Inpatient Psych Facilities Spend $1.7B on Medicare Compliance

March 25, 2019
 – Inpatient psychiatric facilities are spending a significant proportion of their average revenue on compliance with basic conditions of participation for Medicare, according to a new report from the National Association of Behavioral Healthcare (NABH).
Inpatient treatment centers spend a total of $1.7 billion each year on Medicare compliance, which equates to 4.8 percent of the average facility’s annual revenue, including all revenue from services covered by commercial insurance.
The high cost of participation, as well as inconsistent application of regulations in the real-world environment, make it challenging for psychiatric facilities to stay compliant with Medicare.
The administrative burdens associated with participation may even prompt some providers to stop accepting Medicare all together, making access to behavioral healthcare even more challenging for the nation’s aging population.
“Inpatient psychiatric facilities operate under a heavy burden of federal regulatory requirements,” explains NABH. 

Three major categories of requirements that pose the most problems for facilities, the organization said.
A list of regulations known as “B-tag” requirements are among the most problematic, asserted the report.  B-tag regulations include detailed protocols for patient evaluations, medical records, and staffing levels. 
However, many requirements have not been updated in decades, resulting in outdated and confusing workflows for providers and administrators.
“As enforced today, the B-tags produce frequent citations and impose large costs on providers, mostly through low-value documentation requirements,” said NABH. “Among our respondents, almost 80 percent of freestanding psychiatric hospitals report at least one B-tag citation in their most recent three compliance surveys.”
The association estimates that B-tag compliance costs inpatient psychiatric facilities $622 million annually, largely due to on-the-ground interpretation of these rules by Medicare surveyors.

Surveyors may demand specific approaches to meeting compliance guidelines without assessing whether an existing strategy still meets the federal program requirements, the report explained.  This produces an environment in which success is more or less arbitrary, and providers may spend millions of dollars revamping an adequate program simply to meet the criteria of an individual assessor.
Psychiatric facilities are also taking issue with Medicare’s requirement to address ligature risks, or physical structures within the facility that could be used for self-strangulation.
“Psychiatric providers care deeply about keeping patients safe, which includes protecting patients from self-harm or suicidal behaviors,” said the brief. “As CMS has recognized, however, providers cannot feasibly create ‘ligature-free’ environments that are completely devoid of potential ligature attachment points.”
“Nonetheless, some surveyors demand major changes to psychiatric facilities’ infrastructure or staffing to address perceived issues that carry only minimal risk for patients in that setting.”
Sixty percent of NABH members responding to a survey about the issue have received a citation for ligature risk within the last two years, the report notes.  Facilities spend an average of $15,600 per bed to address these issues, again to meet the individual assessments of surveyors who may contradict one another.

