Monday, December 11, 2017

Homecare: Automatic Denials

With the increasing trend of patient care being delivered it the home, and many health care organizations looking at vertical integration into home care, this topic of Home Care can be of assistance to healthcare administrators.

Centers for Medicare & Medicaid Services (CMS) directed Medicare Administrative Contractors (MACs) to start the process of doing an automatic denial of Home Health Prospective Payment System (HHPPS) claims. This process will be automatic when there are some conditions for payment that are not met in the claims submission process, specifically if the patient assessment data is not met.

If the claim is submitted without OASIS Assessment information the claim will be denied.

This information must be submitted within 30 days of completion. For the most part, this window of 30 days will have elapsed by the time the 60 day Plan of Care/Episode for HHPPS is completed. Now when the claim is submitted, for dates of service after April 1, 2017. Medicare claims processing will now look for the corresponding OASIS assessment is present in the Quality Information and Evaluation System (QIES).

If the criteria of the assessment is not found and the date of the claim is more than 30 days after the assessment completion date that is reported on the claim, Medicare will deny the claim. With that said, in the beginning however, Medicare will allow for 40 days.

In the information that Medicare sends back to the agency the following codes:
  • Group Code of CO
  • Claim Adjustment Reason Code 272

The home health agency can do some things to avoid unnecessary denials. Before submitting the claim the home health agency should check to see if the OASIS assessment has been completed and accepted in the QIES National Database. The home health agency can also verify by reviewing their OASIS Agency Final Validation Report to OASIS.

Basically, the home health agency should ensure prior to the submission of the OASIS assessment and the claim and that the following is correct:
  • Home Health CMS Certification Number (OASIS item M0010)
  • Beneficiary Medicare Number (OASIS item M0063)
  • Assessment Completion Date (OASIS item M0090)
  • Reason for Assessment (OASIS Item M0100) equal to 01, 03, or 04

Most importantly, accuracy of home health agency claims information is essential to prevent claim denials.

For more information on various Home Health Prospective Payment initiatives at:

Kevin Harrington, MATS, MSHA, RHIA, CHP  Full-Time Faculty at Saint Joseph's College

Monday, November 27, 2017

ACHCA Announces Bill McGinley, CNHA, CALA, CAS, FACHCA as New President and CEO

We are excited that our very own Bill McGinley is the new President and CEO of ACHCA!

Bill is a member of the Assisted Living Administration Advisory Committee for Saint Joseph’s College of Maine!.  

The American College of Health Care Administrators (ACHCA) has selected Bill McGinley, CNHA, CALA, CAS, FACHCA as its new President and CEO effective December 4, 2017. Mr. McGinley has been in the field of long-term care administration since 1980. His leadership skills and knowledge will greater strengthen ACHCA’s future. He has been a Nursing Home Administrator for 35 years. He began his career with the Greenery Rehabilitation Group, Inc. a nationally known leader in the field of head-injury rehabilitation and sub-acute care. The majority of Bill's career was with SALMON Health and Retirement, a Massachusetts family owned company managing a SNF, ALR, Adult Day Health Center, and a child care center. Most recently he was the executive director of New Pond Village, a CCRC in Walpole, MA.

Bill holds an MBA from Boston University with a concentration in Health Care Management. He is a Fellow of the America College of Health Care Administrators (FACHCA). He is also a Certified Nursing Home Administrator (CNHA), Certified Administrator of Sub-Acute Care (CAS), and a Certified Assisted Living Administrator (CALA). He is certified as an assisted living director (CDAL) by the Senior Living Certification Commission. Bill recently became only the third person in the country to achieve the Health Services Executive (HSE) credential from the National Association of Long Term Care Administrator Boards (NAB).

In May of 2010 he was named Outstanding Member of the American College of Health Care Administrators (ACHCA). In 2017 ACHCA named him as the recipient of the Distinguished Assisted Living Administrator Award.

Bill is the past President of the Massachusetts Chapter of the American College of Health Care Administrators. He was the chair of the 2009 Convocation in Providence, RI. He was the chair of the ACHCA Professional Certification Committee and served as an item writer for the certification exams. He was a founding trustee of the MetroWest Health Care Foundation and served as chair of the MetroWest Healthcare Foundation Commission on Healthy Aging. 

Monday, November 13, 2017

Next Generation Accountable Care Organization (NGACOs)

The NGACO Model offers Accountable Care Organizations (ACOs) the option to participate in a payment model called All-Inclusive Population Based Payment (AIPBP) where the ACO will take the responsibility for entering into payment arrangement with their providers and paying claims instead of Medicare paying it through the Fee-for-Service (FFS) program.

