PRACTICE

Support for Reimbursement, Payment, and Quality System Implementation (Providers, Clinicians, Government, Payors, Facilities)

Next Wave is proud of its track record of providing value to our clients: better treatment outcomes, higher staff satisfaction, lower costs, and improved revenues – many times all four.

• Hospital Diagnosis Related Group (DRG) Payments
  • Measure and Predict documentation/coding “Creep” at facility level, implement internal systems to monitor
  • Identify Medicare DRG Refinements Needed and Prepare Formal CMS Requests
    • Collaboration with the American Academy of Orthopedic Surgeons (AAOS) and Four Major Teaching Hospitals
    • Separate Revision vs. Initial Hip/Knee Replacements Implemented
    • Other Refinements in Process
  • Level of Care/Medical Necessity Reviews
• Skilled Nursing Facility Resource Utilization Group (RUG III) Payments
  • Compute and Validate Individual Facility Impacts of RUG III Refinements
  • Compute and Validate Statewide Impacts of RUG III Refinements,
  • Resolve Implementation Issues for RUG III Refinements
  • Technical Consultant to refine New York’s skilled nursing facility payments.
  • Participated in STRIVE (Staff Time and Resource Intensity Verification project) time studies to be used to update Medicare RUG III rates.
• Long Term Care Service Configuration Strategies
  • Estimated reimbursement calculations for market studies’ due diligence to support a conceptual framework for long term care services for residents (IRF, LTCH, SNF, Assisted Living, and Home Care)
    • Calculate ranges of fiscal impacts for various options
  • Identified alternatives to institutional care for individuals requiring long term care based on analysis of Medicaid, PRI, MDS data and existing/potential placement options for housing, functional, and psychosocial support
• Free-Standing Clinic Payment Reviews
  • Documentation, Coding (E&M, Procedures, Modifiers), and Chart to Bill Review
  • Interactive Learn and Apply© Training for Providers and Staff
  • Policy and Procedure Development and/or Refinement For Compliance
  • Systems and Forms Refinement
• Physician Office Practice Payment Reviews
  • Documentation, Coding (E&M, Procedures, Modifiers), and Chart to Bill Review
  • Interactive Learn and Apply© Training for Provider(s) and Staff
  • Identify and Implement Physicians Quality Reporting Initiative (PQRI) Reporting
  • Review and Validate Denials, Support and/or Prepare Appeals as Appropriate
  • Systems and Forms Refinements
• Outpatient Payment Reviews
  • Documentation, Coding (E&M, Procedures, Modifiers), and Chart to Bill Review
  • Interactive Learn and Apply© Training for Providers and Staff
  • Compare Hospital vs. Physician Documentation and Coding Alignment
• Malpractice Risk Assessment
  • Pattern Review of Historical Events
  • Develop Risk Reduction Strategies and Process Improvements
  • Evaluate Impact of Risk Reduction Strategies on Claims, Settlements, etc.
• Health System Due Diligence Support for Attorneys
  • Chart Reviews
  • Rate Analysis
  • Law->Regulation->Implementation Review
• Insurer Claims Review Process Evaluations
  • Appropriate Payments when Modifiers Billed
  • Appropriate Payments for Physicians Assistants (PA), Nurse Practitioners (NP) “Incident to” Services
  • Review of computer vs. manual claims review accuracy
  • Appropriate E&M level billed per documentation
  • Coordination of Benefits
  • Evaluation of Claims Review Yield vs. Effort