Caregivers Reduce Readmissions When Patients Fear Hospital Discharge
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May 18, 2020
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Hospitals sometimes submit amended claims for services rendered to Medicare beneficiaries. If an amended claim requests payment for a higher-weighted diagnosis related group (HWDRG) than the original claim, then the Centers for Medicare & Medicaid Services (CMS), under its statutory and regulatory claims review authority has the claim reviewed by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). DRG validation ensures that the diagnoses, the procedures, and the discharge status of the patient reported on the hospital’s claim are supported by the patient’s medical record and the attending physician’s notes. These reviews are performed by highly trained coders employed by the QIO who adhere to the accepted principles of coding practice to validate the accuracy of hospital codes that affect the DRG payment.
The article highlights the importance of clear and accurate documentation in the medical record, and the need for more training at some hospitals on the need for proper physician queries for any needed clarification prior to HWDRG claims submission. It is in everyone’s best interests to get the coding right, but only through proper means.
Article author Pamela A. Applegate, MA, RHIT, AHIMA, serves as Livanta's national project coordinator for all claim review services, and Michael F. Berkey, Esq., CPA, MPA, CPC, PMP, serves as Livanta's chief operating officer and provides senior program manager support.
Mr. Wisniewski is the Chief of External and Government Affairs for Livanta LLC. His responsibilities at Livanta have included oversight for all operations and strategic initiatives, legal affairs, compliance, new business development, and project management on federal and state government contracts within specific areas of expertise such as quality reporting.
Previously, Mr. Wisniewski served as a senior vice president at the healthcare accreditor, URAC, leading operations, legal affairs, and strategic development. He led the drafting of and successfully lobbying into law landmark health reform legislation: Section 1311 of PPACA on accreditation of health insurance exchanges. He likewise spearheaded development and ongoing execution of federal and state advocacy plans to incorporate URAC accreditation into mandated health insurance exchanges.
Prior to URAC, Mr. Wisniewski served as executive director for health policy at the U.S. Chamber of Commerce, developing Chamber policy on hospital and physician quality improvement measures, comparative effectiveness, and life sciences and advocating those policies before Congress and the federal agencies. In this role, Mr. Wisniewski served as principal to the Hospital Quality Alliance and Quality Alliance Steering Committee, functioning as a nationally recognized employer stakeholder on the development and reporting of hospital and physician quality reporting measures, as well as healthcare reform payment incentives.
Just prior to joining Livanta full time, Mr. Wisniewski served as the president and chief executive officer of CAHME, the accreditor of graduate-level healthcare management education. While at CAHME, he led the rollout of competency-based criteria for accreditation that factored in healthcare quality improvement measures for the next generation of hospital administrators, and supply chain and other healthcare executives.
Mr. Wisniewski was appointed by the President of the United States to the Christopher Columbus Fellowship Foundation Board of Trustees. He was also appointed by the U.S. Secretary of Health and Human Services to the Agency for Healthcare Research and Quality (AHRQ) National Advisory Council, serving as a key employer voice on national quality measures reporting in areas such as disparities of care for minority populations, hospital associated infections, and overall patient safety. Mr. Wisniewski was also appointed by the Director of AHRQ to serve on its Effective Health Care Stakeholder Group, focusing primarily upon development and reporting of quality measures associated with comparative effectiveness research of designated chronic diseases.
Within the State of Maryland, Mr. Wisniewski has served on the University of Maryland Biotechnology Institute Board of Visitors and is a former gubernatorial appointee to the board of the venture capital Maryland Technology Development Corporation. He is admitted to the bars of both Maryland and Washington, D.C. He received a J.D. from the University of Notre Dame and a B.A. from the Catholic University of America, majoring in politics, with minors in philosophy and history.
