should it be construed or relied upon, as
legal advice
The presenter did not receive compensation from any vendor or consulting firm
referenced during this presentation
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Today’s agenda
Use available data sources to identify those issues common to your facility
Explore how to:
• Create an internal PEPPER (Program for Evaluating Payment Patterns
Electronic Report)
• Maximize your business intelligence
• Create edits for data mining
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Hospitals, Providers, & Health Systems in the Cross-Hairs:
Who’s Watching?
• Medicare and Medicaid Contractors
o Zone Program Integrity Contractors (ZPICs),
o Medicaid Integrity Contractors (MICs),
o Medicare Administrative Contractors (MACs),
o Recovery Audit Contractors (RACs)
• HHS Office of Inspector General
• Medicaid Fraud Control Units/ State Attorney Generals
• Whistleblower scrutiny
o Federal and state False Claims Act
• State Attorney General Scrutiny
• Competitor and Press Scrutiny
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Compliance Officers Face Significant Challenges
• Creating and sustaining a culture of compliance throughout the organization
• Free-flowing communication on compliance and organizational follow-through
Building/Sustaining a culture of compliance
• Accurate relevant data
• Benchmarks/ Best Practices
Gathering and leveraging relevant data
• Regulatory and other healthcare policy programs
• Technology Advances and associated compliance concerns
Keeping Pace with External Changes
• Organizational Complexity creates training, monitoring and auditing challenges
• Geographic footprint
• Not just hospitals anymore
Compliance in the face of Organizational Complexity
• Limited Resources
• Limiting turnover in key positions Building and maintaining
competencies
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Data Sources
OIG Annual Work plan Recovery Audit Contractors OIG Audits/Audit Reports Approved List
Specific Hospital Reviews Other region RAC approved items Internal Data PEPPER
Compliance Risk Review Dep
artm
ent o
f Ju
stic
e
OIG
Rep
ort
OIG
Wo
rkp
lan
CM
S C
om
pre
hen
sive
Rev
iew
s
Med
icar
e R
AC
Med
iCai
d R
AC
CM
S-M
AC
, CE
RT
, Pro
bes
PE
PP
ER
Inte
rnal
Rev
iew
s
Pay
er A
ud
it - c
om
mer
cial
New
Ris
k A
rea
Iden
tific
atio
n
vBp
- V
aue
Bas
ed P
urc
has
ing
Met
ric
Oth
er
Lik
elih
oo
d S
core
Inpa
tien
t
Out
pati
ent
Prof
essi
onal
Bill
ing
Rese
arch
New
Ser
vice
s
EM
R B
uild
/Go
-Liv
es
Acq
uisi
tion
s
Fac
ility
Sco
re
OIG
Wor
kpla
n
NCD
/LCD
OIG
Com
plia
nce
Prog
ram
Gui
danc
e
OIG
Rep
ort
Dat
a M
inin
g
CMS
Qua
rter
ly
Regu
lato
ry C
hang
e
Bas
is o
f Act
ivity
Sco
re
Sub-
tota
l Ris
k Sc
ore
Sys
tem
Co
ntr
ol -
Pre
bill
ing
ed
it
Man
ual
Co
ntr
ol
- re
view
of
Pre
bil
l ed
it c
laim
s
Sys
tem
Co
ntr
ol -
Man
ual
Co
ntr
ol
Rec
ent R
evie
w
Mita
gat
ing
Fac
tors
Sco
re
Tota
l Ris
k S
core
Compliance Coding Audit Categories
Hospital Admission Status
Short hospital stays (0 and 1 day/less than 2MN) 1 1 1 1 1 1 1 1 8 1 1 2 1 1 1 1 1 5 15 (1) (1) (1) (3) 15
Inpatient Hospital
High‐severity level MS‐DRGs
Inpatient claims mechanical ventilation - verify 96 hours. 1 1 1 1 1 1 6 1 1 1 1 2 9 (1) (1) 9
E&M services billed with surgical services (modifier 25) 1 1 1 3 1 1 1 1 1 3 7 0 7
