2010 ubo/ubu conference health budgets & financial policy 1 briefing: using the m2 to identify...
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2010 UBO/UBU Conference
Health Budgets & Financial Policy
1
Briefing: Using the M2 to Identify & Manage MTF Data Quality — Trends and Impacts of Changes in Coding and Grouping
Date: 23 March 2010
Time: 1010–1200
2010 UBO/UBU ConferenceTurning Knowledge Into Action Objectives
The attendee will be able to:– Describe changes in coding for FY10– Characterize changes in RVU scales for CY10– Explain the importance of practice expense in the use
of RVUs– Describe the impact of the change from simple RVU
to enhanced simple RVU– Describe the change from DRGs to MS-DRGs– Characterize the change in RWP weight scales for
FY10– Identify key coding impacts on RVUs and RWPs
2
2010 UBO/UBU ConferenceTurning Knowledge Into Action FY10 Encounter Coding
Minimal changes in coding for FY10 published to date Some items being discussed:
– Consult coding changes driven by Medicare– TBI coding– Case Management Coding (new code for case
management assessment)
33
2010 UBO/UBU ConferenceTurning Knowledge Into Action CY10 Relative Value Units
Annual weight table updates Generally based on Medicare weights, with some
modifications
4
Medicare weights
+
Commercial weights for some non-
Medicare services
+
Modifications for MHS
4
2010 UBO/UBU ConferenceTurning Knowledge Into Action CY10 Relative Value Units
Medicare weights include only those services covered by CMS Commercial weights start with Medicare’s
– But add values for some services not covered by Medicare MHS Changes
– Add values for items that are not covered commercially, but MHS wants to pay for (i.e., telephone consults, LASIK)
– Reduction of weights for global procedures
Code Description DC Work RVU
PC Work RVU
66984 Cataract Surgery 7.25 10.36
In purchased care, pre- and post-op care not recorded, included in global code, not so with direct care
5
2010 UBO/UBU ConferenceTurning Knowledge Into Action
The 10 RVUs from Medicare or commercial data are earned on one claim, but in direct care, earned on separate encounter records
6
2010 UBO/UBU ConferenceTurning Knowledge Into Action CY10 Relative Value Units
Impacts of update in RVUs for CY09 to CY10– CPT Codes: 2.3% increase in weights– HCPCS Codes: 2.1% decrease in weights
Some common codes and their work RVU changes
Code Description 2009 2010 % Chg
99211 Off Visit; Minimal 0.17 0.18 6%
99212 Off Visit; Straightforward 0.45 0.48 7%
99213 Off Visit; Low Complexity 0.92 0.97 5%
99214 Off Visit; Moderate Complexity 1.42 1.50 6%
99215 Off Visit; High Complexity 2.00 2.11 5%
99217 Observation 1.28 1.28 0%
7
2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of Relative Value Units
Units of Service– Reported by MTFs since 2003– Meaning depends on associated procedure code– Can indicate:
Number of times a procedure was performedNumber of time increments of a serviceNumber of visitsEtc…Depends on reported code
8
2010 UBO/UBU ConferenceTurning Knowledge Into Action Example CPTs and Units of Measure
Code Description Unit of Measure
99213 Office/Outpatient Visit of Low to Moderate Complexity
Visit
97761 Prosthetic Training; Upper and/or Lower Extremity; each 15 min
15 min of a visit
A0021 Ambulance, out of state, per mile Mile
73020 Radiology exam, shoulder; 1 view Picture
23600 Tx of proximal humeral fracture Setting + Follow Up Care
59400 Vaginal delivery, pre and post partum care Delivery, Pre and Post Partum Care
33510 Coronary Artery Bypass, Vein only, single graft Procedure + pre and post op
9
2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of Relative Value Units
Historical emphasis on M2 “Simple RVU”– Work component only
Units of service not considered in Simple RVU Led to 5% understatement of provider workload Particularly a problem with codes that are commonly
used with multiple units– Time increments, for example
“Enhanced Simple RVU” includes units of service
10
2010 UBO/UBU ConferenceTurning Knowledge Into Action
Simple RVU = 0.85
Enhanced Simple = 10.20
3 hours of prosthetic training
3 hours of gait training
11
2010 UBO/UBU ConferenceTurning Knowledge Into Action Impacts of Incorporating Units of Service
MEPRS Code Description Simple RVU
Enhanced Simple RVU % Increase
BA Medicine 778,092 842,486 8%
BB Surgery 507,050 530,070 5%
BC OB/GYN 450,694 456,872 1%
BD Pediatrics 441,470 451,992 2%
BE Orthopedics 333,720 337,330 1%
BF Mental Health 826,722 890,153 8%
BG Family Practice 1,313,652 1,322,818 1%
BH Primary Care 1,605,355 1,643,718 2%
BI Emergency Med 461,173 464,635 1%
BJ Flight Medicine 151,313 151,703 0%
BK Underseas Med 3,785 3,788 0%
BL PT/OT 460,798 578,545 26%
Total 7,333,826 7,674,109 5%
FY10, to date12
2010 UBO/UBU ConferenceTurning Knowledge Into Action Impacts of Incorporating Units of Service
Tmt DMIS ID Tmt DMIS ID Name
Enhanced Simple
RVUSimple
RVU % Chg
0052 TRIPLER AMC-FT SHAFTER 833,663 792,398 5%
0280 NHC PEARL HARBOR 156,407 151,442 3%
0284 NBHC NAVCAMS EASTPAC 4,023 4,015 0%
0285 BMC MCAS KANEOHE BAY 67,845 62,679 8%
0287 15TH MED GRP-HICKAM 63,434 61,471 3%
0437 SCHOFIELD BARRACKS AHC 244,251 238,100 3%
0524 BMA BARKING SANDS 26 26 0%
0534 TMC-1-SCHOF 25TH-SCHOFIELD BKS 32,595 32,537 0%
1987 NBHC MCB CAMP HM SMITH 4,025 3,996 1%
5442 ARMY-SURGICARE OF HAWAII (CIV) 931 931 0%
7043 USCG CLINIC HONOLULU 4,128 4,095 1%
13
2010 UBO/UBU ConferenceTurning Knowledge Into Action Practice Expense RVUs
Work RVUs incorporate provider effort Simple and Enhanced Simple RVU are types of work
RVUs Practice Expense incorporates all other expenses
incurred by the provider in order to deliver care
Work RVU
Practitioner
PE RVU
Nurse(s)
Technicians
Supplies
Billing
Rent/Lights,
etc…..
