Use of and Comorbidities Associated With Diagnostic Codes for COVID-19 in US Health Insurance Claims

This quality improvement study assesses the comorbidities associated with COVID-19 diagnostic codes in US health insurance claims.

Seven Deadly Sins of a Medical Practice

The seven deadly sins, also known as the capital vices or cardinal sins, is a list of vices of Christian origin. They are hubris, greed, lust, malicious envy, gluttony, anger, and sloth. Likewise, there are deadly sins (mistakes) that have a negative impact on the medical practice. This article discusses the deadly sins of a medical practice and what each physician and each practice manager can do to combat those sins or mistakes.

Impact of managed care on physicians' decisions to manipulate reimbursement rules: an explanatory model

Objective: To develop and test an explanatory model of the impact of managed care on physicians' decisions to manipulate reimbursement rules for patients.

Methods: A self-administered mailed questionnaire of a national random sample of 1124 practicing physicians in the USA. Structural equation modelling was used. The main outcome measure assessed whether or not physicians had manipulated reimbursement rules (such as exaggerated the severity of patients conditions, changed billing diagnoses, or reported signs or symptoms that the patients did not have) to help patients secure coverage for needed treatment or services.

Results: The response rate was 64% ( n = 720). Physicians' decisions to manipulate reimbursement rules for patients are directly driven not only by ethical beliefs about gaming the system but also by requests from patients, the perception of insufficient time to deliver care, and the proportion of Medicaid patients. Covert advocacy is also the indirect result of utilization review hassles, primary care specialty, and practice environment.

Conclusions: Managed care is not just a set of rules that physicians choose to follow or disobey, but an environment of competing pressures from patients, purchasers, and high workload. Reimbursement manipulation is a response to that environment, rather than simply a reflection of individual physicians' values.

Improving denials management at the enterprise level

Providers have just one last chance to prepare for implementation of ICD-0. These three components are key to a successful transition: Strong leadership, proactive processes and technology, diligence with denials.

Validation study of medicare claims to identify older US adults with CKD using the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

BACKGROUND

Health care claims data may provide a cost-efficient approach for studying chronic kidney disease (CKD).

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

We compared characteristics and outcomes for individuals with CKD defined using laboratory measurements versus claims data from 6,982 REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study participants who had Medicare fee-for-service coverage.

PREDICTORS

Presence of CKD as defined by both the REGARDS Study (CKDREGARDS) and Medicare data (CKDMedicare), presence of CKDREGARDS but not CKDMedicare, and presence of CKDMedicare but not CKDREGARDS, and absence of both CKDREGARDS and CKDMedicare.

OUTCOMES

Mortality and incident end-stage renal disease (ESRD).

MEASUREMENTS

The research study definition of CKD (CKDREGARDS) included estimated glomerular filtration rate (eGFR) < 60mL/min/1.73m(2) or albumin-creatinine ratio > 30mg/g at the REGARDS Study visit. CKD in Medicare (CKDMedicare) was identified during the 2 years before each participant's REGARDS visit using a claims-based algorithm.

RESULTS

Overall, 32% of participants had CKDREGARDS and 6% had CKDMedicare. Sensitivity, specificity, and positive and negative predictive values of CKDMedicare for identifying CKDREGARDS were 15.5% (95% CI, 14.0%-17.1%), 97.7% (95% CI, 97.2%-98.1%), 75.6% (95% CI, 71.4%-79.5%), and 71.5% (95% CI, 70.4%-72.6%), respectively. Mortality and ESRD incidence rates, expressed per 1,000 person-years, were higher for participants with versus without CKDMedicare (mortality: 72.5 [95% CI, 61.3-83.7] vs 33.3 [95% CI, 31.5-35.2]; ESRD: 16.4 [95% CI, 11.2-21.6] vs 1.3 [95% CI, 0.9-1.6]) and with versus without CKDREGARDS (mortality: 59.9 [95% CI, 55.4-64.4] vs 25.5 [95% CI, 23.6-27.4]; ESRD: 6.8 [95% CI, 5.4-8.3] vs 0.1 [95% CI, 0.0-0.3]). Among participants with CKDREGARDS, those with abdominal obesity, diabetes, anemia, lower eGFR, more outpatient visits, hospitalization, and a nephrologist visit in the 2 years before their REGARDS visit were more likely to have CKDMedicare.

LIMITATIONS

CKDREGARDS relied on eGFR and albuminuria assessed at a single visit.

CONCLUSIONS

CKD, whether defined in claims or through research study measurements, was associated with increased mortality and ESRD. However, individuals with CKD identified in claims may represent a select high-risk population.

Reducing lost revenue from inpatient medical-necessity denials

Payment denials based on questions of medical necessity have increased significantly for many hospitals, while the odds of mounting a successful appeal have diminished. Instead of focusing primarily on making appeals more effective, hospitals should construct a strategy for reducing the incidence of medical-necessity denials through the collection and analysis of denials data. Hospitals can break down the data to produce optimal approaches at both the case management and service levels to minimizing lost revenue from medical-necessity denials.

A population health approach to reducing observational intensity bias in health risk adjustment: cross sectional analysis of insurance claims

OBJECTIVE

To compare the performance of two new approaches to risk adjustment that are free of the influence of observational intensity with methods that depend on diagnoses listed in administrative databases.

SETTING

Administrative data from the US Medicare program for services provided in 2007 among 306 US hospital referral regions.

DESIGN

Cross sectional analysis.

PARTICIPANTS

20% sample of fee for service Medicare beneficiaries residing in one of 306 hospital referral regions in the United States in 2007 (n = 5,153,877).

