Digital Health Solutions for Compliance and Reimbursement
Digital health solutions

The Problem

With healthcare reform sweeping our nation, many hospitals and clinical practices are prioritizing compliance to rules, regulations, and laws of healthcare, in order to streamline operations while providing safe, high-quality patient care. Oversight of compliance is managed by the Department of Health and Human Services (HHS) and the Office of Inspector General (OIG). Physicians and their staff face increasing scrutiny when it comes to documentation, coding compliance, and the auditing process conducted by Medicare Recovery Audit Contractors (RACs) and private payers. The combined effects of a national shift towards value-based care and reducing costs have inevitably led to payers auditing more aggressively to identify potential overpayments. In the 2018 Comprehensive Error Rate Testing (CERT) report, the Medicare fee-for-service program documented an improper payment rate at 8.12 percent, representing $31.62 billion in improper payments (5). Common causes of improper payments include:

  • 58% due to insufficient documentation
  • 21.3% due to unnecessary medical proceeding
  • 11.9% due to incorrect coding
  • 2.6% due to lack of documentation
  • 6.3% due to other

Physicians and healthcare providers now face increasing pressure to get documentation right while delivering quality patient care. This shift creates a need for a robust cross-communication platform like cliexa, to foster collaboration between patients, providers, payers, and key stakeholders involved in the healthcare system in order to quantify and qualify patient-reported outcomes (PRO). As seen in the breakdown above, over 70% of improper payments are due to documentation errors or services deemed medically unnecessary.

Documentation Issues

Any healthcare professional who uses electronic medical records (EMRs) with auto-populating templates such as, but not limited to, a quick click-through of a review of organ systems (ROS) template that may not have been fully reviewed or has a default entry, is at risk for audit. For example, a patient can be seen professionally for having back pain, yet the musculoskeletal ROS was documented as negative when it should have said “low back pain.” This is a red flag to the auditor and prompts them to look for other inconsistencies. Errors can also occur during billing and coding, however, CPT and ICD-10 coding errors are less prevalent when documentation is adequate (6).

With cliexa, a substantial portion of the ROS, medical history, family history, and social history can be streamlined into the EMR from the comfort of the patient’s home or shortly before the physician sees the patient. This function will close the gap in clerical errors and serve as a safety net for when a provider forgets to elicit additional questions from the patient during the encounter or enter it into their notes.

It only takes on average 30 encounters of an ICD-10 code reported that was not supported in the physician’s note, or coding one level higher than they should have, to be audited. Medicare or the insurance company (payer) will ask for approximately $45,000 back, yet the actual amount paid will amount to over $1 million after accounting for interest, extraneous fees, and penalties (6). Those who code for a lower level of services or have smaller practices may believe they will not be audited since they are taking the low-risk approach, however, that is far from the truth. Auditing occurs because they identify the physician as an outlying practitioner compared to colleagues in the same specialty nearby. For example, a physician consistently bills level 4 and 5 services, while colleagues are billing mostly level 3 care, raises a red flag.

Even with an active body overseeing clinical documentation improvement (CDI) in the hospital and frequent educational sessions, these errors still persist. The demands on physicians and mid-level providers can get overwhelming, splitting their time between treating patients at increasing volumes and endless documentation despite the adoption of EMRs. Eventually, something gives. The trends show physicians improve significantly in the immediate 6 month period after billing training sessions, and unfortunately, often revert back to the same pattern of minimally edited or rushed medical notes (6).

As shown above, in the CERT report, services deemed medically unnecessary falls in the second most common cause of payment retraction. Having a strong patient medical history component in the physicians’ note lays the foundations for justification for office visits, labs, or imaging services rendered. It will naturally defend the need for such services. This is where cliexa comes in, allowing patients to fill out clinical assessments outside the hospital or clinic walls. This is especially important for chronic care management (CCM) patients because we can capture the trend of the patient’s disease progression, using reliable and objective data. As data accrues while a patient documents their symptoms improving or worsening, clinicians can intervene or change management as necessary. When further lab work or imaging is necessary, it will already be justified and deemed “medically necessary” with trending data, thus decreasing the potential for billing rejections from payers. This real-time data is sent directly to the Cloud and then to the clinician’s EMR system, with no disruption in workflow.

