Medicare Part D
eligibility data has strict parameters on how it’s used. However, a new
report from the Office of Inspector General (OIG) released a report
noting there was a lack of CMS monitoring around the usage of the data. The
report also found that pharmacy providers were taking “gaps” in a system to
verify eligibility.
What
Precipitated the Audit
CMS requested
the audit by OIG for a specific mail-order pharmacy. CMS had concerns regarding
this pharmacy, and the OIG added 29 more thought to be possibly misusing the
information.
Audits of High
Volume E1 Transactions Reveal Misuse
The OIG
performed an audit on 30 carefully chosen pharmacies that had high volumes of
E1 transactions compared to their number of total prescriptions. A pharmacy
should use an E1 transaction to bill Part D when patients don’t have their Part
D plan card.
The appropriate
use of such data should revolve solely around billing for the medication.
However, the OIG discovered that 25 of the 30 pharmacies were using this data
for other purposes. Almost 98% of those companies’ E1 transactions were not
associated with a prescription. This revelation indicated to the OIG that the
data was being misused.
Out of those 25
pharmacies, the OIG contacted 15 to inquire further about their use of data.
They found that 10 of those businesses were either closed or under
investigation.
How Was Data
Misused
Pharmacies used
the Medicare Part D eligibility data in inappropriate ways according to the
report, including for marketing purposes. Pharmacies often have agreements with
marketing companies to provide data about eligibility to fuel telemarketing
services. Further, the data was sometimes used to learn about a patient’s
private insurance coverage
Why It Happened
The OIG said these inappropriate uses of Medicare Part D eligibility data occurred because CMS hadn’t established controls to monitor E1 transactions. CMS has since started a monitoring program. They have also denied E1 transaction access for 20 of the 30 organizations audited.
What to Know
About Pharmacy Audits
Pharmacy audits are
standard practice in the industry. Those audits can be requests from government
entities or insurance companies. When an audit occurs, pharmacies often
scramble to aggregate all the required data to comply. This may include
searching legacy systems
and current systems.
Many pharmacies
have found it beneficial to archive old records. With an archiving platform,
you can meet medical record retention regulations and have easy access to all
patient data should an audit occur.
Pharmacies of
every type have been able to simplify record management with our data archiving
tool ViewMaster. Learn more
about how it can be a valuable tool in audit compliance.
Hospital bankruptcies are becoming more modern, even in a
world where there are more patients, more treatments, and more medications.
According to Bloomberg, 30 hospitals entered bankruptcy in 2019. But why is
this becoming an epidemic, and what happens to patient data once facilities
shutter?
Deciphering the Rise in Hospital Bankruptcies
There are multiple causes for the collapse of hospitals;
like anything in healthcare, it’s complicated. Overall, many hospitals are
thriving and profitable, but it’s not across the board. So, what’s driving the
trend?
Shift to Value-Based Care and Meeting Federal Mandates
CMS initiated this transformation from fee-for-service to
value-based care in 2015. In the past, providers were paid for the amount of
services performed. This model incentivized providers to order more tests and
procedures. Spending was up yet had no real positive impact on patient
outcomes.
To course correct, the federal government developed
value-based care structures, which, in theory, focused on improving the quality
of care and accounting for the price at the point of care. In this model, physicians
are encouraged to use evidence-based medicine, engage their patients, invest in
health IT, and leverage data analytics to get paid for services.
This shift sounds like a winning proposition for all, but it
put enormous stress on the industry, leading to less revenue and more spending.
The American Hospital Association (AHA) found that community hospitals spend an
average of $7.6 million each year on administrative costs to meet
federal regulations related to quality reporting, record-keeping, and
meaningful use compliance. This increase in spending doesn’t exactly correlate
to reducing costs or improving care, making many hospitals vulnerable to collapsing.
Americans Are Leaving Rural American in Droves
According to the U.S. Census Bureau, approximately 80% of U.S. citizens live in urban areas. That number
has continued to rise because urban areas offer jobs, amenities, and better
schools. Employment opportunities in small-town America are drying up, with the
local county hospital often being the biggest employer. With fewer people and
businesses in rural areas, community hospitals are struggling to stay afloat.
Medicare and Medicaid Reimbursement Rarely Covers the Cost of Treating the Patient
The AHA found that CMS paid 90 cents for every dollar a
hospital spent on Medicaid beneficiaries, while it was only 88 cents for
Medicare patients. This inequity leads to a shortage of $41.6 billion for
Medicare providers and $16.3 billion for Medicaid providers. Eventually, these
shortfalls catch up to hospitals and leave them drowning in debt.
Complicating the matter is that the Affordable Care Act
(ACA) cut disproportionate-share hospitals (DSH) payments. The assumption was
that under the ACA, hospitals would no longer need DSH payments. The problem is
that some states did not choose to expand Medicaid under the ACA, leaving them
financially vulnerable.
Urgent Care Facilities Taking a Cut from Hospitals
Years ago, if you need immediate care, the only option was
the ER. The ER was once filled with patients with “minor” injuries like a
slashed finger or a broken arm. Now, patients have more options that are less
expensive and quicker. Urgent care facilities have expanded considerably, often
staying open late and offering services on the weekend.
