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PubMed1994

Internal compliance systems are the best defense against fraud.

Healthcare reform a key issue for the Clinton administration, extends far beyond healthcare coverage concerns. With healthcare fraud estimated by Congress to total as much as $80 billion to $100 billion per year, uncovering fraud has become one of the administration's top priorities. With FBI and other investigators assigned to the problem, all areas of the healthcare industry will face increasing levels of scrutiny. This anti-fraud campaign will affect every type of provider, from large hospitals to small equipment vendors. An internal compliance program can help healthcare managers identify problems and avoid criminal prosecution.

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

Coding for clinical trials.

Although CMS reimburses for routine care associated with clinical trials, it is essential that the correct diagnosis code, modifier, and, where necessary, HCPCS Level II procedure code be assigned to accurately report these qualifying trial services. Remember that not all insurance payors will provide reimbursement for services rendered as part of a clinical trial, and individual payor policies should be obtained and followed for these services.

Clinical Trials as Topic↗
PubMed2002

Improving medication use in newly admitted home healthcare patients: a randomized controlled trial.

OBJECTIVES: To test the efficacy of a medication use improvement program developed specifically for home health agencies. The program addressed four medication problems identified by an expert panel: unnecessary therapeutic duplication, cardiovascular medication problems, use of psychotropic drugs in patients with possible adverse psychomotor or adrenergic effects, and use of nonsteroidal antiinflammatory drugs (NSAIDs) in patients at high risk of peptic ulcer complications. It used a structured collaboration between a specially trained clinical pharmacist and the patients' home-care nurses to improve medication use. DESIGN: Parallel-group, randomized controlled trial. SETTING: Two of the largest home health agencies in the United States. PARTICIPANTS: Study subjects were consenting Medicare patients aged 65 and older admitted to participating agency offices from October 1996 through September 1998, with a projected home healthcare duration of at least 4 weeks and at least one study medication problem. INTERVENTION: Qualifying patients were randomized to usual care or usual care with the medication improvement program. MEASUREMENTS: Medication use was measured during an in-home interview, with container inspection at baseline and at follow-up (between 6 and 12 weeks) by interviewers unaware of treatment assignment. The trial endpoint was the proportion of patients with medication use improvement according to predefined criteria at follow-up. RESULTS: There were 259 randomized patients with completed follow-up interviews: 130 in the intervention group and 129 with usual care. Medication use improved for 50% of intervention patients and 38% of control patients, an attributable improvement of 12 patients per 100 (95% confidence interval (CI) = 0.0-24.0, P =.051). The intervention effect was greatest for therapeutic duplication, with improvement for 71% of intervention and 24% of control patients, an attributable improvement of 47 patients per 100 (95% CI = 20-74, P =.003). Use of cardiovascular medications also improved more frequently in intervention patients: 55% vs 18%, attributable improvement 37 patients per 100 (95% CI = 9-66, P =.017). There were no significant improvements for the psychotropic medication or NSAID problems. There was no evidence of adverse intervention effects: new medication problems, more agency nurse visits, or increased duration of home health care. CONCLUSIONS: A program congruent with existing personnel and practices of home health agencies improved medication use in a vulnerable population and was particularly effective in reducing therapeutic duplication.

Aged↗
PubMed1999

Prediction of hospital readmission for heart failure: development of a simple risk score based on administrative data