14
2010 UBO/UBU ConferenceTurning Knowledge Into Action Example CPTs and RVUs
Code Description Work RVU Practice Expense
80051 Electrolyte Panel 0.00 0.54
S0800 LASIK 7.17 18.63
99211 Office Visit; Low to Moderate 0.17 0.34
99281 ER E&M 0.45 0.09
PE intended to cover “all else”
billed by practitioner
15
2010 UBO/UBU ConferenceTurning Knowledge Into Action Incorporation of Practice Expense
PE RVU is usually more than half of the total RVU. Especially true for:
– Technician dominated product lines, or
– Care where expensive equipment is required
ER PE RVU is low because a facility bill is expected
MEPRS2 Code
Enhanced Simple RVU
Enhanced Practice Expense
RVU PE as a % of Total
BA 842,486 1,240,547 60%
BB 530,070 698,787 57%
BC 456,872 501,732 52%
BD 451,992 544,300 55%
BE 337,330 395,909 54%
BF 890,153 479,606 35%
BG 1,322,818 1,282,304 49%
BH 1,643,718 2,230,775 58%
BI 464,635 275,957 37%
BJ 151,703 154,556 50%
BK 3,788 3,677 49%
BL 578,545 436,254 43%
Total 7,674,109 8,244,402 52%
16
2010 UBO/UBU ConferenceTurning Knowledge Into Action Incorporation of Practice Expense
Two types of practice expense used in private sector:– Facility PE– Non-Facility PE– Provider will receive reimbursement for care based on location
of care
Code Description Work Fac Non-Fac
99211 Off Visit; Minimal 0.18 0.06 0.34
99213 Off Visit; Low Complexity 0.97 0.32 0.80
99282 Emergency Room E&M 0.88 0.19 0.19
Facility PE is low because a bill is expected from the facility where provider delivers care, to cover nurses, supplies, etc.
Out ofOffice
In office
17
2010 UBO/UBU ConferenceTurning Knowledge Into Action APCs and RVUs – Provider Delivery Model
Care provided in own office
Care provided in a facility
Work + In Office PE
Work + Out of Office PE
AND
APC or APG (or other)
18
2010 UBO/UBU ConferenceTurning Knowledge Into Action
Bill #1: Rx
Bill #2: Doctor, payment for seeing patient at ER
Bill #3: ER bill, from hospital
19
2010 UBO/UBU ConferenceTurning Knowledge Into Action
Bill #1: Rx
Bill #2: Doctor, payment for seeing patient at ER (RVU)
Bill #3: ER bill, from hospital (APC)
17% of the bill is paid via RVU
20
2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of RVUs in MHS PPS
Historical PPS:– Ambulatory Earnings based on MEPRS Code and
Simple RVU– Simple RVU: Sum of work RVU weights associated
with reported CPTs– Earnings Rates * Simple RVU = PPS Earnings– Rates based on private sector cost / work RVU– “Count” does not matter– No credit for multiple providers– No credit for unlisted provider specialty codes– MEPRS “B” Codes only
2121
2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of RVUs in MHS PPS
Limitations of Historical PPS:– Work RVU represents provider effort only– Allowed & Work RVU doesn’t necessarily go together– Units of service not incorporated into work RVU– Not terribly consistent with payment methodologies (important
because rates are private sector based)– MEPRS B Only encourages coding practice changes – Do More == More Money
22
Immunization Encounters (MEPRS Code FBI)
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Oct
-07
Nov
-07
Dec
-07
Jan-
08
Feb
-08
Mar
-08
Apr
-08
May
-08
Jun-
08
Jul-0
8
Aug
-08
Sep
-08
Oct
-08
Nov
-08
Dec
-08
Jan-
09
Feb
-09
Mar
-09
Apr
-09
May
-09
Jun-
09
Jul-0
9
Aug
-09
Sep
-09
Oct
-09
Nov
-09
Dec
-09
Jan-
10
A
F
N
22
2010 UBO/UBU ConferenceTurning Knowledge Into Action PPS in FY10
Many limitations have been addressed by new rules in PPS Switch from simple RVU => enhanced simple RVU
– Big impacts on PT/OT, mental health, nutrition– Addresses the units of service issue
Inclusion of practice expense as a basis for earnings– Allows product lines that are technician dominated or use
expensive equipment to be properly resourced– More closely aligns with payment methodology– Big impacts in optometry and mental health– Results in exclusion of earnings for nurse-only care (covered
under PE RVU) Implementation of units of service limits to correct coding errors
23
2010 UBO/UBU ConferenceTurning Knowledge Into Action PPS in FY10
Separation of earnings into “institutional” and “non-institutional” for APV and ER
– Institutional component earnings via APC weight– Non-institutional component earnings based on Enhanced
Simple RVU + Out of Office Practice Expense– Better aligned with payment methodologies– Results in a lower ER earnings rate than previously.
