Hello, and welcome to Module 11, RIS, Top 10 Things to Keep You Up at Night. My name is Nikki Smith, Director, Member Services for Medaxium. Here are my disclosures, and here are our learning objectives. To provide topics that will require more knowledge and further investigation for understanding. Provide topics that are important to practice and department management, but not usually taught at early stages. And to empower the learner to be forward thinking. To round out our education for CV program managers, we wanted to provide you with a list of topics that you'll want to investigate and understand. This is a list of topics that can put your area of responsibility at risk if the right processes are in place and followed. This isn't meant to cause you any great stress, but rather to help you seek out the knowledge and understanding that you'll need that will allow you to sleep well at night, knowing that you have all of these bases covered. And if you identify that you have some opportunity in any of these areas, awareness is the key. And to that, it will allow you to make the needed improvements. So let's go ahead and get started. First, do all of your staff members have what they need to do their jobs? Do they have the right education, the right skill set, or training? Do they keep up with needed training to remain competent? Do they have the needed equipment or access? And are they receiving the right amount of support or guidance? If and when you find that there's an opportunity for your staff with any of these questions, how can you find what they need and then provide it? What resources do you have? Are each of your team members working within their license scope or skill set? Are your RNs working to the top of their license and handling all tasks that require clinical judgment? Who's providing patients with medical education? Is it the clinical staff only? In some practices and programs, our support staff have become so very knowledgeable about the medications that physicians order. They feel compelled to answer patients' questions when they're asked. So who's giving clinical and medication advice over the phone? Is it just your clinical staff? Those are questions that you need to answer. Are your front office staff handing off questions about insurance coverage or testing or procedures? The cost of health care right now has gone up and our patients are becoming more aware of what they're going to be spending out of pocket. When they ask questions about payment or insurance coverage, it's vitally important that your front office staff hand those questions off to the people that are doing the work to pre-auth those procedures and tests so that the patient is getting the best of information. Is your clinical staff competent? How do you know? Does your clinical team have a solid process for onboarding new staff to ensure they have the knowledge needed to provide quality care in your setting? If not, how can you establish one? What are your resources? Maybe you have a lead RN or an APP that would be able to take this on. There are resources online that can guide you or your team through a process of developing a competency program. There are also developed programs out there that you can partner with for an annual fee that will allow you to use their system to educate and evaluate. If you work with other programs or are in a larger system, be sure to ask your peers and leaders what resources are available. Continuity of care or care in between. This is the care that ties all of the pieces together and ensures that there's oversight of the patient through the care continuum. This includes the review of patient tests, hospital admissions, procedural notes to identify any changes that have been made to the plan of care or to the patient's condition. This is usually based on the relationship between the provider and the patient. The patient sees the provider as a partner in their healthcare journey, ensuring that the results and notes are shared when asked. Of course, it's the clinical support team that receives the facts or is in the in-basket message most of the time and then responds by alerting the physician if something's needed to ensure that the medical record is up to date and the patient is responded to. How is this information handled in your practice or program? Do you have staff that's responsible and has time for this important work? How is this work assigned and completed? And what's included in it? It's associated with higher patient satisfaction and leads to better outcomes. Patient compliance. Are patients compliant with the treatment plan? Did they have the diagnostic test or procedure that was ordered? Is there a mechanism that alerts you or the practice if the patient doesn't have the test as ordered? Did the patient have the procedure? Do you know? And is the patient taking the new medication as ordered? How would you know if they weren't? How are test results managed in the practice? What's the process to ensure these don't fall through the cracks and that treatments are created or tailored to results, leading to optimal quality? Process questions should include who and how they come in, which clinical role has responsibility for receiving these and addressing the clinical results, and when and how are providers involved in the process? How are patients notified of their results? What can they expect as a service on this topic? And do they receive a phone call for critical results or higher level tests? Is