CCOs to Use Tools of Trade in New Payment Models, Delivery Systems

This article was first published on February 18, 2013 at AISHealth.

Compliance officers are starting to apply the tricks of their trade to new payment models and health care delivery systems.To keep up with the major transformations rippling through the industry, some compliance officers will need to monitor datathat are used to evaluate their health systems’ performance, tap into new resources and work more closely with finance,revenue cycle and other departments, experts say.

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More hospital revenue will depend on its performance on quality, value and patient satisfaction measures, which impactsthe way compliance officers identify risks. “Establishing a link between finances and compliance makes sense becauseperformance is now integral to compliance,” said attorney Craig Garner, who spoke at a recent Health Care ComplianceAssociation webinar.

Under the value­based purchasing program, for example, CMS will pay bonuses to hospitals based on quality measuresand patient satisfaction, said Garner.

To pay for the bonuses, CMS will reduce overall DRG reimbursement on the front end — by 1% in 2013, 1.25% in 2014,1.5% in 2015, 1.75% in 2016 and 2% thereafter, said Andrew Woodward, a consultant with Garner Health who also spokeat the webinar. Hospitals have to earn it back, and how much they get is based on a “total performance score” (TPS),Woodward said. The TPS is based on (1) 12 clinical processes of care measures (acute myocardial infarction, heart failure,pneumonia and surgical care improvement) and (2) eight patient­care experiences from the Hospital ConsumerAssessment of Healthcare Providers and Systems, known as HCAHPS.

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With more revenue dependent on value and quality, Garner recommends establishing more of a link between complianceand finance. Here are two suggestions:

(1) Develop an alert dashboard to identify anomalies in accounts receivable and accounts payable. If there is a suddenspike in the amount spent or received in any particular category, the compliance officer can look into it, Garner said. He recommends setting it up to identify anomalies according to profits and losses by department. Use an Excel spreadsheet orsome other easy tool that can generate the data automatically. Maybe the operating room spent $20,000 on supplies everymonth and then one month it jumped to $40,000. Was there an insider relationship with a vendor? “This is another way toextract information without necessarily tapping people on the shoulder,” he said.

(2) Track your hospital chargemaster prices to compare them to regional and historical averages and verify they fall withinaccepted levels, Garner and Woodward said. Data are available at www.oshpd.ca.gov/ chargemaster andwww.hospitalcompare.hhs.gov.

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