NABH urges Medicare to institute a more standardized approach to assessing facilities for ligature risks and offer more guidance on areas that present the highest risks.  These steps would reduce the likelihood of high spending on lower-value modifications.
Lastly, the organization is seeking revisions to enforcement of the Emergency Medical Treatment and Labor Act (EMTALA), which is intended to ensure that anyone presenting to a hospital’s emergency department will be screened and stabilized regardless of their ability to pay for services.
While NABH supports the law and its mission to ensure access to care for all individuals, the law’s impact on the inpatient psychiatric environment is not the same as in acute care.
“EMTALA permits each provider to determine which clinicians are designated as ‘qualified medical persons’ (QMPs) who may screen patients for emergency medical conditions,” details the report.
“Some regulators, however, are using EMTALA to raise the baseline licensure requirements for QMPs in inpatient psychiatric facilities. This approach upends decades of accepted clinical practice, and fails to account for widespread shortages of clinicians with psychiatric expertise.”
The law is also putting pressure on some inpatient facilities to admit involuntarily committed patients, regardless of that facility’s ability to manage the risks those patients may present to themselves or others.
“EMTALA should not be used to address the shortage of facilities that treat involuntarily committed patients,” NABM asserts. “Federal regulators should respect state procedures for involuntary commitment, including state arrangements for facility designation and patient transfer.”
The ability for inpatient psychiatric facilities to meet Medicare compliance requirements can have major effects on the commercial insurance industry, as well.
These facilities tend to operate under extreme financial constraints, and the more they spend on Medicare compliance, the more they will need to charge commercial payers to compensate.
The Centers for Medicare and Medicaid Services has made significant efforts to reduce administrative burdens for acute care and physician providers, but has not yet addressed similar pain points in the behavioral health ecosystem.
“These concerns lie at the heart of CMS’ ‘Patients Over Paperwork’ initiative,” the report points out, referencing Administrator Seema Verma’s signature effort to slash redundant, costly requirements for providers.
“CMS should take this opportunity to modernize its guidance and standardize its survey practices. The proposals outlined here would cost CMS little to implement, and would lift a heavy burden from psychiatric facilities and their staff without affecting—and perhaps even improving— care quality and access for patients with severe behavioral healthcare needs.”
Reforming the application of B-tag regulations, which are fundamentally more than half a century old, could significantly reduce unnecessary spending and increase financial security for inpatient psychiatric treatment centers, as would improving the process of assessing facilities for compliance with ligature risk rules and EMTALA protocols.
“Adopting less burdensome requirements would benefit the healthcare system overall by reducing unnecessary costs, and by bringing greater stability and predictability for providers as they navigate the regulatory environment,” stresses the NABH.
“In addition, patients may directly benefit from reduced regulatory burden as clinicians are able to shift more of their attention—and facilities are able to shift more of their resources—away from compliance for compliance’s sake and toward initiatives that meaningfully contribute to safe, high-quality care.”

5 Best Practices To Ensure A Smooth, Expedient ICD-10 Transition

The ICD-10 Compliance date is looming and it is imperative that healthcare providers be prepared to make the transition. It affects everything from claims processing, physicians’ workflow, and patients’ access to care. Many organizations may be rallying employees and resources in order to make the switch from the ICD-9 to the ICD-10 coding for medical diagnoses and inpatient hospital procedures before the implementation date of October 1, 2015.

To make matters worse, the transition is not easy, but a major undertaking with nearly 19 times as many procedure codes and almost five times as many diagnosis codes in the ICD-10 than in the ICD-9. While the ICD-10 switch is definitely necessary, as the outdated and clinically inaccurate ICD-9 has not been updated since its installation, in 1979, the ICD-10 stands to enhance the quality of healthcare, improve data for epidemiological research, as well as enable physicians to make better clinical decisions. However, this is dependent on the ability for the healthcare industry to make a smooth and accurate transition to the new International Classification of Diseases, according to Richard Milam, president and CEO of EnableSoft

In order for healthcare providers to successfully meet the ICD-10 deadline, Milam suggest five best practices to ensure an expedient, smooth ICD-10 transition:

Richard Milam, president and CEO of EnableSoft
1. Employ Robotic Process Automation That Does the Work for You

“You” is meant to imply the entire organization because that is how many resources it will take to have the ICD-10 switch completed by the deadline if Robotic Process Automation is not used to update and add the multiple new codes into EMR, NDC, medical billing, and claims processing data systems. Certain softwares may have to upgraded or replaced to support the 68,000 diagnoses codes and nearly 87,000 procedure codes; however, through a series of human-directed scripts, Robotic Process Automation technologies will populate the specific fields in the data systems with the ICD-10 data required. The already costly transition to the new ICD-10 can be mitigated by not having to outsource or hire new employees to enter the new codes manually. Furthermore, the data transition can take place over the course of a few days, not a few months, ensuring healthcare providers will be ready to transition to using the new ICD-10 codes.