Still not perfectly consistent with purchased care payment rules
– But much closer than before– Discounting is applied in private sector for some codes– Treatment of multiple providers– Use of modifiers in RVU assignment (i.e., 55)
24
2010 UBO/UBU ConferenceTurning Knowledge Into Action
Inpatient Relative Weighted Product Changes
25
2010 UBO/UBU ConferenceTurning Knowledge Into Action FY10 Coding Changes
New ICD-9 Code sets published in October 2009 Minimal changes other than introduction of new codes Major change in requirement to code “present on
admission” indicator (POA) Indicates whether the patient:
– Presented with the problem represented by the diagnosis code, or
– If the problem was acquired while patient in the hospital
A POA is required for every reported diagnosis code Plays a key role in billing
2626
2010 UBO/UBU ConferenceTurning Knowledge Into Action DRG Grouping
Diagnosis Related Groups (DRG):– Coding system used to categorize similar stays into groups– Intent is to assign cases to the same group if clinically
similar, and similar in terms of resource intensity.– Used to pay most acute care hospitals for inpatient care
DRG Grouping Software– Hospitals code records with ICD-9 CM diagnosis and
procedure codes and other data (age, LOS, etc.)– Based on this, DRG software is run to add a DRG to the
hospital record– Many different versions of DRG software – depends on the
payor– CPT codes are not used in DRG assignment
27
2010 UBO/UBU ConferenceTurning Knowledge Into Action DRG Examples
DRG Groupers assemble records based on the combination of reported diagnosis and procedure codes– Expert panels determine the groups– Improperly coded records get a DRG of “ungroupable”
The same diagnosis code can group to a number of different DRGs; – Depending on what comes along with the diagnosis
code– Co-morbidities and complications are particularly
important
28
2010 UBO/UBU ConferenceTurning Knowledge Into Action Records with the Same Primary Diagnosis
Primary Diagnosis: Diabetes with Renal Manifestations (250.4)
DRG Description Sec Dx 1 Sec Dx 2 Proc 1 Proc 2
302 Kidney TransplantChronic Kidney Disease Postop Infection
Kidney Transplant
Ureteral Catheter
331Kidney/UT Diagnosis w cc
Cocaine Dependence
Pathological Kidney Lesion
332Oth Kidney/UT Diagnosis w/o cc Edema
29
2010 UBO/UBU ConferenceTurning Knowledge Into Action Records with the Same Primary Diagnosis
Primary Diagnosis: Diabetes with Renal Manifestations
DRG Description Sec Dx 1 Sec Dx 2 Proc 1 Proc 2
302 Kidney TransplantChronic Kidney Disease Postop Infection
Kidney Transplant
Ureteral Catheter
331Kidney/UT Diagnosis w cc
Cocaine Dependence
Pathological Kidney Lesion
332Oth Kidney/UT Diagnosis w/ cc Edema
• All 3 cases had diabetes as the primary DX
• None grouped to the two Diabetes DRGs!
• The “w renal manifestations” led the grouper to a DRG related specifically to the kidneys!
30
2010 UBO/UBU ConferenceTurning Knowledge Into Action
Major change in the DRG system for TRICARE has just occurred– TRICARE must follow Medicare payment policy, per law– From “DRGs” to Medicare Severity DRGs (MS-DRG)– Reclassification of complications and co-morbidities– Definitions of ‘what is a complication or co-morbidity’ changed– From two levels of complication / co-morbidity to three in some
cases– Introduction of payment reductions for hospital acquired
conditions TRICARE uses a modified version of CMS grouper (newborns,
mental health)– But TRICARE specific relative weights are used, instead of
Medicare’s
Medicare-Severity DRGs
31
2010 UBO/UBU ConferenceTurning Knowledge Into Action Example Changes in DRGs
DRG Description
085 Pleural Effusion w CC
086 Pleural Effusion w/o CC
MS DRG Description
186 Pleural Effusion w MCC
187 Pleural Effusion w CC
188 Pleural Effusion w/o CC/MCC
Names the same but not necessarily the content!
Separate category for “major complications and co-morbidities!
32
2010 UBO/UBU ConferenceTurning Knowledge Into Action
Illustration of Change in “What is a Complication?”
DRG Description Disp RWP CMI
358 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC 67 79.13 1.1810
359UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O
CC 242 239.05 0.9878
Total 309 318.18 1.0297
MS DRG
DRG Description CC No CC Total
358UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W
CC 48 19 67
359UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O
CC 6 236 242
Total 54 255 309
33
2010 UBO/UBU ConferenceTurning Knowledge Into Action FY10 Relative Weight Changes
Annual weight table update in October 2009 Each MS-DRG gets:
– Relative Weight– Average Length of Stay– Short and Long Stay Outlier Thresholds
Weights are based on average TRICARE billed amounts on acute care hospital claims received the prior year (July to July)
3434
2010 UBO/UBU ConferenceTurning Knowledge Into Action Relative Weights
Based on hospital costliness only (private sector) Practitioners paid via RVU Relative weights incorporate only those expenses
incurred by the hospital in order to deliver care
Work RVU + Out of Office PE
Practitioner
Billing
Other minor $
Relative Weight
Nurse(s)
Technicians
Supplies
ICU / OR
Rent/Lights
etc…..
