Quote:
Originally Posted by blueash
Advantage plans are paid a base rate by the government at a negotiated monthly rate to assume the cost of persons who would otherwise be on Medicare. But, and this is a big but... the rate is then adjusted upward if the patient population is sicker thus more likely to be costly to provide care.
UHC and I believe our local Villages Health Care are, reading between the lines, being looked at for managing the system to make it appear that they have a sicker population. The more diagnoses you can add to the paperwork the better your payment will be.
This is a very difficult judgment to make as a doctor or health care system. You get "blood work" every six months and this time your blood sugar is just above the cutoff. Always been fine before but some were at the top of normal.
Does the doctor enter elevated blood sugar into the computer as a diagnosis, or maybe pre-diabetic? Is that cheating or is it important as a reminder next time to ask about eating and maybe get an A1C?
How about the complaint that your fingers are stiff and ache in the morning but after an hour or so it self resolves? Does the doctor enter arthritis into your diagnoses as you clearly have it, or leave it out as it requires no management.
If the director of the Health Care system sends out a memo telling all the providers to be sure to enter all the issues into the diagnoses record is that good medical care or is that fraud?
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yes and no. . .
EMR keep all diagnosis for reference, though not all diagnosis are permanent, so great question, and a legitimate question.
The other issue is that limits for normal versus abnormal can change over time. Does a changed limit change the diagnosis from once healthy to now less healthy or a now has a condition? example here is healthy cholesterol limits.
The other is with EMRs, especially with research hospitals, or teaching hospitals, is that the data is regularly used for research, for healthcare improvements. The more data the better for symptom/condition analysis. Granted the analysis needs to have good stats behind it, reproducible, etc. . so does this change the payer / reimbursement amounts?
what's submitted is reimbursed, and the programmers write the data extraction programs, and most if not all data extraction programmers have zero clinical knowledge, so its easy to give minimal instructions for data extraction, and blame programmers if wrong. Coachk fights this battle on a weekly basis, as she is not clinical, but has lots of clinical reporting knowledge from data interactions with doctors and nurses, having PAs and nurses in her department.
And yes, the battle is real between IT sending data and IT sending the proper data.
good luck to us