NCQAndy

HCCA Northeast Regional Meeting

2014-09-12T13:53:00.000-04:00

Been a bit busy however taking some time to attend the HCCA conference getting some great ideas and some CEU's!

On the road again

2014-06-18T18:25:00.002-04:00

Well after a few months hiatus I'm back in the saddle again working with a few companies in the Boston area. Just a few musings I'm seen lately. HIPAA enforcements are up and the companies need to be ever vigilant. NCQA with standards are definitely working closely with federal guidelines with both HHS and CMS. Standards are slowly being unified but we are a long ways off...

Telemedicine

2014-05-14T09:34:00.002-04:00

Telemedicine has different meanings to different groups. For some it is a nurse line phone service. For others its a video chat service. No matter what your business is you always need to think about compliance and privacy. Do you have your privacy policies available. Do you review you calls for quality. Are your clinicians correctly licenses? Do you follow the states privacy's policies that you operate in? What about security? Do you have adequate protection for your members while streaming. Do you host or contract out? A lot of questions to think about. Servicing Medicare populations is vastly different than commercial..

Food for though.

Healthcare Compliance Consulting just launched

2014-05-12T09:00:00.002-04:00

Well folks checkout out the new website

www.healthcarecomplianceconsulting.com

It's a bit of a work in progress but its up and running..

Andy

Healthcare Compliance Consulting LLC

2014-04-28T08:58:00.002-04:00

Healthcare Compliance Consulting LLC

Well I just got back my paperwork from the State of NH. It's a reality. So now I am free to do some consulting work. More to come on this.. Drop me a line.

Andy
603-554-2336
andrew@healthcarecomplianceconsulting.com

ICD-10 delay

2014-04-16T21:41:00.001-04:00

Just some random thoughts on the delay. The delay simply came down to money and politics. In a nutshell you have the plans who were all set to go live vs. the practices who were still struggling to be able to do the conversion. ICD-10 while it provides greater clarity in diagnosis' its the new additional ,codes that don't match up that's causing angst. For small mom and pop shops this would mean loss of revenue. I think enough of them reached out to congress and got enough folks on their side.

Just my 2 cents

Andy

End of an Era- Health Dialog

2014-04-15T13:05:00.004-04:00

While folks I apologize for not posting more often lately. For the last 5+ years I've been at Health Dialog Services Corporation(A Division of BUPA). Well this month they sold the company to Rite Aid and went in a new direction. A lot of us were impacted including myself. I wish them the best of luck. So now its off to new and exciting things. I'm in the process of setting up some consulting work and looking for a FTE position. Drop me a line. I'll be posting this week on the ICD-10 delay and thoughts about it.

Andy

Data interoperability and Workforce Development - S&I frameworks meetings EU-US Conference

2013-10-28T12:10:00.004-04:00

Data interoperability and Workforce Development - S&I frameworks meetings

I thought I might follow up this a just a bit on what went on with these meetings. Originally we were going to present some results from our meetings on these topics. However the government shutdown put a crimp in those plans. So we met in both groups with whoever attended to go over case studies and have some dialog on the topic. The data meeting was pretty small however Dr. Jaffe Ceo of HL7 came in and basically had a roundtable discussion on a variety of topics. We did review our case studies and got some consensus on the topics.

•Scenario 1: Moving From Country to Country & Immunizations

•Scenario 2: Broken Eyeglasses

•Scenario 3: Planned Care

•Scenario 4: Patient has a heart attack and ends up in the ER (or patient is hit by a car)

•Scenario 5: Group of students traveling with someone acting on behalf of, or in the place of, a parent, legal guardian, patient, or subject who needs to obtain medical records for treatment

•Scenario 6: Ran out of/forgot prescription medication while on vacation and need it refilled (for example blood pressure medication)

•Scenario 7: Ambulatory (patient has pre-existing condition such as diabetes that has been out of control and needs to be addressed.

#1 and #2 weren't very popular. There was considerable discussion to combine a few of the other topics together. A moderator from ONC took down the comments and will use them for the next meeting.

Workforce was much better attended and have a large amount of folks from the EU present. What I found fascinating was the big difference between the EU and US where it comes to education and employment. In the EU what you get your degree in is what you stay in for a career path for the most part. Not always the case here in the US. Also many governmental jobs require masters degrees which also will eliminate younger workers. Here in the US usually it is experience more than the degree. The question of how will match job skills and roles to some type of standard was bantered around. ONC talked about the Meaningful use cert . It appears there was interest on both sides at looking at certification based program. We'll see where this leads.

