Did you know 1% of your total Medicare DRG payments are at stake in 2015?
Not to take away from actual hospital acquired conditions (HACs), like the recent endoscopy superbug infections that manufacturers’ sterilization protocols won’t prevent, which are making headlines. Yet, it appears that one fourth of US hospitals are now coughing up their inpatient reimbursement, plus suffering penalties, often unknowingly and needlessly. Why? For HACs that often may not be Hospital Acquired Conditions at all, but rather a coding and documentation problem.
In 2015, CMS’ HAC Reduction Program begins. This is a pay-for-performance initiative, which penalizes DRG reimbursement for those in the lowest quartile of the HACs with the most incidences.
HACs carry nasty implications of sub-standard care, and certainly everyone wants those incidences reduced. The thing is that often the problem is not actually the quality of care, but instead that the documentation and coding that unknowingly make it look as if HACs are being treated.
Here is how this is happening. When medical issues are present upon the patient’s admission, but are not documented as such; then subsequent treatments are often coded as if the first-time that the medical conditions presented was during the hospital stay.
To avoid lost reimbursement, penalties, and perceptions of poor quality, the people responsible for coding and documentation must correctly represent the conditions present at the time of admission, and specify the conditions that treatments are addressing.
Today’s 2015 performance, will determine the penalties assessed in 2017.
Read more in the AIS Report on Medicare Compliance. Volume 24, Number 3. January 26, 2015.
We all work so hard to ensure quality care, but when something like the recent unforeseeable endoscopy problem in Calif. happens, it will hurt you financially.
If your margins are low, simply because you’re not effectively capturing charges and pricing appropriately, this affects your ability to weather the inevitable ups and downs any health system will experience. Revenue integrity processes help you understand the real state of your revenue cycle.
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