Transforming Revenue Integrity Through Data Mining and Predictive Analytics

Transcription

1 Transforming Revenue Integrity Through Data Mining and Predictive Analytics Anita Reisman, RHIA Manager, Data Integrity & Reporting Mission Hospital St. Joseph Health Laguna Beach CA Mission Viejo CA Marge Gray, PMP Business Solutions Consultant Craneware HFMA Region 11 Symposium 2014

2 Learning Objectives Learn how to re-structure/re-align decision support teams for optimal performance Determine best practices and identify tools for data sharing Embrace financial and quality data together for predicting risk and opportunity 2

3 Big Data Characteristics Describes the exponential growth and availability of data Use it to harness relevant data and better decision-making Hospital acquisitions V-V-V~V 3

4 Data Mining and Predictive Analytics Characteristics Gain useful insights for fact-based decision making Process of analyzing data Finding correlations or patterns Predictive models exploit patterns to identify risks and opportunities Population health vs individual health 4

5 Performance Indicators Characteristics Key Performance Indicators - KPI Set of quantifiable measures KPIs vary depending on priorities or performance criteria Helps an organization define and reach its goals 5

6 Performance Indicators 6

7 Business Intelligence (BI)

8 Revenue Integrity transform the approach Characteristics 100% legitimate reimbursement Renovate approach Why should you care about revenue integrity? Hospital financial health depends on it Each member of your community depends on it Is basis for moving to predictive state of analysis 8

9 How to transform Transform the Data team > Business Intelligence Team Data team responsibilities Update charge capture processes Incorporate visualization tools Focus on quality Monitor patient experience Utilize project management processes Stakeholders and Communication Take advantage of lessons learned 9

10 Time Travel Let s go back to 1995 Remember when Henry said.. 10

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17 We re Proud of Being First and only designated Regional Trauma Center in south Orange County Certified Primary Stroke Center by The Joint Commission (TJC) South Orange County's designated Cardiac Receiving Center by Orange County Emergency Medical Services (EMS) South Orange County's designated Stroke-Neurology Receiving Center by Orange County Emergency Medical Services (EMS), and the only one providing advanced stroke care Designated Premium Surgical Spine Specialty Center by United Healthcare Magnet recognized by the American Nurses Credentialing Center for nursing excellence Baby Friendly designated from Baby-Friendly USA 17

18 Business Intelligence Team 18

19 BI Team Diversity at Its Best Director, Business Intelligence (mentor & negotiator) Mgr, Data Integrity & Reporting (HIM, CDM, IT) Project Manager Clinical (ER Nurse &Quality) Operations Analyst (Patient Satisfaction, Magnet) Decision Support Analyst (Cost Accounting) Data Mining Analyst (2) (Database and Dashboards) 19

20 What Does the BI Team Do? Integrates raw data from disparate source systems Transforms this data into information Predicts outcomes based on risk and opportunity Combines technology, software, analytics, and human knowledge Connects finance and clinical teams 20

21 BI Team Responsibility Structure 21

22 BI Team Huddle Board 22

23 BI Team Huddle Board 23

24 Journey from Decision Support to Business Intelligence Decision Support Team Focus: Financial Analysis Profit/Loss Service Lines Expected Reimbursement Chargemaster Revenue and Usage Business Intelligence Team Focus: Data analysis incorporating both financial and quality data integrity using data mining drilldowns Quality/Patient Satisfaction Predictive Analysis Value Imperatives Streamline/Automate Dashboards 24

25 Where Do I Start? 25

26 Making the Rounds Nursing Leadership Council Quality Patient Satisfaction Clinical Committees Nursing Goals & Action Plans House-wide Huddles Medical Staff Peer Review Risk Management 26

27 Improving Charge Capture Journey began two years ago. CDM system was inefficient and did not capture all potential revenue in the same way CDM was unable to compare utilization, cost of care, lost revenue, coding/billing inaccuracies and potential compliance issues System leaders could not use our own information to understand and leverage best practice for system-wide care processes and instead relied on external vendors and databases. CDM now enables other value imperatives, such as Revenue Cycle, Clinical effectiveness and benchmarking to track progress This investment is less than 0.3% of net patient revenue 27

28 Value of CDM Standardization and Charge Integrity Value Revenue Cycle Charge Structure Integration CIS (Technology) Revenue Cycle: Revenue benefit is realized through charge capture and CDM reviews and operational redesign CIS: There is a dependency on cleaning up and standardizing CDMs when implementing Clinical and Financial systems. There is a need to determine charge triggering events that may be linked to orders, documentation and performed services Supply Chain Pharmacy Supply Chain and Pharmacy: The CDM plays a large part in maintaining current supply and pharmacy mark-up on cost. The integration and link between a health system s item master, formulary and the CDM is integral in order to manage cost to charge and to reimbursement Integration across teams is imperative in order to have a successful Revenue Cycle and System Implementation Transformation and remain Compliant 28