2. Test Your Software

Not only should you confirm with your clearinghouses, billing service, and payers that they will be upgraded and compliant with the ICD-10, but when they will be ready for testing to occur. Robust end-to-end testing must occur with your software in order to ensure claims are being accepted properly and processed by insurance contractors, Medicaid, Medicare, and other payment processes are operational. Test internally to ensure transactions can be generated and sent with the ICD-10 codes and test externally to ensure the transactions are successfully received by payment providers and that the payment can be processed correctly. After October 1, any ICD-9 codes used in transactions will not be accepted for services and will be rejected for payment. Failure to test your software properly can result in disruptions in patients’ receiving the treatment they need and receipt of due payments.

3. Educate or It All Falls Down

The updated, enhanced medical coding that is to enhance and improve patient diagnoses, performed procedures, treatment, and billing will not prove capable of these abilities without humans to employ its codes, terminology, and procedures appropriately and correctly. You must educate your staff about the changes to the ICD-10 and perform practices and routines in order to prepare for the change. Have each of your staff participate in educational seminars in order to become informed of the changes and how that will affect their position, the procedures patients are to undergo based on the new diagnosis codes, as well as the improved treatments that patients are to have performed. Assist and inform staff by identifying the 50-100 most commonly used ICD-9-CM diagnosis codes based on specialties and determine the equivalent ICD-10-CM codes, and have this information accessible before and after the implementation of the ICD-10. Having your staff prepared and knowledgeable about the ICD-10 will reduce delays in patient care and procedures, which is the reason for the ICD-10—to deliver improved diagnosis and advanced medical treatments that will enhance patients’ quality of care.

4. Implement an Effective Communication Method and Coordinate Conflict Resolution

While making the data transition and update to the new and diverse medical coding that is in the ICD-10, it is imminent that there may be delays in processes, confusion over coding and form completion, as well as workflow changes. Make sure your employees know who they can contact or call on if they are unsure of what code to report, how to complete a form, or other transitory questions that may arise following the implementation of the ICD-10. Identify leads and supervisors for each workflow and specialty area that will be available for their staff requests and questions, and make sure those individuals are highly educated on the ICD-10 and have the authority to execute a resolution. Additionally, determine how transactions handled just prior to the compliance date will be handled in order to ensure payment processing will occur—and more importantly—patients are covered financially and receive the best treatment. Identify critical areas or procedures that may be challenging to transition to using the ICD-10 and have practical resolutions for those practices ready to be executed if, and when, needed.

5. Obtain the correct medical documentation and update your forms to support the ICD-10.

Patient intake forms, EMR forms, insurance forms, and superbills must be updated to support the ICD-10 codes. In order to have patient medical records completed correctly and treatments performed effectively, in addition to have payments process, healthcare providers, clearinghouses, and payers must update their forms to reflect the codes in the ICD-10. Physician forms must be updated with the new medical terminology and diagnoses and procedural codes, along with superbills. Identify categories of uncommon services and diagnoses and determine units, time, and cost for each category in order for physicians to be able to report in the EMR and on superbills. Determine and have readily available a list of common or most frequently used abbreviations to ensure they are utilized correctly and correspondently with the ICD-10 terminology and codes. Lastly, and this goes without saying, obtain the updated and correct documentation that will stand as educational and reference material in regards to the ICD-10. The American Medical Association publishes the ICD-10 codebook and other supplementary documentation on topics such as anatomy and physiology, mappings, and coding workbooks. Make sure to have these ICD-10 Bibles available, and in all areas, for staff and physicians to reference when needed or desired.

The healthcare industry is about to embark on an intense change in treatment, reporting, and payment processes as the ICD-10 Compliance date approaches. While the ICD-10 is definitely necessary to reflect advances in medicine and detailed diagnoses, the change is extremely disruptive for healthcare providers. By employing efficient technologies and engaging effective strategies, healthcare providers can execute the ICD-10 transition quickly and accurately by the compliance date.  READ MORE

Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Billing and RCM, Medical Transcription, Pre-Certs with AzaleaHealth EHR.   We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information.  We have education programs in Medical Scribe Specialists. #medicaltranscription #azaleahealthEHR #revenuecyclemanagement