2/1/2017 Chal allenges s of of Lac Lactation Reim eimburse sement in th in the Acu cute Car are Se Setting Jason Silvas, RN Pediatric Program Coordinator January 27, 2017 Kno now Your our Tea eam! • Identify ALL members of the team • Sr. Director Managed Care – Provides oversight to entire operation • CMD Coordinator – Manages CMD’s and pricing with Biller • Biller/Charge Master – Manages insurance contracts • Coders – Validate lactation charges • Revenue Integrity Specialists – Verify charges and documentation • Decision Support – Responsible for monthly reports • Lactation Manager – Responsible for lactation staff • Correct documentation • Correct charges • Updated certificates/licensing • Lactation Specialists – Perform education (CLE)/consults (IBCLC) • CLE’s focus in Labor & Delivery and Postpartum Units • IBCLC’s focus on inpatient consults for entire hospital and outpatient referrals 1
2/1/2017 Bill llin ing an and Revenue Cycle le • DRG vs Individualized Contracts • MediCal – DRG, fixed payment • Internal agreement • Other Insurances • Reimbursement based on % of charges (negotiated, written contracts) • Examples: Kaiser, HMO/PPO’s • Financial Class Breakdown at SJCH: Cha harge Des escrip iptio ion Mas aster (C (CDM) • Comprehensive listing of items that could be billed to a patient, payer or healthcare provider • Lactation CDM’s used at SJCH and base price: 2
2/1/2017 Ad d Hoc oc Cha harge She heet Form orm • Created by Coders • Charges are Lactation responsibility • May only charge once a day for total education • Lactation work flow: • Daily report sheet • Hand off • Charges entered (about 30 minutes) Revenue In Integrit ity Spe pecia ialis ists • Have ability to approve or deny charges • Verify charges and documentation (education) • Must have current list of all lactation staff • Send verified charges to Patient Financial Services for billing • Was 100% chart audit for 6 months, reduced to 50% • Currently, 30% of charts are audited 3
2/1/2017 Edu ducatio ion Doc ocumentatio ion • Must Document: • Topics taught • Individual(s) taught • Teaching method • Teaching evaluation • Language used • Interpreter (if used) • Barriers to learning • Must document in consistent location Edu ducatio ion Doc ocumentatio ion • Revenue Integrity Specialists • Updated staffing list • No specific CLE or IBCLC roles 4
2/1/2017 Cha harge Brea eakdown by Unit nit • August, 2015: Tot otal l Cha harges vs s Tot otal l Wag ages • August, 2015: 5
2/1/2017 Revenue Col olle lected • Approximately 3-4 month reimbursement cycle • August, 2015: Ben enefits of of Lact actatio ion Ser ervic ices • Breastfeeding is normal needs to be supported • Long-term health benefits for mother and baby • Important role for the Baby Friendly Hospital Initiative • Increased HCAHPS scores • Higher reimbursement rate • Patient loyalty • It’s the right thing to do! 6
2/1/2017 Bab aby Fri Friendly Das Dashboard Jason Silvas, RN Pediatric Program Coordinator Baby Friendly Dashboard Exclusive Breastfeeding Rate 100% 90% 88% 82% 81% 80% 80% 80% 78% 77% 76% 73% 70% 70% 64.6 % 61% 58.4% 60% 56% 54% 50% 40% Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 SJCH - Current California - 2013 Kern County - 2013 SJCH - 2013 Trend 7
2/1/2017 Baby Friendly Dashboard Any Breastfeeding (Formula Supplemented) 100% 98% 96% 96% 94% 93% 92.9 % 92% 91% 91% 90.3 % 90% 90% 90% 87.6 % 87% 88% 87% 86% 86% 86% 85% 84% 83% 82% 80% Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 SJCH - Current California - 2013 Kern County - 2013 SJCH - 2013 Trend Baby Friendly Dashboard Feeding Plan Documented 100% 98% 96% 94% 94% 94% 93% 93% 93% 93% 92% 92% 92% 92% 92% 91% 90% 90% 88% 86% 84% 82% 80% Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Trend 8
2/1/2017 Baby Friendly Dashboard Skin to Skin Rate: Vaginal Delivery 100% 85% 84% 82% 81% 81% 80% 78% 78% 77% 80% 75% 73% 68% 60% 40% 20% 0% Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Trend Baby Friendly Dashboard Skin to Skin Rate: C-Section 100% 80% 61% 60% 53% 49% 45% 45% 44% 40% 40% 40% 35% 33% 29% 29% 20% 0% Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Trend 9
2/1/2017 Baby Friendly Dashboard Skin-to-Skin Documented 100% 90% 80% 75% 74% 73% 72% 71% 70% 68% 67% 70% 67% 64% 64% 58% 60% 50% 40% 30% 20% 10% 0% Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Trend Baby Friendly Dashboard Monthly C-Section % 40% 35% 32.2% 30% 29% 28% 27% 25% 25% 25% 25% 25% 24% 24% 24% 23% 21% 20% 15% Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 SJCH 2014 National Average Trend 10
2/1/2017 Baby Friendly Dashboard Monthly Delivery Report 400 350 300 83 89 66 79 91 76 71 66 81 250 67 66 Total Births 62 200 150 253 247 244 236 226 220 223 224 218 212 100 201 197 50 0 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Delivery Type Vaginal C-Section References: California Department of Public Health, Center for Family Health, Genetic Disease Screening Program, Newborn Screening Data, 2013 Martin JA, Hamilton BE, Osterman MJK. Births in the United States, 2014. NCHS data brief, no 216. Hyattsville, MD: National Center for Health Statistics. 2015. 11
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