35
2010 UBO/UBU ConferenceTurning Knowledge Into Action Example DRG Weights and Thresholds
DRG DRG Description RW ALOS SST LST
294 DIABETES AGE >35 0.74 3.4 1 19
295 DIABETES AGE 0-35 0.49 2.5 1 11
302 KIDNEY TRANSPLANT 2.87 6.2 2 22
331OTHER KIDNEY & UT DX AGE >17 W CC 1.19 4.9 1 27
332 OTHER KIDNEY & UT DX AGE >17 W/O CC 0.65 2.5 1 14
Selected DRGs that relate to diabetes
36
2010 UBO/UBU ConferenceTurning Knowledge Into Action Relative Weighted Products
Weighted workload measure intended to represent hospital costliness:– Conceptually similar to payment rules
“Normal cases” receive the same RWP credit in the same DRG– RWP = Relative Weight– Normal Case is one with LOS between long and short
stay thresholds. Most cases are “normal” or short stay outliers
37
2010 UBO/UBU ConferenceTurning Knowledge Into Action Relative Weighted Products
Outlier RWPs: – Relies on the concept of a daily weight – Per diem weight is RW / GLOS – (GLOS= Geometric Mean LOS; because LOS is not
normally distributed)– Short Stay: RWP never higher than relative weight– Long Stay: More credit than a routine stay, but not so
much to encourage excessive LOS.
38
2010 UBO/UBU ConferenceTurning Knowledge Into Action RWP
Short Stay Outlier Rule:– Twice the per diem for first day– Per diem for each additional day– Capped at relative weight– Same as payment rule
1st day gets two times the RWP as the other days
Daily RWP for Short Stay Outlier (with per diem weight ~.12 )
0
0.05
0.1
0.15
0.2
0.25
0.3
1 2 3 4 5 6 7 8 9 10 11 12
39
2010 UBO/UBU ConferenceTurning Knowledge Into Action RWP
Long Stay Outlier Rule:– Relative weight for entire ‘normal stay”– A third of the per diem weight for each extra day– Discourages excessive lengths of stay
DRG Weight
Cumulative RWPs by Length of Stay
0
0.5
1
1.5
2
2.5
3
3.5
4
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45
Slight growth in RWP once Long Stay Threshold is crossed
40
2010 UBO/UBU ConferenceTurning Knowledge Into Action
Total RWPs for a Low BirthweightNewborn DRG
Cumulative RWPs by Length of Stay
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45
Weight = 3.05; Per Diem = .1271
Short Stay Threshold is 12 days; Long Stay Threshold is 36 days
41
2010 UBO/UBU ConferenceTurning Knowledge Into Action RWP
Long Stay Outliers:– TRICARE and Medicare do not pay more for long stay
outliers – Discourages excessive lengths of stays– Cost outliers do receive additional payments, though
RWPs do give the extra long stay credit– Since “cost outlier” status is difficult to determine in
direct care– Done in both direct and purchased care data for
consistency
42
2010 UBO/UBU ConferenceTurning Knowledge Into Action Changes in Weights and RWPs for FY10
MS DRG Description 2009 2010 % Chg
635 NEONATE, BIRTHWT 1000-1499G, DIED 2.166 10.545 387%
108EXTRAOCULAR PROCEDURES EXCEPT
ORBIT AGE 0-17 0.795 2.042 157%
915 ALLERGIC REACTIONS AGE >17 W MCC 0.838 1.920 129%
111 SINUS & MASTOID PROCEDURES AGE 0-17 1.066 2.25 111%
595 MAJOR SKIN DISORDERS W MCC 1.605 3.206 100%
Overall change in MS-DRG Weights of 1% (decline)
Tripler change was -1%
Selected DRGs with significant increases in weights
43
2010 UBO/UBU ConferenceTurning Knowledge Into Action Changes in RWPs for 2010
Selected DRGs with significant decrease in DRG weights
MS DRG Desc 2009 2010 % Chg
422HEPATOBILIARY DIAGNOSTIC PROCEDURES
W/O CC/MCC 1.967 1.084 -45%
949 AFTERCARE W CC/MCC 1.871 1.013 -46%
836ACUTE LEUKEMIA W/O MAJOR O.R.