Update on the EU - US Conference Update 10/24/13

2013-10-24T11:25:00.000-04:00

Well I have to say I was really happy that I went. Sometime things just work out on a conference once in a while. The S&I frameworks groups I was working on did meet and we had some pretty interesting conversations. The irony that only a couple of people attended the. However I got to talk to Charles Jaffe the CEO of HL7 for basically 3 hours one on one as we discussed case studies, C-CDA and a bunch of other topics. It was worth the price of admission for that. I did meet up with Dr.Fridsma(Chief Science Officer, Office of Science and Technology) and his team from the ONC during the workforce development meetings. I learned alot of how healthcare is done in the EU. Their private/public relationships are very different than what we have here in the US. Their rules and regulations are also very different. It's not say we don't have common ground but have a long way to go to understanding how we can find areas of common intersection.

More to follow

3rd EU-US eHealth Business Marketplace and Conference This week

2013-10-21T13:40:00.002-04:00

Well I'm attending this conference. I'm part of the EU-US MOU - Call-to Action and Roadmap Work Streams to support EU-US Collaboration. Basically in a nutshell we are trying to find some ways to unify standards to allow for the exchange of healthcare between the two groups.

Interoperability of Health Records

Dr. Larry Garber, Medical Director for Informatics, Reliant Medical Group
Catherine E. Chronaki, Secretary General HL7 International Foundation

International Workforce Development

Mary Cleary, Deputy CEO, Irish Computer Society Skills, Ireland

Stathis Konstantinidis, Research Scientist, Norut – Northern Research Institute, Norway

Are the two areas I've helped a tiny bit on so I'm pretty curious on what is being presented.

Data Quality Team and Compliance

2013-09-13T11:06:00.002-04:00

I'm going to go off and talk a bit on Data Quality Teams and Compliance. I think there is a constant struggle about who owns the data and who is responsible for it. Data Quality teams began to get some attention a few years ago in the US and you are starting to see the trend in the EU. Typically the Data Quality team resided under the IT or operations wing and it was put in place to review data going in and out of systems for completeness and accuracy. It was basically a check to what the day to day operations folks were doing and to catch issues. I'm going to suggest leveraging these teams if they exist to do compliance reviews. Who owns the DQT is always a good question. Being part of IT doesn't really give it independence and I really don't think a compliance team would have a budget for them. Being part of operations makes sense but there is usually a struggle about cost and value they bring to a organization. Smaller companies I really don't see being able to do this. However with EMR,EHR,Billing and PHA data all going into multiple systems you really need some sort of audit process in place. Also you need to think about HIE's and making sure the data gets and audit before it gets into those systems. Unique ID trackers are going to be required... So is your head spinning? Not only are you going to need legal, clinical and regulatory experience on your team but now also IT? I see alot of blended roles here and that leads to confusion on independence and oversight. Is your data analysis on loan to you from IT really trying to make sure IT or Compliance is happy? Who pays the salary and does the review? It's all questions you need to ask.

Compliance and Data - The Emerging Alliance

2013-09-11T11:17:00.000-04:00

Compliance and Data - The Emerging Alliance

Last year I mentioned a few times the importance of having compliance involved in data collection and analysis. At the HCCA regional conference in Boston this month this came up as a topic several times. In order to provide evidence of compliance for various state and federal programs you need to provide data evidence. How would a compliance officer be able to verify with impartiality that the information is correct? The term data quality compliance analyst came up and I think its worth looking at. Most compliance folks have a clinical or legal background(my background is technical so I must be the extreme minority) and a database is a complete mystery to them. Frankly I would look at anything IT gives you with extreme prejudice. IT doesn't look at things from a compliance standpoint and usually regards most regulatory concerns as a burden and not a requirement. Most Health IT organizations have Data Analysts and these skills do bleed over a bit. However they report to IT and this may be a conflict of interest. You are starting to see the establishment of Data Quality Teams and Data Governance. I would highly suggest talking about establishing these teams or getting involved with them. You need to talk to your CIO on this. You will be surprised he probably knows more than you think about this. IT information security it usually part of the CIO's office and they are getting hit constantly with HIPAA regulations. Talking data compliance and review may spark some serious cross organizational discussions.

The demise of Performance Reporting with the NCQA Disease Management Accreditation

2013-09-09T11:15:00.003-04:00

Well with life some things just fade away. With NCQA's announcement that that it will not be continuing with DM Performance measures in 2014 that will end the certification for the few companies that achieved this. Well what happen? This program seem to have so much promise and then NCQA began to back off with making DM organization from making it mandatory to not required. It was being cited that it was too hard for companies to implement. However as the changes to supplemental went into effect it became quite clear that these two were related. If member supplied data wasn't valid for HEDIS then it didn't make sense for DM companies to keep collecting because it wasn't considered reliable. It's too bad because I don't think any time was spent studying if companies tracking DM measures had better results for their matching HEDIS measures. Once 2015 hits the last DM performance certification will fade into the sunset.

