Bad Mules vs.

The Art of Valued Clinical Documentation

Joanne Wright, RN TAHIMA Presentation March 17, 2016

• False Claims Act (1863)

• Department of Justice

• U.S. Attorney • Healthcare

Fraud Taskforce

• Whistle blower or “qui tam”

Affordable Care Act

Source: http://www.beckershospitalreview.com/legal-regulatory-issues/5-false-claims-act-trends-cases-that-will-fuel-recoveries-in-2016.html

• Enhanced Data analysis capabilities • Strike Force • Trends 1. Extrapolation 2. Compensation 3. Liability 4. Ticking Clock-60 day 5. Implied Certification Theory

Federal False Claim Act Judgments: Healthcare

2014 2015 2016

$2.3B

$1.9B

Source: http://www.fiercehealthpayer.com/antifraud/story/false-claims-act-recoveries-drop-nearly-40-percent-2015/2015-12-07

Bipartisan Budget Act of 2015 (H.R.1314) • FCA penalty

adjustment • Potential

liability even greater

$801M

Mar 1

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Compliance and FWA Training

• Contractors with CMS Medicare Advantage (Part C) Medicare Prescription Drug Benefit Programs (Part D) • Compliance Program • First Tier, Downstream, Or Related Entity (FDR) • CMS Medicare Learning Network

Source:https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/Downloads/2016_Complaince_and_-FWA_Training_Requirement_Update.pdf

Charting Guidelines

• Document at time provided

• Document objectively • Document without reference to staffing • Use quantifiable data with descriptions • Record education provided • Document interventions provided

Copy and Paste Timeline

2013

• AHMIA reports 74-90 notes contain copied text

• OIG recommendations for Fraud Safeguard Ignored or Manipulated

2014 • AHMIA position paper on copy-and-paste

functionality

2015 • The Joint Commission Safety Issue Statement

Source: http://www.jointcommission.org/assets/1/23/quick_safety_issue_10.pdf

The Joint Commission

Copy and Paste Functionality (CPF) • Balance benefits with risks • Develop training and education • Monitor records for accuracy • Feedback loop regarding accuracy and

redundancy • Rigorous quality review process where

potential misuse or errors are evaluated

Patient Record

Complete

Sequenced

Reimbursable Succinct

Accessible

Shared Responsibility

Valued Clinical Documentation

Best Defense is Better Care focus: • Promotion of therapeutic alliance • Provide care to the patient following an

acceptable standard of care • Adhere to the standard of care • Proactive awareness of high risk

Accurate Concise Complete Irrefutable

Valued Clinical Documentation

Clinical Documentation Improvement focus: • Communication across teams • Recognition of comorbid conditions

$$

CQI

• Validation of provided care

• Continuous quality improvement

• Timely feedback • Timely training

Valued Clinical Documentation

Improved input and output mapping focus: • Discrete data • Continued clinical common language • Interoperability goals • Agreed upon professional standards

Valued Clinical Documentation

Alternative Visit focus: • Expansion of service

provision • Core data capture • Data storage

capabilities HCPCS Q3014 Originating site facility fee

99201-99204 Outpatient codes 99490-Chronic Care management GT Modifier

Source: http://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis---coverage-and-reimbursement.pdf?sfvrsn=10

Valued Clinical Documentation

Ease of Capture focus: • Template supports completeness • Macro supports efficiency • Structure supports algorithmic

development and reporting

Source:https://upload.wikimedia.org/Wikipedia/commons/c/cb/Assessment_and_treatment_algorithm_for_overweight_and_obesity.png

Valued Clinical Documentation

Beyond Chart Wall Tools focus: • Registries • Portals • Home Devices • Providers/Patient Mobile • Research • Other not yet known

Valued Clinical Documentation

Persona focus: • Clinician’s cognitive process • Assemblage of seamless story • Longitudinal care teams • Patient Access

Valued Clinical Documentation

Principles

Clinician

Purpose

Ethics

Patient

Engagement

Contributor

AHIMA

CAPA

Governance

Vendor

Usability

Quality

Source: http://perspecitves.ahima.org/impact-of-electronic-healt-record-systems-on-information-integrity-quality-and-safety-implications/

