Radiology RACs: Get ready to rumble

by guest-author Richard M. Chesbrough, M.D.
Board-Certified, American Board of Radiology
Medical Director, RadMetrics™


Now that CMS has begun using Recovery Audit Contractor (RAC) auditors to review hospital-based medical care and durable medical equipment providers, auditing of radiology services is on the immediate horizon. In fact, the OIG has placed radiology audits on their 2010 work list. Forward thinking providers and healthcare systems are preparing now, to formulate compliance plans for diagnostic radiology services.

One area of radiology review will be documentation and proper coding of imaging procedures. CMS and OIG audits will likely include evaluation of the referring physician’s order, appropriate CPT coding of the procedure, documentation of medical necessity and a separate written report for each study billed.

The following are compliance issues that providers should consider, in preparation for RAC auditing of radiology services:

1. Physician Order: Is there appropriate documentation that a treating physician or practitioner requested the specific diagnostic test performed? This is an absolute requirement for reimbursement. Records must be maintained by the billing entity, in order to avoid potential conflict.

2. Coding: Based upon review of images and documentation, is the coding correct and proper CPT coding utilized? For example:

• a complete abdominal ultrasound is provided, but only the liver and gallbladder are imaged. Therefore, only a limited study should be billed.
• a radiological examination consisting of 2 views is provided, but a “complete” radiological examination consisting of a minimum of 5 is was billed.

3. Medical Necessity: Studies must not only be ordered and coded correctly, but they must be medically necessary - used in the care and treatment of the patient. Studies or procedures that are not indicated may be viewed as not reimbursable, and/or subject to recoupment of paid claims. For example:

• A CT scan is provided without contrast followed by with contrast. However, based on the patient’s condition, only a CT scan with contrast was indicated. Not only does this represent over-coding (wrong CPT code), but the patient has received twice as much radiation as medically necessary.
• Billing for 3-D reconstructions on CT Scans, performed without documentation of medical necessity or separate physician order. In addition, reconstructions must be performed on a separate workstation, and noted in the final written report.
• Screening procedures: Ultrasound of the abdominal aorta ordered to screen for aneurysm. However, the patient does not meet appropriate Medicare (or national standards) screening criteria.

4. Imaging Report: Auditors will undoubtedly be reviewing procedures to see that a formal written report has been issued, for cases where there is billing for the professional interpretation (professional component). Such reporting is mandated by;

• AMA guidelines
• CMS / Medicare regulations
• American College of Radiology
• American Association of Orthopedic Surgeons
• Many other professional organizations

The RACs are coming and it’s time to get into compliance. Medical imaging is one of the areas of great interest, and healthcare providers are well advised to get their policies and procedures in order, and to review their compliance programs in radiology.

Benchmarks: Elusive and Expensive, yet Essential to Improving Health Care

One of the most common questions we receive is around benchmarks; whether we have one benchmark or another, how to find one, etc. Usually the person asking is looking for such a specific benchmark, it just doesn't exist. Or if it does exist, it's very expensive to purchase (for example, fall rates or radiology turn around times).

In our experience, when a client purchases a benchmark or obtains a third party benchmark in some form, it usually ends up not exactly matching their own data set. Then their analysts usually spend more time explaining the differences between their institution's performance versus the benchmark (for example, they include overhead cost while we do not). Too many times have we seen hospitals spend large amounts of money on these "benchmarks" only to ultimately explain them away as irrelevant -- especially if the hospital doesn't look so good against them.

Despite these challenges, benchmarks remain essential to determining whether our hospitals are performing within a reasonable range. So what can you do to get benchmarks and cost effectively assess your hospital's performance?

1. Check with your local hospital association. Many, like the Michigan Health & Hospital Association have data sharing, mining and benchmarking systems already in place.
2. Make your own benchmark. Use data from your organization's best performers and compare them to everyone else. Make sure your population is large enough (i.e. statistically significant) and, if you're using people data (like lengths of stay by physician), consider whether you should keep individual performance private. And probably most importantly, severity adjust your data whenever possible.
3. Partner with other organizations. Partner with organizations similar to yours to pool data and create a data-sharing co-op. Chances are, they're working on similar improvement projects and could use the same benchmarks. If competition is too fierce between yours and your ideal benchmark organization and you don't feel comfortable approaching them, ask a neutral third party such as a consultant to broker the deal. Make sure you approach organizations of similar size, case mix and acuity and that they are respected by your project's stakeholders. Finally, make sure your organization has something to offer your potential partner organization. Maybe they don't need your lab TAT data but would gladly make an exchange for radiology data.
   