At HCCA New England Conference today!!

2013-09-09T10:15:00.002-04:00

Looking forward to the discussions for the day

Medicaid Programs and Compliance - Random thoughts

2013-09-05T09:24:00.000-04:00

Medicaid Programs and Compliance - Random thoughts

I've had a few things come across my lap in the past months and read a few articles on some trends. With the ACA I think it is safe to assume that these populations will grow substantially, this does not mean your job will get any easier. These populations are notorious for medical non-compliance for a variety of reasons(apathy, economic, education, age, disability). Organizations will find that traditional methods will not work with them as proven over the last 20+ years. Organizations will try to tap new methods of outreach to get these members to improve their health. I think you will see a host of new services that have been offered to the commercial populations being offered to medicaid as a way to incentive the members. This does come with some danger as these programs could be potentially abused and defrauded. Another area that will constant dangers is communications with the member. Mail just doesn't reach folks the way it used to. That leaves electronic forms, text, phone and email. All areas that are potential HIPAA concerns. Cell numbers and text address changes constantly as plans are dropped and phones retired. There will be a need for better phone look-up and verification. I can see bottom feeding lawyers targeting Health Plans over HIPAA with this. Email has it own problems unless it a free universal provider like Google and Yahoo as people change email fairly regularly. But remember email is that "secure" either. I hope the compliance officer gets cracking on that computer science degree...

Successful HCCA Webinar Presentation

2013-08-20T09:34:00.002-04:00

Successful HCCA webinar Presentation

I do hope everyone who did attend did enjoy the presentation. I was told we had 37 individuals attend the webinar. I really hope people were able to take away a few tidbits of info that will help them. I did see some folks from Kaiser and United Healthcare attend. I'll keep chugging away.

Andy

A bit of self promotion....NCQA Accreditation and the role of the compliance professional Webinar August 19th

2013-08-05T13:51:00.000-04:00

Topics Covered

An explanation of what NCQA Accreditation is and what it represents for Health Care organizations
Why should a compliance professional become involved with the accreditation process
Organizational pitfalls and misconceptions about NCQA and its programs

http://www.hcca-info.org/Events/EventInfo/sessionaltcd/003_AC081913.aspx

8000 hits on this blog!!

2013-07-26T10:29:00.001-04:00

I just want to say thank you for getting to the 8000 hits on my blog mark. My hope is to 10000 by December. I'll do more posting over the next few weeks. I'm working as a volunteer camp councilor next week(cub scouts) So I'll have some down time at night.

Thank you all!

Andy

A possible silver lining to the HEDIS changes

2013-07-22T15:05:00.000-04:00

Well in any situation you do need to find the silver lining in this case. I'm going to look at this from the patients point of view. If there were plans not exactly being honest in their reporting then the fact is people weren't getting better. The point of these measures was to report if people were closing clinical gaps in their conditions. if they were closing these gaps they would be getting healthier or at least not any worse. The point of all this is to provide better health care and make people better. Maybe this gets a little lost sometimes with all the different issues that seem to crop up in health care. What I see changing are organizations turning back to old fashioned health coaching and talking to their members about getting treatments and following up with them. The 20 minute conveyor belt just isn't going to work(not the doctor's fault). The plans and the practices are going to need to work together in outreaching to members after they have left the doctor's office. PCMH is an interesting approach but I think it lacks some teeth in reporting outcomes and outreach post office visit. It's still a good start to seeing changes down the road. The other winner in this change is really the tax payer surprisingly enough. If plans weren't really supposed to get their bonus payments then HHS isn't going to be paying them extra money. I do recognize the fact however that this may impact plans that were doing nothing wrong. It's going to be interesting how this all shakes out.