E&M services billed with modifier 59 1 1 1 3 1 1 1 1 1 3 7 0 7
Outpatient Hospital
Outpatient dental services 1 1 1 3 1 1 1 1 1 3 7 0 7
High Risk Error Prone J codes 1 1 1 1 1 5 1 1 2 1 1 1 1 4 11 0 11
Professional Fee
E&M services billed with modifier 59 1 1 1 1 4 1 1 1 1 1 1 5 9 0 9
Anesthesia Personally Performed 1 1 1 3 1 1 1 1 2 6 (1) (1) 6
Data Mining
• Claims paid amount in excess of claims charged amount 1 1 1 3 1 1 2 1 1 1 3 8 (1) (1) (1) (3) 8
• Outlier payments - LOS > 14 days? 1 1 1 3 1 1 1 1 5 0 5
Basis of Activity Mitigating FactorsLikelihood Other Hospital/ Outpatient
• IP Claims with payments greater than $150,000 1 1 1 1 1 1 3 (1) (1) (1) (3) 3
• Outpatient claim payments greater than $25,000 0 1 1 1 1 2 (1) (1) (2) 2
• Facility E&M Coding - "New" vs "Established" Patient 1 1 1 1 4 1 1 1 1 1 1 1 5 10 (1) (1) 10
Non-Coding Compliance Initiatives
Provider Based Place of Service Location 1 1 1 3 1 1 1 1 1 1 4 8 0 8
Internal PEPPER The How and Why
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Welcome to PEPPER Resources PEPPERresources.org is the official site for information, training and support related to
the program for Evaluation Payment Patterns Electronic Report (PEPPER)
PEPPER provides provider-specific Medicare data statistics for discharge/services vulnerable to
improper payments. PEPPER can support a hospital or facility's compliance efforts by identifying where
it is an outlier for these risk areas. this data can help identify both potential overpayments as well as
potential underpayments.
SHORT-TERM ACUTE CARE HOSPITALS
• User Guide (PDF, 16th Edition)
• Training & Resources
• PEPPER Distribution - Get your PEPPER
PEPPER Resources
Source: www.PEPPERresources.org
HOME PEPPER TRAINING &
RESOURCES DATA FAQ HELP/CONTACT US CMS/MAC
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Data Reports
Short-term
Acute Care
Hospitals
Critical Access
Hospitals Hospices
Inpatient
Psychiatry
Facilities
Inpatient
Rehabilitation
Facilities
Long-term
Acute Care
Hospitals
Partial
Hospitalization
Programs
Skilled Nursing
Facilities
Target Area Analysis – Short-term Acute Care Hospitals
Top 20 Medical DRGs for Same- and One-day Stays for Short-term Acute Care Hospitals
Top 20 Surgical DRGs for Same- and One-day Stays for Short-term Acute Care Hospitals
Peer Group Bar Charts
HOME PEPPER TRAINING &
RESOURCES DATA FAQ HELP/CONTACT US CMS/MAC
National-level Data Reports
Source: www.PEPPERresources.org
Copyright © 2015 Deloitte Development LLC. All rights reserved. 10
Hospital PEPPER report
• The PEPPER DATA tab
• Finding and Using National Data
o Top 20 – One Day Stays
• New! PEER GROUP BAR charts
HUMC - Hypothetical University Medical Center
How to Create an Internal PEPPER
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Purpose of Short-term acute care: PEPPER
Below is a visual representation of how PEPPER is run through Excel
Data Report through Q4 FY 2014
For illustrative purposes only
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Purpose of Short-term acute care: PEPPER (cont’d)
Outlier Rank
For illustrative purposes only
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Purpose of Short-term acute care: PEPPER (cont’d)
Outlier Rank
For illustrative purposes only