PROCEDURE AGE >17 W/O CC/MCC 3.369 1.739 -48%
553 BONE DISEASES & ARTHROPATHIES W MCC 1.511 0.767 -49%
610 NEONATE, DIED W/IN ONE DAY OF BIRTH 0.362 0.155 -57%
794 NEONATAL DIAGNOSIS, AGE > 28 DAYS 5.337 2.042 -62%
729OTHER MALE REPRODUCTIVE SYSTEM
DIAGNOSES W CC/MCC 2.273 0.86 -62%
44
2010 UBO/UBU ConferenceTurning Knowledge Into Action MS DRGs
MS-DRGs include a mechanism to reduce payments for certain hospital acquired conditions (HAC)– Conditions identified are deemed high cost or high
volume by CMS– Based on reported “present on admission” indicators– Required on primary and secondary diagnosis codes– “Pay for performance”: Concept is that hospitals don’t
get paid for problems they cause
45
2010 UBO/UBU ConferenceTurning Knowledge Into Action Hospital Acquired Conditions
Conditions for which Medicare and TRICARE no longer pay if not present on admission:
– Foreign object retained after surgery– Air embolism– Blood incompatibility– Stage III and IV pressure ulcers– Falls and trauma– Manifestations of poor glycemic control– Catheter associated UTI– Vascular catheter associated infection– Surgical site infections after some surgeries– Deep vein thrombosis / pulmonary embolism after knee / hip
replacement
46
2010 UBO/UBU ConferenceTurning Knowledge Into Action MS DRG
Medicare example, primary diagnosis is stroke
DRG Description Sec DxSec DX
POAAvg Pmt
066Stroke w/o
cc/mcc N/A N/A 5,348
065 Stroke with ccDislocation of patella, due to fall Y 6,177
065 Stroke with ccDislocation of patella, due to fall N 5,348
47
2010 UBO/UBU ConferenceTurning Knowledge Into Action MS DRGs
From ~ 500 DRGs to more than 800 DRGs DRGs also have been renumbered!
– 001 used to be a craniotomy; now it’s a heart DRG!– Likely a good thing, since definitions have
fundamentally changed. Some MHS information systems (i.e., CHCS) will only
show one DRG data element, though– Will cause misunderstanding among users as the
same code value will have different meanings depending on date of service.
48
2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of RWPs in MHS PPS
Inpatient Earnings Mental Health vs. Other Mental Health and Substance Abuse:
– # of Bed Days * Local Market Rate– Major Diagnostic Category 19 & 20
All other services based on “relative weighted product” or RWP
– # RWPs * Local Market Rate
49
Type of Care PPS Earnings
Mental Health 54,449,229
Non-Mental Health 1,829,617,221
Total Inpatient 1,884,066,450
49
2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of RWPs in MHS PPS
Historically, PPS used the “old” DRG system FY10 switch to MS-DRGs
– Necessary because old groupers no longer being maintained
Limitations in MHS Inpatient PPS– Earnings rates incorporate hospital + provider– But the RWP only reflects hospital expenses– Some care is expensive for the hospital and not the
doctor– And vice versa
50
2010 UBO/UBU ConferenceTurning Knowledge Into Action
Examples of High Institutional Payment and Low Non-Institutional Payment
DRG DRG Description Institutional Payment
Non-Institutional Payment
Total Payment
% Hospital
481 BONE MARROW TRANSPLANT $ 1,743,798 $ 10,476 $ 1,754,274 99%
606NEONATE, BW 1000-1499G, W SIGNIF OR PROC, DISCHARGED ALIVE $ 1,543,888 $ 54,835 $ 1,598,722 97%
622NEONATE, BW >2499G, W SIGNIF OR PROC, W MULT MAJOR PROB $ 1,256,092 $ 66,102 $ 1,322,194 95%
542TRACH W MV 96+HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R. $ 1,203,798 $ 53,042 $ 1,256,840 96%
For these cases, RWP would do a nice job of explaining
costliness since most of the cost is hospital
51
2010 UBO/UBU ConferenceTurning Knowledge Into Action
Examples of High Non-Institutionaland Low Institutional Payment
DRG DRG Description Institutional Payment
Non-Institutional Payment
Total Payment
% Hospital
601NEONATE, TRANSFERRED <5 DAYS OLD $ 1,321 $ 115,185 $ 116,506 1%
217
WND DEBRID & SKN GRFT EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS $ 14,941 $ 47,094 $ 62,035 24%
257TOTAL MASTECTOMY FOR MALIGNANCY W CC $ 5,988 $ 45,115 $ 51,103 12%
544
MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY $ 9,971 $ 44,351 $ 54,322 18%
For these cases, RWP would do a terrible job of explaining costliness since a small % of
the cost is hospital.
52
2010 UBO/UBU ConferenceTurning Knowledge Into Action Use of RWPs and PPS
Obvious solution is to use RWP for hospital component and RVU for provider component
– But inpatient professional services not fully captured in MHS
Rounds visits are required to be reported by providers– But inpatient procedures are not– (Information about what procedures are done is on the SIDR, but
in ICD-9 terminology– Means that no RVUs can be assigned. RVUs only work with
CPT/HCPCS
53
2010 UBO/UBU ConferenceTurning Knowledge Into Action Example of Rhinoplasty Direct Care Coding
Direct Care Coding
SIDR Value
Admission Date 5/23/2009
Discharge Date 5/24/2009
DRG 056
Procedure 2188
Days 1
SADR SADR #1 SADR #2 SADR #3 SADR #4
Service Date 5/22/2009 5/22/2009 5/23/2009 5/24/2009
MEPRS Code B D A B
Procedure Code NONE NONE NONE 99024
E&M Code 99499 NONE 99499 99499
RVU 0 1.22 0 0.76
• No procedure coded on SADR
• Separate pre-op and follow up visit coded
Roughly 2 RVUs
54
2010 UBO/UBU ConferenceTurning Knowledge Into Action
Example of Rhinoplasty Private Sector Coding
Private Sector CodingTED-I Value
Admission Date 5/14/2009
Discharge Date 5/16/2009
DRG 056
Procedure 2172
Days 2
TED-N TED #1 TED #2 TED #3 TED #4 TED #5
Service Date 5/14/2009 5/15/2008 5/15/2008 5/16/2008 5/16/2008
Procedure Code 99291 99232 99255 99238 21335
RVU 2.27 4.50 1.39 1.28 8.91
• Procedure is coded in both records
• No pre-op or follow up visit (bundling)
Roughly 18 RVUs – almost 10 times as many as direct care
55
2010 UBO/UBU ConferenceTurning Knowledge Into Action Other PPS Changes (Potential)
BRAC has caused a complication in PPS (impacts both inpatient and outpatient)
– Currently, all care is funded based on place of service– Need to separate facility vs. provider, to accommodate providers
of one service treating patients at an MTF of another service– Complicated issue
Poor quality CHCS provider data Not all MTFs are on DMHRS yet Lack of reporting of CPT codes for inpatient surgeries
56
2010 UBO/UBU ConferenceTurning Knowledge Into Action Coding and RWPs and RVUs
Take care to properly document and code all diagnoses and procedures according to UBU guidelines
Units of service– Multiplier for RVU credit. Take caution in coding!
