Midas+ Hospital Case Management and RAC Denial Management

Transcription

1 Midas+ Hospital Case Management and RAC Denial Management Cindy McCollum and Dan Parker Midas+ Product Management Specialists Liz Barnes RN, MS, CPHM Midas+ Solutions Consultant

2 Objectives 1. Describe enhancements in Version 2011 HCM Avoidable/Denied Days and Concurrent Review. 2. Identify the new Interface functionality for Physician Advisor referrals. 3. List the Toolkits available to support denial and appeals management. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 2

3 Version 2011: HCM Avoidable/Denied Days Enhancements 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 3

4 Payer Tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 4

5 Appeal Tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 5

6 Entered By Functionality 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 6

7 Shipping Tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 7

8 Notes Tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 8

9 New or Changed Avoidable/Denied Days Dictionaries (711) (170) (123) (175) (176) Carrier HCM-Type of Days HCM-Cause HCM-Certification Type HCM-Certification Status 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 9

10 Version 2011: HCM Concurrent Review Enhancements 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 10

11 Then: HCM Concurrent Review Now: 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 11

12 Version 2011: HCM Concurrent Review 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 12

13 USING FAVORITES 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 13

14 Midas+ HCM Concurrent Review Live Demo 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 14

15 Physician Advisor Referral Interface 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 15

16 PA Referral Interface A bi-directional interface developed by Midas+ and 3 rd party vendors to help hospitals manage their Physician Advisor Referral process Enables the hospital to electronically submit Referrals and receive electronic communication from the 3 rd party vendors through Midas+ Enables the electronic receipt and attachment of the Determination letter 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 16

17 Concurrent Review 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 17

18 PA Referral 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 18

19 Disposition upon Referral 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 19

20 Outbound Transaction Includes the following data elements: Transmission Date and Time Unique Identifier Patient Name Patient s MRN Patient DOB Patient Sex Facility ID (Vendor specific code) Encounter Type:Type Principal Payer Type Principal Payer Name Insurance ID# Account Number Start Date End Date HCM Diagnoses HMC Procedures Attending Physician Name Attending Physician Phone Number Attending Physician Address Attending Physician ID (code) Current Location/Room Number Comments Review Date Reviewer Reviewer s Phone Number Reviewer s Address Reviewer s ID (code) Level of Care Physician Advisor PA Referral Date Referral Reason

21 Comments 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 21

22 Acknowledgement of Receipt 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 22

23 Inbound Transaction Includes the following: Unique Identifier Account Number Facility ID Disposition Referral Comments

24 Status Updates 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 24

25 Final Disposition 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 25

26 Final Determination Letter 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 26

27 PA Interface Implementation Dictionaries (1) Provider (550) HCM-Referral Reason (117) HCM-Disposition Dictionary (7) Employee (508) Facility ID Type (501) Facility

28 Midas+ EHR Integrated Toolkit for RAC Appeals 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 28

29 EHR Integrated Solution A bidirectional interface developed by Midas+ and EHR to help hospitals manage the RAC appeals process Enables the hospital to electronically exchange RAC appeals information as well as status updates with EHR Optimizes data integrity and completeness throughout the RAC appeals process 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 29

30 EHR Integrated Solution This offering includes a Midas+ created and distributed Focus Study and a distributed dictionary Midas+ has designed a Focus Study to support bidirectional data exchange between a client hospital and EHR The Focus Study will store the data sent by the hospital as well as the data returned from EHR 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 30

31 Requirements Clients must be running Midas+ Care Management version 8.0 or higher Clients must be contracted with Midas+ for the EHR Integrated Toolkit Clients must be contracted with EHR specifically for the EHR Integrated solution 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 31

32 User Documentation User documentation can be found on the Clients Only website under User Documentation. Select Care Management as the category and look for RAC Appeal Tracking using EHR Integrated Data Collection and Extraction Toolkit 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 32

33 Secure FTP Secure FTP (SFTP) is the protocol required to submit these interface transactions to EHR There is no action required by the hospital The SFTP transactions will be sent to and come from the same IP address All communication will be initiated by the Midas+ server 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 33

34 How EHR Integrated Works 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 34

35 EHR Communication Tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 35

36 Worklist Rule Defined Clients may define SmarTrack Worklist Rules for notification of new updtes 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 36

37 EHR Tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 37

38 Worklist 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 38

39 EHR Communication Tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 39

40 Midas+ AHA RACTrac Toolkit 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 40

41 RAC Reporting Needs Internal and External Many clients have expressed the desire to change the dictionaries to better reflect internal reporting needs Many clients have expressed the desire to change the indicator definition to better reflect internal reporting needs RAC data needs to be incorporated with other denial information to present comprehensive reports to hospital administration Clients have requested that Midas+ support automated reporting to AHA RACTrac 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 41

42 AHA RACTrac - Evolution of Data Entry and Reporting A Focus Study to collect the specific information required for RACTrac reporting has been developed! This data is exported in a.csv file suitable for electronic submission to the AHA RACTrac This allows clients to enter hospital based denial information in the Avoidable and Denied Days Module, meet internal reporting needs AND collect and report the unique data required for AHA RACTrac 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 42

43 AHA RACTrac - Client Benefits No need to keep the Avoidable/Denied Days dictionaries updated to support RACTrac No need to keep indicator definitions of profiles updated to support RACTrac The Focus Study is modified by Midas+ to support RACTrac via an overlay You can choose what RAC information to include with other denial information in Avoidable/Denied Days The process for collecting and submitting data for RACTrac is simplified saving you time 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 43

44 AHA RACTrac - Painless Client Process The installation package is now available Focus Study and Standard Report that generates the.csv file will be programmatically distributed Quarterly, clients will simply run the Standard Report, save it to the Fload directory, log onto the AHA RACTrac Tool and upload the file 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 44

45 AHA RACTrac - Focus Study - Automated 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 45

46 AHA RACTrac - Focus Study - Complex 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 46

47 AHA RACTrac - Focus Study - Underpayment 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 47

48 Midas+ AHA RACTrac Live Demo 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 48

49 Thank you for attending. Questions, anyone? Cindy McCollum and Dan Parker Midas+ Product Management Specialists Liz Barnes Midas+ Solutions Consultant