E. Wayne Bachus, Esq.
Consumer Representative
The Honorable E. Wayne Bachus of Temple, Texas, is a former Judge of Bell County, Texas, and has more than 30 years of experience as a practicing attorney in Texas, focusing on general business matters. Judge Bachus has served on numerous boards, including the State Bar of Texas, and served multiple terms as the president of Texas Association of Court at Law Judges. He is also an adjunct instructor at Temple College. He holds a Bachelor of Arts from The University of Texas at Austin and a Juris Doctor from Baylor University School of Law.
Term: May 8, 2023 - March 1, 2025
Edward F. Plocha
Consumer Representative
Mr. Plocha has more than 40 years of diverse experience, including work in public service, education, municipal government, and the nonprofit sector at both the grassroots and policy levels. He worked as director of advancement for the Maryland Province Jesuits until his retirement in 2012. Currently, Mr. Plocha serves on the board of the Commission on Accreditation of Healthcare Management Education (CAHME). He is actively involved with Christian Life Community (CLC), a Jesuit-affiliated lay organization in 65 countries worldwide and serves as Chair of the U.S. Northwest Region and the region’s national representative.
Mr. Plocha holds a graduate degree from the University of Notre Dame and an undergraduate degree from Fordham University. He has studied at numerous universities in the United States and abroad, including Columbia University, Boston University, University of Wisconsin, University of Southern California, Université de Dijon, and Jagiellonian University, Kraków, Poland.
Term: May 8, 2020 - May 7, 2023
David L. Shern, Ph.D.
Provider Representative
Dr. Shern currently holds a faculty appointment in the Department of Mental Health at the Bloomberg School of Public Health, Johns Hopkins University, and Senior Science and Public Health advisory positions at Mental Health America and the National Association of State Mental Health Program Directors, both in Alexandria, Virginia. Dr. Shern’s experience includes more than 35 years of distinguished service in mental health services, research, and system reform. He is regarded as one of the nation's leading mental health experts.
Before his current positions, Dr. Shern was the president and chief executive officer of Mental Health America, which is the nation’s oldest and largest advocacy organization concerned with all aspects of mental health and mental illness. Prior to joining Mental Health America in 2006, Dr. Shern served as dean and professor at the Louis de la Parte Florida Mental Health Institute (FMHI) at the University of South Florida.
Dr. Shern authored more than 100 publications. His research includes studies on the need for community services; the effects of differing organizational, financing, and service delivery strategies on continuity of care and client outcome for adults with severe mental illnesses; and the use of alternative service delivery strategies, such as peer counseling and self-help on the outcomes of care. In addition to Johns Hopkins, Dr. Shern has held academic positions at the University of South Florida, State University of New York at Albany, New York University, and the University of Colorado.
He received his Bachelor of Arts, Master of Arts, and Doctor of Philosophy in psychology from the University of Colorado, Boulder.
Term: May 8, 2020 - May 7, 2023
Frederick J. Wenzel
Consumer Representative
Mr. Wenzel serves as an executive fellow and adjunct professor at the Opus College of Business of the University of Saint Thomas (1996 to date). He is also a visiting professor at the University of Colorado School of Business.
He served as executive director of the Marshfield Clinic Research and Education Foundation for 16 years, and then as executive director of the Marshfield Clinic for 17 years. He served on the Clinics National Advisory Council and as an advisor to the president of the clinic. He now serves as a member of the Marshfield Clinic Health Care System.
Mr. Wenzel was executive vice president and chief executive officer of the Medical Group Management Association of Englewood, Colorado, from 1993-1996 and continues to work with the organization on committees and task forces.
He is a fellow of the American College of Medical Practice Executives. He served on the Commission for Accreditation for Health Management Education for two years as chair of the commission. He also serves on numerous additional boards while teaching at the University of St. Thomas and the University of Colorado. He has published more than 100 papers in health services research and education and is the co-author of two books on healthcare management and leadership.