OBJECTIVES: The purpose of this study was to develop a convenient and inexpensive method for identifying and individual's risk for hospital readmission for congestive heart failure (CHF) using information derived exclusively from administrative data sources and available at the time of an index hospital discharge. BACKGROUND: Rates of readmission are higher after hospitalization for CHF. The significant determinants of rehospitalization are debated. METHODS: Administrative information on all 1995 hospital discharges in New York State which were assigned International Classification of Diseases--9--Clinical Modification codes indicative of CHF in the principal diagnosis position were obtained. The following were compared among hospital survivors who did and did not experience readmission: demographics, comorbid illness, hospital type and location, processes of care, length of stay and hospital charges. RESULTS: A total of 42,731 black or white patients were identified. The subgroup of 9,112 (21.3%) who were readmitted were distinguished by a greater proportion of blacks, a higher prevalence of Medicare and Medicaid insurance, more comorbid illnesses and the use of telemetry monitoring during their index hospitalization. Patients treated at rural hospitals, those discharged to skilled nursing facilities and those having echocardiograms or cardiac catheterization were less likely to be readmitted. Using multiple regression methods, a simple methodology was devised that segregated patients into low, intermediate and high risk for readmission. CONCLUSIONS: Patient characteristics, hospital features, processes of care and clinical outcomes may be used to estimate the risk of hospital readmission for CHF. However, some of the variation in rehospitalization risk remains unexplained and may be the result of discretionary behavior by physicians and patients.

Journal Article↗
PubMed1999

Prediction of hospital readmission for heart failure: development of a simple risk score based on administrative data.

OBJECTIVES: The purpose of this study was to develop a convenient and inexpensive method for identifying an individual's risk for hospital readmission for congestive heart failure (CHF) using information derived exclusively from administrative data sources and available at the time of an index hospital discharge. BACKGROUND: Rates of readmission are high after hospitalization for CHF. The significant determinants of rehospitalization are debated. METHODS: Administrative information on all 1995 hospital discharges in New York State which were assigned International Classification of Diseases-9-Clinical Modification codes indicative of CHF in the principal diagnosis position were obtained. The following were compared among hospital survivors who did and did not experience readmission: demographics, comorbid illness, hospital type and location, processes of care, length of stay and hospital charges. RESULTS: A total of 42,731 black or white patients were identified. The subgroup of 9,112 patients (21.3%) who were readmitted were distinguished by a greater proportion of blacks, a higher prevalence of Medicare and Medicaid insurance, more comorbid illnesses and the use of telemetry monitoring during their index hospitalization. Patients treated at rural hospitals, those discharged to skilled nursing facilities and those having echocardiograms or cardiac catheterization were less likely to be readmitted. Using multiple regression methods, a simple methodology was devised that segregated patients into low, intermediate and high risk for readmission. CONCLUSIONS: Patient characteristics, hospital features, processes of care and clinical outcomes may be used to estimate the risk of hospital readmission for CHF. However, some of the variation in rehospitalization risk remains unexplained and may be the result of discretionary behavior by physicians and patients.

Black or African American↗
PubMed1992

Patient selection to peritoneal dialysis versus hemodialysis according to comorbid conditions.

An historical prospective sample of 2,420 non-diabetic and 1,738 diabetic Medicare patients incident from 1986-87 was analyzed for the selection of patients to peritoneal dialysis (PD) and hemodialysis (HD) according to comorbid factors. Data measuring the degree of comorbidity, describing the major diagnosis leading to end-stage renal disease (ESRD), and reporting other sociodemographic factors for incident ESRD patients were collected in a special study of the USRDS. Patients selected to PD were more likely to be white (greater mortality risk), diabetic (greater mortality risk), and younger (lower mortality risk) than patients assigned to HD. Estimates of the overall level of comorbidity with adjustment for race, gender, diabetes, and age provided evidence of a reduced total count of comorbid factors for PD compared to HD, particularly among diabetic patients under 60 years of age (p < 0.01). Assessment of selected risk factors, with adjustment for age and diabetes, indicated that patients selected to PD were not at greater comorbid risk according to cardiovascular factors but demonstrated a 20 percent increase in the likelihood of peripheral vascular disease (p = 0.02).

Cardiovascular Diseases↗
PubMed2000

An economic evaluation of levofloxacin versus cefuroxime axetil in the outpatient treatment of adults with community-acquired pneumonia.

