Spring 2019

IN THIS ISSUE

NY-RAH to Release New Potential Missed Opportunities Report

Second Round of Telligen Site Visits & Chart Audits Completed; New Participation Requirements Introduced 

Group B Facilities Celebrate NHDD 

NY-RAH Promotes Use of Practitioner Payment Incentive 

In Case You Missed It 

NY-RAH to Release New Potential Missed Opportunities Report

In June, NY-RAH will introduce the Potential Missed Opportunities Report, a new quarterly report that uses Medicare claims data to identify potential instances where a nursing facility may have been able to bill for one of the six NY-RAH conditions but did not. The Potential Missed Opportunities Report will be web-based and released through the NY-RAH Data Portal, with only facility administrators receiving access at the time of release. Prior to the release, all Quality Improvement Specialists (QISs) working with Group B facilities will receive training on the report's functionality and associated data to help determine actionable next steps for those facilities.

The Potential Missed Opportunities Report uses nursing home and hospital claims information to identify instances where a resident was admitted to and diagnosed at the hospital with one of the six conditions, but the nursing home did not bill for an episode prior to the admission. The report displays a facility's overall number of potential missed opportunities during a quarter, potential missed revenue for these cases, and the specific resident-identifiable cases that comprise the missed opportunities. The NY-RAH project management team (PMT) believes analyzing these cases will help facilities identify potential clinical and non-clinical gaps within a facility's episode billing process. For Group B facilities, the QISs will lead this analysis by reviewing and summarizing these cases using structured quality improvement tools to target any process elements that may have been overlooked. For Group A facilities, the facility staff themselves will be requested to work with the reports to identify any gaps in the billing process. The overall aim is to ensure that all facilities continuously improve their billing workflow and processes moving forward.

If you have any questions about the Potential Missed Opportunities Report, please contact Scott Gaffney or Courtney Zyla.

Second Round of Telligen Site Visits & Chart Audits Completed; New Participation Requirements Introduced

In April, Telligen, a CMS subcontractor for the Nursing Facility Initiative (NFI), completed its second round of annual site visits and chart audits at 16 Group A and B NY-RAH facilities. The purpose of Telligen's visits is to ensure that facilities and practitioners are in compliance with criteria and requirements associated with the Initiative, review supporting documentation for a sample of claims submitted, and identify successes and opportunities for improvement across NY-RAH facilities. The site visits are a requirement of participation in the project, and the NY-RAH PMT appreciates each facility's cooperation with Telligen during the audits. During this second round of audits, NY-RAH facilities achieved an overall pass rate of 75%, which is 11% higher than last year and the highest among all six projects across the country in their second round of audits.

NY-RAH has completed/scheduled calls and meetings with each of the 16 facilities that received a visit to discuss specific results and findings for each claim reviewed by Telligen. In addition to discussing the findings in depth with facilities that received audits, NY-RAH also shared the information with all 55 facilities during a combined Group A and B Clinical Intervention Learning Community webinar on May 14. From the webinar, each facility learned about common themes from the visits and the upcoming recoupment process.

Based on Telligen's review of documentation and interviews with facility staff, two common opportunities for improvement were noted across all facilities. The first regarded each facility's beneficiary notification process about the NFI and NY-RAH. Many facilities were unable to outline their process for informing residents of their participation in the NFI and providing them with an option to opt-out if they choose to. The second opportunity centered on incomplete or insufficient nursing documentation, which makes it difficult to understand the full story of billed episodes. Based on these opportunities for improvement, NY-RAH developed and introduced two new participation requirements for all facilities during the May webinar. First, each Group A and B facility was asked to improve and outline a clear beneficiary notification process by 1) placing the beneficiary notification form on facility letterhead, 2) entering appropriate information into the opt-out form, and 3) providing a written statement to NY-RAH about the process for notifying residents about the NFI and NY-RAH. Each of these was due to NY-RAH by May 24. Each facility was also asked to provide an in-service training on nursing documentation -- similar to last year's requirement -- and submit a sign-in sheet to NY-RAH by June 14. The NY-RAH PMT is monitoring completion of the new deliverables, and failure to comply could jeopardize a facility's participation in the project.