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PEPPER Dashboard
KEY >National 80%tile < Min 20%tile KEY >National 80%tile < Min 20%tile
>Juris 80%tile In Normal Range >Juris 80%tile In Normal Range
>State 80%tile No data (less than 11 cases) >State 80%tile No data (less than 11 cases)
Q1=Oct -Dec
Q2=Jan-Mar
Q3=Apr-June
Q4=July-Sept
Time Periods Str
oke I
ntr
acra
nia
l
Hem
orr
hag
e
Resp
irato
ry I
nfe
cti
on
s
Sim
ple
Pn
eu
mo
nia
Sep
ticem
ia
Un
rela
ted
OR
Pro
ced
ure
Med
ical
DR
Gs w
ith
CC
or
MC
C
Su
rgic
al
DR
Gs w
ith
CC
or
MC
C
Sin
gle
CC
or
MC
C
Excis
ion
al
Deb
rid
em
en
t
Ven
tila
tor
Su
pp
ort
Tra
nsie
nt
Isch
em
ic A
ttack
Ch
ron
ic O
bstr
ucti
ve P
ulm
on
ary
Dis
ease
Perc
uta
neo
us C
ard
iovascu
lar
Pro
ced
ure
Syn
co
pe
Oth
er
Cir
cu
lato
ry S
yste
m
Dia
gn
osis
Oth
er
Dig
esti
ve S
yste
m
Dia
gn
osis
Med
ical
Back P
rob
lem
s
Sp
inal
Fu
sio
n
Th
ree-d
ay S
kil
led
Nu
rsin
g
Facil
ity-q
uali
fyin
g A
dm
issio
ns
30-D
ay R
ead
mis
sio
ns t
o S
am
e
Ho
sp
ital
or
Els
ew
here
30-D
ay R
ead
mis
sio
ns t
o S
am
e
Ho
sp
ital
2D
S M
ed
ical
DR
G
2D
S S
urg
ical
DR
G
1D
S M
ed
ical
DR
G
1D
S S
urg
ical
DR
G
Sam
e D
S M
ed
ical
DR
G
Sam
e D
S S
urg
ical
DR
G
Q4 GFY 2011 38.6
Q1 GFY 2012 20.2
Q2 GFY 2012
Q3 GFY 2012 46.2 13.5
Q4 GFY 2012
Q1 GFY 2013 56.4 60.9 31.9 19.7
Q2 GFY 2013 2.9
Q3 GFY 2013 2.4 7.4 14.3 14.5
Q4 GFY 2013 22.9 14.5
Q1 GFY 2014 61.6
Q2 GFY 2014 2.2.
Q3 GFY 2014 70.49
Avg Volume
GFY 2013/1445 <11 30 55 18 700 250 300 12 45 < 11 15 25 12 15 19 15 12 150 250 150 155 69 87 55 36 15
The Compare Targets Report displays statistics for target areas that have reportable data in the most recent time period. To prioritize Compare Worksheet findings, hospitals should consider their target area
percentile values for the nation, jurisdiction and state. Percentile values at or above the 80th percentile (for all target areas) or at or below the 20th percentile (for coding-focused target areas) indicate that
the hospital is an outlier. Outlier status should be evaluated in the priority order of 1) nation, 2) jurisdiction and 3) state. The higher (or lower, for coding-focused areas) the percentile, the greater the outlier
status. Hospitals should also consider the number of target discharges and the sum of payments in prioritizing their findings to maximize potential impact of their efforts.
DRG Validation & Coding MEDICAL NECESSITY - SHORT TERM STAY
CATEGORIESMEDICAL NECESSITY -
Admissions MEDICAL NECESSITY: Admission Rate Categories
For illustrative purposes only
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Short-Term Acute Care PEPPER Visit PEPPERresources.org
Same- and 1DS Top Medical DRGs
HYPOTHETICAL UNIVERSITY MEDICAL CENTER
Hospital Top Medical DRGs for Same- and 1-Day Stay Discharges, Most Recent 4 Qtrs.
In Descending Order by Same- and 1-Day Stay Totals Per DRG NATION JURISDICTION
DRG Description
Same- and
1-Day
Stay
Count*
Total Dis-
charges
for DRG
Proportion
of Same-
and 1-Day
Stays to
Total Dis-
charges
for DRG
Hospital
Average
Length
of
Stay
for DRG
Same- and
1-Day
Stay
Count*
Total Dis-
charges
for DRG
Proportion
of Same-
and 1-Day
Stays to
Total Dis-
charges
for DRG
National
Average
Length
of
Stay
for DRG
Same- and
1-Day
Stay
Count*
Total Dis-
charges
for DRG
Proportion
of Same-
and 1-Day
Stays to
Total Dis-
charges
for DRG
Jurisdict.