Another common issue occurs during documentation of the chief complaint and history of present illness (HPI) in the patient’s medical record. For example, a CCM patient with rheumatoid arthritis has been under your care for a couple of years. It is not sufficient to say “patient is here for a follow-up visit” as the chief complaint. The status of the patient must be further explained, such as comparisons made to previous visits: are they improving, worsening, stable, or well-controlled, as a result of any medications? The HPI is a section in the patient’s medical note that requires the physician to document, not ancillary staff such as nurses or medical assistants. An auditor will review the HPI and grade it in two levels: brief or extended.

  • Brief HPI, 1-3 HPI elements
    • “Patient is here for arm (location) pain that started a week ago (duration)”
  • Extended HPI, 4+ HPI elements
    • “Patient is here for waxing and waning (timing), arm pain (location) that started a week ago (duration). He states it is a constant ache (quality) type pain that worsens when he wakes up (provoking factor).

Leaving out important parts of the documentation will lead to a lower level of service in billing and lower reimbursements. To mitigate this issue, cliexa offers screening and compliance tools that are already integrated on the platform.

Evaluation & Management Audit

A major pitfall in an audited record of high concern for the HHS and OIG stems from EMRs “assisting” physicians and mid-level providers with coding and documentation prompts. Most EMRs come with a feature that supports accurate evaluation and management coding, yet they can also cause inaccurate coding. Often times, the EMR does not have the ability to identify key data elements related to complex medical-decision making (MDM), which is alarming when it comes down to identifying the most accurate E&M code to use. Common mistakes made by the EMR system include:

  • Inaccurate level of service calculation (E&M codes) based on content in the documentation
  • Inability to create content and set system defaults
  • Inability to automatically detect a conflict between the information in the HPI and the ROS section

Understanding the inner workings of the EMR as well as optimizing its billing elements requires extensive time that physicians and HCPS do not have. As such, an over-reliance on the EMR’s suggested E&M code develops, which leads to unintentional upcoding or down-coding. Many providers believe that using the EMR-provided code would protect them from coding at a level not supported by documentation or medical necessity. Compensation may rise at first, but end up in payment retractions from payers or increase their risk for fraud. For example, if a patient comes for a follow-up visit, it is not necessary to include the 12-system ROS or family history of this patient, as it was already detailed in the initial consultation note. This can trigger the EMR to suggest a higher coding level, which is not justified. Physicians need an automated process that can quickly categorize the nature of the visit, which is offered in the cliexa platform with our coding compliance programming.

Medical Decision-Making (MDM)

The MDM portion of the E&M record makes up the criteria for the visit code physicians bill. In other words, it is more important than the history and exam portion of the physician’s note. MDM constitutes the complexity of the diagnosis and/or creating a management plan. From the desk of the auditor, these factors include:

  • The number of possible diagnoses and/or the number of management options that must be considered
  • Amount or complexity of medical records, diagnostic tests, and/or other information that must be ordered, reviewed and analyzed
  • The risk of complications, morbidity, or mortality and associated comorbidities related to the patient’s presenting chief complaint, diagnostics and management options (6)

In order to qualify for a given type of MDM (Straightforward, Low Complexity, Moderate Complexity, High Complexity), at least 2 out of the 3 elements listed above must be met. Each tier has its own designations under each element. For example, straightforward has a minimal or established problem that is stable and improved for a number of possible diagnoses. Whereas low complexity would have a low number of possible diagnoses or established problem that is worsening. cliexa has compliance measures built into the platform to ensure patients actually qualify for the right codes. You can also build in custom screening tools, such as a CCM patient with 2+ chronic conditions. At the same time, the physician can collect clinical metrics and compliance data through our system that directly integrates to your MIPs quality reports in the EMR. MIPs, which stands for Merit-based Incentive Payment System, is CMS’ largest value-based care payment program, which was adopted to shift the healthcare industry from fee-for-service to pay-for-value. There is a public reporting aspect of MIPs that impacts a clinician’s reputation as well as reimbursements: better MIPs score results in higher payments. It’s important to note that if one does not submit data for MIPs, there will be up to 5% reduction of Medicare reimbursements; this process is automated in our platform.

