Florida HFMA Fall 2018 – Changes in Latitude and Attitude

Author: Maureen Kelly, Executive Director, Axea Solutions

This year’s Florida Hospital Financial Management Association (HFMA) Fall Conference at the Margaritaville Beach Resort in Hollywood, Florida on September 5 – 7, was the perfect location for their fast-paced and innovative program.  Attendees packed the sessions, networking events, and exhibitor hall throughout the conference and took advantage of networking time to discuss strategies and share inventive ideas about navigating the upheaval going on in healthcare revenue cycle operations.  

Transformative Trends

The kick-off speaker, Jacque Sokolov, MD, spoke about the continued evolution of healthcare and why healthcare organizations need to plan for an upheaval in healthcare operations and revenue cycle in his presentation, Management of Transformative Healthcare Trends – How to Expect the Unexpected.  In particular, he discussed the many disruptions that healthcare organizations are experiencing, including:

·       New revenue cycle methodologies,

·       Payment and reimbursement challenges, such as the impact of quality metrics and at-risk payment models, and

·       Aligning hospital and professional services and billing, as the move to value-based healthcare continues, direct employment of physicians increases, and managed care plans require documentation such as hierarchical condition coding

New entries into the traditional healthcare delivery system such as Amazon, Uber, and Microsoft, to name a few, are creating alternatives for healthcare organizations and consumers that are both beneficial and competitive to hospital operations.  Healthcare executives will need to carefully decide how, when, and with whom to align to optimize their business models and serve their communities. 

If you have the opportunity to hear Dr. Sokolov speak at an upcoming event, you should run (not walk) to the meeting room and prepare to be amazed. He definitely has his hand on the pulse of change. 

Compliance Programs: More Important Than Ever

There is a lot going on in the compliance world, and it takes input from everyone in a healthcare organization to ensure that they are meeting compliance goals and objectives. As Joanne Byron, Chief Executive Officer, American Institute of Healthcare Compliance (AIHC) noted in her presentation, 7 Habits of Highly Successful Compliance Programs, an effective program includes:

·       Continued evaluation of medical practices, especially those deemed as high risk,

·       Monitoring for potential conflict of interests,

·       Managing the OIG 7 Step Program, and

·       Handling OIG and CMS self-disclosures.   

The good news is that there are many free government toolkits to help healthcare organizations to comply with the mandated programs via the OIG website. 

Florida State Legislative Initiatives

Ashley Boxer, Corporate Director Government Relations at Memorial Healthcare System, provided an insider’s view to the many healthcare issues that the Florida State Legislature has under consideration.  The pending issues include:

·       Overall healthcare funding,

·       Possible expansion of the state’s Medicaid program, and

·       Potential Certificate of Need (CON) new legislation. 

Ashley provided some essential guidelines on how to communicate with hospitals’ respective representatives to gain their support for legislation important to the hospital.  Most important is to be in regular contact with the representative and their administrative staff, provide high-level responses to questions asked by the representative (bullet points that can be opened on their phone while in session is in progress), and network with lobbyists and government relations personnel from other health systems. 

Click here to learn more about upcoming events hosted by the Florida Hospital Financial Management Association.

Axea Solutions’ team of credentialed HIM and Revenue Cycle experts assist healthcare organizations to review their compliance processes and identify any areas of high performance and those that need improvement. Customized for each healthcare organization, Axea offers one-time service, periodic reviews, or fully managed services. Contact Axea at info@axeasolutions.com or 855.424.4249 to learn more.

Axea Solutions CEO Susan Gatehouse Unveils How to Discover Hidden Financial Pitfalls Post-EHR Transition

Axea Solutions CEO Susan Gatehouse chatted with John Lynn of Healthcare Scene during this week's Healthcare Financial Management Association (HFMA) conference about discovering hidden financial pitfalls post-EHR transition, identifying the root causes of denials, and why healthcare organizations shouldn't always take technology data at face value.

Is your healthcare facility working towards a denial management solution or denial free solutions? Contact Axea Solutions for reducing, remediation, and irradiating your denials.

Axea Solutions CEO Featured in Becker's Hospital Review

Axea Solutions CEO Susan Gatehouse was recently featured in Becker's Hospitals' "Female vendor RCM leaders to know in 2018." 