29 Future State: Standardized CDM as Key Information Engine for Analytics Clinical System (Applications) Room and Bed Application Pharmacy Application Emergency Department Application Radiology Application Laboratory Application Operating Room Application Orders Application Charge Capture Processes Charge Tickets HIM Coding Manual Charge Entry Order Entry Documentation Charge Reconciliation ClaimScrub/ Edit Remediation Information Engine Standardized CDM Hospital A CDM Hospital B CDM Hospital C CDM Hospital D CDM Hospital E CDM Financial System 29

30 Sample Surgical Charge Variance Examples 30

31 Final Product for OR MAIN OR GRP A LVL1 UP TO 30MIN MAIN OR GRP A LVL2 UP TO 30MIN MAIN OR GRP A LVL3 UP TO 30MIN MAIN OR GRP A LVL4 UP TO 30MIN MAIN OR GRP A LVL5 UP TO 30MIN MAIN OR GRP A LVL6 UP TO 30MIN MAIN OR GRP B LVL1 UP TO 30MIN MAIN OR GRP B LVL2 UP TO 30MIN MAIN OR GRP B LVL3 UP TO 30MIN MAIN OR GRP B LVL4 UP TO 30MIN MAIN OR GRP B LVL5 UP TO 30MIN MAIN OR GRP B LVL6 UP TO 30MIN MAIN OR GRP D LVL1 UP TO 30MIN MAIN OR GRP D LVL2 UP TO 30MIN MAIN OR GRP D LVL3 UP TO 30MIN MAIN OR GRP D LVL4 UP TO 30MIN MAIN OR GRP D LVL5 UP TO 30MIN MAIN OR GRP D LVL6 UP TO 30MIN MAIN OR GRP E LVL1 UP TO 30MIN MAIN OR GRP E LVL2 UP TO 30MIN MAIN OR GRP E LVL3 UP TO 30MIN MAIN OR GRP E LVL4 UP TO 30MIN MAIN OR GRP E LVL5 UP TO 30MIN MAIN OR GRP E LVL6 UP TO 30MIN MAIN OR GRP C LVL1 UP TO 30MIN MAIN OR LVL 1 EA ADDL MIN >30 MAIN OR GRP C LVL2 UP TO 30MIN MAIN OR LVL 2 EA ADDL MIN >30 MAIN OR GRP C LVL3 UP TO 30MIN MAIN OR LVL 3 EA ADDL MIN >30 MAIN OR GRP C LVL4 UP TO 30MIN MAIN OR LVL 4 EA ADDL MIN >30 MAIN OR GRP C LVL5 UP TO 30MIN MAIN OR LVL 5 EA ADDL MIN >30 MAIN OR GRP C LVL6 UP TO 30MIN MAIN OR LVL 6 EA ADDL MIN >30 31

32 Integrity of the Claim! Data Integrity: changes made to the claim are also made to the host database. 32

33 Revenue Integrity Audits o Missing Charges.. S&I (radiological supervision & interpretation) CPT injection for myelogram requires an S& I code such as myelography Potential linked charges CPT treat shoulder dislocation is linked to x-ray of shoulder Procedure to device code CPT insertion heart pacemaker requires a C- Code such as C1786 pacemaker, single chamber 33

34 Revenue Integrity Audits o Missing Charges.. Administration of vaccine Influenza and Pneumonia Infusion and injections add-ons (addt l hour) L& D outpatient area 34

35 Soft vs. Hard Coded CPTs GI Charge Audit Main Procedure Interventions 35

36 Routine Revenue Integrity Audits Group Proration Audit Proration Audit Coding Audit Coding Audit Coding Audit Charge Audit Monitor INS No Auto Proration Occurred Expected Reimbursement Trend Inpatient DRG Not Final Outpatient Dx is Not Coded APC Status Not Final Net Negative Charges for Patient + Service Date + Charge code Charge Audit Service Date Outside Patient's Admit Date / Discharge Date Range. Charge Audit Account Audit Pricing Audit Demographic Audit Utilization Monitoring Improper Charge Quantities Accounts Not Cancelled (with or without charges) Same CPTs different Pricing Incorrectly Entered Zip Codes One Day Stay and 2 Midnight Rule Review 36