Some ridiculous values appear in the data at times Present on admission indicators
57
2010 UBO/UBU Conference
Health Budgets & Financial Policy
58
Briefing: Using the M2 to Identify & Manage MTF Data Quality — Playing the Game to Win
Date: 23 March 2010
Time: 1010–1200
58
2010 UBO/UBU ConferenceTurning Knowledge Into Action
59
Objectives
Briefly describe how the incentives inherent to Resource Allocation Systems (like PPS) create incongruent goals, depending on the roles of different organizations.
Describe instances that illustrate data error (1) caused accidentally, (2) that maximizes revenue, (3) where policy directs miscoding that maximizes revenue, (4) where data suggest missed opportunities, (5) where events and resulting revenues are duplicated, and (6) where data problems obscure understanding the real world.
Describe goal-maximizing strategies available to (1) payors, (2) revenue receivers, and (3) for jointly held goals.
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2010 UBO/UBU ConferenceTurning Knowledge Into Action Overview
Effects of Resource Allocation Systems Illustrations of Data Error Defensive Strategies
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Payment Systems– Generally characterized by goal– Medicare (like PPS) seeks cost containment– Pure resource allocation systems must add up to the
available funds (equitable sharing goal)– Systems may also want to encourage/discourage
numbers in the system, such as numbers of: Given types of providers Use of preferred settings Frequency of services Prevention of unwanted services
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The MHS Prospective Payment System (PPS)– Discourages use of clerks or non-medical personnel– Discourages direct care pharmacy– Discourages case management– Encourages use of emergency rooms– Discourages furnishing of non-doctor care, such as
prosthetics (HCPCs) “Encourages” means pays more when it is true;
“Discourages means pays nothing when it is true.
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All payment systems involve payers and receivers of funds. Most of the time, the patient is neither.
Payers (TMA for PPS) generally prefer lower payments to higher, and equity among fund distribution.
Receivers (SGs, and potentially major commands and MTFs) prefer higher payments to lower, and to maximize their share of resourcing.
Productivity is a different issue, but can influence payment systems when the incentives for scoring high on productivity involve data elements that affect PPS earnings.
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Illustration:– A patient presents with an ear ache, an itchy patch of
skin on the elbow, and a sore knee.– Lowest earnings and worst productivity:
The PCM diagnoses and treat the three conditions.
– Almost triple the earnings and productivity: The PCM diagnoses and treats one of the conditions and
books two more appointments for the remaining conditions.
– More than triple the earnings and productivity: The PCM refers to ENT the sore throat; in a second
appointment the PCM refers to dermatology the elbow, and in a third appointment, the PCM refers to Ortho the knee.
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The inevitable consequence is that receivers investigate, discover, and implement opportunities that will add revenue (or productivity) with minimal consumption of additional resources.
Another consequence is usually that the payer instigates strong controls (audits of records, data mining for gaming, harsh penalties for violators of good coding) to offset the incentives created by a PPS system.
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Illustrations– The following sections look at data error that:
Appears to be accidental.May be accidental, but was very advantageous to
receivers.Is policy driven, and very advantageous to
receivers.May not be gaming, but which can harm revenues
or healthcare by the “Fog of War”.
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The following slides are all real data from M2 and clearly show data that cannot be right, but mostly unrelated to coding.
Accidental Data Error
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Just Missed the Centennial Celebration, but his service continues!
Accidental Data Error
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24 Years Older thanthe World Record Holder
Accidental Data Error
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What difference does it make?
1. Affects eligibility for benefits
2. Affects validity of coding (maximum and minimum ages)
3. Affects TPC and OHI
4. Affects equivalent lives
5. Affects screening for prophylaxis
6. Affects normal values
Accidental Data Error
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Accidental Data Error
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Accidental: Phantom Encounters
Phantom encounters can’t be found in central data, or have only their skeletons without their flesh! Typical causes are:
1. Submitted completed records are sometimes “cached” and not processed into the central data bases.
Missing Data
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Cached
Accidental: Phantom Encounters
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NOTE: This is countingthose we know did not
come, but does nottell us of those wenever heard about!
Nor can we tell where coding waschanged, or changed back!
Accidental: Phantom Encounters
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Phantom encounters can’t be found in central data, or have only their skeletons without their flesh! Typical causes are:
1. Submitted completed records are sometimes “cached” and not processed into the central data bases.
2. Disconnects between the capture system (AHLTA) and the transmitting system (CHCS) prevent the encounters’ transmission.