Finding the perfect benchmark doesn't have to break the bank or consume all of your project hours. Like all health care improvement projects, it just takes a little creative thinking.

Do you have other tips for obtaining or creating benchmarks? Share them here by posting your comments below.

Health Reform: How Hospitals Should Prepare

In the wake of all the health reform discussion, one important issue is rarely raised: Quality of healthcare. Most of the attention is on health insurance and covering the uninsured. However, we know quality reform is on the President's agenda. From the White House website:

"The President’s plan includes proposals that will improve the way care is delivered to emphasize quality over quantity, including: incentives for hospitals to prevent avoidable readmissions, pilots for new "bundled" payments in Medicare, and support for new models of delivering care through medical homes and accountable care organizations that focus on a coordinated approach to care and outcomes."

You can't count on this going away quietly either, because quality improvement is center in the President's strategy to pay for health insurance for everyone.

This could mean a lot of significant changes will be headed toward providers, especially hospitals. The sooner we prepare, the better. So what should you do to prepare your organization?

We'll focus on readmissions here, since some private-sector initiatives are already in place. First and foremost, start looking at your hospital's readmission rates. Don't track them in all areas? Start. Your quality department might already track readmission rates of open heart patients, but this won't be enough. Surely financial incentives will start with the most common diagnostic groups and eventually be rolled out across the board. For many hospitals, just implementing the ability to track and monitor these readmissions could prove to be difficult. If you're using a manual method, you better start thinking about upgrading your technology and improving your process. Otherwise, it will be very costly to manually track readmissions of large numbers of patients down the road.

Once you have an efficient monitoring system in place, you'll need to develop a methodology to determine whether readmissions were clinically related to the initial admission. Make sure your entire team from physicians to coders are properly recording evidence along the way that clearly indicates when readmissions are not related to the initial admission. This could mean re-evaluation of processes, physician and staff education, and building new rules to hold people accountable. As such, this too could prove to be a difficult task, so the sooner you prepare and practice, the better.

With accurate coding data, you'll be able to weed out the unrelated readmissions and focus on those admissions which are related. Only then will you be able to efficiently determine why readmissions are occurring and how you can prevent them. You'll be able to identify trends and sources (such as nursing homes) and solutions will become evident.

Underscoring the importance of reducing readmissions, the Institute for Healthcare Improvement has already begun an initiative to address readmissions. Reducing readmission rates is important from both a financial as well as quality perspective.

Cut Nursing Home Marketing Costs with Testimonials

Marketing is expensive. With nursing home reimbursements on the decline, it is more imperative than ever to trim costs. During crunch times, marketing budgets are often among the first to be slashed in favor of direct patient care budgets. However, this can be detrimental to bottom lines when it leads to empty beds. So how do you balance effective marketing while conserving money? One way is the effective use of resident and visitor testimonials.

Notice the use of the word "effective." You already know testimonials are an effective way to connect with consumers and build trust - so let's focus on the best way to leverage these testimonials. It's no longer enough these days to put a couple glowing visitor comments on brochures that sit in your lobby. Consumers see right through hand-picked testimonials and place little value on them...that is, if they ever even come in to see your brochures.

Consumers are savvy these days when it comes to obtaining information to help them make informed decisions. They're accustomed to researching purchases such as automobiles and travel online, comparing vital facts like quality, price, features and consumer reviews. They expect, and get, detailed information on the products and services they need. Now they're beginning to transfer these expectations to their health care decisions as more consumer websites and government agencies spend time and effort educating them. As a result, consumers are turning to the Internet for information. According to Google, they had about a million Internet searches on the phrase "nursing homes" in August 2009 alone.

When these consumers search for nursing homes on the Internet, most pieces of information regarding quality, services provided, and even cost are found relatively easily. Consumer reviews however, are more difficult to find - and that's where your opportunity lies. By participating in and encouraging reviews on third party websites, you differentiate yourself from competitors and you begin to build trust with consumers. Having these testimonials on a third party website accomplishes two things: 1) Your information is more likely to be found and exposed to a wider audience because these sites specialize in driving traffic and 2) Consumers will be more likely to trust the information because it is coming from a neutral third party.

You can spend time and money on traditional marketing that may go unnoticed, or you can start building trust and relationships with consumers already searching for nursing homes by participating with an independent ratings website.

