MResult Healthcare Insights

We are very excited to be co-presenting our Pre-Admissions Screening Program at next week’s NALTH conference in Washington D.C. Our CEO Yann will be attending and we’ll have a demo version of the application available. If you are attending the conference and would like to meet please feel free to contact us.

This week the New York Times carried an article with an in-depth, and at times critical look at long term acute care hospitals. In some ways the article paints unfair comparisons between LTCs and “normal” acute care – for example LTCs have higher complication rates than acute care, but after all they do see sicker patients!

Overall though the article does provide an excellent view into the necessary business drivers behind LTACs as well as some of the unique issues they address.

Long-Term Care Hospitals Face Little Scrutiny by way of NYtimes.com

As a follow up to last week’s post on bundled payments, here is a link to an interesting policy paper from the National Institute for Health Care Reform that discusses the ins and outs of a bundled payment plan based on Episodes of Care. Many issues to address, including

• What should constitute an episode of care?
• Striking the right balance between financial incentives and risks
• Adjusting payments based on case mix and quality
• Strategies for phased implementation

As mentioned before, bundling brings both pros and cons. But if post care facilities are going to be compensated based on pre-defined services tied to specific diagnosis, they’ll need to be sure they have in place systems to ensure that those diagnosis are correct.

Episode-Based Payments: Charting a Course for Health Care Payment Reform

This story from healthcarelawyerblog.com talks about a Detroit LTAC’s settlement of a suit filed under the False Claims Act – more». The claimants allege that the LTAC submitted claims to the Medicare Program for services which were not medically necessary because they were provided beyond the date when the patient should have been discharged, or because the patient did not meet admission criteria for an LTAC. Under the terms of the settlement the LTAC admits no wrong-doing, but the total payout was over $800,000.

There is fraud out there, to be sure. But it’s equally true that admission criteria are complex and many additional factors can play into deciding whether or not to admit a patient. Going back and justifying an admission that might have happened months ago can be nearly impossible without an underlying set of processes and documentation to govern the admission process. These processes don’t have to be onerous, but they should be based on accepted criteria (our Pre-Admissions Screening Program is based on the NALTH criteria) and they should be automated to the extent that a proper digital “paper trail” exisits for the decision making process.

As reported on ModernHealthcare.com, the Obama administration will be looking hard at reducing the number of improper payments made through Medicare and Medicaid – White House puts focus on medicare and medicaid fraud. As the article suggests, weeding out fraud is a major focus of the effort, but the guidelines are certainly confusing enough to admit to a good percentage of honest mistakes. We’ve been looking at this from the standpoint of post care pre-admissions and long term acute care, where adherence to admitting guidelines is particularly important. We believe the combination of sound preadmitting procedures, clearly defined admitting guidelines and software to manage the process is the key to avoiding potentially costly mistakes.