the authorization process working? Is it used as it should be? What is your rate of denials to claims? Pre-auth, prior-auth, or pre-certification are all terms used for the same process, which is to determine if the healthcare insurance covers the medication, the durable medical equipment, the test, or procedure. This is a method used to contain costs by payers. This process is most often performed by the office or department of the ordering provider or facility in which the test or procedure will be performed. If pre-auth is not performed, the cost may not be covered, leaving the patient with the entirety of the bill, leaving the payment at risk. Often the process of pre-auth requires an inquiry into the insurance company with required information. If the process is not followed as required, the pre-auth may be denied, leaving the patient without needed care or to shoulder the burden of the cost. Either way, putting the provider, practice, and organization at risk if it's not well documented. Again, this process can be cumbersome and requires constant management to reach coverage. If denied, what's the result for the patient? Is there an alternative? How does it impact the patient care? What's your practice or program's process for pre-auth? Who's responsible for it? And is it seamless to ensure care and coverage? Is your practice or program capturing all charges? Are you leaving money on the table due to a faulty process or staff not following the process or perhaps you're performing tasks that aren't even generating a bill? Should they? So this is where it's important to have or be an expert. Do the processes for coding and billing work in your area? Are providers documenting care correctly? Are coders capturing the needed documentation for accurate coding? And how do you know? Do you have someone who understands the revenue cycle for your area and can assess or audit to ensure all gaps are closed? If not, how can you create a lead from your staff who will monitor this and look for areas of opportunity to be sure you're charging and billing for everything you can and that processes are followed to ensure that billables are charged? Remember that MedAxiom has a listserv specifically for coders to ask questions. They can lean on this tool as they need to. It's free to our member organizations. Do all of your coders have access? Reach out to your director of membership services at MedAxiom to be sure. Are there pieces of your patient's history or care that aren't captured in your EMR? Do EKGs transfer over easily? Do you have the ability to see if your patient has been receiving their medications? Did they have the procedure or were meant to? Again, is there a comprehensive view of your patient's care, allowing your clinical staff to manage the patient's care appropriately and avoid ER visits and omissions? And what about remote patient monitoring and information from your device clinic? Is that in the EMR? How are critical results handled and by whom? Again, important question to answer. Are there operational efficiencies to be gained by integration with your payers or perhaps vendors who offer services that you need assistance with? Could there be? Data and technology integration is constantly changing and growing. Understanding what you currently have and staying in touch with what's available are two ways you can ensure that technology is working for you and not against you. Cybersecurity breaches. Unfortunately, there have been recent breaches that we've all heard about. Somehow, ransomware is able to get into a health care system, delaying or even stopping the delivery of patient care and putting patients' sensitive information and even lives at risk. I think it's safe to say that every health care organization has an IT department that is diligent about cybersecurity. So what's your role? It's to ensure that you and your employees and vendors follow cybersecurity policies. You need to stay up to date on changes, trainings, and monitor for the compliance of your team with all policies. It's easy to let your guard down and make things easier by cutting some corners that seem inconsequential. Stay vigilant. Imagine being the person, department, or practice that allowed the ransomware into your system. Some last big picture thoughts. Our cardiovascular patient population is growing. Cardiologist supply is declining. Demand for services is declining. How do we innovate to deliver care, survive, and thrive? This module is not meant to make you anxious. We make you aware of these topics to empower you, to educate you, and show you where you may have opportunities to continue your learning and growth into the future. As you step out into your role, remember you're the future of cardiovascular leadership. Be courageous and look for opportunities to do things differently, to be innovative, and to implement new ways of doing things. And remember, you don't have to be the expert in all of these areas, but you do need to be aware that they exist, and better yet, have a resource or person that is the expert and can provide information of current state and maybe even guidance at times. That not only concludes this module, but it concludes our course on the essential skills for the CV program manager. I hope you've enjoyed it as much as we did putting it together. Again, if you have any questions, please reach out to academy at medaxium.com.

CV program management

staff readiness

patient compliance

cyber security

technology in healthcare