Assessment of Policies & Procedures

Specialized Providers have a heavy burden of conforming to rules and regulations promulgated by CMS, State and Local laws. The intricacies of the needs of their patients and the specialized billing involved, sometimes result in increased scrutiny by the regulatory bodies, such as the OIG.

In order to be appropriately reimbursed for the services you render, these rules must be adhered to; but what about policies and procedures that support a well-functioning organization where goals and objective are clear to the entire staff not just the administration?

Policies must be based in the reality of day to day functioning and they must support a “Patient-Centered” service.  HSMN often finds that Policies and Procedures written in another era are still extant in organizations that simply update them with new dates and a fresh coat of paint.

In our view, organizations succeed or fail on the basis of whether they understand their objectives and realize when they are not being met.  There should be no policy or procedure that isn’t intricately woven into the fabric of the organization.

From time to time, in order for a Healthcare Organization to rediscover and reinvent itself into “Best Practice”, all of the organizations’ processes, functions, workflows and roles need to be reexamined to assure relevance.  This presents an opportunity for staff to get involved in reshaping the organization.

HSMN has worked with many specialty providers to assist them in revisiting who they are and what they are about.  It must start with the head of the organization’s realization that it is time to look at what we do and how we do it. We often have “Practice Heads” say they have the Joint Commission as their guide.  We remind our clients that the Joint Commission is a minimal standard, and to be the best practice, one’s organization must exceed any minimal standard by creating its own.

Review of Roles & Functions

Tied closely to our “Organizational Assessment” is an assessment of whether the correct functions have been described.

We often hear that “Mary does verification” instead of “are we prepared to do both the verification of insurance, the authorization for the procedure, and the transmittal of the information into the data base.” Have we linked the work process that accurately associates the “Procedure to be done” with the correct authorization. HSMN looks at the detail level of functions, roles, processes and workflows.

How do they match the functions and is there leadership? Too often we hear the following, “we put that in place two years ago”.

But the output shows it is not working. Any processes put into place as part of each function must be monitored with the leadership of the function able to ascertain whether anything is changing up or down quickly.

Data Review & Analysis

Data analysis technology enables auditors and examiners to analyze an organization’s business data to gain insight into how well internal controls are operating and to identify transactions that indicate missing opportunities. Data analysis is applied to just about anywhere in an organization where electronic transactions are recorded and stored. Analyzing business transactions at the source level, helps auditors provide better insight and a more complete view. Once an organization gets started with data analysis, they usually find that they want to do more and dig deeper into the data. Modern organizations have increased management demands for information.

From ad hoc analysis, through to repeatable automated procedures, and continuous auditing and monitoring, analytics provide insight into the integrity of financial and business operations through transactional analysis. Technology provides more accurate audit reports and better insight into the internal controls framework, and improves the ability to access and manage business risk.

The objective of the analysis is to discover interesting and unexpected insights through data analysis to see if bills are being produced for services provided; subsequently, these insights can be used to make business decisions that influence cost, revenue, and operational efficiency. HSMN investigates this business problem from different levels of abstraction: the department, payer, and CPT level. For the analysis, we looked at Medicare, Medicaid and private insurance outpatient claims. Below are some techniques that HSMN uses that are effective while performing an analysis of billing for healthcare organizations.
They include the following (not an all-inclusive list):

• Validating data entry – to identify suspicious or inappropriate information
• Duplicate testing – to identify duplicate transactions such as codes, accounts or patients
• Classification – to find patterns amongst data elements
• Calculation of statistical parameters (e.g., averages, high/low values) – to identify outliers
• Stratification of numbers – to identify unusual (i.e., excessively high or low) entries
• Joining different diverse sources – to identify matching values (such as CPTs to APCs, staffed physicians, and fee schedules) where they shouldn’t exist

Summing of numeric values – to identify control totals that may have been coded improperly.

Performance Reviews & Creating Benchmarks

The Hospital administrator or the Revenue Cycle Manager or a Practice manager asks, “I don’t think we are getting the performance we should.

We have added two people to this function but it is still static.” HSMN has observed that instincts can carry only so far but with the implementation of a new set of goals and objectives there must also be a new set of benchmarks or performance standards that are able to distinguish between individual performance and group performance.

When the benchmarks or performance standards are set, each person in the organization by function has to be able to feel how much of a difference they make each day and be able to match that with the data outcomes. Individuals in an organization sense when they are effective. They will always say, “I am working hard but they will admit things can be better”.

HSMN for over 25 years have been able to understand each organization from the folks who inhabit it and from the data. Benchmarks can only be successful with input from the staff on the front lines. Staff knows they can meet a higher challenge but they have to be included.

Restructuring the Organization

In the teaching setting teaching trumps Patient care.

Patient care doesn’t suffer it is enhanced because those who are learning, must have a complete understanding of all of the facets, morbidities and co morbidities that are at the heart of the patient’s illness. In order to do that, patients are studied not only for themselves but for the richness of the medical experience gained by the House Officers and fellows. Typically, cases are presented on grand rounds or routine rounds in which the main Care Giver analyzes the history, looks at the data from studies and pieces together a picture of the patient’s current state, this picture is then used to formulate a treatment plan.

At each step the other “learning members’ of the team deconstructing what they have been told in order to see if the case and the picture really hold up. Was something left out, or overlooked.

Was there a question not asked of the patient? So deconstruction is tool that is used intuitively by physicians in training and it also a useful tool in working with Attending physicians who have not quite caught on to the elements of the E&M scenario and the accompanying clinical documentation requirements. Physicians understand deconstruction and HSMN has pioneered this technique in working with physicians on clinical documentation. It will be one of the tools we will use as we work with physicians, faculty and others to prepare them for the ICD-10 environment.