This week’s updates include new waived tests; appeals of claims decisions, revisions to timeliness requirements for forwarding misfiled appeal requests, reconsideration request form, and guidelines for writing appeals correspondence; and more!
The following is an excerpt from Inpatient-Only Procedures Training Handbook, written by Debbie Mackaman, RHIA, CPCO, CCDS. For more information and to purchase, visit the HCPro Marketplace.
The FY 2017 IPPS proposed rule released April 27 is replete with modifications and expansions to claims-based quality and cost outcome measures. Although many of these proposed changes are for future fiscal years, ICD-10 codes reported for current discharges will impact the future financial performance for our organizations.
Cost measures
Two new payment measures are proposed as additions to the efficiency and cost reduction domain beginning in FY 2021:
Hospital Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Acute Myocardial Infarction
Hospital Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Heart Failure
The risk adjustment methodologies used for these measures are similar to those used for risk-adjusted mortality. The payment measure is intended to be paired with the 30-day mortality measures, thereby directly linking payment to quality by the alignment of comparable populations and risk adjustment methodologies to facilitate the assessment of efficiency and value of care.
The baseline period for these measures is July 1, 2012, through June 30, 2015. The performance period for these measures is July 1, 2017, through June 30, 2019. Performance for these new measures will be scored using the methodology used for the Medicare Spending Per Beneficiary measure.
CMS expands on its interest to further integrate quality and cost measures to reflect value, and is seeking public input on potential approaches. Underlying present challenges in reflecting value are noted as follows:
Currently, the HVBP assesses quality and efficiency separately through distinct performance measures in different domains, which as of FY 2018 are equally weighted to create the overall Total Performance Score. The four domains include:
Safety
Efficiency and cost reduction
Clinical care
Personal and community engagement
The current scoring approach can permit a hospital to earn a higher payment adjustment relative to other hospitals by performing well on quality-related domains without performing well in the efficiency and cost reduction domain, or vice versa.
Without a measure or score for value that reflects both quality and costs, the ability to assess value is limited.
Q: I am a certified case manager working in an acute care hospital. As part of our job requirements, when working in the emergency room (ER), we are asked to problem solve throughout the day. We often get requests for information on patients seen in the ER who have since been discharged.
Q: Is it permissible to take pictures of patients for identification purposes as a part of the registration process? Do the patients need to sign a consent form before their picture can be taken?
A: It is permissible to take pictures of patients for identification purposes if the patient agrees to it. Since the Privacy Rule considers full-face photographs to be a patient identifier, it is a good practice to get the patient's written consent to take a photograph and file it with the patient's electronic record. The patient should be allowed to opt out of the photograph if he or she chooses.
Editor's note
Brandt is a healthcare consultant specializing in healthcare regulatory compliance and operations improvement. She is also an advisory board member for BOH. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Opinions expressed are those of the author and do not represent HCPro or ACDIS. Email your HIPAA questions to Associate Editor Nicole Votta at nvotta@hcpro.com.
As Phase 2 of the HIPAA audit program begins, covered entities (CE) and business associates (BA) will be watching their email for an audit letter from OCR. Of those chosen for audit, most will be selected for a desk audit. They'll have 10 days after receipt of the email to gather requested documents for OCR's auditors.
But how will CEs and BAs know they are collecting the right information? A careful reading of the updated Phase 2 audit protocol (www.hhs.gov/hipaa/for-professionals/compliance-enforcement/audit/protocol/index.html) will help guide CEs and BAs. But if the protocol isn't read carefully, and in full, important documents could easily be left out, leading to inaccurate audit reports and even a visit from OCR's investigators.
The Phase 2 audit protocol expands the Phase 1 compliance areas to reflect changes made by the 2013 HIPAA omnibus final rule. The updated audit protocol also includes information for BAs, which were not audited during Phase 1 but will be in the current round of audits. The protocol contains a description of the audit areas, general instructions and definitions, and a keyword-searchable table.
Phase 2 audits will be conducted in three rounds. The first two rounds will consist of desk audits of specific audit targets, while the third round will be comprehensive audits. Round one audits will target CEs and round two audits will target BAs.