MAIN OUTCOME MEASURES

The effect of health risk adjustment on age, sex, and race adjusted mortality and spending rates among hospital referral regions using four indices: the standard Centers for Medicare and Medicaid Services--Hierarchical Condition Categories (HCC) index used by the US Medicare program (calculated from diagnoses listed in Medicare's administrative database); a visit corrected HCC index (to reduce the effects of observational intensity on frequency of diagnoses); a poverty index (based on US census); and a population health index (calculated using data on incidence of hip fractures and strokes, and responses from a population based annual survey of health from the Centers for Disease Control and Prevention).

RESULTS

Estimated variation in age, sex, and race adjusted mortality rates across hospital referral regions was reduced using the indices based on population health, poverty, and visit corrected HCC, but increased using the standard HCC index. Most of the residual variation in age, sex, and race adjusted mortality was explained (in terms of weighted R2) by the population health index: R2=0.65. The other indices explained less: R2=0.20 for the visit corrected HCC index; 0.19 for the poverty index, and 0.02 for the standard HCC index. The residual variation in age, sex, race, and price adjusted spending per capita across the 306 hospital referral regions explained by the indices (in terms of weighted R2) were 0.50 for the standard HCC index, 0.21 for the population health index, 0.12 for the poverty index, and 0.07 for the visit corrected HCC index, implying that only a modest amount of the variation in spending can be explained by factors most closely related to mortality. Further, once the HCC index is visit corrected it accounts for almost none of the residual variation in age, sex, and race adjusted spending.

CONCLUSION

Health risk adjustment using either the poverty index or the population health index performed substantially better in terms of explaining actual mortality than the indices that relied on diagnoses from administrative databases; the population health index explained the majority of residual variation in age, sex, and race adjusted mortality. Owing to the influence of observational intensity on diagnoses from administrative databases, the standard HCC index over-adjusts for regional differences in spending. Research to improve health risk adjustment methods should focus on developing measures of risk that do not depend on observation influenced diagnoses recorded in administrative databases.

A multidisciplinary approach to improving revenue integrity

Intermountain Healthcare's journey toward a modern revenue integrity process began with five key steps: building a multidisciplinary team, developing department-specific charge-capture teams, providing ongoing education and training on best practices for revenue integrity, leveraging new technology and business support services, establishing a proactive approach to managing audits and compliance.

Internal audits can safeguard hospital revenue

Hospitals should routinely perform internal audits of all functions affecting billing accuracy to mitigate the effects of payer audits and to protect revenue by improving billing processes. A primary focus for internal audits should be on coding accuracy, because coding errors leading to denials often reflect gaps in coders' knowledge or training. Effective communication between coding and denials management professionals is a critical success factor. Audits should support appeals processes, and audit findings should be used in educational initiatives aimed at improving coding accuracy.

ICD-10: cracking the code

Healthcare organizations should address physician clinical documentation improvement now, before the Oct. 1, 2014, implementation deadline for ICD-10, if they are to mitigate risk related to ICD-10 and optimize operational processes. Improving documentation now will have an immediate effect on revenue and will minimize the potential for losses related to denied claims after ICD-10 goes into effect. Training of physicians should not be just a "once-and-done" process. Organizations should plan now for training to continue even after the implementation deadline.

Part A to part B rebilling: understanding the rules in a changing environment

Under a recent CMS ruling, hospitals that have been denied payment for Medicare Part A services have the option to submit follow-up claims to Medicare Part B for some of these denied services. A CMS proposed rule threatens to remove that option by imposing barriers to the rebilling of claims denied under Part Afor payment under Part B. By commenting on the rule, hospitals may be able to persuade CMS to reject the proposed rule and, instead, adopt a policy similar to that in the ruling. Should CMS decide to finalize the rule, hospitals can use their comments in efforts either to convince Congress to enact statutory changes that would mandate expanded Part B rebilling or to challenge the final rule in litigation.

Simplification at last?

The HIPAA transaction standards-meant to streamline financial and administrative transactions--have instead devolved into a kind of free-for-all. Now the first operating rules are in hand to standardize use of the standards and gain the efficiencies originally intended.

Eight reasons payer interoperability and data sharing are essential in ACOs. Interoperability standards could be a prerequisite to measuring care

It makes strategic and business sense for payers and providers to collaborate on how to take substantial cost out of the healthcare delivery system. Acting independently, neither medical groups, hospitals nor health plans have the optimal mix of resources and incentives to significantly reduce costs. Payers have core assets such as marketing, claims data, claims processing, reimbursement systems and capital. It would be cost prohibitive for all but the largest providers to develop these capabilities in order to compete directly with insurers. Likewise, medical groups and hospitals are positioned to foster financial interdependence among providers and coordinate the continuum of patient illnesses and care settings. Payers and providers should commit to reasonable clinical and cost goals, and share resources to minimize expenses and financial risks. It is in the interest of payers to work closely with providers on risk-management strategies because insurers need synergy with ACOs to remain cost competitive. It is in the interest of ACOs to work collaboratively with payers early on to develop reasonable and effective performance benchmarks. Hence, it is essential to have payer interoperability and data sharing integrated in an ACO model.

Will you be ready for ICD-10 conversion?

In less than two years, the United States will convert to ICD-10, which will result in major changes in coding requirements. Much more detailed documentation will be needed for the coders to do their job correctly. Every department in the hospital that uses data will be affected. Case management software must be adjusted to accommodate the expanded fields. Case managers don't need extensive training on the new codes, but they do need to be aware of the documentation requirements.