"A number of healthcare organizations seek out input from vendors for revenue cycle management and financial improvement. At these vendors, there are women who have the expertise to help providers with everything from front-end processes to coding and billing."

Check it out

Axea Solutions Supports Local Efforts To Combat High School Homelessness

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For the past two years, The Place of Forsyth County has celebrated high school graduations with area young people that through many life struggles, including homelessness, have succeeded in receiving their diplomas. 

This year The Place identified 26 deserving seniors who received a decorated jar with eight $25 gift cards! Axea Solutions proudly contributed gift cards, which offered assistance for gas, clothes, fast food, Walmart, Target and entertainment needs. 

"The gifts will bring a smile on the face of kids who beat the odds and are following their dreams!" said Naomi Byrne, The Place Of Forsyth County.

"This is a great local organization that is instrumental to helping those in need right here in our community," said Axea Solutions CEO Susan Gatehouse. "We are proud to support their efforts and we encourage everyone to also lend a hand."

To donate to The Place Of Forsyth, visit http://theplaceofforsyth.org/ or call 770.887.1098.

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The Major Hitter: The 340B Drug Reimbursement Scramble

By: Susan Gatehouse, Axea Solutions CEO

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Another year, another raft of changes from CMS. A major hitter this year is the change in 340B drug reimbursement.

Remember 340B’s history? Signed into law by President George H.W. Bush in 1992, the 340B program was part of the Veteran Affairs Act. It required pharmaceutical companies that participate in Medicaid to provide discounts on certain drugs to facilities that meet specific requirements, primarily that they provide care to medically underserved populations.  

Fast forward to 2016. The Medicare Payment Advisory Committee (MedPAC) started looking into the average payments hospitals were receiving through 340B. The conclusion? Hospitals were making too much money from the program, and reimbursements needed to be decreased.

In late 2017, CMS finalized a proposal to pay hospitals the average sales price (ASP) minus 22.5% for those drugs acquired through the 340B program (except pass-through drugs and vaccines). This is a 28.5% payment difference from 2017 to 2018.

There are exceptions. The payment rate of ASP + 6% will continue for sole community hospitals in rural areas, children’s hospitals, and PPS-exempt cancer hospitals.

Clearly, this new ruling packs a powerful financial punch. However, the savings from this new iteration of 340B are earmarked to meet other facility costs. CMS is implementing this policy in a budget neutral manner by offsetting the estimated $1.65 billion in reductions in drug payments by redistributing that amount to other non-drug services within the OPPS.

A consortium of entities, including the American Hospital Association, Association of American Medical Colleges, America's Essential Hospitals, and three hospitals, sued the Department of Health and Human Services in November 2017, shortly after CMS issued the final ruling on the new reimbursement structure for 340B.

U.S. District Judge Rudolph Contreras dismissed the lawsuit because the proposed cuts had not gone into effect at the time of filing. He did not rule on the merits of the case. The lawsuit is expected to be refiled.

From intensive inventory analysis to programming and assigning the correct modifiers to 340B drug codes, the revisions to this program provide lots of “learning opportunities.” Even facilities that are exempted from these changes are required to use a voluntary modifier to delineate which drugs would fall under the 340B guidelines.

As you grapple with the procedural headaches, uncertain financial impact, and compliance risk that the new version of 340B has wrought, remember that education and training help alleviate at least some of these stressors.


Stay tuned! We hope you’ll return for our next blog.

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CDI: Not Just for Inpatient Any More

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By Susan Gatehouse, Axea Solutions CEO

Once considered a luxury of well-endowed major medical facilities, clinical documentation improvement (CDI) specialists have made their way to the mainstream. The majority of facilities nationwide now provide some CDI oversight. The requirement for microscopic review of patient safety indicators, severity, and risk of mortality, along with the complexity of both patient care services and procedures, have made CDI specialists a staple of inpatient hospital coding departments.

The same cannot be said for outpatient areas. It is not a given that outpatient documentation will receive the same attention that is found in the inpatient setting. This may be because "outpatient" and "hospital" are two entities that have not historically been linked. However, healthcare is shifting to more interdependence between the outpatient and inpatient settings. This more holistic approach to patient care carries with it some logistical and reimbursement challenges.

The hospital is not the only place to get services.