The compliance aspect of a clinician’s life cycle is complicated and frustrating, to say the least. That is why our platform can offer solutions to maximize your patient-facing time. Many aspects of the office visit require filling out surveys or patient information that ends up taking more time than the visit itself. cliexa brings increased efficiency to your practice by:

  • Streamlining the documentation aspect via integration with EMR for audit protection and compliance
  • Improve physician-patient communication
  • Allow customizable built-in surveys and questionnaires to improve your MIPs score

References

 

Mobile Health Applications - Value Based Care

In today’s healthcare system, there is a focus on creating a value-based care system to foster a standard of effectiveness, and efficiency when it comes to patient health outcomes, and reduced costs. Through this model, healthcare providers are incentivized to deliver high quality care and this value is derived from measuring health outcomes over time. There is significant pressure that many providers face to be able to quantify their patient’s health outcomes in order to show they are in fact delivering “value-based care.” A value-based model creates a need for a fruitful cross-communication system that extends to patients, providers, payers, and all involved in the healthcare system in order to quantify and qualify health measures.

In a effort to utilize patient-reported health status to improve care, cliexa is collaborating with the American College of Cardiology to develop technical modules targeting cardiology-specific diseases using remote patient monitoring. The first module, cliexa-PULSE, has been developed is for Atrial Fibrillation and includes patient-reported symptom tracking, medication reconciliation functions, connections to wearable data and claims data connection. This information will fulfill reporting needs for patients through visual tracking graphics in the application and to physicians in a summarized, customized manner. Moving forward we are looking to commercialize this product through the ACC’s 2,500 members and beyond.

Improved communication and reduced costs can be achieved by improving patient engagement, streamlining clinical workflow, and implementing a customizable technology that will automate clinical processes, analyze and simplify patient data, which can lead to improved care and health outcomes. By the incorporation of patients’ health status and value via patient-reported outcomes (PROs), providers can monitor the quality of health care delivery.

PROs can be used as absolute terms, or as a change from a previous result as well as a measurement in clinical trials. Physicians can better determine baseline status, clinical trial endpoints, monitor therapy effectiveness, assess change in stats and prognosis predictor, while the patient experiences positive impacts on daily activities, emotional wellbeing, psychological health, and social function. In addition, PROs can aid clinics to improve patient outcomes, quality of life and satisfaction by using the PROs to better inform their care. PROs prioritize the important details in a clinical encounter and aid a better understanding of the motivation behind patient behavioral change. With this information, the clinic can analyze the evidence, design clinical trials and change their practice and policy. In addition, PROs can aid clinics to improve patient outcomes, quality of life and satisfaction by using the data to better inform their care. PROs prioritize the important details in a clinical encounter and aid a better understanding of the motivation behind patient behavioral change. With this information, the clinic can analyze the evidence, design clinical trials and change their practice and policy.

Patient-centered data collection outside of a traditional clinical is the next frontier of modern healthcare. By digitizing and automating PROs, both patients and physicians benefit financially and through effective time management. PROs tackle the challenge of long surveys, care integration, multimorbid patients, and improving the relationship between patient and provider. Clinicians need instruments (surveys) to capture patient-reported measures of symptom status, functional status and health-related quality of life. PROs help quantify the disease from patients’ perspectives, makes disease- specific measures more sensitive and relevant, help meet all the requirements of performance measures and can improve the process of delivering clinical care while bringing the patients’ voices into care. Physicians have found that PROs, in the right setting with the right workflow, are a helpful mechanism for shared decision making and help tackle the treatment goals of patient survival, free of hospitalization, and increased quality of life.