37 Coding World Turns Upside Down Transition from ICD-9 to ICD-10 October 1,

38 Comparison of diagnosis codes ICD-9 Length 3-5 characters ICD-10 Length 3-7 characters About 13,000 codes About 68,000 codes First digit alpha or numeric; digits 2-5 are numeric No detail Digit 1 is alpha; digits 2 and 3 are numeric; digits 4-7 are alpha or numeric Very specific i.e. codes identify right vs. left 38

39 Example ICD-9 code Synovectomy, foot and toe ICD-10 has 24 possible options: 0SBH0ZZ Excision of Right Tarsal Joint, Open Approach 0SBH3ZZ Excision of Right Tarsal Joint, Percutaneous Approach 0SBH4ZZ Excision of Right Tarsal Joint, Percutaneous Endoscopic Approach 0SBJ0ZZ Excision of Left Tarsal Joint, Open Approach 0SBJ3ZZ Excision of Left Tarsal Joint, Percutaneous Approach 0SBJ4ZZ Excision of Left Tarsal Joint, Percutaneous Endoscopic Approach 0SBK0ZZ Excision of Right Metatarsal-Tarsal Joint, Open Approach 0SBK3ZZ Excision of Right Metatarsal-Tarsal Joint, Percutaneous Approach 0SBK4ZZ Excision of Right Metatarsal-Tarsal Joint, Percutaneous Endoscopic Approach 0SBL0ZZ Excision of Left Metatarsal-Tarsal Joint, Open Approach 39

40 Predict Risk Deep dive analysis Detect patterns Determine root cause 40

41 ICD-10 Predictive Model for Risk Identify codes that will be impacted the most by the ICD-10 conversion (top unspecified dx) Prioritize physician and coder education by isolating the populations at greatest risk for missing documentation Estimate revenue at risk from likely MS-DRG changes Re-profile physicians and service lines 41

42 MS-DRG Potential Change Analysis Potential negative/positive * MS DRG change ($) * MS-DRG change (#) Documentation risk based on ICD-10 changes above what was required in ICD-9 for principal diagnosis or principal procedure 42

43 Documentation Specificity Risk ICD-9 Procedure Code Total hip replacement There are 34 ICD-10 Equivalents ICD-10 Documentation Area Approach Laterality Device Prosthesis More specificity Open or closed Left or right Synthetic substitute: metal, polyethylene, ceramic, autologous tissue Cemented or uncemented 43

44 Adding Clinical to the Mix The biggest force in the transformation from Decision Support to Business Intelligence is incorporating CLINICAL. 44

45 Quality Nursing Rounding Tools *Beta-Blockers during perioperative period (Joint Commission Core Measure, SCIP) *Catheter-Associated Urinary Tract Infection (Joint Commission Patient Safety Measure) *Venous Thromboembolism (VTE) Prophylaxis (Joint Commission and NQF) 45

46 Hospital Outpatient Quality Reporting (OQR) Program Measure # Measure Type of Measure OP-10 Abdomen CT-Use of Contrast Material Claims-Based OP-11 Thorax CT Use of Contrast Material Claims-Based OP-12 OP-13 OP-14 The Ability for Providers With HIT to Receive Laboratory Data Electronically Directly into their ONC-Certified EHR System as Discrete Searchable Data Cardiac Imaging for Preoperative Risk Assessment for Non Cardiac Low Risk Surgery Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT) Web-based (Data entered on CMS web site) Claims-Based Claims-Based OP-15 OP-17 Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache Tracking Clinical Results between Visits Claims-Based 46 Web-based (Data entered on CMS web site)

47 Hospital Outpatient Quality Reporting (OQR) Program Measure # OP-18 OP-20 OP-21 Measure Media Time from ED Arrival to ED Departure for Discharged ED Patients Door to Diagnostic Evaluation by a Qualified Medical Professional Median Time to Pain Management for Long Bone fracture Type of Measure Chart-Abstracted Chart-Abstracted Chart-Abstracted OP-22 ED-Patient Left Without Being Seen Chart-Abstracted OP-23 ED-Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan Interpretation Within 45 Minutes of Arrival Chart-Abstracted OP-25 OP-26 Safe Surgery Checklist Use Hospital Outpatient Volume on Selected Outpatient Surgical Procedures Web-based (Data entered on CMS web site) Web-based (Data entered on CMS web site) 47

48 Hospital Outpatient Quality Reporting (OQR) Program Measure # Measure Type of Measure OP-1 Median Time to Fibrinolysis Chart-Abstracted OP-2 Fibrinolytic Therapy Received Within 30 Minutes Chart-Abstracted OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention Chart-Abstracted OP-4 Aspirin at Arrival Chart-Abstracted OP-5 Median Time to ECG Chart-Abstracted OP-6 Timing of Antibiotic Prophylaxis Chart-Abstracted OP-7 Prophylactic Antibiotic Selection for Surgical Patients Chart-Abstracted OP-8 MRI Lumbar Spine for Low Back Pain Claims-Based OP-9 Mammography Follow-up Rates Claims-Based 48