Term: May 8, 2020 - May 7, 2023
William J. Naber, MD, JD
Provider Representative
Dr. Naber practices emergency medicine at the University of Cincinnati Health System (UCHS) community hospital in West Chester, Ohio and its Level 1 Trauma Center. He also works part-time in the emergency department at Cincinnati's Veterans Administration Medical Center.
He is the medical director for utilization review and clinical documentation improvement at West Chester Hospital and the University of Cincinnati (UC) Medical Center.
Dr. Naber received his Bachelor of Science from the University of Dayton, Ohio, Doctor of Medicine from the University of Cincinnati, and Juris Doctor from the UC College of Law. He is a member of the Ohio Bar Association and the Cincinnati Bar Association.
Term: May 7, 2019 - February 29, 2024
Maricela P. Moffitt, MD
Provider Representative
Dr. Moffitt has served as the director of the doctoring curriculum at the University of Arizona College of Medicine, Phoenix since 2007. She is responsible for the curriculum and education of preclinical students in communication and physical examination skills. Dr. Moffitt holds the academic rank of associate professor of medicine. Currently, she practices at the Cart T. Hayden VA in Phoenix as a hospitalist.
Dr. Moffitt joined the faculty in the Department of Medicine at Maricopa Integrated Health System (MIHS) in 1990 and held many academic and administrative positions, including director of medical education and director of academic affairs. During her tenure at MIHS, she was also elected president of the medical staff and served as a medical staff officer from 1998-2003.
Dr. Moffitt completed medical school at the University of Texas Health Science Center in Houston. She completed her residency at this facility in internal medicine and served as chief resident. She is board certified in internal medicine and has practiced medicine in Arizona for 25 years. She received a Master of Public Health from the University of Arizona. Her research interests include tuberculosis and medical education.
Term: May 8, 2020 - May 7, 2023
John A. Capasso
Provider Representative
Mr. Capasso is a former executive vice president of the Continuing Care Group at Trinity Health, which provides continuing care services, including home health, hospice, senior living, and nursing homes in 20 states. He has more than 35 years of experience in healthcare and senior living services.
Previously, Mr. Capasso served as the senior vice president of the Continuing Care Management Services Network at Catholic Health East (CHE). He also served as the president and chief executive officer of St. Joseph of the Pines Health System, a continuing care ministry providing a variety of housing and healthcare services to seniors in central North Carolina.
Prior to CHE, Mr. Capasso served in various executive roles at Asbury Services, Gaithersburg, Maryland, a provider of senior living services across multiple states. Before his various roles in continuing care, he held positions in four acute care hospitals, culminating in the role of assistant vice president for Professional Services at Holy Cross Hospital in Silver Spring, Maryland.
Mr. Capasso received a Master of Science in health services administration from George Washington University and a Bachelor of Arts in biology from Geneva College, Beaver Falls, Pennsylvania. He is a certified healthcare executive with the American College of Healthcare Executives. He is also a licensed nursing home administrator.
Term: August 9, 2023 - February 28, 2025
Patty McCormac, RN
Consumer Representative
Ms. McCormac is a healthcare provider, educator, and advocate. She believes working with Livanta provides an opportunity to help inform and grow the good this organization offers to patients, their families, and the healthcare providers they strive to engage, educate, and support in giving the best care possible.
Starting a nursing career at the University of California San Francisco Medical Center, Ms. McCormac gained experience in cardiology and oncology. From there, she moved into clinical research in lifestyle changes and their impact on heart disease and prostate cancer for 12 years, leading her to the role of director of clinical operations, working with an interdisciplinary team at the Preventive Medicine Research Institute. Ms. McCormac then worked with the National Kidney Foundation (NKF) as the program director for Northern California and the Pacific Northwest and just marked her 12th anniversary with NKF.
Ms. McCormac received a Bachelor of Arts in human biology from Stanford University and a Bachelor of Science in nursing from the University of San Francisco.