Missing Data
Accidental: Phantom Encounters
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AHLTA?
Accidental: Phantom Encounters
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Phantom encounters can’t be found in central data, or have only their skeletons without their flesh! Typical causes are:
1. Submitted completed records are sometimes “cached” and not processed into the central data bases.
2. Disconnects between the capture system (AHLTA) and the transmitting system (CHCS) prevent the encounters’ transmission.
3. CCE Edits (CHCS) are sometimes “undone” by a retransmission of the AHLTA record.
Missing Data
Accidental: Corrupt Encounters
Not Discernable from Central Data
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2010 UBO/UBU ConferenceTurning Knowledge Into Action Advantageous Data Errors
Several common types of data error, which can be advantageous, are:– Incorrect pharmacy pricing– Date errors gaining outlier per diem rates– Recording duplicates– Coding Creep
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Prime Vendor priceused by other MTFs
Local CHCS pharmacypricing table
$9.7 Milliontoo high
Advantageous Data Errors: Pricing
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This is a storedcorporate document
in M2
1. Bad pricing can be caused by either or both of local CHCS prices, or using the wrong “unit” for counting quantities.
2. In this case, the second MTF has CHCS loaded with the “box” price, but is using the correct “inner package” quantities.
3. This overstates the pharmacy cost (and OHI bill) by 60 times.
Advantageous Data Errors: Pricing
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1. The low end is often as destructive as the high end.
2. Captopril (an ACE inhibitor for hearts) costs 19¢ each.
3. Coumadin (a blood thinner) costs 6¢ each.
4. This understates the pharmacy cost (and OHI bill) by dividing a unit or box cost by the case quantity!
This is a storedcorporate document
in M2
Advantageous Data Errors: Pricing
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Advantageous Data Errors: Pricing
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Advantageous Data Errors: Outliers
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Mirrored encounters have a single event represented in multiple records, as though it occurred many times. Typical causes are:
1. MTF’s changed their identifier (“DMIS ID”) between reports of the event.
Advantageous Data Errors: Duplicates
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Advantageous Data Errors: Duplicates
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Advantageous Data Errors: Duplicates
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Mirrored encounters have a single event represented in multiple records, as though it occurred many times. Typical causes are:
1. MTF’s changed their identifier (“DMIS ID”) between reports of the event.
2. Persons create a new record, possibly because they are unaware a record already exists.
Advantageous Data Errors: Duplicates
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2 records for each
twins sharingone ID, or
duplicates?
Same day readmission and
redischargeor duplicates?
Has to beduplicates!
Advantageous Data Errors: Duplicates
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• Normal and predictable
• Created by financial or other reward incentives
• Moderated by penalties, audits, or other controls
• Confounded by “optimization” vs. “gaming”
Advantageous Data Errors: Coding Creep
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Advantageous Data Errors: Coding Creep
AmbulatoryFlavor
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Advantageous Data Errors: Coding Creep
AmbulatoryFlavor
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SETTINGS, SKILLS, AND PROCEDURES
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In aggregate, MHS isdoing as well as
purchased care inavoiding “mismatches”
A “match” is when the E&M is for highlevel treatment, by
an appropriate provider specialty,
in an ER.
Advantageous Data Errors: Coding Creep
AmbulatoryFlavor
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These E&M CodesMUST
be in an ER!
MHS-WIDE
Advantageous Data Errors: Coding Creep
AmbulatoryFlavor
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Just 2 MTFswith DentalClinic ERs
Just 2 MTFswith ERs in1 other OPD
Where are they from?
Advantageous Data Errors: Coding Creep
AmbulatoryFlavor
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QUANTITIES AND MODIFIERS BY SETTINGS
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Occupational Medicine Physician$24K in
PPS
Advantageous Data Errors: Coding Creep
AmbulatoryFlavor
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QUANTITIES AND MODIFIERS BY SETTINGS
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Good Coding, Bad Results
Advantageous Data Errors: Coding Creep
AmbulatoryFlavor
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Bad Coding, Bad Results
15 hours of continuous therapy
10.2 days of continuous therapy
QUANTITIES AND MODIFIERS BY SETTINGS
Advantageous Data Errors: Coding Creep
AmbulatoryFlavor
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2010 UBO/UBU ConferenceTurning Knowledge Into Action Policy-driven Adv. Data Errors
Formal Policy is sometimes given requiring advantageous data errors:– Mandated coding creep– Mandated inappropriate admissions– Mandated unbundling
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Policy-driven Coding Creep
DIRECTED ????
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Policy-driven Coding Creep
DIRECTED ????
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Myringotomies – Inpatient or Same Day Surgery?Which MTF is Different?
Policy-driven Admissions
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Over 150 Admissions/Year
Policy-driven Admissions
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Potential Impacts (FY08)
150 x 0.7 = 105 RWPs x $9,300 = $1 million
150 x 1.4 = 210 RVUs x $72 = $16 thousand
PPSEarnings
But also…
Quality of Care?
• Nosocomial Infection
• Psychological Impact
• Safety Risks
Patient Admin Burden?
OHI Billing Appropriateness?
