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Health Economics
According to the 2022 Medicare Fee-for Service Supplemental Improper Payment Data, there was a $4.4 Billion overpayment in hospital-owned outpatient provider-based departments1. This was due to improper documentation with items such as missing orders or inadequate documentation to support an order, missing documentation to support medical necessity, and missing attestations to support unsigned orders and records. These high error rates lead to overpayments that can create loss of business, loss of patients, or loss of Medicare billing abilities. Comprehending all aspects of wound care, including the guidelines associated with documentation and billing, is essential.
Understanding the proper steps to follow to ensure accurate indications, review of contraindications, utilization management and documentation need, is critical. This poster presentation will detail the mapping of the guidelines and policies of wound care, linking the Clinical+Operational+Regulatory+Economic/Financial (CORE*) processes.
Methods:
The proprietary process of CORE takes into consideration all aspects needed when determining the steps in care planning, treatment, and goals of the wound care business. Each of the four distinct parts need to be equally assessed to best serve the patient and business; building the accurate structure to meet the goals in mind. Following the process of CORE, while embedding the Center for Medicare and Medicaid Services (CMS) policies and guidelines for wound care, will create the opportunity for proper documentation and regulatory compliance; leading providers to improved compliance and greater success with payment processes, audits, and appeals.
Results:
When detailing the clinical needs of a patient, building in the CORE guidelines mapping process will support the clinical treatment choice, while supporting the operations, regulations and economics. This will lessen the risk of overpayments, ensuring the supportive material on the treatment plan is in place.
Discussion: Managing the work required for your role can be a daunting task. The rules and regulations of work performed, coupled with the need to accurately capture the clinical documentation of your work, must be carefully accounted for to meet the proper documentation requirements and reimbursement within your place of service.
Trademarked Items: * CORE is a proprietary process developed by the primary author.
References: 1. 2022 Medicare Fee-for Service Supplemental Improper Payment Data, US Dept of Health and Human Services, accessed February 2023