Corinne Kuypers-Denlinger, VP of Post-Acute Growth Strategies at QIRt was recently published in HCAF's newsletter. In her article, Corinne share with members her expertise and knowledge on the potential impact of PDGM and discusses the pros and cons of outsource coding. See the article in its entirety below. Originally published in HCAF Home Care Connections Magazine, Fall/Winter 2018.
Managing Your Bottom-line in an Ever-changing Regulatory Environment
By Corinne Kuypers-Denlinger, Vice President, Post-Acute Care Growth Strategies, QIRT
CMS’ proposed patient-driven groupings model (PDGM) is a giant leap forward in shifting healthcare payments from volume to value, and from resource consumption to clinical status as the basis for payment. PDGM is much more than a change to the prospective payment system, it represents a paradigm shift for agencies.
The transition from the current prospective payment system to PDGM is just one of the many regulatory changes agencies must manage while increasing revenue and holding margin. Agencies still are adjusting to the new Conditions of Participation (CoPs) and some are preparing for the next round of pre-claim review (which many anticipate will become a national initiative in short order).
Every agency is working to maintain and improve Star Ratings and Home Health Compare scores, while nine states also are participating in the value-based purchasing demonstration. The Targeted Probe and Educate (TPE) continues and the January 1, 2019 implementation of OASIS-D is just on the horizon.
Agencies are doing all they can to keep pace in an ever-changing regulatory environment and that’s before you factor in the most important job of all: patient care.
For PDGM, providers will need to greatly increase efforts to ensure complete documentation and accurate patient-assessment reporting that leads to the correct selection and sequencing of diagnosis codes for placement in the appropriate clinical groups. Each functional area from intake to patient discharge will need policies and procedures in place that can be measured, benchmarked, and monitored for continuous improvement, as an agency’s long-term viability will depend on effective care management, including resource utilization.
Applying the Principles of Quality Cycle Management
In other words, PDGM requires applying the principles of Quality Cycle Management (QCM) in your agency. QCM is a means by which management can hold staff accountable, including senior management. QCM encompasses and connects all parts of the workflow process to patient outcomes, thereby achieving the goal of patient-centered care. In QCM, best practices at each point in the work flow process result in outcomes that can be measured, monitored, and remediated, when necessary.
Fortunately, the initiatives required to ensure viability in a PDGM model also are good business practices in any payment model. They are difficult, but not impossible to achieve. For virtually every agency it is a matter of resource management, which means ensuring every staff member is working to his or her highest level of competency and, potentially, finding trusted partners that can provide operational solutions to your biggest challenges.
Outsourcing as a Time- and Revenue-management Option
To outsource, or not to outsource? Every home care agency administrator asks that question at one time or another. There is no right answer. There is the answer that is right for your business. And even that can change over time. But, there are some things to consider when you reach that reflection point in your agency’s business development.
The pros and cons of outsourcing coding and OASIS review apply equally to claims billing, managed care authorization, quality assurance, even denials management. When you find a trusted partner to complete essential, but routine, operational tasks, your staff can do what it does best: provide exceptional patient care.
Advantages of Outsourcing (Pros)
Expertise: CMS’ rules and guidelines governing code selection and sequencing and OASIS responses are complex and ever-changing. A mistake repeated on claim after claim, however innocent the intent, can be construed as fraud, costing your agency time and money. Outsource coding companies are staffed by expert auditors who are carefully screened before hiring, regularly trained to new rules and guidance, and routinely monitored to ensure continued accuracy.
Efficiency: Contracted coding companies do one thing, and they do it very well. Expert auditors have the knowledge and skills to quickly review charts for patient data that supports the claim, and to know when additional information and documentation is needed. Because it is all they do, they do it more efficiently than a staffer who also is responsible for quality assurance, or intake, or scheduling.
Prompt and proper payment: Expert auditors ensure that every patient is assigned to the HHRG that most accurately reflects the level of skill needed to achieve treatment results, leading to prompt and proper payments, lower risk of audits, and improved cash-flow management. Further, some outsource companies are staffed 24/7, 365 days a year so your claims always are promptly processed.
Lower cost of doing business: Outsourcing your coding and OASIS can reduce the number of full-time positions (FTEs) or allow you to focus your staff on the most important work: patient care. Working with the right outsource coding partner also can help lower your annual training costs, as reporting on individual and agency-wide knowledge and skill gaps from your vendor helps you pinpoint precisely where training is needed.
Improved scores: In today’s patient-centered regulatory environment, scores matter: outcome scores, of course. But your Home Health or Hospice Compare Scores, Star Ratings and Value-based Purchasing all start with accurate OASIS assessments. Your expert partner can work with your in-house quality team to ensure that every patient encounter is properly reported.
Patients First: Patient-centered care isn’t just a regulatory directive; it’s the reason most of you are working in home care. Outsourcing coding and OASIS review and other operational/administrative tasks allows you and your clinical team to put their full energy and attention on the caregiving, not the record keeping.
Disadvantages of outsourcing (Cons)
Loss of control: The number one reason cited for choosing not to outsource operations and administrative tasks is fear of losing control — control over workflow processes, control over quality, control over staffing. While that concern is understandable, you have more control over vendor output than you do over staff output. Outsource coding companies are only as good as the last audit they did for a client. Repeated failure to meet expectations is easily handled by ending the contract. There are all sorts of HR issues to navigate when terminating recalcitrant staff.
HIPAA protections: Many agency decision makers worry that protected patient health information will be compromised. That is a legitimate concern, and it’s important when exploring outsourcing options that you know what protective measures a prospective vendor has in place, and how often those measures are reviewed and upgraded.
Cost: Always the CFO’s first question: what’s outsourcing going to cost? When looked at as a line item on your P&L, outsourcing can appear to be expensive. However, you should consider the cost savings of fewer employees, salary and benefits, or the value of having those same staff members perform work more appropriate to their skill and education. Also, consider that expert auditors with outsource coding companies often deliver higher episode payments through more accurate code selection and sequencing.
Quality Assurance: An overarching concern for many agency owners is the challenge of assuring accuracy and compliance when tasks are completed remotely by non-staff. That a reasonable worry, which is why agencies are encouraged to thoroughly vet potential outsourcing vendors.
About QIRT: QIRT leads the post-acute industry in coding, billing, and consulting. Across the United States, QIRT provides agencies with multi-level internal and outsourced coding, quality assurance, appeals, billing, consulting, and education. Only QIRT's Advantage Platform tracks processes with real-time checkpoints and Quality Cycle Management (QCM) tools along the journey to compliance and success. For more information: ContactUs@QIRT.comor call 855.485.QIRT (7478).