Term: June 4, 2021 - February 28, 2024
Milagros Abreu, MD
Consumer Representative
Dr. Abreu is the president, chief executive officer, and founder of the Latino Health Insurance Program. She has dedicated her career to providing high-quality and accessible primary care for minority residents.
She serves as chair of the Massachusetts Medical Society, Committee on Ethnic Diversity; executive committee member of the Massachusetts Healthy Aging Collaborative; and steering committee member for the Massachusetts Comprehensive Cancer Prevention and Control Plan.
In 2006, Dr. Abreu founded the Latino Health Insurance Program. The organization has assisted 40,000 families with access to healthcare, chronic disease prevention, disease management, and nutritional programs.
Many organizations have recognized Dr. Abreu for her tremendous efforts to reduce health disparities and enhance public health, including the Massachusetts Black & Latino Legislative Caucus, Framingham Medical Reserve Corps, City of Boston, Massachusetts State Senate, Massachusetts Medical Society, and Massachusetts Immigrant and Refugee Advocacy Coalition, and others.
Dr. Abreu worked for Boston Medical Center and received her master’s degree in epidemiology from Boston University School of Public Health.
Term: June 11, 2021 - February 28, 2024
Russel Bantham, Esq.
Consumer Representative
Mr. Bantham has held several roles with the Pharmaceutical Research and Manufacturers of America (PhRMA), including executive vice president, chief operating officer, senior vice president, general counsel, and secretary. Prior to PhRMA, he worked for Bristol-Myers Squibb Company as vice president and associate general counsel, vice president and counsel at Westwood Pharmaceuticals, and staff attorney at the Drackett Company. Since 2005, Mr. Bantham has represented global pharmaceutical companies in the areas of organizational development and legal and regulatory issues; served the U.S. Chamber’s life science initiative; participated as a member of the Global Exchange on Healthcare; and advised start-up companies in the healthcare arena. He currently serves as a board member of Inspire, the largest and fastest growing support community for cancer, rare diseases, and chronic conditions.
Mr. Bantham is a graduate of Hamilton College, where he served as a member of the board of trustees from 1990 to 1994. He earned a Juris Doctor from the University of Chicago Law School and has served on the board of directors of the Non-Prescription Drug Manufacturers Association, the Council on Family Health, the Food and Drug Law Institute, and the National Association for Biomedical Research.
Term: November 30, 2020 - November 29, 2023
Lorenza Cooper
Consumer Representative
Lorenza Cooper, CIC, CPIA has over 30 years of property & casualty insurance leadership and management experience with four of the top ten national insurance companies. Mr. Cooper’s risk management acumen and underwriting expertise are value-added business attributes for his current employer - Consolidated Insurance + Risk Management. Mr. Cooper has held various positions with increasing responsibility advancing from Underwriting Director, Branch Vice President to Regional Vice President of Underwriting with leadership responsibility for the profit and loss of the commercial business segment. As the Regional Vice President of underwriting for Harleysville Insurance Company, responsibilities included profit improvement initiatives as well as transformational strategic planning for underwriting continuous improvement throughout the region. He also served over 21 years with CNA Insurance Company in various positions, including Branch Vice President and Underwriting Director leading a team of insurance professionals.
Simultaneously, Mr. Cooper continuously served his country for over 30 years as an officer in the Army National Guard in multiple states while building his professional insurance career. He has served in various military leadership positions including Company, Battalion, and Brigade Commands. Mr. Cooper is combat veteran with deployment to Iraq as the Battalion Commander as well as a retired Brigadier General (MD).
Mr. Cooper is a graduate of North Carolina Central University School of Business.
Term: August 14, 2023 - August 13, 2026
Edward J. Kasemeyer, MD
Consumer Representative
Edward J. Kasemeyer was born in Baltimore in 1945 and moved to Howard County in 1957 where he currently resides. He graduated from Western Maryland College, now McDaniel College, in 1967 with a degree in political science.
