MONTANA REGIONAL SLEEP SEMINAR

Transcription

1 [ MONTANA REGIONAL SLEEP SEMINAR Accreditation Alternatives for Sleep centers and Labs Timothy Safley MBA, RCP RRT Director of DMEPOS, Pharmacy and Sleep ]

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3 GENERAL ACCREDITATION KISS Keep it simple and specifically focused to your organization Know what you want to get out of accreditation CMS compliance only or more? Pick a place to store data Makes it easier to review Pick a time each month to review Set a date on your calendar as a reminder Develop a plan to address any identified negative trends Trends are what we are looking for Document activities

4 PURPOSE OF ACCREDITATION CMS & Private Payer requirement Since you have no choice, let s add some value! Accreditation enables the organization to assess processes of care, services and operations. Organizational-wide performance improvement efforts address priorities for improved quality of care/service, client/patient/staff safety, operational efficiencies, and regulatory compliance. Performance Improvement (PI) can help you find issues before they turn into problems, problems that could lead to patient issues, payment refunds, etc.

5 Accreditation Why Bother Centers for Medicare and Medicaid (CMS) coverage: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Two types of coverage rulings: 1. National Coverage Determination (NCD) 2. Local Coverage Determination (LCD)

6 MAINTAINING COMPLIANCE CAN SAVE YOU MONEY Fraud, Waste, and Abuse (FWA) Fraud - An intentional deception or misrepresentation that the individual knows to be false and makes knowing that the deception could benefit the individual. Waste Unintentional misuse of Medicare funds through inadvertent error, most frequently incorrect coding and billing. Abuse - Incidents or practices of providers, or suppliers of services that are inconsistent with acceptable sound medical practices, directly or indirectly resulting in unnecessary cost to the Medicaid Program.

7 NATIONAL COVERAGE DETERMINATION An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCD. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision.

8 LOCAL COVERAGE DETERMINATION LCDs are policy developed and published by a Medicare administrative contractor, carrier or fiscal intermediary. An LCD cannot contradict an NCD, but it can expand on and specify the limitations of coverage for a specific state or region.

9 [ ] CURRENT STATUS OF A/B MAC JURISDICTIONS (AS OF 3/12/2012) 9

10 [ ] CONSOLIDATED A/B JURISDICTIONS 10

11 Accountable Care Organizations (ACOs) ACOs are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated highquality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

12 SPECIALTY BENEFIT MANAGERS (SBMs) SBMs are an outtake of Pharmacy Benefit Managers (PBMs). Managed Care Organizations (MCOs) have looked at a way to save on Obstructive Sleep Apnea (OSA) and the co-morbidities associated with this condition. In doing so, they have create these Specialty Benefits programs.

13 INTEGRATED CARE FOR OSA The American Academy of Sleep Medicine (AASM) submitted a proposal to The Centers for Medicare & Medicaid Services (CMS) titled "Innovative Care Delivery and Management Program for Patients with Obstructive Sleep Apnea" (ICDMPPO). The ICDMPPO program creates a new model of patient management with an emphasis on the following goals: improved care coordination, increased adherence to Positive Airway Pressure (PAP) therapy, reduced co-morbidities, strengthened patient satisfaction, and significant cost savings for CMS. The program will improve patient outcomes through treatment compliance by tracking, managing, and educating patients. The program requires coordinated patient care led by board-certified sleep medicine physicians (BCSMPs) and sleep center facilitators.

14 INTEGRATED CARE FOR OSA Under this pilot program, all sleep care management, including evaluation, testing, and treatment for patients with OSA, will be coordinated by the BCSMP. All education, including continuing education and fitting (mask selection/machine selection/pressure delivery), will be provided by the BCSMP and their staff. In addition, a new role of "sleep center facilitator" is created. Responsibilities of the facilitator include providing patient education, assisting with treatment adherence, supporting the physician with patient monitoring and interface adjustment, importing data into the database including the CPAP/APAP adherence information, scheduling sleep studies, refitting masks for PAP devices, and aiding with interface adjustment.

