Hospital Billing and the new Penalties under the Affordable Care Act which will be in place in 2015

The Wall St. Journal in a recent article by Stephen Soumerai and Ross Koppel stated that CMS is very focused on reducing rates of readmission of Medicare/Medicaid patients.  They draw the following conclusions:

1) Research shows that most readmissions can’t be prevented;

2) Readmission penalties which will be 1%-3% starting in 2015 will incentivize hospitals to keep patients in the Emergency room rather than admit;

3) There will be a temptation to change the coding for patients that are readmitted to indicate that they were not admitted with the same Dx or infection;

4) Hospitals serving poor communities will be severely hurt financially.

The authors of this article promote a team approach in which a Physician and Nurse Practitioner can help manage patients better at home.  However, if the patient must be readmitted our own finding is that that Clinical Documentation does not always measure up to the need to support readmissions.

Under ICD-10-CM/PCS it will grow increasingly difficult to justify readmission if there is not a significant improvement to the Clinical Documentation supporting admission.  Health Systems Management Network, Inc. has worked with many Medical staffs on Clinical Documentation in its almost 30 years of Consulting.  HSMN’s consulting engagements have been improvementprojects that have helped our clients improve revenue and reduce denials. In the new ICD-10-CM world, more than slight improvements to specificity are required.  The new Scenario requires such specificity that any omission will result in denial of payments and penalties to reimbursement.

HSMN has begun a “Start Ten Program” which focuses its efforts on the Clinical Documentation of the Medical staff and its partnering with Coders who must use both knowledge and Critical Thinking Skills.  Because of our vast experience in Case Management and Utilization over the past 30 years we are coupling our “Start Ten Program” with our Patient Focused Clinical Documentation Improvement.  The “program” developed with many of the best clinical minds in our country focuses the entire Clinical Team on patient problems/diagnoses with a view to specificity required by ICD-10-CM and what is required to show how well the integration of care would leave no doubt about the need for the Current admission and its treatment.

Health Systems Management Network, Inc. thus announces the “The Start Ten Program Plus”.

Please contact our offices 866-908-4226 or email for a consultation on how we can be of service to your organization. This initial teleconference consultation is without cost.