The goal here is to establish a monthly cash flow for the AIPBP participating ACOs through a mechanism called the Next Generation Participants and Preferred Providers. The plan is that the AIPBP builds on population based payments in the NGACO Model but actually allows for more flexibility in establishing payment relationships between the ACO and their providers.

So to establish a monthly cash flow, under the AIPBP a participating ACO can receive a monthly lump-sum payment for those providers that have entered into a written agreement for AIPBP Payment Arrangements. The monthly payment will be based on an estimation of the care that the provider will deliver to the beneficiary in the performance year by AIPBP participating providers. These lump-sum payments will be reconciled after the performance year so they can balance out the monthly payments against what AIPBP participating providers would have received under the Fee-for-Services program.

Providers will continue to submit Fee-for-Service claims to Medicare, but payments will not be made on these submissions to providers that signed-up to participate AIPBP (outside of add-on payments for inpatient hospitals (outlier, disproportionate share, IME, new technology and Islet isolation cell transplantation payments). If a provider does not have an AIPBP Payment Arrangement in place with an ACO, they will continue to receive Fee-for-Service payments for all of the patients/beneficiaries they treat.

Providers will continue to submit all Fee-for-Service claims to CMS and CMS will make coverage and liability determinations and assess beneficiary liability. Beneficiary liabilities will be calculated based on what Medicare would have paid the provider if they were not involved with an AIPBP. Medicare Summary Notices (MSN) should reflect the amount that would have potentially been paid. Providers in the AIPBP will continue to receive MSNs.

For more information on this topic, feel free to visit

Provided by Kevin Harrington, MATS, MSHA, RHIA, CHP  Faculty, Saint Joseph's College

Friday, October 27, 2017

Communication in Healthcare

Medical errors are the third leading cause of death in the United States.  While patient safety efforts have gained momentum over the years, we still have a long way to go. One important area of patient safety for healthcare administrators to consider is effective communication.

Where should communication efforts focus?  Patient safety improves when we improve both staff communication and patient/healthcare professional communication.  Some barriers to affective communication include:

1.  Competition for time – healthcare professionals are pressed for time in many ways.  Productivity requirements, multi-tasking, and emergencies can create stressful environments that reduce effective communication.
2.  Competition for attention – we live in a fast-paced world where technology often competes for personal attention.  Managing the use of technology can impact the ability to be an effective listener.
3.  Managerial philosophy – administrators  set the tone for proper communication in the healthcare environment.

1.  Socioeconomic background – various backgrounds can result in communication breakdowns.  Healthcare professionals and patients do not always come from the same background, which creates a rift in contextual knowledge.
2.  Previous experiences – patients with negative previous experiences in healthcare settings might have difficulty with trust, which can result in a lack of proper communication
3.  Cultural background – healthcare providers in diverse communities face cultural differences that can cause communication breakdowns.
4.  Language Differences – lack of trained interpreters can result in communication difficulties.
5.  Sensory Issues – vision difficulties and hearing loss impact the ability to communicate properly with patients.

What can we do to improve overall communication in the healthcare setting?  Consider the above list of barriers and choose one or two that is a critical issue in your healthcare setting.  Brainstorm ways to improve communication efforts and implement one or two new policies at a time.  Be sure to keep the new initiative as simple as possible.  After a set amount of time, evaluate the new policy to see if it had an adverse or positive impact on overall communication efforts.  Eliciting feedback from both staff and patients is the best indicator of overall improvements.

For more information, please see:

Contributed by Valerie Connor, MA CCC-SLP; MS CHES, Faculty at Saint Joseph's College

Monday, October 02, 2017

Emergency Preparedness

Steve Chies, Program Manager of the Long-Term Care Administration Program at Saint Joseph's College, has written an excellent blog about being prepared in the face of hurricanes and other emergencies!  Check it out at

Wednesday, September 13, 2017

Defending Patient Rights

Consent is a tricky issue in healthcare.  Every procedure performed by a healthcare professional requires consent.  It can be obtained in three ways:

Informed Consent – the procedure is explained to the patient (in language they can comprehend), including any options and possible outcomes.  The patient agrees or refuses.  A signed form is sometimes obtained.

Implied Consent – the procedure is explained to the patient and they indicate with their body language that they consent (e.g., rolling up a sleeve for a blood draw or sticking out a tongue for a strep culture).

Assumed/Presumed Consent – the patient is unconscious, but it is assumed that they would want life-saving measures taken as needed.  Once the patient becomes conscience, informed consent is obtained.