Shifting ideals of healthcare and wellness, in addition to changing reimbursement structures, have prompted hospitals to add outpatient services, either on-campus or remotely, to their retinues. Outpatient services offered close to home are attractive to a population that can get a sports physical at a pharmacy, or a flu shot at a big box store. Additionally, the move toward reimbursement linked to total population care may be a factor behind the increase in hospital-affiliated outpatient services.

Outpatient coding continues to have a significant role in the hospital itself, particularly with patients coming into the emergency department. Ambulatory surgery provided in the hospital may lead to observation stays that will be coded as outpatient.

But outpatient coding is so much simpler…

Inpatient coders typically have a greater depth of knowledge because of the more complex patient records that they code. But outpatient coding should not be relegated to second-class status. While inpatients may be sicker and more complex to code, with more outpatient services offered, outpatient coding will become significantly more demanding in terms of volume. That volume equates to a greater piece of overall revenue. The importance of CDI in the outpatient setting becomes evident when the number of records is considered.

In addition, recent OPPS changes for 340B drugs further drive home the point that outpatient services are no longer considered easier to manage and code, and are not necessarily more likely to be accurately reimbursed. 

Why CDI is ALWAYS important

The primary goal of CDI is making the patient record as accurate as possible to ensure that the most correct, most granular picture of the patient is captured. Thorough documentation in any setting can make a huge difference in the outcome for every patient. For outpatient care, physicians need to have and provide excellent documentation in order to treat a patient with whom they may have only a brief encounter, but a potentially life-changing one. Goal one is always the patient's wellbeing.

It is also true that without documentation, the care might be outstanding, but the hospital will not be reimbursed for it. The hospital needs to keep its doors open, whether they be the doors at the main campus or those in an imaging center in the distant suburbs. Outpatient care may offer another stream of revenue for a hospital. It is one that deserves top-notch CDI, just as inpatient does.

Axea Solutions has proven success in assisting outpatient coding departments with the implementation of CDI, coder training, and charge reconciliation procedures. We realize that every dollar counts, and outpatient procedures and services require the same level of detailed attention that inpatient receives.

We hope you’ll return for our next blog.

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Attributes of the Exceptional Healthcare Coder

Whether they're providing preventive care or rushing a patient into emergency surgery, healthcare providers are focused on one thing: ensuring the best possible outcome for each patient.

Healthcare administrators share that goal. Administrators also know that the bottom line needs the best possible outcome as well.

One of the most effective means of keeping the bottom line in great shape is ensuring that the revenue cycle moves smoothly through its rotations. Provide the service, bill the payor, receive reimbursement. Repeat.

The demand for exceptional healthcare coders is growing exponentially. The field is expected to grow by 21 percent between now and 2020.* Coders are essential to patient safety, a healthy revenue cycle, and efficient operations.

We may be biased, but we fully believe that coders are among the most vital players in maintaining that revenue cycle in effective motion. Submitting detailed, accurate, and complete reimbursement requests saves time and money, not to mention headaches.

How do you know you have the best people in the coding role? Axea Solutions recently completed a small survey of uber coders - they were all identified as truly outstanding in their field. Let's look at some of the insights we gained.

Coder Survey Insights

The coders we surveyed had varying educational backgrounds. One had simply a certificate, while others had associate's and bachelor's degrees. They were unanimous, however, in their ongoing pursuit of knowledge. Journal reading was a daily requirement, and watching webinars, professional networking, and taking advantage of continuing education opportunities were frequent activities.

Interestingly, most of the respondents mentioned science and math as their favorite high school subjects. And many specifically indicated that the medical knowledge they gained on the job was both rewarding and interesting. A predisposition to enjoying medical- and health-related topics may lead to more tenacity in getting to the right code, as well as to greater job satisfaction for these super coders.

Key Coder Attributes

When asked to rank the relative significance of several attributes useful in coding, every single person indicated "attention to detail" as being the most important. Runners-up were "sound decision-making" and "ability to communicate effectively." Less important were "speed" and "good memory."

Those answers ring true to us. Coding is based on attention to detail. The level of detail required for this task is truly demanding. And coding always requires decision-making. "Which code is most appropriate, most exact, in this scenario? " is a question coders ask multiple times a day. Relying on data analysis skills is important, as coders must follow medical diagnoses and convert that information into the proper codes for medical records.  

Effective communication involves the ability to communicate both verbally and in writing, and the coders we surveyed indicated they use both methods, with email being the most prevalent form of communication employed. Almost every coder mentioned a go-to person or group who provided assistance and feedback for coding challenges. Most of these relationships were initiated informally.