49 Hospital Outpatient Quality Reporting (OQR) Program Measure # Measure Type of Measure OP-27 * Influenza Vaccination Coverage among Healthcare Personnel Healthcare Associated Infection (HAI) OP-28 * Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures Chart-Abstracted (Webbased reporting) OP-29 * Endoscopy/Poly Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients Chart-Abstracted (Webbased reporting) OP-30* Endoscopy/Poly Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps- Avoidance of Inappropriate Use Chart-Abstracted (Webbased reporting) OP-31 * Cataracts Improvement in Patient s Visual Function within 90 Days Following Cataract Surgery Chart-Abstracted (Web- 49 based reporting)

50 New Territory for Business Intelligence Patient Satisfaction not just measure if patient is happy with the care Medicare reimbursement tied to scores 50

51 HCAHPS Hospital Consumer Assessment of Healthcare Provider and Systems National standardized survey designed to: produce comparable data based on discharged patient s perspective on care comparisons between hospitals on domains important to consumers public reporting of results to create incentives to improve care 51

52 HCAHPS Survey is 32 Questions 21 patient perspectives on care and patient rating items that encompass eight key topics: Nurses communicate - Always Doctors communicate - Always Staff responsiveness - Always Pain management - Always Medicine communication Always Discharge information - Yes Cleanliness of the hospital environment - Always Quietness of the hospital environment- Always 52

53 Hospital Value-Based Purchasing (VBP) Links a portion of IPPS hospital s payment from CMS to performance on a set of quality measures. 53

54 Med Surg LB HCAHPS Scores FY2014 Med/Surg LB FY2013 FYTD14 difference % difference Overall Rating % Communications with Nurses % Communications with Doctors % Communications about Medications % Responsiveness of Hospital Staff % Discharge Information % Pain Management % Cleanliness of the Hospital Environment Quietness of the Hospital Environment % % Average difference % Above the 50th percentile FYTD14 54

55 Tap into the Power of Visual Perception Vision is by far our most powerful sense. Seeing and thinking are intimately connected. This can be applied directly to the dashboard design: what works, what doesn t and why. 55

56 Nothing Screams Sexy like Dashboards Sepsis Day of Stay HCAHPS Productivity Cost per Adj Discharge Profitability OR Volume LOS all Physicians Payor 56

57 (All) ALL DRGs Monthly Breakdowns by DRG *Peer data date range (Jul 2011 Jun 2013) MIMG CMI MHR 1.42 Top Decile 1.43 CA 1.52 SJHS

58 Day of Stay Totals for DRG's 870, 871, & 872 7/1/2012 6/30/2013 DRG (All) REV CTR (All) Mission Hospital Top Decile Performers CHG CODE (All) ALOS Day # Patients Diff # Charges Var Dir Cost Cost per Pat , , ,322 36, ,821 1,337,161 2, (11) 19,878 1,105,629 1, (27) 15, ,090 1, (82) 12, ,239 1, (125) 9, ,835 1, (89) 7, ,244 1, (81) 5, ,647 1, (55) 4, ,941 1, (44) 3, ,122 1, (25) 3, ,325 1, (17) 2, ,266 1, (19) 2, ,269 1, (16) 1,781 93,307 1, (14) 1,591 86,081 1, (4) 1,421 73,924 1,344 58

59 Decision Support (DS) & Business Intelligence (BI) both use IT tools but DS turns data into information BI transforms data into informed actions and predict future outcomes incorporating risk Multi-disciplinary connection between clinical and financial 59

60 In Summary: Top 5 Ways to Transform DS to BI 1. Create a cross functional team: Clinical, technical & business expertise for a 360 degree view of organization. 2. Be flexible in approach to data: Not all data is created equal 3. Deliver value: Be objective and evaluate BI decisions with a critical eye fresh eyes. 4. Determine the BI vision: Document your roadmap of projects 5. Involve Users: Whatever the analysis, reports or dashboards, identify the parameters that you can provide and communicate these expectations to users. 60

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62 Contact Us Marge Gray, PMP Business Solutions Consultant Craneware (407) Anita Reisman, RHIA Manager, Data Integrity & Reporting Mission Hospital St. Joseph Health Laguna Beach CA Mission Viejo CA (949) ext 2175 (949) cell 62