15 STARK LAW AND IN-OFFICE DURABLE MEDICAL EQUIPMENT (DME) CMS will need to waive Stark Law rules to permit a physician to bill Medicare and Medicaid for PAP equipment and supplies dispensed from the referring physician's own medical practice. The federal Stark Law prohibits a physician's referral of Medicare or Medicaid PAP to an entity in which the physician has a financial interest. The prohibition currently extends to a physician's referral of Medicare or Medicaid PAP to their own patient for PAP from their own medical practice. CMS could limit its waiver on this point to integrated sleep programs that achieve and maintain an acceptable accreditation credential as an integrated sleep disorders center. This status could help safeguard against abusive overutilization of sleep services.

16 ACCREDITATION ORGANIZATION FOR SLEEP PROVIDERS Accreditation Commission for Health Care (ACHC) (Accreditation Organization) Full Deemed as DMEPOS provider American Academy of Sleep Medicine (AASM) The Joint Commission (Accreditation Organization) HST done as telemedicine and Sleep Lab are done as IDTF s. Full Deemed as DMEPOS provider The Compliance Team ( Accreditation Organization) Full Deemed as DMEPOS provider

17 HOW TO CHOOSE THE RIGHT ACCREDITOR The following are suggestions for providers to consider when comparing accreditation organizations (AOs): 1. Review the accreditation application and standards 2. Compare the TOTAL cost of accreditation 3. Identify the professional support provided by the AO 4. Examine the performance improvement requirements 5. Evaluate the process for submitting the application

18 SLEEP ACCREDITATION Patient-focused sleep accreditation program Realistic accreditation standards developed with direct input from industry professionals to ensure relevancy Service-specific standards for: Sleep Lab/Center Accreditation (SLC) Home Sleep Testing (HST) SLC accreditation includes HST standards, meaning there is no additional accreditation needed for labs that provide HST services

19 ACCREDITATION STANDARDS ACHC standards were created For Providers. By Providers. What differentiates us? Reputation for providing industry relevant standards Standards centered on the service recipient and applicable to the type of services and care being provided Clear, concise language with helpful interpretations for implementing and maintaining compliance

20 ACHC ACCREDITATION STANDARDS What differentiates ACHC sleep standards? ACHC requires that the medical director is an active medical director who understands the operations of a sleep facility. ACHC requires that all testing be reviewed by a physician who is a board-certified sleep specialist but does not require a specific number of hours per month in a specific lab. ACHC standards do not require patients to be referred to the sleep facility by a member of any specific organization. ACHC does not specify the size that a sleep facility must be.

21 ACHC ACCREDITATION STANDARDS Section 1: Organization & Administration The standards in this section apply to the leadership and organizational structure of the company. All items referring to business licensure including federal, state and local licenses that affect the day to day operations of the business should be addressed. This section includes the leadership structure including board of directors, advisory committees, management and employees. Also included are the leadership responsibilities, conflict of interest, chain of command, program goals and regulatory compliance.

22 ACHC ACCREDITATION STANDARDS Section 2: Program/Service Operations The standards in this section apply to the specific programs and services an organization is supplying. This section addresses rights and responsibilities, complaints, protected health information, cultural diversity, compliance with fraud and abuse prevention laws.

23 ACHC ACCREDITATION STANDARDS Section 3: Fiscal Management The standards in this section apply to the financial operations of the company. These standards will address the annual budgeting process, business practices, accounting procedures and the company s financial processes.

24 ACHC ACCREDITATION STANDARDS Section 4: Human Resource Management The standards in this section apply to all categories of personnel in the organization unless otherwise specified. Personnel may include, but are not limited to, support personnel, licensed clinical personnel, unlicensed clinical personnel, administrative and/or supervisory employees, contract personnel, independent contractors, volunteers, and students completing clinical internships. This section includes requirements for personnel records including skill assessments and competencies.