Average
Length
of
Stay
for DRG
287 Circulatory disorders except AMI, w card cath w/o MCC 40 108 37.0% 2.1 19,358 82,690 23.4% 3.3 1,723 9,138 18.9% 3.8
310 Cardiac arrhythmia & conduction disorders w/o CC/MCC 18 65 27.7% 2.5 26,124 83,347 31.3% 2.3 2,901 10,260 28.3% 2.4
392 Esophagitis, gastroent & misc digest disorders w/o MCC 17 99 17.2% 3.9 31,933 189,828 16.8% 3.3 3,155 21,277 14.8% 3.5
313 Chest pain 14 34 41.2% 2.2 28,727 71,154 40.4% 2.1 3,034 7,942 38.2% 2.3
192 Chronic obstructive pulmonary disease w/o CC/MCC 13 99 13.1% 4.4 10,245 71,629 14.3% 3.3 1,017 7,965 12.8% 3.4
191 Chronic obstructive pulmonary disease w CC 12 44 27.3% 5.0 10,639 115,883 9.2% 4.0 1,055 13,488 7.8% 4.4
638 Diabetes w CC 12 44 27.3% 2.9
309 Cardiac arrhythmia & conduction disorders w CC 12 44 27.3% 2.5 16,381 94,851 17.3% 3.3 1,672 11,134 15.0% 3.5
312 Syncope & collapse 12 62 19.4% 2.7 21,446 90,863 23.6% 2.9 2,599 12,120 21.4% 3.1
Top Medical DRGs 150 599 25.0% 3.1 315,810 2,159,767 14.6% 3.6 32,651 258,041 12.7% 3.9
All
Medical
DRGs 589 4,683 12.6% 4.7 698,068 6,852,549 10.2% 4.7 71,612 785,500 9.1% 5.0
*Excludes deaths (20), transfers to a short-term hospital for inpatient care (02), leaves against medical advice
(07), and transfers to a short-term general hospital with a planned acute care hospital inpatient readmission
(82).
Note: DRGs will display if they had at least 11 same- or one-day stay discharges in the most recent four
quarters.
Use the Data Tab to obtain detail and create reports:
For illustrative purposes only
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Short-Term Acute Care PEPPER
PPS Hospitals for JL Novitas Solutions, Inc. (12001)
Same- and 1DS Top Medical DRGs
Jurisdiction Top 20 Medical DRGs for Same- and 1-Day Stay Disch., Most Recent 4 Qtrs.
In Descending Order by Same- and 1-Day Stay Totals Per DRG
DRG Description
Same- and
1-Day
Stay
Count*
Total Dis-
charges
for DRG
Proportion
of Same-
and 1-Day
Stays to
Total Dis-
charges
for DRG
Jurisdict.
Average
Length
of
Stay
for DRG
392 Esophagitis, gastroent & misc digest disorders w/ o MCC 3,155 21,277 14.8% 3.5
313 Chest pain 3,034 7,942 38.2% 2.3
310 Cardiac arrhythmia & conduction disorders w/ o CC/ MCC 2,901 10,260 28.3% 2.4
312 Syncope & collapse 2,599 12,120 21.4% 3.1
069 Transient ischemia 2,105 8,357 25.2% 2.7
641 Misc disorders of nutrition,metabolism,fluids/ electrolytes w/ o MCC 1,929 12,514 15.4% 3.6
287 Circulatory disorders except AMI, w card cath w/ o MCC 1,723 9,138 18.9% 3.8
309 Cardiac arrhythmia & conduction disorders w CC 1,672 11,134 15.0% 3.5
812 Red blood cell disorders w/ o MCC 1,577 9,303 17.0% 3.6
690 Kidney & urinary tract infections w/ o MCC 1,562 19,328 8.1% 3.9
292 Heart failure & shock w CC 1,437 24,868 5.8% 4.7
293 Heart failure & shock w/ o CC/ MCC 1,056 8,419 12.5% 3.2
191 Chronic obstructive pulmonary disease w CC 1,055 13,488 7.8% 4.4
603 Cellulitis w/ o MCC 1,047 16,047 6.5% 4.2
683 Renal failure w CC 1,034 16,139 6.4% 4.6
192 Chronic obstructive pulmonary disease w/ o CC/ MCC 1,017 7,965 12.8% 3.4
066 Intracranial hemorrhage or cerebral infarction w/ o CC/ MCC 999 6,480 15.4% 3.0
378 GI hemorrhage w CC 933 15,468 6.0% 4.1
291 Heart failure & shock w MCC 918 21,494 4.3% 6.2
101 Seizures w/ o MCC 898 6,300 14.3% 3.5
Top Medical DRGs Jurisdiction-wide 32,651 258,041 12.7% 3.9
All Medical DRGs Jurisdiction-wide 71,612 785,500 9.1% 5.0
Visit PEPPERresources.org
For illustrative purposes only
17
DRG DRG Description
Same- and
1-Day Stay
Count*
Total
Discharges
for DRG
Proportion of
Same- and 1-
Day Stays to
Total
Discharges
Average
Length of
Stay for DRG
392 Esophagitis, gastroent & misc digest disorders w/o MCC 31,933 189,828 16.8% 3.3
313 Chest pain 28,727 71,154 40.4% 2.1
310 Cardiac arrhythmia & conduction disorders w/o CC/MCC 26,124 83,347 31.3% 2.3
312 Syncope & collapse 21,446 90,863 23.6% 2.9
641 Misc disorders of nutrition,metabolism,fluids/electrolytes w/o MCC 19,379 112,339 17.3% 3.3