Mr. Kasemeyer served in the Maryland General Assembly for 32 years, 4 years in the House of Delegates where he served on the Economic Matters Committee. He served 28 years in the Senate during which he served as Chairman of the Senate Budget and Taxation Committee from 2010 to 2018. He also served as Majority Leader; Senate Chair, Joint Committee on Administrative, Executive and Legislative Review; Senate Chair, Joint Committee on Pensions; and Senate Chair, Joint Committee on Children Youth and Families.
Following his retirement at the end of the term in 2018 he was appointed to serve as Chairman of the Community Health Resource Commission and Chairman of the Interagency Commission on School Construction and continues to serve in those leadership roles today.
Term: August 15, 2023 - August 14, 2026
Elizabeth L. Chung
Consumer Representative
Mrs. Elizabeth L. Chung is a native of Hong Kong, China and immigrated to the United States in 1970. Mrs. Chung completed her graduate study in public health from Pennsylvania State University in 1981. She is the founder and Executive Director of the Asian American Center of Frederick (AACF) established in 2005, with a mission to equip immigrants with essential skills to be independent and successful contributors to the community. AACF is a leading entity in addressing health equity through partnership. Under her leadership, AACF has become a vital and trusted community-based organization in Maryland for immigrants. Mrs. Chung's primary focus has been on equity for marginalized populations through education, workforce, and community development.
Governor Larry Hogan appointed Mrs. Chung to the Maryland Community Health Resources Commission, and she served as Chairperson, 2020 - 2021. For the past three and current Maryland administration, she was/is sought after for her expertise in health and human services policies. Mrs. Chung has received numerous awards and recognition in public health and community services. Her most recent accomplishment is the development of the Community Health Worker Training Program for US Department of Health Human Services, expanding public / community health workforce development to address health disparities for the most vulnerable populations in the community. Mrs. Chung resides in Frederick, Maryland with her husband, Dr. Stanley Chung - Orthopedic Surgeon. (retired)
Term: August 25, 2021 - August 24, 2026
Gavin Long
Consumer Representative
Mr. Long is a purpose-driven technology entrepreneur, transaction professional, and private equity investor with a highly successful track record of delivering superior value creation in the information technology, software, and services industries.
As Executive Director of the Economics of Mutuality organization, Mr. Long leads a team that equips companies to create enduring mutual value for the benefit of all stakeholders by implementing the Economics of Mutuality operating model. He is also a Co-founder and Partner at Acacia Group, a specialist private equity investment firm, through which he has served as CEO of two portfolio technology companies.
Previously, Mr. Long worked with future Acacia colleagues at Global Strategies Group, a US-focused buyout firm, where he led corporate development within the firm's M&A strategy including a NASDAQ IPO. Mr. Long has completed more than 50 M&A transactions with an aggregate value of more than $4B. He has also held leadership positions overseeing strategy development and transactional execution for BAE Systems, Imperial Capital, and Arthur Andersen Corporate Finance.
Mr. Long has a BA in Philosophy from Appalachian State University and has undertaken graduate studies at Gordon Conwell Theological Seminary and Duke University.