25 ACHC ACCREDITATION STANDARDS Section 5: Provision of Care and Record Management The standards in this section apply to documentation and requirements for the service recipient / client / patient record. These standards also address the specifics surrounding the operational aspects of care/service provided.

26 ACHC ACCREDITATION STANDARDS Section 6: Quality Outcomes/Performance Improvement The standards in this section apply to the organization s plan and implementation of a Performance Improvement program. Items addressed in these standards include who is responsible for the program, activities being monitored, how data is compiled and corrective measures being developed from the data and outcomes.

27 ACHC ACCREDITATION STANDARDS Section 7: Risk Management: Infection and Safety Control The standards in this section apply to the surveillance, identification, prevention, control and investigation of infections and safety risks. The standards also address environmental issues such as fire safety, hazardous materials, and disaster and crisis preparation.

28 ACHC ACCREDITATION SURVEY ACHC sleep surveys are conducted in a consultative manner by experienced, licensed sleep professionals with a minimum of 10 years of sleep lab experience. ACHC surveys consist of 2 stages: The Surveyor conducts interviews with the medical team at the sleep facility to learn about their operations, reviews the company s Quality Improvement/Performance Improvement, personnel training records, and client records. The Surveyor visits the sleep facility in order to observe the service provided, including the patient education, interaction between the clinician and patient, and the actual sleep testing.

29 ACHC ACCREDITATION SURVEY A surveyor will be scheduled once all information is received into your assigned accreditation advisor Time frames can vary for completion but once all of your information is received your announced survey is usually scheduled to be on sight within 60 days Your assigned accreditation advisor will work with you to ensure that patients are scheduled when we are present for the site visit

30 REGULATORY BOOK 1. Everybody knows location 2. All documentation required by CMS 3. Organizational chart (Names Present) 4. Emergency phone numbers 5. Location listing of where all documents/records are kept (Examples ): 1. Complaint log 2. Training log

31 PAYERS COMPLIANCE PROGRAM

32 COMPLIANCE PROGRAM Key elements of a Compliance Program from the Office of Inspector General (OIG): 1. Policies and Procedures: Code of Conduct 2. Designation of Compliance Officer 3. Open Communication / Organizational Chart 4. Education and Training 5. Internal Auditing and Monitoring 6. Investigation of Detected problems 7. Enforcement of Sanctions

33 Keep It Simple Stupid 33

34 INTERPRETATION TURNAROUND TIME

35 INTER-SCORER AGREEMENT

36 PERFORMANCE INDICATORS TO MONITOR

37 PERFORMANCE INDICATORS TO MONITOR CON T

38 PERFORMANCE INDICATORS TO MONITOR CON T

39 PERFORMANCE INDICATORS TO MONITOR CON T

40 PERFORMANCE INDICATORS TO MONITOR CON T

41 PERFORMANCE INDICATORS TO MONITOR CON T

42 PERFORMANCE INDICATORS TO MONITOR CON T

43 PERFORMANCE INDICATORS TO MONITOR CON T

44 PERFORMANCE INDICATORS TO MONITOR CON T

45 SECTION 6 SELF AUDIT

46 SECTION 6 SELF AUDIT CON T

47 Maintaining Compliance Maintain survey readiness Avoid the big push Continue to audit, educate & observe Develop a timeline

48 Annual Education Any specialized training is completed Supervisors have on-going education/training related to supervisory duties Education Plan is current Patient/family education materials are current

49 The Home Stretch 12 months out Start Policy & Procedure review in order to prepare 12 months out Start staff education 8 months out Compile P&P s & complete application 7 months out Mail P&P s, application & deposit Complete a Mock Survey Continue with education with staff

50 Timothy Safley MBA RRT RCP Director DMEPOS, Sleep & Pharmacy Accreditation Commission for Health Care