Read more from ACC: //www.acc.org/latest-in-cardiology/articles/2019/04/14/12/42/innovation-at-acc-collaboration-using-patient-reported-health-status-to-improve-care

In 2018, cliexa was selected as one of Jumpstart Foundry’s portfolio companies. Jumpstart recognizes the value of recent healthcare industry trends including “Remote Patient Monitoring” and “Telehealth.” In their recent article, JSF featured cliexa in their discussion of these recent technological trends in healthcare.

One of the key challenges in healthcare that we are solving is being able to render results interpretable to patients and providers, while creating efficient, streamlined communication and workflow. cliexa’s Remote Monitoring platforms assist providers in making more informed decisions about treatment plans and enable them to respond more quickly to new data so their patients will have fewer complications or side effects. cliexa suite of products enables providers to deliver value-based care which translates to significant cost savings.

With clinically validated scoring models, our platform provides clinicians multiple reference points with correlations to identify the accuracy of patient reported data which will result in better patient and clinician experience and enables more responsive and preventive treatments.

Patients will play a greater role in their care with cliexa and will be able to make valuable correlations to causative factors for pain flare-ups through remotely reported outcomes. The discrete clinical data and patient-reported outcomes enable providers to improve clinical decision making, while reducing liability and billing concerns with payors. These algorithms help providers respond more efficiently to new data so their patients will have fewer complications or side effects.

Click here to learn more about cliexa’s Digital Solutions for Healthcare.

 

Last week, over 12,000 public health professionals flocked to San Diego for the 75-degree weather, ocean views, and the most significant public health conference in the U.S, the American Public Health Association’s Annual Meeting and Expo. Two large buildings downtown were dedicated to housing deep dive conversations about, among other things, tobacco use, obesity, women’s health, racial inequity in health and the most cutting-edge research in the field. In reflection, I had three takeaways from the conference about the role and use of digital health in public health.

#1. Health technology and its benefits are not largely understood in its application to the public health community.

Many times, throughout the conference I found myself reiterating the value of a health platform for clinical, research or evaluation processes. Many people I spoke to had a genuine interest but weren’t sure how technology could optimize their work. In reality, many public health programs and projects are researched and evaluated using patient-reported data. Imagine digitizing that process so patients can participate through an application on their phone; imagine the impact that would have on response rates and loss-to-follow-up. Imagine the benefits of pushing routine surveys to patient’s phone instead of having to call to do scheduled evaluations. Not to mention the equitable distribution of programs and interventions across diverse populations, rural populations and those who have transportation barriers that technology can help address. In public health we operate in a world of outcomes, without being able to show outcomes we don’t see funding renewals, patient participation fades away, and programs fail. Health technology provides a way for researchers and evaluators to track outcomes in real time.

#2. UX/UI can be a major make-or-break when looking at making a tool that applies to diverse or vulnerable populations.

My first event was a meeting in a small room with other health technology professionals discussing the process that they’ve undergone to get health technology recognized as a section at APHA. In this room, we considered the impacts on research, evaluation, follow up, data visualization and overall patient experience. One of the most impactful conversations that I had was with a social worker who embraced technology as a tool for diverse or vulnerable populations. She emphasized how user interface and user experience can shape program success in diverse and vulnerable populations. She encouraged me to reach out to individuals who interact directly with the specific population when designing products to be used in public health settings. Only if the patient or client is engaged with the tool, can we see the successes or obtain accurate information for physicians, for researchers, or health program evaluators. A crucial point when considering Take Away #1, and the importance of highlighting tangible outcomes over time.

#3. There is “data overload” in public health.

This conference had some of the country’s top experts in health, with rows of poster projects, all with their own calculated data sets backing the findings that they were at APHA to present. Some will likely be published while others will remain in the researcher’s computer with little other exposure. I spoke to individuals who were collecting health data, payor data, and policy data, and all were positioning their data sets in different areas independent of each other despite their overwhelming connectivity. With the rate that new studies are conducted, data changes so quickly so even systematic reviews and meta-analyses become outdated far too quickly. There is an opportunity to leverage technology to collect a real-time outcomes database to ensure the hard work that researchers do to make correlations and identify patterns is not lost in the data black hole. Entities such as the CDC, NIH and WHO do an excellent job of collecting and displaying related data sets for public use, however the time that it takes to gather data often puts the data sets months to years behind the times. There is a significant opportunity for technology to lend to this real-time collection process.

