In this episode of Infinicast, Mike Billings sat down with Tim Esau, PT, MSPT, Director of Compliance, to discuss major legislation that is currently under review at the federal level. These bills each will have a major impact on the the post-acute care environment. Watch the video to learn more.
My interest in the Medicare appeals process is fairly new, however I have long been dedicated to the importance of documentation in the clinical setting. As the RAC process has become a pressing issue with management and administration, I’ve found I enjoy organizing, researching, and contributing however I can. I am actively involved in medical record reviews, letter writing, and developing a definitive process for addressing reimbursement denials. My contributions at this juncture are focused on study and review of the Medicare Manuals and the integration of this information into the appeal letters.
My experience thus far, working closely with my Director of Rehab, Amy McCarthy, has revealed a great opportunity for our company to develop a comprehensive RAC process.
What we have started to develop is a system of checklists, review grids and timelines in order to help organize the (exhaustive) breadth of information that is involved in a review or appeal. In my opinion, a rigorous response to the initial Additional Documentation Review (ADR) is required. A serious and multi-discipline review of the entire medical record is needed from the beginning, with specific attention directed to documented skilled services (nursing and therapy). With an excellent review of the medical record, we have the opportunity to write a statement or position letter, bulleting where the documentation supports medical necessity at the level billed. In my opinion, if we can present an organized, comprehensive medical review in response to the ADR, there is a greater likelihood of a favorable response. At the very least, having done significant review at the ADR level, the next steps in the appeal process will become easier.
The technical detail of what Medicare is reviewing can be overwhelming. There are several opportunities in the record that can flag for a technical denial, like a missing Physician certification, illegible documentation or single document missing from the ADR. At the clinical level, what has become apparent in my review of medical records is the lack of skilled language supporting medical necessity. We as clinicians have now heard this countless times, gone through multiple trainings, and have been drilled on the importance of this. Fortunately with the use of electronic documentation, this has become easier to “build” our notes, wrought with skilled language and rationalizations. Utilizing the resources we have to make our documentation strong is imperative to favorable findings in the future. In my opinion denials for services at the SNF level will continue across payors, and definitely become more voracious as the rehabilitative healthcare environment evolves. Therefore it is a challenge (and kind of fun!) to make sure our services are undeniable to the people that we serve.
I am currently pursuing additional certification to be a Resident Assessment Coordinator (RAC-CT) in order to integrate the nursing side of skilled service (including MDS and Care Assessments) with the therapy side of skilled service (PPS coding and RUGs). With this certification I hope to bring a larger scope of understanding to clinicians involved in the RAC process in their buildings. I am excited to help Infinity become a leader in this area.
Melissa Fryer MA, CCC-SLP has been a Speech Pathologist with Infinity Rehab since 2006. Her primary facility is Village Healthcare in Gresham, Oregon, but she has worked at multiple facilities in Oregon and Washington since starting with the company. Melissa is passionate about interdisciplinary treatment and making the practice of speech pathology in SNF’s as functional and holistic as possible. Melissa is an active Clinical Instructor and Mentor to Clinical Fellows.
In an effort to provide clarity to what can at times be a murky subject – changes in healthcare – Infinity Rehab will host a panel of experts on Sunday at our 9th annual Continuing Education Symposium.
The panel is comprised of professionals who have in-depth knowledge at a national and local level on the ongoing impact legislative changes have on clinicians and those they serve.
Learn more about the panel here: http://www.prweb.com/releases/2014/03/prweb11647001.htm
Curious about the 2014 NW Continuing Education Symposium? Watch this:
For this edition of Infinicast, Mike Billings sat down with Bob Thomas, PT, President of Signature Services. The two industry leaders spoke about a variety of topics affecting post-acute care in America. Topics ranged from the roll-out of Coordinated Care Organizations (CCO) and Accountable Care Organizations to upcoming legislation and how it will impact clinicians. There is a lot of great information packed into this interview. So, sit back and enjoy and let us know what you think in the comments!
