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Chief CRNA: Billing audits, Are You At Risk?

Every year the Department of Health and Human Services Office of the Inspector General conducts audits and on-site inspections of Health Care Facilities to ensure that billing and payment policies are being followed. Recovery audit contractors are utilized to make the inspections and are reimbursed by collecting a percentage of the money saved due to the inspection. In other words, the more billing discrepancies they uncover, the more they make. The office of the Inspector General has over 600 auditors, the largest number of auditors of any Federal Agency.

Writing for the on-line blog MiraMed, Tony Mira discusses the 2013 OIG work plan and the implication for hospitals. According to Mira,

“While the Work Plan sets forth the OIG’s attention for the upcoming year, it also provides insight into the attention other agencies and contractors (e.g., the Centers for Medicare and Medicaid Services (CMS), Recovery Audit Contractors (RACs), etc.) will pay, as well. When the OIG cracks down on one body (e.g., CMS), that body cracks down on bodies beneath it (e.g., Medicare Administrative Contractors (MACs)), sending a ripple downstream all the way to the provider. As such, it is important for providers to be aware of the OIG’s focal points in the upcoming year as they, too, will feel the impact.”

Click here to review the OIG 2013 work plan

According to the plan, several ongoing areas of review remain from previous work plans:

Hospitals—Same-Day Readmissions
Program Integrity—Medical Review of Part A and Part B Claims Submitted by Top Error-Prone Providers
Program Integrity—High Cumulative Part B Payments
Physicians—Error Rate for Incident-To Services Performed by Nonphysicians
Physicians—Place-of-Service Coding Errors
Evaluation and Management (E/M) Services—Potentially Inappropriate Payments in 2010

New areas of interest for review in 2013 include:

Hospitals—Inpatient Billing for Medicare Beneficiaries
Hospitals—The DRG Window
Hospitals—Non-Hospital-Owned Physician Practices Using Provider-Based Status
Hospitals—Compliance with Medicare’s Transfer Policy

The OIG has published a video discussing the priorities of the 2013 work plan. Click here to view the video.

As anesthetists, it is essential that our records and the billing for our services are accurate. Inspectors have a plan to uncover billing fraud and recover excess payment. As providers, we must be aware of the issues being audited.

Clinical Topic: Intraoperative Hypotension and Stroke

As guardians of patient safety during the surgical procedure, anesthetists are tasked with the prevention of adverse intraoperative events. Of the many risks of surgery, death and stroke are two of the most devastating events that can occur. Ischemic stroke occurs in 0.1-3% of patients undergoing general anesthesia. Thus, maintenance of cerebral perfusion is essential during the perioperative period.

In an article by Bijker JB et al titled Intraoperative Hypotension and Perioperative Ischemic Stroke After General Anesthesia (Anesthesiology. 2009 Dec;111(6):1217-26) the relationship between intraoperative hypotension and stroke is evaluated. The purpose of the study was not only to validate a correlation between hypotension and stroke, but also to determine the degree of hypotension and the length of time associated with an adverse outcome.

The study found that the incidence of ischemic events was increased when the blood pressure dropped 30% below baseline. The longer the blood pressure was below the critical level, the greater the incidence of adverse outcome. In the words of the author:

“Our results suggest that intraoperative hypotension accounts for an increase in stroke risk of approximately 1.3% per minute hypotension (i.e., the risk is increased 1.013 times for every minute of hypotension), depending on the definition of IOH that is used (in this case a decrease in mean blood pressure more than 30% from baseline). For example, a cumulative duration of 10 min of hypotension will result in a 1.14 times increased stroke risk (1.01310). If applied to the POISE trial, this would mean an increase in absolute stroke risk from 0.5% (POISE trial control patients) to 0.57%.”

Again, in the words of the authors: “In conclusion, the most widely proposed mechanism of a postoperative stroke is arterial embolism. Nonetheless, the results of the current study support the hypothesis that hypotension can influence the evolution of a postoperative stroke by compromising (collateral) blood flow to ischemic areas. In this context, hypotension is best defined as a decrease in mean blood pressure relative to a preoperative baseline, rather than an absolute low blood pressure value.”

Since patients present with a wide variety of baseline blood pressures, there is no magic number for a mean blood pressure to be maintained during surgery. The anesthetist is advised to calculate each patients lowest acceptable blood pressure based on maintaining the blood pressure within 30% of baseline.

Click here to read the complete article

Chief CRNA: CRNAs as OR Leaders

Across the Nation, Chief CRNAs are probably among the most under utilized group of talented health care providers. In addition to developing the work schedule and assuring that providers are present to support the posted schedule, Chief CRNAs know the strengths and weaknesses of the staff members and are in a unique position to guide the work flow to optimize patient care.

An original article Written by Sabrina Rodak details why Anesthesia providers are well positioned to guide the work flow in the operating room. Click here to read the original article.

Three experts on anesthesia services explain why anesthesia providers are best positioned to lead the operating room of a hospital.

1. “The perioperative leader should be an excellent communicator with a deep knowledge of OR management in order to successfully make the necessary changes required in carrying out the hospital’s overall goals. As anesthesiologists are present in the OR every single day, it is important that the anesthesia chair takes on this role to promote consistency across the board through this time of change,” says Leo Penzi, MD, executive vice chair of the department of anesthesia at North Shore University Hospital in Manhasset, N.Y., a member of the board of directors of North American Partners in Anesthesia and assistant professor in the department of anesthesiology at Hofstra North Shore-Long Island Jewish School of Medicine.

2. In a case study presented by Surgical Directions, a hospital recruited anesthesia providers to drive perioperative performance by granting them leadership positions and aligning incentives. The anesthesiologists received financial rewards for increasing patient volume and a stipend for fulfilling certain service standards, including increasing the availability of regional blocks, accommodating add-ons and participating in the OR’s daily huddle, a process in which the OR team discusses issues from recent cases and prepares for the next day’s schedule. Anesthesia leadership was an important element of the hospital’s success in perioperative services.

3. Proper anesthesia leadership in the OR is a key element of integrated delivery of care. Robert Stiefel, MD, a principal with Enhance Healthcare, defines this as “healthcare professionals and supporting facilities working towards one goal: optimized patient care that is more efficient and cost effective.” Integrated care in the OR depends on the coordination of hospital administration, OR staff, surgeons and anesthesiologists. Anesthesia providers’ involvement in all aspects of the OR makes them prime candidates to oversee this coordination. “Anesthesia providers are the most consistent component of the entire perioperative experience,” Dr. Stiefel says.

Clinical topic: Lower Central line infections

In the midst of the pressure to lower infection rates and meet CMS standards, is it possible to reduce the rate of central line infection to zero? That question was addressed in an article by Kate O’Rourke published in Anesthesiology news. The author states that new research has found that multidisciplinary team approaches are making great strides in dramatically reducing rates. She describes a study done at the University of Massachusetts finding that involving caregivers at all levels and providing frequent, regular feedback on infection rates to hospital staff are two key elements that have made these programs a success, experts said.

The article continues by quoting Matthias Walz, MD, chief of vascular anesthesiology at UMASS Medical Center, who said the guidelines at his facility were developed by a small task force and then approved by the institution’s Critical Care Operations Committee prior to implementation. “From the ICU physicians to the ICU nurses, respiratory therapists, pharmacy team, occupational therapists—everybody is at the table.” Because all disciplines were involved in creating the guidelines, all caregivers feel they have a stake in the process, he said.

A good infection control program will show positive results, however, for the success to be continued, participants must continue to be updated and motivated. Ongoing education is essential. Reducing infection rates is a total team effort by all caregivers. Communication and coordination is mandatory.

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