Shore up access defenses to survive advent of PPS
Additional training, staff may be necessary
Hospitals that want to weather the storm of the new prospective payment system (PPS) for outpatients — due for implementation in July — would do well to raise competency levels and wages in their access departments, which will form the first line of defense.
That’s advice from Laura Frazier, RHIT, manager of ambulatory patient classifications (APC) solutions for San Rafael, CA-based QuadraMed Corp. Frazier says the expense of shoring up access services will be more than outweighed by accompanying benefits to the hospital’s bottom line.
To justify the additional training and staffing that might be necessary, she points out, it is crucial to have a comprehensive quality assurance (QA) program that shows the reimbursement the hospital loses if access practices are not up to par. "Without the QA process, how do they know what [registrars] are doing wrong?" she asks. "Where the buck stops is in patient accounting, and it’s left to that department to handle damage control of what started in registration."
As the first data-entry point, patient registration is the most critical step in the process, she explains, and other departments will assume information collected there is accurate. "In the facilities I’ve been in, it’s a quantum leap assumption. If there is central registration, nobody double-checks the information for outpatient service."
Educate other departments
With that in mind, Frazier recommends that one of the first things access managers should do in regard to APCs is to qualify for all other departments exactly what functions access personnel perform.
"Say, This is what we do here, and in case you need other data points, let us know or do them yourself,’" she suggests. "It’s dangerous heading into this to assume anything on any department’s part."
The question to ask, she says, is "Who’s checking on a weekly basis to ensure that this service or the administration of this particular drug will be covered?" If no one is checking, and those delivering the service are assuming the checks have been made, the result is that the account is not going to be paid, she adds.
A new access position — APC coordinator — is the likely result as hospitals realize the impact the new payment system will have on reimbursement, she says. This APC "guru" would be responsible for monitoring missives from the Health Care Financing Administration (HCFA) and letting registrars know that "this is covered; this is not."
With the plan choices now available to Medicare recipients, Frazier points out, patients can roll from one eligibility status to another between hospital visits. Additionally, medical review policies may vary from region to region, she says. For those reasons, she recommends 100% verification of insurance for all seniors, regardless of coverage.
Make medical knowledge a must
At QuadraMed, one of the benchmarks for APC solutions is making knowledge of medical terminology an entry-level competency for admitting personnel, Frazier notes. "Registration people are receiving diagnostic statements from physicians, and they have to be able to communicate [the information] throughout the entire hospital system."
Registrars who depend on phonetic spellings of terms they don’t understand may mistake, for example, "cholelithiasis" for "cholecystectomy," she says. The first word indicates the presence of gallstones, while the second is the surgical removal of the gall bladder, Frazier explains. Using one in place of the other could mean a reimbursement denial.
"One of the most important questions to ask when doing an operational assessment is, Is someone calling in a patient diagnosis or a patient symptom?’ A registration person may not know the difference," she says. "If a physician hasn’t established that a person has gallstones, that person needs to be admitted with a cluster of symptoms that go along with [the suspicion of that condition]."
A perfect example of what can happen when diagnosis and symptom are confused, Frazier says, is when an orthopedic surgeon takes an X-ray of a patient’s knee, which shows nothing definitive, and then orders magnetic resonance imaging (MRI), which shows torn cartilage.
In ordering the MRI, the physician says "medial meniscus tear," and the registrar — happy they physician has said anything at all — writes that on the order. In fact, what should be written to justify the MRI is not the diagnosis, which has yet to be determined, but the sign, symptom, or finding, which is pain and swelling, she explains. "The picture is being taken to find out what’s causing this."
The health information management (HIM) personnel, Frazier points out, don’t have time to call the physician back and say, "Were you thinking out loud and giving a diagnosis instead of a symptom?’ The HIM department is relying on the registration people."
Like DRGs, only faster
The changes being brought about by the advent of APCs are similar in scope to those that occurred when diagnosis-related groups (DRGs) became the basis for inpatient payments in the mid-1980s, Frazier says. The institution of DRGs "created brand new control systems at hospitals, with utilization review coordinators, DRG coordinators, or case managers. All of the scrutiny of inpatient care will transfer to the outpatient."
The difference, she notes, is that there was a five-year implementation window for DRGs, and only "a matter of months" for APCs. At Hospital Access Management’s press time, final rules were expected to be issued any day. A 90-day period is required between final rules and implementation, which is scheduled for July 1, 2000.
Recent HCFA memorandums indicate implementation will be on schedule, Frazier says. However, some changes to the outpatient PPS — initiated by the Balanced Budget Act of 1997 — have been made in the Balanced Budget Refinement Act (BBRA) of 1999, she points out.
While the rules as first proposed state that the APCs will be updated, they don’t specify how often that will happen, Frazier says. "The changes specify that there will be annual updates of the APC payment rate and the classifications.
Changes also were made to the list of services that will not be paid for under the APC system, she notes. Those services are paid under a fee schedule that already provides cost control, she explains. Renal dialysis, for example, is paid by a method called "composite rate." As a result of the changes, chronic renal dialysis will remain under the composite rate, but treatment of acute renal poisoning will not, she adds. "HCFA made the change because they felt there was not adequate cost control over [the latter service]."
In many instances, Medicare patients are denied coverage for "experimental" drugs that often provide the best treatment available, she says. Another provision in the BBRA, made in response to an outcry from experimental drug interests, allows a pass-through for "additional costs of new and current medical devices, drugs, and biologicals for at least two but no more than three years," she says.
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