Ty Keeter, PT, DPT, MHA and Area Rehab Director for Infinity Rehab was recently featured on the ChangingAging.org blog. Ty shares his thoughts on 10 ways clinicians and care practitioners can position patients at the center of every process and decision. Follow the link to read Ty’s wonderful article:
Infinity Rehab is an active member of the National Association for the Support of Long-term Care (NASL). The therapy industry is faced with the possibility of the therapy cap exceptions process expiring at the end of March this year. This would have a severe impact on the older adults we serve every day. Please read the notification from NASL and send a letter to your Congressional leaders requesting their support of access to rehabilitation services for older adults.
Derek and Mike sat down to talk about the finer points of this wonderful continuing education event.
Topics covered in the video:
- Why therapists from across the country should attend the 2014 Northwest Symposium
- The amazing class schedule
- Fun and camaraderie as core concepts to the Symposium
- A new format for Sunday that includes guest subject matter experts in a round-table discussion on the changing landscape of post-acute care
Click here to register: www.infinityrehab.com/nwsymposium
Click below to watch the highly informative video about the event.
Classes are filling up quick, so be sure to register pronto!
In this edition of Infinicast, Infinity Rehab’s Director of Professional Development, Derek Fenwick, PT, MBA, GCS, sat down with our President, Mike Billings, PT, MS, CEEAA, to discuss a wide range of topics. Triple aim, rising health care costs, coordinated care and how those three issues impact therapists are discussed at length. So, sit back, tune in and enjoy the latest episode of Infinicast!
Imagine that you are a new short-term guest in a Skilled Nursing Facility (SNF) for rehabilitation and nursing services. After you move in, you go through the admission process. It includes a lot of information, some of which you may or may not eventually recall; you are just happy to be out of the hospital and in your own clothes. Over the next few days, you go through the various introductory interviews with the SNF staff, including the dietician, social worker, therapists, and nurses. Many of these people ask you the same questions, leading you to wonder, “Are these people talking to each other?”
This annoyance notwithstanding, you end up getting most of your questions answered and have an idea of what is going to occur over the next couple of weeks. These weeks go by without another formal discussion about your plan of care, your progress, or your plans once you leave the SNF. You are not sure how your recovery is going in the minds of the SNF decision makers, and you have some lingering questions and concerns that have not seemed important enough to bother anyone about. You are generally content with the SNF and the rehab and are not seriously thinking about going home yet.
At the beginning of the third week, the social worker talks with you about setting up a care conference with your important family members. During this conference, you hear that the therapists and nurses believe that you are physically ready to go back home. This comes as a bit of a surprise to you and your family. There are a number of barriers to a smooth transition home that could have been addressed much earlier had you been offered a forum in which to share your situation, and your lingering questions were found to be quite important. The SNF decides you need to stay an extra week to resolve these barriers to the transition home.
Alternatively, imagine that during the admission process the interdisciplinary team (IDT) invites you and your important family members to meet with them once per week, every week, until you go home. They refer to this discussion time as Grand Rounds. The Director of Rehabilitation (DOR) leads the discussion, which makes sense, since you are at the SNF for rehab in order to return home. The idea of Grand Rounds eases your mind. You will get to show the IDT your progress, reiterate your goals, and discuss the questions you may have. The team will get to review any concerns they have with your progress or goals. You will be included in the weekly management of your care while at the SNF, and all parties concerned will understand your goals, wants, and needs in preparation for a smooth transition back home.
The second scenario describes a program called “Grand Rounds” or “Progress Rounds.” Cindy Benfield, Healthcare Administrator at Good Samaritan Loveland Village, and Melissa Riehl, Loveland’s Director of Rehabilitation, have recently transitioned to Grand Rounds at their SNF. Cindy says they are quickly realizing many benefits. “Compared to the traditional Medicare meeting system and inconsistent Care Conferences, we have found that Grand Rounds strengthen the relationship bonds between our care givers and those we serve. Additionally, we’re finding valuable time savings for our often overwhelmed staff.”
Cindy describes an additional benefit to holding Grand Rounds: Streamlining patient management meetings. The randomly scheduled Care Conferences with families have all but disappeared, and the various phone calls and on-site visits to social workers from family members have drastically reduced in number. Melissa has noticed the enhancement in communication, “Family members at Loveland Good Samaritan have been very happy with the increased communication with staff, and Grand Rounds are quickly becoming our best resource for relaying information between all the important parties, including the guest and their family members.”
