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A message from

our President Don’t Lose Focus Around Medicare
Advantage (MA) Shadow Billing
Opioids
Problem:
“…more than 300,000 deaths from prescription and Medicare Advantage shadow billing represents a strong reason for providers to have
illegal opioids since 2000, a drug-dependent baby born knowledgeable people, iron clad processes and properly working technology in place.
every 25 minutes, and life expectancy in the U.S. down for Hospitals are under increased pressure to make sure that they identify and re-coup
the second year in a row.” Wow, what a way to greet 2018! money that is rightfully theirs while balancing the challenges of dealing with a myriad
You can’t read a newspaper, listen to the radio, or surf of compliance issues.
your news websites and not see an article about opioid
abuse. In a recent article by NBS News, there is significant Solution:
discussion about whether the Food and Drug The following are some insights to aide in maximizing efforts and reimbursement:
Administration (FDA) could have done more to stem the
tide of opioid drug availability. Regardless, any web search 1. A comprehensive understanding and reconciliation to the PS&R report (both
using the words “opioid” and “crisis” will find hundreds Report type 110 and 118) will ensure that the MAC has captured the correct claims.
of current references. Jaime Caldwell
So, while the FDA tries to “right the ship” (they have 2. The function of shadow billing should occur within a reasonable period and not
taken one formula off the market because of the potential of it being addictive and allow too much time to pass by when performing retrospective reviews. Timely filing
have beefed up prescribing rules), what can we do? is non-negotiable in this case.
In a recent 117-page publication by the ECRI Institute entitled, “ECRI Institute
PSO Deep Dive: Opioid Use in Acute Care 2017”, the study’s authors use data sub- 3. Conduct on-going reviews to ensure that you are capturing and shadow billing
mitted to patient safety organizations to help identify opioid-related events. all MA patients you treat through automation and tracking (not just for Inpatient
Analyzing data from more than 7,000 reports collected over a three-year period, the acute patients but also for other related patient settings including Psych and Rehab
authors developed a list of recommendations for healthcare providers. units).
There are ten data-supported recommendations and I mention just a couple of
those recommendations below. The first recommendation calls for the formation of 4. Based on the results of your reviews, you may need to tighten existing internal
an interdisciplinary team “to review and improve on pain management and safety of processes and controls and create new ones as needed based on the results of your
opioid use in the hospital.” The importance of this recommendation comes from the review. Include team members that are familiar with the impact to reimbursement
review of the data where 35 percent of the reviewed opioid events resulted from when it comes to patient days and what is captured on the cost report.
administrative causes where communications issues came up in the root cause analy-
ses. Finally, stay in touch with your peers and industry experts and continually look in
Some of the other recommendations that I summarize below all involve the human areas where you didn’t look before (i.e., misclassified MA patients continue to be an
element in meeting the challenges caused by opioid use. Some of these recommenda- area of opportunity as well as non-traditional aged MA beneficiaries) to capture shad-
tions talk about the importance of leadership support to encourage staff buy-in, for- ow bills.
mulary options in clinical decision support and clinical judgment decisions, clinical
education, and giving feedback to healthcare providers. Potential Gain:
What the majority of the recommendations say to me is that there is a substantial Providers should not lose sight of the requirement to shadow bill! In fact, because
change in the pain relief paradigm. From our being focused on the total of declining reimbursement, you should put more focus on niche areas to help make
avoidance/management of pain, regardless of level, to the intelligent management of up potential deficits - simply missing 1% - 2% of these claims can result in significant
pain with the patients’ wellbeing of major concern. What we see in these recommen- lost revenues!
dations is that it is going to take a community of professionals focused on our
patients’ best interests to move us from that old paradigm, to our new one. Providers are successfully capturing between 92% – 99% of the claims that should
I highly recommend that you contact ECRI Institute at 5200 Butler Pike, Plymouth be shadow billed. This appears to be a strong success rate, but even a small percentage
Meeting, Pennsylvania 19462 or by telephone at (610) 825-6000, and get a copy of increase to your IME/ GME can increase payments by $250,000 to $750,000 annually.
this report.
Mario Feher
Director, IMA Consulting

2018 BOARD OF DIRECTORS SFHHA COMMITTEES

CHAIRMAN: David Wagner, Kindred South Florida Market CEO
VICE CHAIRMAN: Mark Doyle, Chief Executive Officer, Memorial Hospital Pembroke
SECRETARY: William "Bill" Duquette, Chief Executive Officer, Homestead Hospital, Baptist Health South Florida Education Committee
TREASURER: Charles Felix, Publisher, South Florida Hospital News and Healthcare Report
IMMEDIATE PAST CHAIR: Chantal Leconte, Chief Executive Officer, Joe DiMaggio Children’s Hospital
AT-LARGE: Ben Riestra, Chief Administrative Officer, UHealth’s Lennar Foundation Medical Center Healthcare Finance and Management Committee
AT-LARGE: Joel Wherley, Chief Operating Officer, VITAS
Doug Bartel, MBA Patricia Greenberg Patrick Taylor, MD
Sr. Director of Business Development, Media President Chief Executive Officer Health Information Technology Committee
and External Relations National Healthcare Associates Holy Cross Hospital
Florida Blue
Ralph A. Marrinson, NHA, FACHA Steven Ullmann Marketing and Public Relations Committee
Wael Barsoum, M.D. President Director
Chief Executive Officer Marrinson Group University of Miami Health Policy
Cleveland Clinic Hospital Management
Lincoln Mendez Membership Committee
Kevin Conn Chief Executive Officer Ana M. Viamonte Ros, M.D.
Regional Vice President of Operations South Miami Hospital Medical Director for Palliative Care
HEALTHSOUTH Corporation and Bioethics Quality and Patient Safety Committee
Charles Michelson Baptist Health South Florida
Darcy Davis Partner
Chief Executive Officer Saltz Michelson Architects Enrique Vicens-Rivera, JD, MHSA
Health Care District of Palm Beach County Chief Executive Officer Safety and Security Committee
Aristides (Ardy) Pallin HEALTHSOUTH Rehabilitation Hospital Miami
Michael Gittelman Chief Operating Officer
Chief Executive Officer Catholic Health Services
Bascom Palmer Eye Institute

38 February 2018 southfloridahospitalnews.com South Florida Hospital News