WhereToFindCare.com can help nursing home operators incorporate testimonials in marketing efforts at no cost. Visit http://www.wheretofindcare.com/PatientSatisfaction.aspx to learn more.

Improve Patient Satisfaction by Learning from Restaurants

Patients usually rate providers in relation to some standard, namely their expectations. Therefore managing those expectations can be a critical way to improve patient perception and thus, patient ratings.

Some hospitals are managing patient expectations by posting their ER wait times online. Much like popular restaurants who tell patrons upon arrival how long they should expect to wait for a table.

Why would this work? Picture the alternative. Can you imagine waiting for a table not knowing how long you'll be there? The second-guessing at each seemingly eternal, passing minute ("should I have gone to a different restaurant? I've already waited this long, I might as well stay. But what if it's another hour? What if they call my name right after I leave and I'm starting over and stuck waiting at another restaurant for a table?!") All the while, other people with reservations (or as in the case of the ER, more serious conditions) walk right by you and are seated right away. You can't help but wonder..."did they forget about me?" And then you become irate. Suddenly you begin to look forward to completing the customer satisfaction survey you know you'll get when this is all over. This is what patients in waiting rooms go through every day.

Sounds like a nightmare doesn't it? Restaurants know that if a patron knows in advance that she will be waiting 30 minutes for a table, she will be less likely to complain about that wait. It's all about managing expectations. Start managing your patients' expectations by letting them know when you're behind schedule and give them an approximate wait time. Make sure you under-promise and over-deliver!

High Failure Rates Warrant Improvement of Test Result Management Systems

A recent study by the Archives of Internal Medicine looked at the number of times practices failed to inform patients of abnormal test results. It found that failure to inform occurred in on in 14 cases. It also found that failure rates varied widely among practices - from 0% to 26%. Does your practice have a 26% failure rate? You can imagine the implications to your patients and your business.

Besides the obvious implications, not notifying your patients of test results will also increase inbound calls from patients looking for results. Your office staff will then be forced to handle inquiries in an disorderly and inefficient manner. It is much more efficient to process test results at the same time by the same person. And how satisfied do you think your patients will be if they have to follow up with you for a result?

Root causes uncovered in the failures include lack of processes or poor processes. The best practices had efficient processes in place to notify patients. Those practices with the highest failure rates did not have clear processes, did the work when they found the time and did not have official policies in place.

What you can do:

You can do a chart review to determine how often your practice has failed to notify patients of abnormal test results. However, if you have a "no news is good news" policy of not informing patients of test results, it is highly suggested that you reassess your process. The AHRQ advises patients to never make this assumption, and common sense says that you'll very likely have more inefficient inbound calls than necessary.

Flowchart your test result management process and identify weak points, redundancies and hand-offs. Set aside blocks of time and assign key staff to handle test results in batches.

If you need assistance, contact Enovasis Healthcare Solutions. Our experts can streamline your process and reduce failure rates with minimal disruption to your practice.

Guarantee Project Success by Getting Team Members Invested

Getting your team truly invested in the outcome of your project greatly increases the chance of success. Team members who are invested are naturally inclined to work harder and to remove barriers within their control.

Getting everyone invested can be difficult, especially if you have members who were assigned to your project and don't even want to be involved. That's why we've compiled a few tips to help you:

1. Make it their idea. Who wouldn't want their own genius idea to succeed? you can do this by guiding your team in a brainstorming session. Plant a few ideas and watch them develop before your eyes. For example, if you know color coded flags outside patient rooms will improve flow, throw out an idea like "maybe some sort of visual cue would help nurses...." If they're awake, they'll take the lead and run with it.

2. Figure out what's in it for them. Obviously, if your project's success negatively impacts them, team members won't want it to succeed. Think about what will change for a team member, her department or her workload as a result of your implementation. Any negative (perceived or real) changes should be addressed. Sometimes simply discussing the issues will alleviate fears, but be prepared to make minor changes to your project if necessary.

3. Appeal to their intrinsic needs. Monetary rewards are rarely successful motivators in the healthcare field. Fortunately, your team members are probably in healthcare to help people. So help them understand how their work will improve the lives of your patients.

Employing these techniques with your team should quickly get you the level of investment you need from your team members for your project to be successful. Giving them ownership of ideas, alleviating their fears and appealing to their intrinsic needs will get your team members invested in and working for your project, not against it.

Do you have a tip? Share them by leaving a comment, we'd love to hear them!

If you need help with your team, contact Enovasis Healthcare Solutions for project management or team building assistance.