As for those attributes deemed less useful, again, we agree. Speed is not always the friend of accuracy, as our grandparents knew. (Remember, "Measure twice, cut once"?) And a good memory, while helpful, is not what the best coders rely on when making decisions. Regulations change with startling frequency. Research, not a good memory, is what serves coders, and the bottom line, best.

The absolute need for ongoing education and the imperative nature of attention to detail were strikingly unanimous responses. However, coders show a lot of variability in how they describe themselves, and how they imagine others might describe them. "A leader," "goofy," "tenacious," and "giving" were some of the responses we saw here. And let’s not forget the importance of honesty and professionalism at all times. These coders prove they can do the job and have a lot of personality!

In Their Own Words

We finished the survey with this question: What advice would you give to someone entering your field?  Here are some of our favorite answers:

  • "You will need to have a passion for research and dissecting documentation and looking at the overall picture."
  • "The details can be taught…the actual desire to know, learn, and do cannot be taught."
  • "Study, study, study. Understand that you will never know everything. Understand that coding is not black and white, there is always gray. And . . . understand that 3M doesn’t take you to a code, you take 3M to a code."

Axea Solutions extends our heartfelt thanks to all the participants in our survey. Your efforts as coders support the ultimate goal of healthcare - the best possible outcome for every patient. You drive the revenue cycle that enables our organizations to have the best possible outcomes for our bottom lines as well. 

What have you found are the key attributes that result in “Attributes of the Exceptional Healthcare Coder”? We’d love to hear your thoughts.

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*Source: The U.S. Bureau of Labor and Statistics’ Occupational Outlook Handbook.

The Context of Coding and Bundled Payment

Bundled payment (also known as episode-based payment, episode-of-care payment, and global bundled payment) is likely to be a feature of the American medical landscape. Although similar to MS-DRG related reimbursement, bundled payment goes further in its all-encompassing nature. The full episode of care across providers and facilities is bundled into one reimbursement. Add to this mix the transition to ICD-10, and it's no wonder that the tracking and reimbursement of bundled care services prove to be a challenge.

If your health care organization participates in a bundled payment initiative, it is crucial that your coders be familiar with the codes that are part of the bundled payment protocol. Given its prevalence, expense and the breadth of care required, a joint replacement procedure identifies as an ideal model for bundled payment.

The Centers for Medicare and Medicaid Services (CMS) initiated the Comprehensive Care for Joint Replacement Model (CJR) in November 2016. The appropriate use of MS-DRGs 469 and 470 served as key indicators in the identification of patient participants in this model. Clearly coding matters at this initial entry point as different target prices are determined by which MS-DRG is specified.

How does a coder navigate the complexity and context required within the bundled payment initiative? Here are some suggestions.

1.  Develop expertise in the bundled care initiatives already within the ICD-10 CM/PCS arena. A solid understanding of the nuances of diagnostic and procedural codes provides a firmer foundation in coding for episode-of-care.

2.  Establish good communication with contacts at outpatient provider offices. Bundled payment encompasses continuity of care. Relationship building serves as a key component, as a patient receives treatment modalities in varying settings.   

3.  Do not underestimate the importance of post-acute care. Rehabilitative services remain a reality for many patients with a diagnosis that will be reimbursed under bundled payment. It is particularly helpful to have good relationships with personnel at these facilities.

4.  Make clinical documentation improvement (CDI) a priority. This area consistently provides ongoing growth opportunity. With the implementation of ICD-10, further provider education should focus on the various code selections included in the bundled payment initiatives to ensure that the complete clinical picture is documented. It is also imperative to help the provider understand the importance of communicating in a timely and informative manner with the coding staff. The essence of CDI is translating a clinical diagnosis into a numerical code. Both skill sets prove invaluable in creating an accurate depiction of the severity of a patient’s condition, along with all aspects of their treatment.

5.  Education and training are well worth the investment, time and effort to increase productivity. Coding accurately and efficiently on a daily basis is a demanding job. Throw in the vicissitudes of health care regulation, reimbursement and reform, and it’s obvious that seeking professional training is a smart move.

As with every other change that has arisen in health care administration, bundled payment affects the overall revenue cycle. Learn how to meet the challenge in this unchartered territory and to not only survive, but thrive.