Policy-driven Admissions
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Unbundling of Electrolyte Panels, by Service
BILLING MUST RE-ASSEMBLE
THE PANELS
October 2005 – December 2009
Policy-driven Unbundling
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Bad Data Obscures Mgt– Missed Opportunities– Lumpy Pictures Abound
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Data “Fog of War”
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Worth a Try?
Data “Fog of War”: Missed Opportunities
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People Thought to Have No OHI in October
People Known to Have OHI in November
Peoplefor whom
the MTFran
ancillarytests
inOctober
$$$
Data “Fog of War”: Missed Opportunities
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How M2 Solves this Kind of Question
But TRICK: Never more than 500,000 allowed!
1. Create a list of those with Medical OHI in November (the smallest list of the three).
2. Create a subset of the list with just those eligible but with no Medical OHI in October
3. And for just those, retrieve their October ancillary data and costs.
Main Query 1
Sub-Query 1.1
Sub-Query 1.1.1
And then build it backwards from your logic
Data “Fog of War”: Missed Opportunities
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• Cyclical lumpy data
• Perverse lumpy data
• Invalid lumpy data
Data “Fog of War”: Lumpy Pictures
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CYCLICAL LUMPY DATA
MHS WORLDWIDE BED DAYS (FY09)
Bad Months!
Most productive months?
Data “Fog of War”: Lumpy Pictures
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MHS WORLDWIDE BED DAYS (FY09)
CYCLICAL LUMPY DATA
LUMPINESSCAUSED BY
UNEVENINTERVALS
Data “Fog of War”: Lumpy Pictures
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LUMPINESSCAUSED BYSEASONALEFFECTS
TFL
Data “Fog of War”: Lumpy Pictures
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LUMPINESSCAUSED BY
EVENTEFFECTS
9/11
Iraq
TAMP Extension
Surge
Data “Fog of War”: Lumpy Pictures
TRS Change
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CYCLICAL LUMPY DATA
LUMPINESSCAUSED BYARTIFICIALPARTITIONS
Data “Fog of War”: Lumpy Pictures
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CYCLICAL LUMPY DATA
LUMPINESSCAUSED BYARTIFICIALPARTITIONS
Data “Fog of War”: Lumpy Pictures
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CYCLICAL LUMPY DATA
The “Drag Forward” RuleReplacing Interim Bills
LUMPINESSCAUSED BYARTIFICIALPARTITIONS
Data “Fog of War”: Lumpy Pictures
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INVALID LUMPY DATA
Data “Fog of War”: Lumpy Pictures
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INVALID LUMPY DATA
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
$5,000,0001 2 3 4 5 6 7 8 9
10 11 12
1 2 3 4 5 6 7 8 9
10 11 12
1
2007
2008
2009
ONE MEDICAL CENTEREXPENSES IN
MEPRS
Data “Fog of War”: Lumpy Pictures
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0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1 2 3 4 5 6 7 8 9
10 11 12
1 2 3 4 5 6 7 8 9
10 11 12
1
2007
2008
2009
WTD SCRIPTS IN MEPRS
INVALID LUMPY DATA
Data “Fog of War”: Lumpy Pictures
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10,000
100,000
1 2 3 4 5 6 7 8 9
10
11 12 1 2 3 4 5 6 7 8 9
10
11 12 1 2 3 4
2007
2008
2009
INVALID LUMPY DATA
ONE MEDICAL CENTERPTDTS ISSUE
COST
Data “Fog of War”: Lumpy Pictures
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INVALID LUMPY DATA
One MTF
One MTF
Data “Fog of War”: Lumpy Pictures
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INVALID LUMPY DATA, One MTF
New CY07RVU table
Data “Fog of War”: Lumpy Pictures
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Data “Fog of War”: Lumpy Pictures
Data Types Prone to Lumpiness:
– Institutional Purchased Care
– Non-Institutional Purchased Care for OB and Surgeries
– Direct Care Inpatient (SIDRs)
– MEPRS (EAS)
– Enrollment, especially newborns
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Data “Fog of War”: Lumpy Pictures
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2010 UBO/UBU ConferenceTurning Knowledge Into Action Data “Fog of War”: Lumpy Pictures
Data Types Prone to Lumpiness:
– Institutional Purchased Care
– Non-Institutional Purchased Care for OB and Surgeries
– Direct Care Inpatient (SIDRs)
– MEPRS (EAS)
– Enrollment, especially newborns
Precautions on perceptions with Lumpy Data:
– Redistribute when feasible to “unlump”
– Avoid “answers” from lumpy systems (i.e., MEPRS cost/RVU)
– “TLAR” anomalies based on knowledge
– Caveat
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Payor Strategies Receiver Strategies Joint Strategies
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Penalize Creeping (and enforce!) Penalize (Inapp) Admissions (and enforce!) Penalize setting mismatches (and enforce!) Limit units of service Pay least of Rx “should” or “did” cost Test duplicate records (and penalize when appropriate)
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Rebundle mandated unbundling before billing Check for low-price outliers (esp. Rx) Demand release of cached records Check peers for gamesmanship and request payor rules to
prevent; OR Adopt peer gamesmanship
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Analyze and dissect lumpy data for hidden management needs.
Audit records for balance of full disclosure (Pxs and Dxs) and relevance.
Fix or replace automation that does not work.
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Summary
If resource allocation follows arbitrary rules. . .– Know the causes and symptoms of data error– Take steps to maintain equity against
advantageous or disadvantageous error– Avoid policy-driven data error– See through the data “fog of war”– Adopt defensive strategies to protect resources
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