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Missed Opportunities?

October 1, 2007
by Daphne Lawrence
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Post-acute care's special challenges don't have to stand in the way of an optimized revenue stream

Jonothan Skinner

Jonothan Skinner

If post-acute, rehab or long term care is part of an integrated delivery network (IDN) or hospital system, it may not be getting paid what it deserves. Though there is a large revenue stream associated with these services, there's also a big challenge in collecting it — business rules from Centers for Medicare and Medicaid (CMS) have recently become so stringent that reimbursement is often less than it should be. Not surprisingly, a new crop of IT solutions is meeting this need, and some providers are already seeing results.

"There's a whole other level of complexity in rehab," say Paula Dillon, revenue cycle manager at the Healthcare Financial Management Association (HFMA) in Chicago. "Most of the payment approaches are based on what kind of resources do you provide. And if you categorize a rehab patient as the highest level, then you need the documentation to support it."

Jonothan Skinner, president of the 116-bed Baylor Institute of Rehabilitation, part of 2,793-bed Baylor Health Care System (Dallas) agrees. "From a legislative standpoint, it's been getting harder for patients to qualify for inpatient rehab. It is vital to document accurately in order to capture all the patient deficits to maximize reimbursements."

A good record can make all the difference and, many agree, electronic documentation can help ensure that all the rules are in place.

Major changes in the space happened about four years ago, says Bruce Mortensen, CEO of Tempe, Ariz.-based MediServe, an IT vendor for post acute and rehab care. "With our baby boomer demographic shift, CMS saw the problem looming in rehab and pulled the only lever they can — financial." Skinner says CMS started increasing the amount of documentation required both for initial patient classifications and therapies. "We saw an explosion in terms of requirements imposed on the post acutes," he says. "Revenue went down."






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In inpatient rehab, for instance, Medicare's payment is based on patient assessments by physical, occupational and speech — the FIM, or functional independence measure. Medicare has very specific guidelines on how to score the patient on their functions, and divides the data into case mix groups, with 14 levels of severity in each group.

"It's really about putting the right patient into the right case mix," says Gerrit Helbig, clinical IT director for Banner Health, a 19-hospital 3,357-bed system based in Phoenix. "Medicare has three things we have to deal with for payment — case mix group for payments, co-morbidities that can add on payments for that case mix group, and the 75 percent rule that mandates 75 percent of the patients have to be from certain diagnostic groups."

Both Banner and Baylor Rehabilitation use MediServe's MediLinks product, an EMR for post-acute and rehabilitation care, and both say revenue has increased due to improvements in documentation.

"We've seen a more than $3,000 per case increase in expected payments since we rolled it out at Baylor in 2004," says Skinner. "Part of the financial gain is improved coding and the improved ability to score clinical outcomes that alter the payments." He says the organization decided to use the system as an EMR in the rehab space because it wanted a system that was specialized for rehab's unique needs. "We knew we had to be capturing clinical morbidities, and we knew we had to be more consistent with the FIM scoring." Previous paper-based workflows were not timely, Skinner says, and the business rules were so complex that it was difficult to customize a system to meet all needs.

Baylor's MediLinks system assembles the FIM score and calculates all the information for the facility, in addition to complying with Medicare guidelines that may change twice a year — it's automatically updated with new rules and regulations.

"We're one of 13 hospitals, and the central billing office for the system handles all the claims," Skinner says. "We interface, pushing and pulling data to our central business office to do the billing." It's just one interface, he adds. Though the MediLinks EMR is standalone for rehab, Skinner says they are working on integrating it into their enterprise system.

Banner, which went live with the same system in January 2007 for inpatient rehab, saw the first savings in increased charge capture accuracy and increased productivity for the therapists. "We expected to recoup one billable unit (15 minutes of therapy) per therapist per day," Helbig says. "We built that into the ROI."

With the recent CMS mandates, how accurately a patient is scored determines the reimbursement level, and many vendors today are getting in the game. For increasing the bottom line of the IDN, those using special systems for post acute say it makes a difference in their revenue stream. "You may not be denied payment, but you may be denying yourself the appropriate payment by not evaluating the patient correctly," says Bruce Mortensen, CEO of Tempe, Ariz.-based MediServe, an IT vendor for post acute and rehab care.

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