The distinction between these consent lines is sometimes blurred, but for liability purposes, healthcare professionals should obtain informed consent on any invasive procedure.  Using language the patient understand is crucial – we don’t want patient’s agreeing to something simply because we suggest it – that is considered paternalism and prevents the ability of a patient to make an informed choice.  A culture of patient autonomy depends on providing as much information to the patient as possible and allowing them to make an educated choice.

Enter the situation in Salt Lake City.  A nurse was recently arrested for refusing to draw blood from an unconscious patient.  The patient could not give informed consent, was not under arrest (which causes an individual to lose certain rights), and the blood draw was not for medical purposes.  The police officer forcibly removed the nurse from the hospital in handcuffs.  She was later released and not charged.  The police officer was put on administrative leave and the incident gained national attention.  As a result, the hospital created a new policy – all police officers must stay out of clinical areas and must go through a liaison versed in health law and ethics.  There is also an ongoing federal investigation.

What can we learn from this incident?

1.  Healthcare administrators need to make sure that healthcare professionals understand patient rights, including consent.  

2.  Hospitals and HCO’s need to have clear policy for outside authority – including police, firefighters, federal agents, etc.

3.  A clear chain of command needs to be in place to avoid situations from escalating to violence in a healthcare setting.
Obviously, it is easy to look at this situation and list all the problems.  It would be better to use this issue as a teachable moment.  Here we have a healthcare professional ready to defend patient rights to the end.  That is an amazing culture for a HCO to have developed.  Follow up is needed to ensure the support for that healthcare professional exists beyond just her own integrity.

Valerie Connor, MA CCC-SLP; MS CHES

Thursday, August 31, 2017

MHA Competency Model

The Master of Health Administration Program at Saint Joseph’s College has adopted a modified version of the Healthcare Leadership Alliance Competency Model as the basis for the program. Students completing the program are expected to have achieved at least intermediate mastery of each competence noted below.

Communication & Relationship Management
Utilize effective Interpersonal Communication

Exhibit Effective Writing Skills

Demonstrate Effective Presentation Skills
Effectively Lead and Manage Others

Manage Change Effectively

Able to Honestly Assess Self

Demonstrate Systems Thinking

Effectively Solve Problems and Make Decisions

Exhibit Personal and Professional Ethics

Contribute Profession and in Community

Work Effectively in Teams

Knowledge of the Healthcare Environment

Explain Health Care Issues and Trends

Analyze Population Health and Status Assessments

Explain Health Policy

Apply Health Care Legal Principles

Business and Analytical Skills

Manage Healthcare Finance

Effectively Manage Human Resources

Explain Organizational Dynamics and Governance

Apply Strategic Planning

Utilize Effective Marketing Principles

Understand and Effectively Manage Information and Use Technical Skills

Employ Quality Improvement/Performance Improvement Strategies

Demonstrate Quantitative Skills

Planning and Manage Projects

Analyze and Apply Economic Principles

Adopted July 2017

Tuesday, August 15, 2017

The Reason for Our Hope - Knowing Our Calling

Throughout all our lives, there comes a defining moment where we must decide what our calling in life is. Those in the healthcare industry generally aim to serve those in need. Why is this? I like to think every one of us desires to serve some greater good. From an anthropological standpoint, humans have had somewhat of a natural inclination to help those in need. Regardless of our ethical and moral views, we as humans take care of someone in our lives. This can be our parents, children, friends, or from a healthcare setting, patients.

While taking the Leadership in Healthcare Administration course, we were required to listen to a podcast for one of our assignments. The title of the podcast was, "Erie Chapman - Bettering Healthcare with a Servants Heart." As I began to listen to the podcast, I was struck with somewhat of an epiphany. All of us in healthcare are servants. No matter what job title you obtain, you are a leader and servant to someone in need.

Knowing we are leaders and servants is a humbling, but exciting thing. As a future leader in healthcare administration, I always want to have the reason for my hope held tight to me. Our calling in life is ultimately serve daily for the betterment of others in need. THIS is why we work in a healthcare industry. If it is not, then maybe we should have some self reflection.

How is servant leadership effective? This question strikes and provokes my mind very often. Servant leadership reminds us daily of why we are involved in healthcare. It reminds the nurse every day of why she cares for the sick and dying. It reminds the surgeon of why he saves a dying child's life. It reminds the hospital manager of why he makes sure patients and caregivers are taken care of, and lastly, it reminds me of why I chose Saint Joseph's for graduate school.

