Overview

This Performance Task Assessment is based on a case study set in Brooklyn Presbyterian Hospital, in the Park Slope neighborhood of Brooklyn, New York, as the hospital confronts the new quality standards set by the Patient Protection and Affordable Care Act (PPACA) for Medicare patients. To complete this Assessment, read the scenario below, and then complete Parts I and II that follow. You will use information from the scenario, along with the supporting documents, to demonstrate your ability to adapt internal policies and practices to align with changes to healthcare laws and regulations.

Part 1: Analyzing HRRP Policy and Evaluating Hospital Performance

Read the Health Affairs Policy Brief on the “Medicare Hospital Readmissions Reduction Program.” Then, analyze the document “Brooklyn Presbyterian Hospital—Unplanned Readmission Rates,” which presents statistics on the unplanned readmission rates at the hospital and how they compare to the national averages. Also, review the current, “Acute Inpatient Hospital Admissions Payment Policy” document.

Use these resources to develop a report (4–5 pages) to the CEO that completes the following:

• Describe the key elements of the Medicare Hospital Readmissions Reduction Program (HRRP) established in the Affordable Care Act (ACA).
• Identify two factors at Brooklyn Presbyterian Hospital based on the current policy that contribute to the risk of failing to meet HRRP criteria.
• Explain how current internal practices and the changes in policy might positively impact alignment to current and future healthcare laws.
• Suggest one revision to the current policy to help Brooklyn Presbyterian Hospital meet HRRP criteria.
• Suggest one change in current practice across the hospital’s organization in order to help Brooklyn Presbyterian Hospital meet changes in Medicare reimbursement. Include 2–3 sentences explaining the importance of adapting internal policies and practices to align with changes in healthcare laws and regulations.
• Describe at least three key elements needed in a new program to earn the maximum reimbursement under HRRP by reducing readmission rates.
• Create five goals for Brooklyn Presbyterian Hospital for earning the maximum reimbursement by following the HRRP criteria. These goals may focus on processes or outcomes.

Part 2: Developing an Action Plan to Maximize Reimbursements and Adapt to Change

 Political pressure will result in changes to Centers for Medicare and Medicaid Services (CMS) policy and reimbursements. Develop a 10- to 12-slide presentation, to senior management, proposing strategies for executing a plan for earning maximum reimbursement under HRRP, specifically by changing the behavior of providers and patients. Your goal is to secure resources to put your plan into action. In this presentation, explain your approach, your plan for implementation, at least two ways you will prepare and monitor for change in CMS policy, and your education plan for staff. 

Brooklyn Presbyterian Hospital Acute Inpatient Hospital Admissions Payment Policy

Please Note: The policy described below is hypothetical.

Purpose of the Billing Process

The purpose of the hospital billing process is to obtain reimbursement for services and items rendered by the hospital. Reimbursement is received from patients, insurance carriers, and government programs. The hospital billing process begins when a patient arrives at the hospital for diagnosis and treatment of an injury, illness, disease, or condition. The patient’s demographic and insurance information is obtained and registered in the hospital’s information system. Physician’s orders or a requisition outlines the patient care services required. Patient care services and items provided during the patient’s stay are recorded on the patient’s account. Charges are posted to the patient’s account by various departments. When the patient leaves the hospital, all information and charges are prepared for billing.

Definition

An acute inpatient hospital is a facility licensed as a hospital by the State Department of Public Health. This type of facility makes diagnosis and treatment available and offers provider services 24 hours a day but does not include any facility licensed as a chronic disease and rehabilitation hospital; any hospital licensed primarily to provide mental health services; or any unit of a facility licensed as a nursing facility, chronic disease unit, or rehabilitation unit.

An inpatient admission is a member’s admission to a hospital for the purpose of receiving inpatient services.

Authorization Requirements

The rate of payment is determined by the effective date of a member’s inpatient admission and applies for the length of the admission (i.e., any rate change under the contract during the member’s stay will not apply). We require notification for emergency inpatient admissions.

We require prior authorization 5 business days prior to an elective admission.

We require notification through an emergency services provider for all behavioral health inpatient admissions.