OBJECTIVE: To examine treatment costs of community-acquired pneumonia (CAP) in adult outpatients given oral (p.o.) levofloxacin or cefuroxime axetil as initial therapy. STUDY DESIGN: Patients with a primary diagnosis of CAP were enrolled in a multicenter, prospective, randomized, open-label, active-controlled Phase III clinical trial. Both inpatients and outpatients were assigned to 1 of 2 treatment groups: (1) intravenous (i.v.) or p.o. levofloxacin; or (2) i.v. ceftriaxone and/or p.o. cefuroxime axetil. METHODS: To make legitimate and meaningful cost comparisons between similar types of patients receiving drugs via the same route of administration (i.e., orally), this outpatient economic study examined the resource utilization of the 211 patients enrolled as outpatients who received oral formulations as initial treatment (levofloxacin, 103 patients; cefuroxime axetil, 108 patients). Resource utilization data and clinical trial data were collected concurrently. To generate cost estimates, Medicare cost estimates for resources were multiplied by the resource units used by patients in each treatment arm. RESULTS: Cost estimates indicated a total cost difference that favored the levofloxacin group (base case: $169; sensitivity analysis: $223 [P = .008]). The results for the base case were not significant (P = .094). In addition, within the cost categories, there was a statistically significant study drug cost differential favoring levofloxacin ($86; P = .0001 for both the base case and sensitivity analysis). CONCLUSION: Oral levofloxacin is less costly than oral cefuroxime axetil in the outpatient treatment of adults with CAP.

Adult↗
PubMed1991

The cost of home air-fluidized therapy for pressure sores. A randomized controlled trial.

BACKGROUND: Recurrent pressures sores are a serious problem that often cause chronically ill patients to be hospitalized. We hypothesized that home air-fluidized bed therapy may be a safe and effective way to treat these patients, thus avoiding the costs of hospitalization. METHODS: One hundred twelve patients with 3rd or 4th stage pressure sores were randomly assigned to 36 weeks of either (1) home air-fluidized bed therapy that included the services of a visiting nurse specialist as long as the patient had 3rd or 4th stage sores, or (2) conventional therapy. RESULTS: Compared with patients in the control group, patients receiving air-fluidized bed therapy spent fewer days in the hospital (11.4 days vs 25.5 days, P less than .01) and used fewer total inpatient resources, as reflected both in charges ($13,263 vs $25,736, P less than .05) and in Medicare DRG and physician payments ($6,646 vs $12,131, P less than .05). Total resources used (inpatient and outpatient) were lower for patients treated with air-fluidized bed therapy, but the difference was not statistically significant. Clinical outcomes were similar. CONCLUSIONS: Home air-fluidized bed therapy is safe, reduces hospitalizations, is no more costly than alternative therapy, and allows the patients to receive their needed care in a more desirable, nonhospital setting.

Aged↗
PubMed2003

How nurse practitioners obtained provider status: lessons for pharmacists.

The history of nurse practitioners, their efforts to achieve provider status, and lessons learned from their activism are discussed. The nurse practitioner profession arose out of a need to meet a rising demand for primary care services, especially in rural areas. Some nurses and physicians vehemently opposed the nurse practitioner model, but studies documented the value of nurse practitioner services, and the utilization of these practitioners continued to grow. Compensation was provided via salary or per-member-per-month agreements. Nurse practitioners recognized that direct federal reimbursement (provider status) was needed to recognize them as independent health care providers and assign specific monetary values to their services, so they undertook an aggressive lobbying campaign. Contacts on Capitol Hill were exploited, and nursing organizations encouraged nurse practitioners to get involved in grass-roots activism. Nurse practitioners discussed their patients during meetings with their representatives in Congress, and legislators were invited to make site visits. In 1993, the American College of Nurse Practitioners was formed to unite the profession and move the campaign forward. Ultimately, the Balanced Budget Act of 1997 granted nurse practitioners provider status and authorized them to bill Medicare directly for services furnished in any setting. The key strategies that contributed to this victory were (1) gaining recognition that nursing had the potential to expand its role, (2) documenting nurse practitioners' value, (3) establishing standards in education and credentialing, (4) using professional organizations to empower individuals, and (5) being willing to accept small, incremental gains over time. The experience of nurse practitioners in obtaining Medicare provider status offers valuable lessons for pharmacists as they pursue the same goal.

Economics, Pharmaceutical↗
PubMed1985

Evaluation of the Arizona health care cost-containment system.

This article evaluates Arizona's alternative to the acute portion of Medicaid, the Arizona Health Care Cost-Containment System (AHCCCS), during its first 18 months of operation from October 1982 through March 1984. It focuses on the program's implementation and describes and evaluates the program's innovative features. The features of the program outlined in the original AHCCCS legislation included: Competitive bidding, prepaid capitation of providers, capitation of the State by the Health Care Financing Administration, assignment of gatekeepers, beneficiary copayment, private administration, inclusion of private and public employees and county financed long-term care. An assessment of implementation during the second 18 months of the program reporting on more recent developments and is now being prepared by SRI International.

Arizona↗
PubMed2005

The transfusion services committee--responsibilities and response to adverse transfusion events.

Healthcare institutions in the United States must review blood transfusion practices and adverse outcomes in order to receive payments from the Centers for Medicare/Medicaid program, but it is not required for a specific committee to be assigned to oversee the review process. Regardless of the group or individuals responsible, the review process must include a program of quality assessment and performance improvement that is ongoing, hospital-wide, and data-driven, reflects the complexity of the hospital's organization and services, and involves all hospital departments and services (including those contracted). To be most effective, the performance improvement activity should be prioritized around high-risk, high-volume activities and/or in problem-prone areas. Even if a hospital elects not to receive payments from Medicare, it must still comply with applicable sections of the Code of Federal Regulations pertaining to transfusion services such as the follow up of adverse outcomes of transfusion.

Aged↗
PubMed2000

Variability in code selection using the 1995 and 1998 HCFA documentation guidelines for office services. Health Care Financing Administration.

BACKGROUND: Documentation guidelines have been developed by the Health Care Financing Administration (HCFA) to promote consistent selection of physician evaluation and management (E & M) codes. Our goals were to determine whether medical providers and auditors agree in their assignment of office codes using 1995 and 1998 guidelines and to ascertain if the code levels assigned are affected by auditor experience and training. METHODS: A total of 1,069 established patient charts from private family physician offices were reviewed by a family practice faculty physician, a family practice resident physician, and a professional coder. The main outcome measures were the agreement between the auditors and the medical care provider on code selection and the degree to which documentation supported the code selected. RESULTS: All auditors agreed with the medical provider code selection in only 15.2% (1995 guidelines) and 29.2% (1998 guidelines) of visits. Professional coders were more likely than faculty physicians or resident physicians to agree with the code assigned by the medical provider (51.7% vs 40.7% and 39.6%, P <.001). Documentation adequately supported the most common office code selection, 99213, in 92.7% (1995) and 91.0% (1998) of the charts reviewed. Concurrence among all auditors was only 31.0% (1995) and 44.3% (1998). CONCLUSIONS: Interobserver differences exist in the assignment of E & M codes by auditors using both 1995 and 1998 HCFA guidelines. The 1998 documentation guidelines produce greater agreement among auditors. The documentation supported the level of code billed in the majority of established patient office visits.

Ambulatory Care↗
PubMed2006

Cash and counseling: a promising option for consumer direction of home- and community-based services and supports.

The Cash and Counseling Demonstration began as a 3-state social experiment to test the claims of members of the disability community that, if they had more control over their services, their lives would improve and costs would be no higher. The 2004 expansion to 12 states brings us closer to the tipping point when this option will be broadly available. The original demonstration was a controlled experiment with randomized assignment, supplemented by an ethnographic study and a process evaluation. Consumers managing flexible, individualized budgets were much more satisfied, had fewer unmet needs, and had comparable health outcomes. Access to service and supports was greatly improved. Consumer direction is increasingly accepted as a desirable option in home and community services.

Aged↗
PubMed1995

Financial implications of noninvasive positive pressure ventilation (NPPV).

Noninvasive positive pressure ventilation (NPPV) is effective in the treatment of acute and chronic respiratory failure. However, the costs and financial balance between costs and diagnosis-related group (DRG) reimbursement for patients with moderate to severe respiratory failure treated with NPPV are unknown. We examined the costs and DRG reimbursement for 27 patients receiving Medicare referred with moderately severe respiratory failure for NPPV to the ventilator rehabilitation unit (VRU) at Temple University Hospital. This unit is one of four Health Care Financing Administration chronic ventilator-dependent demonstration sites that evaluates patients for NPPV, instructs them in home NPPV use, emphasizes rehabilitation, and uses strict cost accounting methods. Nineteen patients were treated with NPPV in the ICU and then referred to the VRU, and 8 patients were directly admitted for NPPV to the VRU. Patients were (mean +/- SE) 69 +/- 9 years age, 14 had severe COPD, and 13 had various restrictive disorders. All were hypercapneic at the time of hospital admission (restrictive 60 +/- 15; obstructive 67 +/- 3 mm Hg, PaCO2) with impaired lung mechanics and limited functional status. Patients averaged 8 +/- 15 days in the ICU, or 8 +/- 4.7 days on the medical floor prior to VRU transfer. The VRU length of stay averaged 20 +/- 18 days, for a total length of stay of 29 +/- 21 days. After implementation of NPPV, all patients had an improvement in gas exchange while spontaneously breathing and functional status that was maintained in follow-up. At 1 and 2 years of follow-up, 74% and 63% of patients were alive, respectively. Eleven patients were admitted with DRG 475 (respiratory system diagnosis with ventilator support); however, 16 of 27 patients were admitted across five different non-475 DRG codes with reimbursement rates ranging from $2,673 to $4,215. After DRG and outlier reimbursement, a total deficit of $261,948 remained (average deficit $9,701 per patient). However, individual patient deficits ranged from $1,113 to $32,892. Eighty-two percent of patients treated with NPPV incurred substantial financial losses that were underreimbursed across all assigned DRGs, including DRG 475, the highest-weighted DRG. We conclude that patients with moderate to severe respiratory failure receiving NPPV demonstrate an improvement in functional status and gas exchange that is maintained in follow-up. In addition, patients treated with NPPV incur high costs that are currently underreimbursed by the present DRG system. Newer DRG payment scales that recognize NPPV as specific treatment should be implemented.

Aged↗
PubMed2006

Outcomes in a nursing home transition case-management program targeting new admissions.

PURPOSE: The Providing Assistance to Caregivers in Transition (PACT) program offers nursing home discharge planning and case management for individuals in the transitional period following a return to the community. The PACT program targeted individuals newly admitted to nursing homes and worked with a family caregiver to develop and implement a nursing home discharge plan. DESIGN AND METHOD: Reported are the results of a randomized control design evaluating the program's effectiveness. Those individuals randomly assigned to the intervention group (n = 33) received PACT case management in addition to their usual medical and nursing home care. The individuals in the control group (n = 29) continued their usual care. RESULT: There were no statistical differences in the discharge rate (84% treatment vs 76% controls) or in the median length of stay (42 days vs 55 days) between the two groups of individuals. IMPLICATIONS: Replications or extensions of a PACT-type intervention might consider a broader mix of nursing homes, working directly with the nursing home's admission Minimum Data Set coordinator in patient selection, or working with Medicare or Medicaid HMO plans.

Caregivers↗
PubMedDate not supplied

Education does pay off: pneumococcal vaccine screening and administration in hospitalized adult patients with pneumonia.

Streptococcus pneumoniae-associated infections are an important cause of hospitalization and mortality in high-risk and elderly patients. Even in the setting of appropriate therapy, the case fatality rate of invasive pneumococcal disease in the elderly may approach 40%. Since approximately 40,000 people die annually from pneumococcal-associated disease, it represents a substantial target for vaccine-preventable, bacterial fatalities. The 23-valent pneumococcal polysaccharide vaccine has proven consistently effective in preventing invasive pneumococcal disease. Despite its endorsement by numerous specialty societies, the pneumococcal vaccine is underutilized in the inpatient setting. In a recent report of quality indicators for Medicare beneficiaries, the percentage of Medicare beneficiaries in Louisiana admitted with pneumonia who were screened or received the pneumococcal vaccination prior to discharge was only 4%, the lowest percentage in the United States. The Louisiana State University-New Orleans Internal Medicine Department and its house staff embarked upon a retrospective study to determine its baseline pneumococcal vaccination or screening rates for all patients with pneumonia on its inpatient services at the The Medical Center of Louisiana in New Orleans from July 2000 through June 2001. From July 2001 through June 2002 an intensive educational intervention concentrating on the indications and benefits of pneumococcal vaccination was directed toward the Louisiana State University Internal Medicine house staff assigned to the inpatient service. Retrospective analysis for pneumococcal vaccine screening and administration of charts of all patients with pneumonia on the LSU Medicine service from July 2001 through June 2002 was performed in order to determine the effects of the intervention. Data from the pre-educational intervention period revealed a baseline pneumococcal vaccine screening or administration rate of 11% for all patients with pneumonia on the LSU Internal Medicine inpatient service. During the one-year intervention period, the pneumococcal vaccine screening or administration rate increased to 71%, a clinically and statistically significant increase (p-value < 0.0001). Data targeting patients 65 years of age and older revealed a baseline pneumococcal vaccine screening or administration rate of 10% for patients with pneumonia on the LSU Internal Medicine inpatient service which increased to 82% during the one year educational intervention (p-value < 0.0001). House officer scores (possible range 0-100) on a questionnaire assessing their understanding of the indications and benefits of pneumococcal vaccination were significantly higher after the educational intervention compared to before the intervention (means +/- standard deviations, 68 +/- 9 vs. 59 +/- 10, p < 0.0001). The findings from this study highlight the importance of education in increasing compliance with widely-accepted practice guidelines such as pneumococcal vaccine screening or administration in patients hospitalized with pneumonia.

Female↗
PubMed1989

Civil monetary penalties--weapon against fraud or instrument of health policy?

Most physicians are aware of the highly publicized aspects of government health care regulation, including attempts at mandatory physician assignment and recoupment of services deemed medically unnecessary. There is less awareness of the potential pitfalls of civil monetary penalties, as many physicians believe they are primarily applicable to false claim allegations. However, the use of civil monetary penalties is increasing as Congress creates new bases of liability. This development leads to the question: Are civil monetary penalties a weapon against fraud or an instrument of federal policy?

Crime↗
PubMed1980

Assignment of benefits; collection of medical support and payments--Health Care Financing Administration. Final regulations.

These regulations authorize States to require Medicaid applicants and recipients, as a condition of eligibility, to assign to the State their rights to medical support or other third party payments for medical care. Under these regulations, State Medicaid agencies can make agreements with other agencies (including State child support enforcement agencies) for assistance in collecting on third party liability. State agencies must make incentive payments to other States or political entities that collect medical support and payments. These incentive payments are taken from the Federal share of the collection. The regulations also prohibit Federal sharing in payments for medical assistance that would be covered by a private health insurance policy if that policy did not exclude services covered by Medicaid. The regulation implements section 11 of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1979 (Pub. L. 95--142). The intent is to conserve Federal and State Medicaid funds by ensuring maximum use of available third party resources.

Eligibility Determination↗