Overall, the themes of APHA for me centered around how much opportunity there is to impact the way public health programs are research, delivered and evaluated through the use of digital health. These conversations were inspiring and exciting but also demonstrated how much we still have to do to fully optimize the work that we do in the public health field.

Digital health benefits

2018 has seen a significant boom in the application of technology in digital health innovation, which are poised to disrupt the healthcare industry. Innovations have included advances in mobile health (mHealth), health information technology (IT), as well as wearable and Internet-of-Things (IoT) devices.

cliexa has identified six specific areas of medicine already reaping the benefits of digital health innovation:

1. Rheumatology

Disease Activity Scoring (DAS) metrics remotely collected by cliexa from patients are used by physicians in their offices when assessing the severity of rheumatoid arthritis through a Q & A approach. cliexa empowers patients with the ability to communicate their patient-reported outcomes to their physicians at the touch of a finger, on their own mobile devices, providing physicians with instantly-scored clinically-validated assessments. The application of cliexa innovations in rheumatology drastically increases the efficiency and quality-of-care for both patients and their providers.

Check out the cliexa mobile platform for Rheumatoid Arthritis, cliexa-RA: //www.cliexa.com/cliexamobile/rheumatoid-arthritis/

2. Pain Management, Primary Care, & Integrative Medicine

Chronic pain, affecting over 10% of American adults, is a leading cause of opiate abuse. Managing and overcoming chronic pain is a complex obstacle for many healthcare providers. With the increased shift away from the prescribing of opioids in the treatment of chronic pain, cliexa enables providers to remotely monitors opioid-prescribed patients while empowering them to relay their patient-reported outcomes and track their mental health conditions in association with their chronic pain, while catering specifically towards the individual needs of each patient-provider relationship.

Check out the cliexa mobile platform for Pain Management, cliexa-EASE: //www.cliexa.com/cliexamobile/pain-management/

3. Behavioral Health & Addiction Treatment

Though struggles with addiction are becoming increasingly more prevalent in society, the present methods of addiction treatment are limited. Through innovations in health technologies, patients and providers are shifting towards new ways of treating addiction. The monitoring of patients in real-time is essential for positive treatment outcomes for both patients and their providers. By leveraging patient-reported data, patients adhere to their treatment plans and overcome addiction as a disease, rather than as a fault.

Check out the cliexa mobile platform for Behavioral Health, cliexa-SENSE: //www.cliexa.com/cliexamobile/behavioral-health/

4. Digestive Health

Through cliexa innovations, providers better manage chronic gastrointestinal diseases, such as inflammatory bowel disease or ulcerative colitis, using specifically-designed, highly-structured treatment plans that leverage disease activity scoring models taken from qualitative patient responses to assessments which quantify and track symptoms over long periods of time.

Check out the cliexa mobile platform for Digestive Health, cliexa-IBD: //www.cliexa.com/cliexamobile/inflammatory-bowel-disease/

5. Respiratory Care

cliexa enables providers to qualitatively track chronic diseases of the respiratory system, like chronic obstructive pulmonary disease (COPD), through remote patient-reported outcomes. The ability to structure individualized and specialized care leads to improved patient-provider experiences.

Check out the cliexa mobile platform for Respiratory Care, cliexa-COPD: //www.cliexa.com/cliexamobile/chronic-obstructive-pulmonary-disease/

6. Pediatric Care

cliexa health technology drives innovations in mental health resiliency in adolescents, a hot topic in today’s health community. cliexa’s clinically validated medical assessment applications, coupled with its mHealth prevention services, help providers identify and reduce risk behaviors in adolescents and young adults. cliexa’s mobile patient-engagement applications equip providers with the tools adolescents use to overcome anxiety and depression, increasing the overall quality-of-care for both patients and providers.

Check out the cliexa mobile platform for Pediatric Care, cliexa-OPTIONS: //www.cliexa.com/cliexamobile/adolescent-resiliency/