287 Circulatory disorders except AMI, w card cath w/o MCC 19,358 82,690 23.4% 3.3
069 Transient ischemia 18,456 64,033 28.8% 2.5
309 Cardiac arrhythmia & conduction disorders w CC 16,381 94,851 17.3% 3.3
690 Kidney & urinary tract infections w/o MCC 16,319 162,909 10.0% 3.7
812 Red blood cell disorders w/o MCC 14,662 77,131 19.0% 3.5
292 Heart failure & shock w CC 13,364 193,549 6.9% 4.4
683 Renal failure w CC 11,860 146,552 8.1% 4.3
378 GI hemorrhage w CC 10,888 139,745 7.8% 3.8
191 Chronic obstructive pulmonary disease w CC 10,639 115,883 9.2% 4.0
192 Chronic obstructive pulmonary disease w/o CC/MCC 10,245 71,629 14.3% 3.3
066 Intracranial hemorrhage or cerebral infarction w/o CC/MCC 10,090 53,366 18.9% 2.8
293 Heart failure & shock w/o CC/MCC 9,392 65,853 14.3% 3.1
603 Cellulitis w/o MCC 9,105 129,351 7.0% 4.1
640 Misc disorders of nutrition,metabolism,fluids/electrolytes w MCC 8,758 62,952 13.9% 4.5
194 Simple pneumonia & pleurisy w CC 8,684 151,742 5.7% 4.4
Top 20 Medical DRGs 315,810 2,159,767 14.6% 3.6
All Medical DRGs 698,068 6,852,549 10.2% 4.7
Short-Term National Q3FY14 Report − Top 20 Medical DRGs for Same- and 1-Day StaysDischarges for most recent 4 Quarters, ending Q3FY2014
In Descending Order by Same- and 1-Day Stay Totals Per DRG
*Excludes deaths (20), transfers to short-term acute care hospitals (02 and 82) and leaves against medical advice (07).
Source: www.PEPPERresources.org
For illustrative purposes only
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7.4%
10.1%
13.5%
6.6%
9.4%
12.6%
0% 2% 4% 6% 8% 10% 12% 14% 16%
20th Percentile
50th Percentile
80th Percentile
Location
Urban Rural
6.8%
9.2%
12.7%
7.0%
9.9%
13.2%
6.5%
9.2%
12.3%
0% 2% 4% 6% 8% 10% 12% 14% 16%
20th Percentile
50th Percentile
80th Percentile
Teaching Status
Other Teaching Nonteaching Major Teaching
7.1%
10.0%
13.6%
7.7%
10.1%
13.9%
6.6%
9.4%
12.4%
0% 5% 10% 15%
20th Percentile
50th Percentile
80th Percentile
Ownership Type
Nonprofit/Church Government Forprofit/Phys
6.9%
9.6%
12.9%
0% 2% 4% 6% 8% 10% 12% 14% 16%
20th Percentile
50th Percentile
80th Percentile
Surgical Focus
Surgical Other
Percentiles by Peer Group - Short Term Q3FY14 Apr –June
One-day Stays for Medical DRGs
Source: Visit PEPPERResources.org
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Example – ventilator support
For illustrative purposes only
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Example – ventilator support (cont’d)
For illustrative purposes only
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Short-Term National Q3FY14 Report − Target Area Summary Report
Target Areas and data for quarter and year Q4 FY 2013 Q1 FY 2014 Q2 FY 2014 Q3 FY 2014
Ventilator Support
DRGs 003, 004, 207, 870, 927, 933 with px code 96.72 on the claim 19,906 22,028 26,752 21,594
All DRGs 003-004, 207-208, 870-872, 927-929, 933-934 Discharges 165,399 177,835 191,225 182,114
Proportion of Target to Denominator Discharges 12.0% 12.4% 14.0% 11.9%
Average Length of Stay for Target 19.4 18.8 18.9 18.7
Average Medicare Payment for Target $61,601 $58,119 $56,934 $56,931
Sum of Medicare Payments for Target (in Millions) $1,226.226 $1,280.247 $1,523.111 $1,229.358
HUMC --Ventilator Support
DRGs 003, 004, 207, 870, 927, 933 with px code 96.72 on the claim 19 36 32 32
All DRGs 003-004, 207-208, 870-872, 927-929, 933-934 Discharges 48 87 85 116
Proportion of Target to Denominator Discharges 39.6% 41.4% 37.6% 27.6%
Average Length of Stay for Target 30.5 23.1 21.1 20.2
Average Medicare Payment for Target $100,519 $73,751 $70,376 $69,419
Target Sum Medicare Payments $1,909,861 $2,655,036 $2,252,032 $2,221,408
Using PEPPER in UM/Quality Conversations
For illustrative purposes only
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PEPPER Compare Dashboard
For illustrative purposes only
Business Intelligence
24
Advancement in
technology Healthcare reform
Regulatory
mandates
Value-based payment
models
Predictive analytics
What drives
predictive
analytics?
