May 292013

By Deborah Marquette

It was the classic conundrum: how do you fit a square peg into a round hole?

The County of San Diego is widely known for doing things a little differently, and our model for providing community-based care transitions project (CCTP) services is no different.  The San Diego Care Transitions Partnership (SDCTP) CCTP model includes the Care Transitions Intervention (CTI).  However, in addition to CTI, the SDCTP model includes a variety of interventions that are completed prior to discharge (e.g. High-Risk Health Care Coach, Inpatient Navigator, Bridges, and Pharmacy).  The model also includes additional post-discharge interventions, such as CTI Care Enhancement and non-CTI follow-up phone calls.

These additional interventions posed our first challenge for invoicing.  We quickly realized that the List Bill design (CMS’ method for billing Medicare for CCTP) wouldn’t meet our internal needs for gathering, monitoring, and tracking invoice and intervention data.  For some of our interventions, there is no clear mapping between our intervention and the List Bill’s Care Transition Services.  For others, the List Bill was too ambiguous.  For example: if we select “Telephone follow-up…” as the Patient Encounter, how will we know whether that patient received CTI or our non-CTI follow-up phone call intervention?  Hmm…thoughtful pause…we needed to find a way to meet the List Bill requirements, while capturing the data in a way that would be meaningful for us as well.  That’s how our Manual Invoicing Process was born.

I’ll be completely honest – this invoicing baby is less than attractive.  Alright, it’s downright ugly!  Picture this, an Excel worksheet 41 columns long.  With no margins, and at a scale of 75%, the worksheet still prints out on six (6) legal-size pages.  And that’s just to capture the data we need for managing and tracking our List Bills!  It doesn’t include the additional 32 columns that we use for capturing other data elements such as “Reason for Non-Enrollment” or “Reason for Withdrawal.”  Now, factor in the fact that at full-capacity we’ll be maintaining these data for 13 hospitals and roughly 21,000 patients/year.  What fun the manual process will be then!  Like I said, it isn’t pretty.  But, it does work, and it seems to work well.  We may even be sad to see the manual process go (not likely) when it’s replaced by our web-based invoicing and data collection system, ALEX.  I’ll share more about ALEX in a later post.

The format of the List Bill led to our second invoicing challenge.  Considering our size, there’s no way we can manage all of our List Bills by entering them one-by-one using the List Bill template.  Aside from increasing the risk for data entry errors, entering all of the List Bills manually would be a more-than-full-time  job for several people.  Since that isn’t an option, it was back to the drawing board.  Here we had some help.  Reaching out to our Project Officer and other CCTP sites, we asked if anyone had successfully submitted a List Bill in a format other than the List Bill template.  Our call was answered by the Southwestern Ohio CCTP!  They had figured out the Excel formulas needed to convert data into the format(s) that would meet Gentran’s requirements.  (Gentran is the online application for submitting List Bills to CMS.) With a little tweaking, we’ve tailored those formulas, and added a few of our own, to convert the information collected on our Manual Invoicing worksheet.  With just a little copy-and-paste action of data and formulas, we’re now able to create a List Bill for all of our patients in 10-15 minutes.  It doesn’t matter if we have 1 or 1,000, the timeframe is the same.  Around here, we call that a success!

Ms. Marquette is the Principal Administrative Analyst for the San Diego Care Transitions Partnership. This is part of our regular series on San Diego’s experiences launching its CCTP work.

Key words: CCTP, CMS, Medicare, care transitions, quality improvement, hospital readmissions, frail elders, San Diego County

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