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Ingredients for Improving Patient Safety Indicators

Business Challenge

A 900+-bed acute care hospital operating within a major academic medical system was identified in Vizient's annual Quality & Accountability Study* as having poor performance measures in mortality and composite patient safety indicators (PSI). The percentage of hospital-acquired conditions at this facility was significantly higher than that at other institutions in the study. Clearly the situation required immediate remediation to improve patient outcomes and to stop the reduction in payment, which resulted from underperformance.

* Vizient is an alliance of the nation’s leading academic medical centers (AMCs). Its annual Quality & Accountability Study ranks AMCs on measures of mortality, effectiveness, safety, equity, patient centeredness, and efficiency.

The Solution

The facility administrators sought counsel on quality improvement from Axea Solutions. Together, the hospital and Axea Solutions implemented an enhanced process of clinical documentation improvement (CDI), addressing documentation matters related to PSI. The use of Axea’s PSI/HAC database allowed the client to track and to trend the occurrences of hospital-acquired conditions, the physicians treating these conditions, and ultimately, the number of occurrences overturned after following the process described here. Most importantly, this tracking was used for education of coders, quality improvement analysts and physicians.

Process for PSI Quality Improvement

1.     If a record is coded with a condition known as a PSI, the record is reviewed by a coding supervisor. If the supervisor agrees with the code assignment, the record is forwarded to a performance improvement analyst for review.

2.     If a disagreement presents at that juncture, the case is discussed by both the coder and the analyst.

3.     Further input is solicited from the physician advocate of the service line under review or from the chief quality officer at the hospital.

4.     At that point, the case is discussed with the senior coder and analyst and a final determination is made.


This was an intensive process and required complete commitment and participation from both teams. With Axea’s support implementing the new review process, the facility improved its ranking from the bottom 50% to the top 25% in the subsequent Quality & Accountability Study's observed-to-expected (O:E) mortality index.

The composite score of patient safety indicators improved significantly – the facility’s ranking increased from 75 out of 113 to 13 out of 116 hospitals in a composite score of patient safety indicators. The facility was awarded four stars by Vizient and received the designation of "Rising Star" for its ascent in the annual rankings by more than 20 spots in a 12-month period.

The work that began years ago has delivered lasting change within the facility, improving accountability across clinical and nonclinical teams for improved patient safety and quality of care. Upon receiving the 2016 inaugural Innovation Excellence Award from Vizient, the accepting representative acknowledged, ”we are constantly looking for new, effective ways to help patients, and the best way to measure that is by keeping an eye on our quality data."

Key Learnings

Susan Gatehouse, CEO, Axea Solutions, offers these takeaway lessons.

•      Buy-in is everything. Most people and institutions are not comfortable with change. It's human nature. However, when human lives are on the line, people react differently. This facility's administration and staff made the decision to do whatever it took to improve outcomes for their patients and to advance their ability to provide quality care.

•      Hard numbers help. Without the results of the analysis provided by Vizient, it would likely have taken longer for this facility to address the areas of weakness identified. Good data is important for initiating change.

•      Change is possible. Even when the hard data is not what you want to see and the task of turning it around is daunting, systems can be repaired. It is important to realistically assess what is not working, identify where improvement is necessary, and begin the process.

•      Relationship-building is crucial. Fostering an atmosphere of open communication and respect during times of transition is paramount. Axea's knowledge of the challenges that coders, quality assurance analysts, and clinicians encounter on a daily basis allows us to build bridges and to eliminate divisiveness.

•      Get help. Administrators can often become overburdened and time-crunched. Seeking outside counsel from experts in process improvement provides that critical stepping-back view, and allows for change to unfold.

•      Know that you're not alone. Even if your institution is not a medical center nor exposed to the public scrutiny of a study like the one described here, it will begin being benchmarked to the same measures. This era of health care reimbursement reform affects all of us. Let's work together to maximize effectiveness, safety, patient centeredness, and efficiency for our bottom lines and our patients' wellbeing.

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Axea Solutions Milestone Awards 2016

We celebrate our professionals’ pursuit of exceptional outcomes by presenting them with milestone awards at our bi-annual Axea meetings. These meetings focus on our valued teamwork, having fun and taking the time to be recognized, encouraged and rewarded. Axea’s strong emphasis on relationship building and internal support provide our clients with noticeably enhanced experiences.