Term: September 11, 2023 - September 10, 2026
Contracts
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CMS BFCC-QIO National Contractor for Beneficiary Oversight: Claim Review Services
CMS BFCC-QIO Regions 2,3,5,7, and 9 (12th Scope of Work)
CMS BFCC-QIO Area 1 Contractor (11th Scope of Work)
CMS BFCC-QIO Area 5 Contractor (11th Scope of Work)
CMS MEDIC RAC Data Validation Contractor
CMS Comprehensive Error Rate Testing II Contractor
CMS Comparative Billing Report Disseminator
CMS PERM Statistical Contractor
CMS PERM Database and Documentation Contractor
CMS Electronic Submission for Medical Records Contractor
CMS MEDIC IDIQ Contract Holder
CMS MEDIC Retiree Drug Subsidy Audit Contractor
CMS Review of Provider Medicaid Integrity Task Orders
CMS MAC Medical and Appeals Review Center
CMS Worker's Compensation Review Center
CMS Zone Program Integrity Subcontractor for multiple ZPICs
DHHS OIG Medical Review Projects
CMS BFCC-QIO National Contractor for Beneficiary Oversight: Claim Review Services
CMS BFCC-QIO Regions 2,3,5,7, and 9 (12th Scope of Work)
CMS BFCC-QIO Area 1 Contractor (11th Scope of Work)
CMS BFCC-QIO Area 5 Contractor (11th Scope of Work)
CMS MEDIC RAC Data Validation Contractor
CMS Comprehensive Error Rate Testing II Contractor
CMS Comparative Billing Report Disseminator
CMS PERM Statistical Contractor
CMS PERM Database and Documentation Contractor
CMS Electronic Submission for Medical Records Contractor
CMS MEDIC IDIQ Contract Holder
CMS MEDIC Retiree Drug Subsidy Audit Contractor
CMS Review of Provider Medicaid Integrity Task Orders
CMS MAC Medical and Appeals Review Center
CMS Worker's Compensation Review Center
CMS Zone Program Integrity Subcontractor for multiple ZPICs
DHHS OIG Medical Review Projects
Contract Vehicles
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Beneficiary and Family Centered Care (BFCC)-Quality Improvement Organization (QIO) Indefinite Delivery Indefinite Quantity: 75FCMC19D0070
Professional Service Schedule: (PSS) GS-00F-194DA
GSA 00CORP Schedule GS-00F-194DA: SIN 874.7SIN 00CORP 500SIN 874.1
GSA IT 70 Schedule GS-35F-374DA: SIN 132.51SIN 132.56SIN 70 500
Beneficiary and Family Centered Care (BFCC)-Quality Improvement Organization (QIO) Indefinite Delivery Indefinite Quantity: 75FCMC19D0070
Professional Service Schedule: (PSS) GS-00F-194DA
GSA 00CORP Schedule GS-00F-194DA: SIN 874.7SIN 00CORP 500SIN 874.1
GSA IT 70 Schedule GS-35F-374DA: SIN 132.51SIN 132.56SIN 70 500
Current and past performance
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Beneficiary and Family Centered Care (BFCC)-Quality Improvement Organization (QIO) Indefinite Delivery Indefinite Quantity:
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2019-Present
BFCC-QIO Area 1 and 5
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2014-2019
Medicare Part D Recovery Audit Contractor Data Validation
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2011-2017
Medicare Drug Integrity Contractor (MEDIC) IDIQ contract holder
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2011-2017
Beneficiary and Family Centered Care (BFCC)-Quality Improvement Organization (QIO) Indefinite Delivery Indefinite Quantity:
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2019-Present
BFCC-QIO Area 1 and 5
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2014-2019
Medicare Part D Recovery Audit Contractor Data Validation
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2011-2017
Medicare Drug Integrity Contractor (MEDIC) IDIQ contract holder
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2011-2017
Beneficiary and Family Centered Care (BFCC)-Quality Improvement Organization (QIO) Indefinite Delivery Indefinite Quantity:
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2019-Present
BFCC-QIO Area 1 and 5
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2014-2019
Medicare Part D Recovery Audit Contractor Data Validation
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2011-2017
Medicare Drug Integrity Contractor (MEDIC) IDIQ contract holder
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2011-2017
Beneficiary and Family Centered Care (BFCC)-Quality Improvement Organization (QIO) Indefinite Delivery Indefinite Quantity:
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2019-Present
BFCC-QIO Area 1 and 5
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2014-2019
Medicare Part D Recovery Audit Contractor Data Validation
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
Date: 2011-2017
Medicare Drug Integrity Contractor (MEDIC) IDIQ contract holder
Client: U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services