While this new type of care does reduce some of the costs
across the entire healthcare ecosystem, it means hospitals lose patients. Most
hospitals only considered competition to be the other healthcare system; now,
the competition is much closer and offers more convenience to the average
consumer.
Hospital Closures: What Happens to Patient Data?
Not all hospitals that file bankruptcy disappear. Many are
sold to larger health systems that consolidate and initiate strategies to go
lean like laying off workers. However, some completely liquidate. The question
is, what happens to patient records?
Federal and state laws impose mandatory medical record
retention requirements on hospitals and physician practices. The Medicare
Conditions of Participation, for example, require hospitals to retain records
for five years (six years for critical access hospitals). HIPAA and HITECH have
included new requirements on top of this, while states also have their own
requirements.
Thus, whether that hospital is sold or closed forever, those
records have to be kept and be accessible to patients. In many cases, if a
healthcare system takes over a hospital, they may choose to add the data to
their EHR system, which would require a data
conversion.
However, since the buyer doesn’t have insights into the
quality or relevancy of the data, they may choose to keep it separate, opting
for a data archiving solution. Archiving can be a low-cost,
compliant way to retain access to the data.
Who Becomes the Holder of Records with Closures?
If a hospital closes, records management planning must take
place, and typically the organization is still held liable for keeping PHI safe
and secure. A closed hospital can transfer its patient records to another
entity, which then agrees to accept responsibility. Like in the scenario of a
hospital being sold, the new holder of the data could choose to convert them to
their system or archive them.
Should there be no healthcare organization that wants to
take ownership, a reputable commercial storage firm can then hold those
records. It’s also critical that any impacted patients be formally notified of
the closure and how they can access their records. Bankruptcy doesn’t protect
these entities from doing their due diligence when it comes to maintaining and
providing access to the data.
Hospital Bankruptcies Have Significant Impacts
Unfortunately, the trend of hospital bankruptcies isn’t
projected to decline. The lasting effects of these bankruptcies is felt by the
community, patients, and medical professionals. As the ecosystem of healthcare
continues to evolve in this country, having access to care and medical records
will continue to be a concern and challenge.
New Study Reveals Physicians Spend More Time with EHRs Than Patients
Electronic
health records (EHRs) were supposed to revolutionize the healthcare industry,
making it easier and more efficient for clinicians. After years of incentives,
the majority of physicians leverage EHRs, but that doesn’t mean technology has
solved the problem. The question is: are EHR workflows hurting or helping
physicians?
New Study Shines Light on EHR Usage
The Annals of Internal Medicine published a new study
about how long physicians spend on EHRs. The results reveal some cause for
concern. On average, a doctor spends 16 minutes and 14 seconds using their EHR
for every patient seen. Since the average patient visit is 30 minutes, half of
the time is spent on the screen rather than solely with the patient.
The study
included data from over 155,000 physicians cover over 100 million patient
visits. The average time of usage was determined based on the user being
active, not just being logged into the system. The activities were placed into
three categories:
Chart review (33% of the time)
Documentation (24% of the time)
Ordering (17% of the time)
There are lots
of tasks related to these three categories, and there is no way to know from
the study if EHR workflows were efficient or if the user had any
training.
Technology Should Help, Not Hinder Physician Workflows
Doctors have
frustrations with EHRs. Those frustrations can lead to burnout, which is on the
rise. MedScape released a report that found 44% of physicians feel “burned out.” Documentation
requirements increase due to complexity and all the different areas of
information needed. It’s not simply about entering information about the
patient’s symptoms, treatments, and care. There is also the billing and coding
component.
Ideally,
technology should help, not hinder physician workflows. If EHRs are not
intuitive and don’t match physician workflows, then they’ll spend more time on
the screen than with the patient. No doctor wants to do this. The expectation
is that clinicians are intelligent and understand how to use EHRs. While that’s
true, how many EHRs are actually designed to align with physician
workflows?
If it’s not
intuitive, then why bother. In looking at the EHR
satisfaction gap among clinicians, much of the time, it comes down to
lack of relevant training. Of course, the other side of the argument is why
should something “intuitive” need hours and hours of training!
What’s Wrong with EHR Workflows
It serves to
reason that if workflows were more accurate, physicians would spend less on
technology. That’s not to say that every EHR lacks efficient workflows, but
often they may not be designed by actual users. Every EHR provider certainly
takes into consideration the user experience but apparently not enough,
considering the EHR dissatisfaction is often linked with burnout, according to
a Mayo Clinic survey.
Technology is a
part of modern medicine, but it still has challenges and limitations.
Overall, data management
for healthcare continues to be a struggle. They have concerns with
accessibility, portability, and interoperability. Those three things should be
a given with healthcare technology and are certainly the foundation of the
services we provide healthcare organizations.
Until the
industry reaches alignment with physician users, EHRs won’t decidedly be deemed
as helpful rather than troublesome.
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