Copyright © 2015 Deloitte Development LLC. All rights reserved.
25
• Shift away from using retrospective data
• Real time data to make prospective predictions
• Focus on the future: “What’s next?”, “What should we do
about it?”
Use of predictive analytics
Copyright © 2015 Deloitte Development LLC. All rights reserved.
26
Some benefits of using predictive analytics
Develop
Complex
Analyses (in
real time)
Enhance
Budget
Forecasting
Provides Business
Intelligence
Copyright © 2015 Deloitte Development LLC. All rights reserved.
27
Best Source for Hospital information and custom data services
The American Hospital Directory provides data and statistics about more than 6,000
hospitals nationwide.
AHD.com® hospital information includes both public and private sources such as
Medicare claims data, hospital cost reports, and commercial licensors.
AHD®is not affiliated with the American Hospital Association (AHA) and is not a source for
AHA Data. Our data are evidence-based and derived from the most authoritative
sources.
• Free hospital profiles
• Free state & national stats
Source:
http://www.ahd.com/
28
Number
Medicare
Inpatients
Average
Length
of Stay
Average
Charges
Medicare
Case Mix
Index (CMI)
Cardiology 2,120 5.05 $33,394 1.0654
Cardiovascular
Surgery 2,241 4.72 $80,827 3.8744
Gynecology 110 2.76 $26,716 1.0741
Medicine 4,568 7.14 $42,986 1.2459
Neurology 814 6.37 $36,001 1.0962
Neurosurgery 191 6.12 $68,321 3.0907
Obstetrics 21 3.24 $24,193 0.7287
Oncology 539 8.11 $71,482 2.0516
Orthopedic Surgery 1,327 4.98 $54,179 2.4552
Orthopedics 421 5.98 $33,828 1.0004
Psychiatry 574 12.69 $43,859 0.9202
Pulmonology 1,328 6.60 $35,341 1.3299
Surgery 2,426 10.46 $96,255 3.4254
Surgery for
Malignancy 294 3.82 $42,206 1.6938
Urology 1,135 5.37 $35,421 1.2231
Vascular Surgery 473 4.83 $53,262 2.2744
Total 18,583 6.73 $53,931 1.9696
HUMC -- Inpatient Utilization Statistics by Medical Service Definitions
Source: http://www.ahd.com For illustrative purposes only
29
Hospital #1 Hospital #2 Hospital #3
Number Average Average Medicare Number Average Average Medicare Number Average Average Medicare
Medicare Length Charges Case Mix Medicare Length Charges Case Mix Medicare Length Charges Case Mix
Inpatients of Stay Index (CMI)
Inpatients of Stay Index (CMI)
Inpatients of Stay Index (CMI)
Cardiology 836 4.39 $43,437 1.1197 1,531 4.64 $49,101 0.9991 954 5.76 $77,862 1.1645
Cardiovascular
Surgery 258 7.43 $166,433 4.1841
464 7.04 $166,418 4.3527
1,268 9.1 $296,179 5.2693
Gynecology 22 2.5 $45,042 1.0954 64 3.28 $62,691 1.1582 66 2.59 $65,016 1.0855
Medicine 2,474 8.24 $56,933 1.2093 3,136 5.83 $57,691 1.1608 2,189 7.25 $79,346 1.2382