Chapman proposes a leadership concept called the Radical Loving Care Program. In this program, he asks himself who are his clients. His immediate answer was the employees - Those who take care of people. With compassion, empathy, and vision, leaders must guide and show their team members the reason for their hope. Not just the reason for their hope, but for the hope of every patient in need. The front-line caregivers are the reason for every patients hope. This is the passion and vision leaders should have! Leaders must have confidence in their employees. In doing this, it is imperative that leaders re-spark that passion into employees every single day. This is effective servant leadership. May we all follow the reason for our hope, and through this, know our calling.
Written by Cameron Davis, Graduate student at Saint Joseph's College 

Monday, July 24, 2017

A Leader's Role in the Patient Experience

Healthcare is a highly regulated and in some cases, a highly competitive environment.  Healthcare delivery is changing at a rapid pace. Healthcare leaders are learning how to adapt and lead their hospitals into the future.  The center for Medicare services over the last few years adapted the Hospital Consumer Assessment of Healthcare Providers and Systems; better known as HCAPHS patient satisfaction scores to tie patient satisfaction in the calculation of reimbursement for patient stays (CMS, 2015).

Hospitals in competitive environments focus on how to deliver care and stand out from the competition. Additionally, social media has changed how patients share their healthcare experiences.  Patients can praise or complain about their hospital experiences on Facebook, Twitter, Instagram and the like.

Leaders are in a great position to help staff understand the importance of patient experience to an organization, whether it be to improve overall scores or patient perception. Quality care is increasingly linked to efficiency, cost reduction and optimal utilization of resources. Healthcare quality care programs and metrics are increasingly influenced by financial incentives and measured by state of the art scientific tools and sophisticated methodologies. (Belasen, Eisenberg & Huppertz, 2016 p 144)
Patients and families view their experience of care in its entirety: The clinical treatment, the interactions with staff, and the physical and ambient environment all tie together as one, overall impression and journey. Leaders and caregivers who commit to observing and learning in detail about this journey quickly identify what needs to improve to create a better experience. (IHI, 2011)

How can you as a leader showcase the importance of patient experience in your workplace? Interpersonal relationships can go a long way to helping organizations improve scores. Effective leaders practice with conviction, and demonstrate the importance of the caregiver/patient relationship.

 An important leadership quality is social intelligence. “Socially intelligent leaders have strong conversation and listening skills, a keen understanding of social roles and rules, confidence in interacting with different types of people and a fine-tuned ability to understand other’s thoughts and feelings.” (Sowick et al, 2015) One of my favorite quotes is from Maya Angelou “I have learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”  This statement holds true not only to the patient’s we serve but also how we as leaders serve our teams.

 Leaders of today must use both transactional leadership skills and transformational leadership skills to be an effective leader in today’s workplace.  Being the vison setter to bring new ideas forward, to have the courage to lead by example and advocate for employees and patients will go a long way toward improving not only the patient but staff experience.


Balik, B. (2011, July). Institute for Healthcare improvement, Patient Safety Reprinted from
Belasen, A. T., Eisenberg, B, Huppertz, J. W., (2016). Mastering Leadership: A Vital Resource for Health Care Organizations, pgs.
Sowick, M, Andenoro, A, McNutt, M, Murphy, S.E (2015) Leadership 2050: Critical Challenges, Key Contexts, and Emerging Trends; Emerald Group

Provided by Robyn McDevitt, Graduate Student, Saint Joseph's College

Tuesday, July 18, 2017

There is Hope!!

Lately, I pondered the question of “….how would the retiring Boomer Long-Term Post-Acute Care (LTPAC) leaders be replaced….?"  With the average age of administrator’s being in their 50’s, this is a real challenge for licensure boards, employers and educators.  Public policy makers will need to find some solutions to this complex problem.

I had the opportunity to work with a number of students who are majoring in healthcare administration and are going out on a one-year practicum.  I found them to be a delight to teach, but also to learn from.  They are bright, focused,  passionate about the LTPAC sector and were excited to learn about the profession.

It was enlightening and heartening to interact with this group, as they progressed in their studies.  They asked great questions, researched many of the challenges facing our sector, and suggested innovative methods to approach some of the difficult issues facing the LTPAC sector. 

What has been encouraging to me was that the students were from the millennial generation and very interested in an aging services career!   There have been some articles and suggestions about the characteristics of this coming generation that were considered to be negative, when compared to Boomers.   I did not find the “generalities” about millennials that have been suggested to be true nor accurate.  They were serious with their studies, willing to learn, and excited about working in the sector. 

It gave me considerable comfort that these students will make great leaders in the LTPAC sector.  Now the question is how do we find more of the millennials that will be willing to prepare to learn and enter this profession?

Submitted by Steven Chies, Faculty at Saint Joseph's College