As ideal as this sort of system sounds, it is not always easy to move away from the traditional IDT-only Medicare Meeting. Sara Dent, Administrator for St Paul HealthCare Center in Denver, Colorado, explains how their team managed the change, “Because Grand Rounds aligns with our person-directed values, we were in agreement that we had no choice but to move to it. We knew that there would be problems and challenges to overcome, so we said that we were going to try it for three months, no matter what. We’re now one month into it. While we have had to make a number of adjustments and refinements along the way, we now average only seven minutes per guest discussion.”
Besides being person-centered, Grand Rounds is a system that may align with the future of healthcare reimbursement incentives. The days of 30-day Skilled Lengths of Stay appear to be ending, and a financial premium will be placed on quality, specifically, patient satisfaction. SNFs will need to help assure that re-hospitalizations do not occur even after patients leave the SNF. They will be accountable for up to 30 days following the hospital discharge, yet might only have the person under their roof for 20 days. Grand Rounds serves to assure a coordinated, client-included process that aims to remove barriers to health improvement efficiently, and then prepares the person to successfully transition out of the SNF. It begins this process early and maintains it each week.
Does this sound like something that might benefit your SNF? Do you have a strong dedicated DOR that could lead this sort of weekly discussion? If so, here are ten lessons learned from the St Paul and Loveland Good Samaritan experiences:
- Start by gaining buy-in, or at least understanding, from the IDT as to the overall rationale for the change. Keep these reasons in front of people as they struggle to make Grand Rounds work.
- Rather than demanding the change at once, suggest a trial, and then commit to a time frame. People may be more agreeable to a trial and before you know it, they will make it their own system.
- Be flexible on whether or not you will ask the team to travel room to room or if you will have each client be transported to one location to meet with the IDT. Either method may work.
- Clearly communicate the Grand Rounds system to each client and family. For everyone to get the full value out of it, people need to understand that Grand Rounds is the preferred time and place for them to communicate with the IDT. St Paul and Loveland Good Samaritan provide a short explanation letter within their admission packets, and then the social worker and DOR explain it to them again during their introductions.
- Pragmatically make sure everyone understands the amount of time allocated for each client discussion. 10 minutes seems to be a reasonable ceiling. Both St Paul and Loveland Good Samaritan now average about 7 minutes per client discussion.
- To respect family member’s time while allowing the team some flexibility, let the client and family know that their meeting will be within the period of an hour. For example if you have 12 skilled clients, you might tell 6 of them that their meetings will be between 9 and 10am, while the other 6 will have their meetings between 10 and 11am.
- Typically, the DOR leads the discussions. This leader needs to address the important areas with each client, assure team and family members have a chance to speak, and keep people on task. While in this capacity, the DOR becomes an even more vital part of the SNF’s Skilled operations.
- Do not be afraid of scheduling out individual family conferences for really complicated or sensitive situations. Grand Rounds may not meet the needs of every situation, but it has been found to cover the needs of the vast majority of skilled clients.
- Allow the IDT to complete much of their paperwork during and between the discussions. Care planning can be completed, nursing progress notes can be written to support the skilled stay, even orders can be written. The meeting time can be billable for therapy if they document the skilled discussion, education, and problem solving that occurred. Sometimes, it may be appropriate for other therapists to attend a respective meeting..
- Consider meeting as an IDT prior to Grand Rounds to review any notable situations quickly, so that everyone is on the same page. St Paul meets at 9:15am, and then begins grand rounds for about 20 skilled clients at 9:30am.
SNF Administrators and DOR’s may soon realize that they need to revamp vital patient management systems. Those that thoughtfully switch from the institutional Medicare Meeting to the patient-centered Grand Rounds will realize the benefits that come with enhanced patient and family involvement, while those that keep the status quo may struggle to successfully manage patients given a reduced number of days in which to do so. If you find yourself struggling to make sense of the change, put yourself in the patient’s shoes. What sort of system would you prefer?
Tyler Keeter PT, DPT, MHA is the Colorado Area Rehab Director for Infinity Rehab. He is also Adjunct faculty for Regis University’s Doctor of Physical Therapy program, teaching courses in business planning, professional advocacy, and service learning. Dr. Keeter has presented the concepts of person-directed rehabilitation at many conferences including the American Health Care Association National Conference, Colorado Health Care Association Conference, and the Nebraska chapter of Leading Age. He thoroughly enjoys supporting the therapists in the Colorado Region in the service of their residents and clients.