Billing and Reimbursement

Providers must file a claim for hospital inpatient services through an 837i HIPAA-compliant file or on a 1234A form, using industry standard revenue codes.

An inpatient reimbursement rate is the rate in effect on the date a member begins an inpatient admission. The inpatient reimbursement rate includes all services a member receives during an inpatient admission, as applicable (see our Hospital Hierarchy Payment Policy). We will only reimburse for the portion of a patient’s stay during which they were enrolled as a Health Plan—Network Health member.

Hospital Newborn Services

We reimburse for inpatient services for well newborns. With prior authorization, we reimburse for inpatient services for boarder babies and newborns admitted to a neonatal intensive-care unit (see our Hospital Newborn Services Payment Policy).

Provider Preventable Conditions and Serious Reportable Events

We do not reimburse for provider preventable conditions or serious reportable events (see our Provider Preventable Conditions and Serious Reportable Events Payment Policy).

Adapted from:

Tufts Health Public Plans. (2015). Acute inpatient hospital admissions payment policy. Retrieved from

https://network-health.org/Providers/Policies-and-Manuals/Payment-Policies/Acute-Inpatient-Hospital-Admissions-Payment-Policy.aspx

©2015 Walden University
1

Brooklyn Presbyterian Hospital (BPH)
Hospital
 re-­‐admission
 rates
 through
 6/30/2012

Description
 of
 measures
 below:

Measures
 of
 30-­‐day
 death
 (mortality)
 show
 when
 patients
 die,
 for
 any
 reason,
 within
 30
 days
 of
 admission
 to
 a
 hospital.

BPH U.S.
 NATIONAL
 RATE
Rate
 of
 unplanned
 readmission
 for
 heart
 attack
 patients No
 Different
 than
 U.S.
 National
 Rate 18.30%
Death
 rate
 for
 heart
 attack
 patients No
 Different
 than
 U.S.
 National
 Rate 15.20%
Rate
 of
 unplanned
 readmission
 for
 heart
 failure
 patients Worse
 than
 U.S.
 National
 Rate 23.00%
Death
 rate
 for
 heart
 failure
 patients No
 Different
 than
 U.S.
 National
 Rate 11.70%
Rate
 of
 unplanned
 readmission
 for
 pneumonia
 patients Worse
 than
 U.S.
 National
 Rate 17.60%
Death
 rate
 for
 pneumonia
 patients No
 Different
 than
 U.S.
 National
 Rate 11.90%
Rate
 of
 unplanned
 readmission
 after
 hip/knee
 surgery No
 Different
 than
 U.S.
 National
 Rate 5.40%
Rate
 of
 unplanned
 readmission
 after
 discharge
 from
 hospital
 (hospital-­‐wide) Worse
 than
 U.S.
 National
 Rate 16.00%

Below,
 each
 hospital’s
 performance
 on
 the
 death
 (mortality)
 and
 unplanned
 readmission
 measures
 is
 compared
 to
 the
 U.S.
 national
 
observed
 rates
 for
 those
 measures.
 The
 performance
 results
 take
 into
 account
 how
 sick
 patients
 were
 before
 they
 were
 admitted
 to
 the
 
hospital.

Measures
 of
 30-­‐day
 unplanned
 readmission
 show
 when
 patients
 who
 have
 had
 a
 recent
 hospital
 stay
 need
 to
 go
 back
 into
 a
 hospital
 
again
 for
 unplanned
 care
 within
 30
 days
 of
 their
 initial
 discharge.

Patients
 who
 are
 admitted
 to
 the
 hospital
 for
 treatment
 of
 medical
 problems
 sometimes
 get
 other
 serious
 injuries,
 complications,
 or
 
conditions,
 and
 may
 even
 die.
 Some
 patients
 may
 experience
 problems
 soon
 after
 they
 are
 discharged
 and
 need
 to
 be
 admitted
 to
 the
 
hospital
 again.
 These
 events
 can
 often
 be
 prevented
 if
 hospitals
 follow
 best
 practices
 for
 treating
 patients.

Readmissions,
 Complications
 and
 Deaths: