Quality medical practice management is equally as significant as quality patient care in establishing healthcare organization practices that are efficient and effective in providing quality patient care.
Successful medical practice management ensures that all staff members, providers, medical billing staff and clerical support staff are aware of all medical regulations and laws (e.g., HIPAA, Federal Deficit Reduction Act of 2005, DOH Waived Testing Regulations) that pertain to their job function. All staffing levels should be trained to implement and adhere to these regulations properly and notified when any updates take place.
A prospective medical record review includes claims/encounters that have been submitted to and paid/denied by insurance carriers.
This type of audit allows for adjustments in coding to be corrected prior to claim submission.
A retrospective medical record review includes claims/encounters that have been submitted to and paid/denied by insurance carriers. Retrospective audits are occasionally focused audits based on specific procedures or billing concerns.
Generally, a random sampling of 10-15 encounters/dates of service are selected for review. The sample may be selected by the client or RRHS. In some cases, a statistically valid sample is required and OIG’s RAT-STATS software program is utilized for a sample selection.
A focused audit concentrates on a particular element, type of service, place of service or provider of service to determine the appropriateness of documentation and associated coding/billing.
RRHS provides a customized, detailed report summarizing key audit findings and associated recommendations. The Department and/or provider overall compliance score in all areas (E/M, Procedures, Modifiers, ICD-10 Codes) is provided in an easy to understand format.
The audit process can typically take 1-3 weeks for completion. The time frame varies based on the size of the audit.
RRHS utilizes a secure File Transfer Protocol (FTP) website which assists in transferring files between two remote locations.
The Patient Centered Medical Home (PCMH) is a care delivery model for primary care practices in which the patient is the center of all processes and decisions. This model describes an approach to the delivery of primary care that is patient centered, comprehensive, coordinated, accessible and committed to both quality and safety.
Your practice will be guided through the entire PCMH process by RRHS’ expert facilitators. Weekly webinars will assist with the implementation of NCQA’s requirements. Our facilitators will also take part in the submission process, which entails three scheduled “check-ins” with an NCQA assigned representative.
The National Committee for Quality Assurance (NCQA) is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Founded in 1990, NCQA has been a central figure in driving improvement throughout the health care system, elevating the issue of health care quality to the top of the national agenda.
Benefits include improvements in quality of care, patient experience and access, enhanced work environment, and reimbursement from key payers, including Medicaid. PCMH recognized practices also see a reduction in cost related to preventable, duplicative and unnecessary care. As a result of medical homes, hospitals are experiencing a reduction in ER visits and inpatient admissions.
The initial recognition timeline varies based on practice and RRHS level of support. Historically, practices attain recognition within 12 months.
Recognition is for one year with annual reporting requirements thereafter. There is only one level of recognition based on the 2017 PCMH redesign.
Yes, PCMH recognition also aligns with Delivery System Reform Incentive Payment (DSRIP), Medicare Access & CHIP Reauthorization Act (MACRA), Merit-Based Incentive Payment System (MIPS) and Healthcare Effectiveness Data Information Set (HEDIS).
Yes, the amount of reimbursement is as follows:
| PCMH Statewide Incentive Payment Program (PMPM) | 2017 |
|---|---|
| Medicaid Managed Care (MMC – PMPM) | $7.50 |
| Fee For Service (FFS) – Institutional, Per Visit | $29.00 |
| Fee For Service (FFS) – Professional, Per Visit | $25.25 |
PCMH is not a one-time process, the practice must continue performance improvement initiatives and providing care in a patient-centered manner to maintain their recognition status.
At RR Health Strategies, we have the tools and knowledge to simplify the PCMH process for you. Our consultants will conduct a gap analysis and develop a personalized workplan for your practice. The workplan aligns with the required elements needed to obtain recognition.