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Achar S. and Wu W. July/August 2012. Family Practice Management .How to Reduce your Malpractice Risk. Retrieved from http://www.aafp.org/fpm/2012/0700/p21.pdf. http://www.aafp.org/fpm/2012/0700/p21.pdf American College of Emergency Physicians. 2014. Telemedicine for Medicare Patients FAQ. Retrieved from http://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Telemedicine-for-Medicare-Patients-FAQ/ American Health Information Management Association (AHIMA). Appendix B: Case Studies. January 2007. Journal of AHIMA 78, no.2 (January 2007): [web extra]. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_033093.hcsp?dDocName=bok1_033093 American Health Information Management Association (AHIMA). Policy and Position Statement: Appropriate Use of the Copy and Paste Functionality in Electronic Health Records. March 17,2014. Journal of AHIMA. Available online as of March 2015 at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf Bowman S. Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications. Perspectives in Health Information Management (Fall 2013): 1-19. Retrieved from http://perspectives.ahima.org/impact-of-electronic-health-record-systems-on-information-integrity-quality-and-safety-implications/ Carlson J. December 10, 2013. Fed eyes crackdown on cut-and-paste EHR Fraud. Retrieved from http://www.modernhealthcare.com/article/20131210/NEWS/312109965

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Carrier ER, Reschovsky JE, Meelo MM. et al. February 2016. Vol 35. No 2. Physicians’ Fears of Malpractice Lawsuits are Not Assuaged by Tort Reforms. Retrieved from http://content.healthaffairs.org/content/29/9/1585.full Cartwright-Smith L, Thorpe JH, and Rosenbaum S. October 28, 2014. Ebola and EHRs: An Unfortunate and Critical Reminder. Retrieved from http://healthaffairs.org/blog/2014/10/28/ebola-and-ehrs-an-unfortunate-and-critical-reminder/ Cedarbaum JG, and Babbitt CE. December 7, 2015. Supreme Court to Address Permissibility and scope of Implied Certification Liability Under the False claims Act. Retrieved from https://www.wilmerhale.com/pages/publicationsandnewsdetail.aspx?NewsPubId=17179880061 Chavis S. October 2013. Two Systems, One Direction. For the Record. Vol. 25 No. 14 P.10. Retrieved from http://www.fortherecordmag.com/archives/1013p10.shtml Christino MA, Matson AP, Fischer SA, Reinert SE, et al. December 2013. Paperwork Versus Patient Care: A Nationwide Survey of Residents' Perceptions of Clinical Documentation Requirements and Patient Care. J Grad Med Educ. 2013 Dec; 5(4): 600–604.doi: 10.4300/JGME-D-12-00377.1 Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3886458/ Conn J. July 25, 2013. Two competing clinical code groups team up. Modern Healthcare. Retrieved from http://www.modernhealthcare.com/article/20130725/NEWS/307259944

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Eastwood B. March 2, 2015. Aetna hits South Texas hospital with $120 million kickback lawsuit-Insurer alleges five-year fraudulent billing scheme. Retrieved from http://www.fiercehealthpayer.com/antifraud/story/aetna-hits-south-texas-hospital-120-million-kickback-lawsuit/2015-03-02 Edwards S. November 11, 2015. Bipartisan Budget Act Jacks Up Civil Monetary Penalties Under the Social Security Act and False Claims Act Penalties. Retrieved from https://www.healthindustrywashingtonwatch.com/2015/11/articles/legislative-developments/bipartisan-budget-act-jacks-up-civil-monetary-penalties-under-the-social-security-act-and-false-claims-act-penalties/ Ellison A. October 8,2015. 504 hospitals hit with whistle-blower lawsuit alleging false claims violations. Retrieved from http://www.beckershospitalreview.com/legal-regulatory-issues/504-hospitals-hit-with-whistle-blower-lawsuit-alleging-false-claims-violations.html Ellison A. January 6, 2016. 5 False Claims Act trends, cases that will fuel recoveries in 2016. Retrieved from http://www.beckershospitalreview.com/legal-regulatory-issues/5-false-claims-act-trends-cases-that-will-fuel-recoveries-in-2016.html Finn C. June 5, 2015. Narrative Nursing Notes in the Electronic Health Record: A Key Communication tool. Online Journal of Nursing Informatics (OJNI), 19 (2). Retrieved from http://www.himss.org/ResourceLibrary/GenResourceDetail.aspx?ItemNumber=42737 Gibson Dunn 2015 Mid-Year False claims Act Update. July 8, 2015.Retrieved from http://www.gibsondunn.com/publications/Pages/2015-Mid-Year-False-Claims-Act-Update.aspx

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