“What do you think about health care professionals using social media?”
I hear discussion about this question often. Opinions are wide-ranging, as are the statements in support and against health care professionals embracing social media.
I’ve integrated social media into my personal and professional life gradually over the last five years. I keep my LinkedIn profile up-to-date, I explore Facebook for a few minutes each day, and I’m closing in on 2,000 Tweets. In the diffusion of innovation curve, I land as an Early Majority adopter on most innovation items. This was the case for my social media experience.
As I’ve been asked this question more often, I began to think more about why I’ve embraced social media. While the answer is well beyond one person’s opinion, here are a few points to consider as you decide how you integrate social media into your life:
Being “social” is not new to you.
Our first order of business is to take a deep breath. You are probably already very good at being social. Clinicians are some of the most social beings on the planet. Most of use were drawn to our practice of choice because of our love of people. Well, clinicians are people too! People who work in relationship with each other can accomplish great things.
It’s the “media” part of social media that seems to give us pause. In this case, media means internet. Newspapers, magazines, television and radio are all forms of media already well-integrated into our lives. The internet is closing in quickly on the top spot among these more seasoned forms of communication.
Pew Research Center cites that 85% of Americans use the internet, and 7 in 10 have a social media profile. As the internet continues to evolve, more information is being shared back and forth in two-way and group communication. Sounds a lot like “conversation” to me. Don’t let the technology piece hold you up from exploring new ways to be social.
It is OK to ask for help.
Health care professionals are problem-solvers. We are good at helping others. One thing we’re not so good at is asking for help when we need it.
The technology part of the social media revolution is the part that is hanging up most providers. This concern is highly valid. We have a responsibility to protect the privacy of our patients and ourselves that the average person does not hold. You know HIPAA well when it comes to person-to-person interaction. Taking the conversation online is no different. As a health care professional, you need to hold the same high standards in all your online communications.
One simple rule can help: When in doubt, don’t. If you would not share it in person, don’t share it online. One poor judgment can last forever online. This is where asking for a little help and feedback from your peers comes in handy for many of us.
Licensed practitioners have an opportunity and a duty to err on the side of caution when it comes to making judgements. It’s why best practices for surgeons include a pause right before they begin. Practice your own “pause” before you hit Send, Post, Tweet or Tag, and when in doubt, don’t.
You can better influence the outcome on the offense.
This is the primary reason I adopted social media into my professional life. I wanted to influence my own career path and online presence, and there is no better way than to get involved in the process.
Many sports demonstrate this idea well. Let’s take football for example. The team with more points at the end of the game wins. Your team starts with zero. You have to go on offense to score points. Sure, you can score a few points on defense. Defense will always be part of the equation in any strategy or effort. But the majority of your points will come on offense, when you get to make the calls and move the ball the way you want.
Your professional reputation is the most valuable asset in your career. You have two options to help form that reputation: let others do all the talking, or do a little talking yourself. It’s not selfish; it’s smart. You already do it locally in your person-to-person interactions. Social media presents the opportunity for you to project your reputation into the world.
What you say, what you post, what you “like” – all these things express your values and your passions. In career development the term is “professional branding.” You can help shape how others view you by participating in the conversation. Highlight articles that resonate with your professional interests. Build trust by weighing in on conversations from your professional point of view. Comment on your career goals to hold yourself more accountable. All of these things can be accomplished through social media. Managing your online presence is so important in shaping the Story of You. Go on offense.
Social media is important to the future of health care.
More health care information is being shared online than ever before. In 2012, 13% of Americans used both offline and online means to interact with healthcare providers. Expect this number to continue to rise each year. Studies have also shown that social media users are more likely to trust online posts by doctors and nurses than other health-related posts. Allied health professionals surely aren’t too far behind. Best to be prepared and proactive.
Being social is human and it is natural to you. Consider using social media to help your career thrive in new ways.
Derek Fenwick, PT, MBA, GCS is a physical therapist and board-certified geriatric clinical specialist. He develops leaders in healthcare as the Director of Professional Development at Infinity Rehab. Find him on LinkedIn and on Twitter @DerekFenwickPT.