More on the HEDIS Supplemental Changes

2013-07-19T11:07:00.003-04:00

I think there will be extra angst as the changes are fully implemented over the next year. First for measures that have multiple year look backs you will need primary source data in those look back years. That may be difficulty especially if records are stored and not accessible easily. One area that I think will cause additional pain when plans take on new members. You will need accurate records to prove that members got required tests and screening from the year that they weren't members of the plan. Now we all have been dealing with EHR's in some shape or form and this may not be as easy as you think. What about the pneumonia vaccine you got 4 years ago or the double mastectomy 12 years go. How about doctor tests and results? Hopefully you got your portable records with you. Now as the impacts become more apparent I think some of the rules maybe modified as NCQA gets the feedback rolling in. Personally I don't see any major changes allowing anything but primary source validation. Because there is state and federal money implications with these scores and there appears to be some indications that there was improper reporting going on NCQA was placed in a pretty difficult position. Either ratchet down the rules or face possible litigation from the OIG is probably what occurred. While NCQA was formed from Health Plans trying to put industry standards and its roots are in health plan promotion I don't think they had much choice in these changes.

HEDIS Supplemental Changes

2013-07-18T08:25:00.001-04:00

Sorry I haven't been blogging a while tied up with submission dates and some time off. I would like to talk about the recent changes to HEDIS supplemental data rules. Back in April NCQA notified its participants of the changes. In a nutshell unless you have primary source validation for your supplemental data you can't use it. What is primary source? Basically the hard copy receipts or results of tests and exams. Without that you can't use the data. Why did this happen? I suspect there were legal issues with HHS were organizations were playing fast and loose with the rules. Someone had to have complained and most likely there are open investigations and I suspect you will see OIG cases going to court. There is a lot of money tied in Medicare STAR ratings and somebody or a few somebodies had to be doing some rather sketchy things. While the organization that I work for is doing HEDIS Data collection we also were putting this into a disease management registry system, recording calls and had a documented process on what was valid information plus following clinical guidelines for health coaching of patients(our phone staff are RN's). I suspect there were companies out there just doing cold calling and recording information... With the changes that have occurred we will be out of that line of business. My guess is there will lowering of scores across the board for Health Plans. If Plans were using to supplemental data to even boost them half a star its going to hurt.

More on this on the next post

17th Annual Compliance Conference Thoughts

2013-05-02T09:43:00.000-04:00

Well now that I have gotten through my 200+ emails since getting back to work all I can say it is really refreshing to be in a place where everybody is in the same boat as you. Whether you do billing, privacy, audit, or anything else we all feel the same pressures and stress. Having Dan Levinson the US Inspector General for HHS as the keynote speaker there, really reinforced the importance of compliance and another topic, Data Quality. I don't think he could be any clearer that data quality is going to be extremely important. The push for EMR's is the first step, the next step are HIE's. All medical data is going to be tracked and checked. There are going to be more than a few compliance officers reading books on Data warehouses in the next couple of years.
The other take away I have is reach out to colleagues and ask for help. It's a huge networking event at the conference and to be honest most compliance departments are pretty small staffing wise to have a huge knowledge base. . Reach out and ask questions!!! The only bad question is the one that is never asked.

ACO discussion with HCCA at the 17th Annual Compliance Conference

2013-04-23T09:40:00.001-04:00

Listening to a panel discussion on ACO's
with Shawn DeGroot, Frank Sheeder, Troy Barsky, and Mary Fischer

Interesting Points

They are run by providers no VC money involved
Their board has to be made up of 75% of membership
ACO's are involved in shared savings, shared risks models
They are judged on performance benchmarks as a measure of success
ACO's don't totally follow the OIG 7 elements for compliance but have their own structure and a mandatory compliance position that reports to the board.
Privacy concerns along with standard federal guidelines are all still present
Anti-trust concerns with ACO's DOJ and FTC have published papers on this
ACO's and physicians share money which raises concerns but waivers are available
Need to focus on quality data
Potential for false claims based on bad data(IT Data warehouse be aware!!)
Need to think about Stark and anti-kickback more about co-mingling of money
Compliance concern needs to be at the table early and often because of the multiple of potential issues.
ACO has to service at least 5000 members
Litigation's will be a concern with ACO's if they run a foul of regulations
Serving people vs. financials concerns are a tightrope
Compliance is a critical part of making an ACO a success

Day 3 HCCA National Conference - Personal Reflection

2013-04-23T08:30:00.003-04:00

All I can say it is such an uplifting experience to spend time with people in the same field, who go through the same aggravations and give you inspiration to be passionate about what you do.

Day 2 Social Media and Compliance

2013-04-22T16:16:00.002-04:00

Social Media and Compliance

Let's just say this was a popular topic for behavioral health organizations

Excellent discussion on issues people have faced and efforts done to avert issues.

Key points

Social Media is the wild west for compliance
Organizations struggle to monitor
Policies are constantly be changed
National Labor Relations board needs to be checked for social media policies. It's rulings have directly affected policies and proceedures.
Social monitoring is now a clear and present issue for compliance
Training is a big part of averting issues.

Just a great discussion.