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Opioids as it relates to Revenue Cycle Donna Graham, Executive Director Revenue Cycle Jennifer Davis, Director PFS 1

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Page 1: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Opioids as it relates to Revenue CycleDonna Graham, Executive Director Revenue Cycle

Jennifer Davis, Director PFS

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Page 2: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Drug Overdoes Rates 1999-2016➢Ohio leads the nation in per capita overdose deaths and has become the posterchild of the crisis in national media

➢Drug overdoses are now the leading cause of death for Americans under 50 years old nationally (Quinones 2017).

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Page 3: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Causes of Death in Ohio➢Overdose deaths are now the leading cause of death for Ohioans under the age of 55 and the sixth leading cause of death overall.

➢More than two and a half times as many people die from drug overdoses than in car accidents in Ohio

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Page 4: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Cost of Opioid Abuse & Dependency - Ohio

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Page 5: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Cost Per Capita of Opioid Abuse

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Page 6: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

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Page 7: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

The MetroHealth’s System Journey to Serve Cuyahoga County Residents

2012

88% of Population within 10 min of MH Outpatient Facility

40% of Population within 15 min of MH

Inpatient Facility

• 1 Inpatient facility

• 1 Emergency Depts.

• 20 Outpatient sites

• 3 Pharmacies

• 875,000 visits

• 180,000 unique patients

Integrated Health Delivery System

2018

97% of Population within

10 min of MH Outpatient

Facility

80% of Population within 15 min of MH Inpatient Facility

• 4 Hospitals

• 742 staffed beds

• 628 employed physicians

• 4 Emergency Depts.

• 27 Ambulatory sites

• 9 Pharmacies

• 1,300,000 visits

• 300,000 unique patients

Page 8: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Total Opioid Encounters MH Patient Origin

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Page 9: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

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45.1%

38.0%

14.0%

2.9%

79.4%

18.4%

0.0%2.2%

37.6%

32.4%

25.1%

4.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Medicaid FFS / HMO Medicare FFS / HMO Commercial Self Pay

MHS Payor Mix Distribution

Narcan Vivitrol MetroHealth

Page 10: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

MetroHealth’s Opioid Initiative

➢As a part of a multi-pronged community plan to fight against

opioid addiction and overdose, our initiative is to optimize the

Epic EHR to enable optimal pain management, promote safe

opioid prescriptive practices, identify high risk providers and

patients, and engage patients and providers in reducing the

impact of the opioid epidemic.

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Page 11: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Power of Best Practice Advisories

11

➢ Epic Medication & Orders Best Practice Advisory #1

➢ Epic Medication & Orders Best Practice Advisory #2

Page 12: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

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Order Validation Check➢ Epic Order Validation #1

➢ Epic Order Validation #2

Page 13: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

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Order Validation Hard Stops

Page 14: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

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Comprehensive treatment including

psychosocial support

Patient requires detox and relapse prevention support

Monthly, extended-release, injectable

Naltrexone (Vivitrol)

Healthcare Provider administered

Outpatient coaching integration – Allied

Professional

Vivitrol Clinic

Page 15: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Vivitrol Clinic: Unique Opportunities

Lower hospital cost in Population Health model and

value based payment system

HOPD Physician Clinic

Specialty Pharmacy

Training for Family Medicine

residents

Applications of external grants

Clinical research and publications

Innovation Community

Outreach

15

Page 16: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Clinic MAT Team16

Page 17: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Vivitrol Medication Adherence Program

17

Initial

15 Minute Video

E&M Visit

Oral Naltrexone Challenge (unless client is delayed in follow up and outside the window of 28 days)

Every 4 Weeks

Urine Toxicology

Urine beta-HCG

Vivitrol Injection ( up to 12 months)

E&M Visit

Every 6 Months

Liver Function Test

Page 18: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Vivitrol Coverage 2018

18

PAYOR NAMEEXPECTED REIMBURSEMENT

PER UNIT AVG ADMINISTERED UNITSTOTAL EXPECTED REIMBURSEMENT

Medicare FFS $3.26 380 $1,239

Medicare HMOs*Buckeye Medicare

Contract Rates 380

*MyCare (Duals)

Medicaid FFS $3.25 380 $1,235

Medicaid HMOs Contract Rates 380

Commercial Contract Rates 380

* Requires Authorization

Vivitrol Billing and Coding Guide:

https://www.vivitrolhcp.com/content/pdfs/billing-and-coding-guide.pdf

Page 19: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Coverage Implications➢Medical Benefits do not provide coverage

➢ Use Pharmaceutical Benefits

➢ Review Available Grants for Coverage

➢Payor Nuances➢Sublocade (buprenorphine-naloxone)

➢Denials: By Injection

➢Preference: Sublingual (oral) or use Vivitrol

➢Appeals with reason for needing Sublocade by injection were denied by CareSource

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Page 20: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Reimbursable DRG’s

20

DRG 894

Alcohol / Drug Abuse or

Dependence, Left AMA

DRG 895

Psychoses

DRG 896 Behavioral &

Developmental Disorders

DRG 897

Other Mental Disorder

Diagnoses

Page 21: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Top 5 Reimbursable Diagnosis

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T50.7X6A: Under dosing of analeptics and opioid receptor antagonists, initial encounter

T50.7X5A: Adverse effect of analeptics and opioid receptor antagonists, initial encounter

T50.7X2A: Poisoning by analeptics and opioid receptor antagonists, intentional self-harm, initial encounter

T50.7X1A: Poisoning by analeptics and opioid receptor antagonists, accidental (unintentional), initial encounter

T40.696A: Under dosing of other narcotics, initial encounter

Page 22: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

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Mobile Vivitrol Unit

FLIPPING THE PARADIGM

➢ MetroHealth continues to provide a

care delivery model focused on

community engagement, outreach,

and wellness at the earliest

opportunity for connection.

Page 23: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Clinic P/L

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Page 24: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

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Summary of Project: As a part of a multi-pronged community plan to fight against opioid addiction and overdose, this initiative is to optimize the Epic EHR to enable optimal pain management, promote safe opioid prescriptive practices, identify high risk providers and patients, and engage patients and providers in reducing the impact of the opioid epidemic.

Opioid Initiative

Clinical Benefits

• Safer and more accurate prescribing

• Improve provider education• Increase patient education• Improve patient advocacy• Improve treatment• Reduce overdose rate• Alternative medicine• Improved Clinical Decision

Support through Epic Best Practice Alerts (BPA)

Financial Benefits

• Reduced impact of opioid use disorder (OUD)

• Opportunity to participate in grants and other programs with financial impact

Strategic Benefits

• Supports MetroHealth goal to address the opioid crisis in our area.

• Led by the Office of Opioid Safety and Executive Leadership to improve patient safety and reduce risks.

• Meet Medical Board, Federal and OBoP Regulations

Multi-Disciplinary Resources

• Revenue Cycle• Clinical Operations• Information Technology• Providers• Nurses• Finance

Project Score

✓ Financial Return

✓ Patient Safety

✓ Quality

✓ Strategy

✓ Enterprise

✓ Complexity

✓ Regulatory

Page 25: Donna Graham, Executive Director Revenue Cycle Jennifer ......Jennifer Davis, Director PFS 1. Drug Overdoes Rates 1999-2016 ... REIMBURSEMENT Medicare FFS $3.26 380 $1,239 Medicare

Contact Information

25

Phone: 216-778-4175Email: [email protected]

Phone: 216-957-2505Email: [email protected]


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