Neurology 373 4.64 $45,804 1.1466 1,344 5.05 $60,377 1.1677 504 5.92 $87,932 1.1705
Neurosurgery 35 8.06 $142,486 3.1084 466 6.16 $144,136 3.4499 201 8.39 $191,160 3.2565
Obstetrics 32 2.91 $23,293 0.6986 26 3.58 $25,035 0.7216 29 3.69 $40,102 0.8185
Oncology 150 4.67 $52,317 1.4369 556 5.71 $77,046 1.6555 603 9.45 $133,063 2.2359
Orthopedic
Surgery 210 6.19 $111,276 2.5026
2,022 4.18 $93,184 2.6664
493 6.74 $140,947 2.4504
Orthopedics 135 4.96 $42,896 0.9842 365 5.56 $50,134 1.0353 163 6.05 $80,243 1.1756
Psychiatry 371 14.68 $52,937 0.913 280 12.6 $63,906 0.8971 42 4.98 $60,698 0.8865
Pulmonology 604 4.28 $43,554 1.3308 930 5.99 $57,824 1.2491 532 6.02 $82,930 1.4219
Surgery 526 10.42 $160,880 3.8038 1,798 8.61 $147,021 3.3287 1,702 10.21 $212,650 3.7798
Surgery for
Malignancy 33 4.97 $94,970 1.8987
179 4.53 $91,220 2.0197
210 5.65 $117,328 1.9099
Urology 591 4.56 $46,107 1.191 1,009 5.18 $58,962 1.2355 524 5.85 $81,923 1.4269
Vascular
Surgery 111 9.16 $121,542 2.6366
220 6.47 $124,373 3.0117
242 8.17 $157,446 2.3085
Total 6,761 7.13 $67,352 1.5777 14,391 5.86 $81,652 1.8636 9,722 7.7 $142,850 2.4198
Inpatient Utilization Statistics by Medical Service
Source: http://www.ahd.com For Illustrative purposes only
30
APC
Number APC Description
Number
Patient
Claims
Average
Charge
Average
Cost
0656 Transcatheter Placement of
Intracoronary Drug-Eluting Stents 539 $10,339 $1,700
0080 Diagnostic Cardiac Catheterization 1,652 $7,585 $1,247
1327 Imiglucerase injection 183 $99 $62
0605 Level 2 Hospital Clinic Visits 26,733 $223 $138
0927 Factor viii recombinant 25 $2 $1
0948 Gamunex-C/Gammaked 710 $92 $57
8000 Cardiac Electrophysiologic Evaluation
and Ablation Composite 139 $22,678 $3,730
0932 Factor IX recombinant 31 $2 $1
0108 Level II Implantation of Cardioverter-
Defibrillators (ICDs) 46 $15,743 $2,614
0107 Level I Implantation of Cardioverter-
Defibrillators (ICDs) 59 $15,373 $2,528
0082 Coronary or Non-Coronary Atherectomy 154 $6,018 $2,506
0039 Level I Implantation of Neurostimulator
Generator 46 $5,128 $2,189
0606 Level 3 Hospital Clinic Visits 10,931 $265 $164
9295 Injection, carfilzomib 802 $71 $44
0325 Group Psychotherapy 6,977 $175 $109
9119 Injection, pegfilgrastim 6mg 380 $4,987 $3,105
2616 Brachytx, non-str,Yttrium-90 72 $30,000 $20,049
0229 Level II Endovascular Revascularization
of the Lower Extremity 96 $7,799 $2,194
0412 Level III Radiation Therapy 195 $3,100 $408
0440 Level V Drug Administration 3,409 $1,018 $134
Outpatient Utilization Statistics by APC Source: http://www.ahd.com
Definitions
For illustrative purposes only
Physician Practice Compare
32
Source: MDAudit Demo Slide
33
http://www.aapcps.com/resources/em_utilization.aspx
Where to find the data – Free!