For any questions about the Telligen visits or the new participation requirements, please contact Faiza Haq.

Group B Facilities Celebrate NHDD

In April, NY-RAH encouraged all Group B facilities to participate in National Healthcare Decisions Day (NHDD). NHDD occurs annually on April 16 and is part of a national initiative to promote the completion of advance directives and advance care planning. Since 2016, NY-RAH has encouraged facilities to hold events on April 16 or sometime during April to promote NHDD and its goals. This year, 11 Group B facilities held events, with several others incorporating education on advance directives and advance care planning into upcoming practitioner in-services and family and resident council meetings.

NHDD followed several months of palliative care training for Group B facilities to continue working toward NY-RAH's goal of increasing use and completion of the Medical Orders for Life-Sustaining Treatment (MOLST) forms and increasing the number of residents who have designated a Health Care Agent. NY-RAH created a Health Care Proxy Wallet Card to further encourage staff, residents, and families to assign and document their Health Care Agent. NY-RAH promoted the resources available via the project to residents' families and staff members. The resources include MOLST forms and brochures, Health Care Proxy forms, NY-RAH palliative care brochures, The Conversation Project Starter Kit, an Institute for Healthcare Improvement guide on How to Choose and Be a Health Care Proxy, and a new case study on the importance of interdisciplinary efforts toward advance directive completion.

NHDD_2019

The NY-RAH PMT greatly appreciates the facility directors of nursing, directors of social work, administrators, social workers, and palliative care champions for organizing the events. Although NHDD occurs annually, NY-RAH encourages all facilities to hold regular educational in-services and events on the importance of documenting end-of-life wishes. Regular communication between practitioners, residents, and families on advance care planning can help ensure that a resident's wishes are known, respected, and documented, which can help reduce the likelihood of a potentially avoidable hospitalization following a change of condition.

NY-RAH Promotes Use of Practitioner Payment Incentive

The NY-RAH project has brought on two Clinical Project Specialists (CPSs) to work more closely with NY-RAH medical directors and eligible practitioners. The initial focus area for the CPSs has been working with Group B practitioners who are able to bill under the new Medicare payment code made especially available for eligible practitioners providing care in facilities that participate in the NFI. At the beginning of Phase Two, CMS modified the NFI to provide this new billing opportunity as a means to incentivize better and timelier care for NFI eligible residents. Under Phase Two, eligible practitioners can now use bill code G9685 for an initial visit to treat an eligible resident at a NY-RAH participating nursing facility. The new Medicare part B code -- which is only available to eligible practitioners providing care to eligible residents at a NFI facility -- equalizes the payment rate for providing an initial visit in the nursing facility with what a practitioner would be eligible to bill for in the hospital. The reason for equalizing the payment level was specifically to remove the financial disincentive for practitioners to care for residents in place at the nursing facility.

The two CPSs have been meeting with medical directors and eligible practitioners at Group B facilities specifically to promote use of G9685. The CPSs have attended medical staff meetings, reviewed the clinical criteria associated with the code, and addressed concerns about documentation requirements. As for concerns raised by practitioners about the documentation level required, CMS modified its documentation requirements as of January 1, 2019, to further incentivize the use of G9685. The CPSs are available for presentations at medical staff meetings and to work directly with individual eligible practitioners to ensure the use of the new practitioner payment code.

If you wish to speak to or meet with one of the NY-RAH CPSs, please contact Faiza Haq.

In Case You Missed It

May 14: Clinical Intervention Learning Community Webinar on Telligen Round Two Audits, Recoupment, and New Participation Requirements
During the May 14 webinar, the NY-RAH PMT reviewed the results from Telligen's second round of site visits and chart audits, discussed the upcoming recoupment process, and introduced two new participation requirements. 

Webinar Recording
Access a recording of the webinar.

Additional Items
Some items mentioned during the webinar are also listed below:

For questions, please contact Faiza Haq.

      NY-RAH is supported by Funding Opportunity Number 1E1CMS331492-01-01 from the US
Department of Health and Human Services, Centers for Medicare & Medicaid Services. The
contents provided are solely the responsibility of the authors and do not necessarily represent
the official views of HHS or any of its agencies.