between care pathways that have vastly different financial
consequences unless they are both included in the conversation about developing those pathways and reminded of
those pathways when atypical patients present.
Similarly, combining clinical documentation improvement (CDI) programs with new clinical and financial measurements helps make the case for both. Compliance doctrine would indicate that there needs to be valid clinical
reasons present when business office or HIM staff request
additions to or changes to medical record documentation
after discharge (such as hospital-acquired conditions or
“present on admission” indicators). Any changes to medical records after discharge typically relate only to changes
in fee-for-service reimbursement, which as a motivator typically does not impress physician partners and impresses
regulators even less.
However, correcting clinical documentation concurrently with an admission—or correcting entries in the record after admission that relate to the continuum of care—
in a clinically integrated network has more than a simple
“change the document to upcode the care” impact. It affects how all of the participants in the APM structure approach ongoing care and the financial incentives for persons other than the care provider whose record has been
Providing Feedback on Benchmarks
Frequent feedback on both clinical and financial bench-
marks needs to be provided to all participants. Industry in-
formation shows that this “dashboard” information is more
effective when presented as a comparison with other partici-
pants (on an anonymous basis, of course), as most providers
do not want to be viewed as negative outliers. Additionally,
the completeness and accuracy of clinical documentation
can be dashboarded and compared with industry and com-
petitor norms in order to show the effect on care provided—
or not needed—and the corresponding effect of medical
spending and enterprise costs. Both are helpful in establish-
ing the proof of clinical and financial integration desired by
regulators and payers.
If a separate organization has been established to man-
age the APM arrangements, then one compliance-related
item of documentation should be a business associate
agreement between each APM provider and the manage-
ment organization. Unless the manager is a licensed entity
under state insurance law, most likely it will be viewed as
a “legal stranger” to the flow of “protected health infor-
mation” (PHI) and will need a business associate agree-
ment with each provider. Likewise, the provision of pro-
tected health information (PHI) to members of the APM
collaborative not involved in direct patient care creates
another compliance risk and such information should be
“de-identified” before sharing with APM management and
Finally, audits of payments and explanation of benefit
forms should be undertaken regularly to make sure that
the payer pays in accordance with the APM agreement.
For many providers, these payments will be all that they
receive for services rendered, and it is not uncommon (un-
fortunately) for payers not to pay in accordance with their
Barry S. Herrin ( email@example.com) is the founder of
Herrin Health Law, P.C., based in Atlanta, GA.
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