34
35
36
37
Creating Edits for Data Mining
39
Prioritizing edits
– Inpatient LOS less than 2 Midnights
Post Payment Review – Weekly Monitor Reports
– Payment greater than Charges
– Inpatient Payment greater than $150,000
– Outpatient Payment greater than $25,000
– Medically Unlikely Edits
• Pharmacy Units
• Units > 1
Monthly or Quarterly Review
– Place of Service
– New vs Established Patients
40
2015 OIG Work Plan
Nationwide review of cardiac catheterizations and endomyocardial biopsies
We will review Medicare payments for right heart catheterizations (RHC) and endomyocardial
biopsies billed during the same operative session and determine whether hospitals complied with
Medicare billing requirements. Previous OIG reviews have identified inappropriate payments when
hospitals were paid for separate RHC procedures when the services were already included in
payments for endomyocardial biopsies. To be processed correctly and promptly, a bill must be
completed accurately. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 1,
§80.3.2.2.) (OAS; W-00-14-35721; various reviews; expected issue date: FY 2015)
Bone marrow or stem cell transplants
We will review Medicare payments to hospitals for bone marrow or stem cell transplants to
determine whether the payments were made in accordance with Federal rules and regulations.
Bone marrow or peripheral blood stem cell transplantation includes mobilization, harvesting, and
transplant of bone marrow or peripheral blood stem cells and the administration of high-dose
chemotherapy or radiotherapy before the actual transplant. When bone marrow or peripheral
blood stem cell transplantation is covered, all necessary steps are included in coverage.
(CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 3, §90.3.) Bone marrow or stem
cell transplants are covered under Medicare only for specific diagnoses. Procedure codes must be
accompanied by the diagnosis codes that meet specified coverage criteria. Prior OIG reviews have
identified hospitals that have incorrectly billed for bone marrow or stem cell transplants. (OAS;
W-00-14-35723; expected issue date: FY 2015)
http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/FY15-Work-Plan.pdf
http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/FY15-Work-Plan.pdf
41
Billing Edits
42
Increased scrutiny by governing bodies
Utilizing PEPPER and creating your own PEPPER
• How to get started
• Need for real time data analytics
Physician practice compare
• Take advantage of free data
‒ Establish goals, prioritize, develop a plan
Importance of the use of edits and data mining
Summary
Appendix
44
45
46
MD
47
48
49
50
Today’s presenters
Nancy Toll Perilstein, Sr. Manager [email protected]
Deloitte & Touche LLP +1 609 870 2102
Nancy is a Senior Manager in the Deloitte healthcare advisory practice with over 30 years’ experience in
healthcare management and administration. She has a diverse clinical background as a Registered
Nurse, with broad experience in critical care, maternal child health, and home care. Nancy is considered
an industry leader when it comes to level of care for the hospitalized patient and CMS guidelines
regarding the two-midnight rule. Nancy and her team assist health care providers with OIG investigations,
by conducting reviews to evaluate compliance and identify opportunities for the appropriate utilization of
observation and outpatient services. This includes analyzing and remediating internal controls related to
utilization management, case management activities, physician advisor services, registration and
admission processes and revenue cycle functions. Nancy is a national speaker on regulatory topics
including documentation requirements, leading case management practices and medical necessity. Nancy
has served as an expert witness on litigation concerning the medical necessity of inpatient and outpatient
claims.
Angela M Melillo, Chief Compliance Officer [email protected]
Cooper University Health System 856-536-1303
Angela is the Chief Compliance Officer for the Cooper University Health Care in Camden NJ.. With 25
years of progressive healthcare administration experience in integrated delivery systems, acute care
hospitals, business development and physician practice management, Angela’s previous experience
includes serving as the VP- Chief Compliance Officer at Saint Peter's Healthcare System in New
Brunswick, New Jersey; the Executive Director of Community Medical Associates, a primary care MSO,
and as the Executive Director-Chief Operating Officer of Kimball Medical Center. A graduate of Rutgers
College with MBA in Healthcare Administration from CUNY-Mt Sinai School of Medicine, Angela is
certified in healthcare compliance and healthcare research compliance and a member of HCCA, ACHE,
AAPC and HFMA.
This presentation contains general information only and Deloitte is not, by means of this presentation, rendering accounting, business, financial, investment,
legal, tax, or other professional advice or services. This presentation is not a substitute for such professional advice or services, nor should it be used as a basis
for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a
qualified professional advisor.
Deloitte shall not be responsible for any loss sustained by any person who relies on this presentation.
About Deloitte
Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited, a UK private company limited by guarantee (“DTTL”), its network of member firms, and their
related entities. DTTL and each of its member firms are legally separate and independent entities. DTTL (also referred to as “Deloitte Global”) does not provide
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