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Home My WebLink About98-01405 ..... .~ ' (, ~ ~ ...... ~ ~ ~ ~ ~ ~ 'l ^, "J ~" , ,.j ;.-'" '. '<~ i.',' j J ~ c., \: ~ ,~ ~....... -, ;;~ ':) <"l , '-:l~ .,:';:iJ 'm -.,.~~ 'f~ .'''' .':-.,t' <I: .'}f .~ i~ :.::~ ;~ ',',).$ .: ~.~~ '~l ,,\~ ,,';j~ ,i.:n; ,ii~ .~~ ":~ ::jt,.~ "'~:.,!~};:~ , ';.J "'rm :;~1 :'~;~'i~ ,,'<:.t;~ "..~~~ , <':1M :>~ "1 :'~i "'w ::::~~1'~ ..':'J ~~.1 ~-;l'; . ,,}! , ."':.1 ~ ~ ....... It ~ " \ \ \ ....... I ~ I ~ ) ~/ :'}!l , , "." .;\ ,~ , ". I ":.' c":\? >i'ii 'c." ,. ~ .-~l "\' -. . .~ " .... ''J ~ ~ ::r-.. ........ , ~ HEALTH SYSTEMS, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION v. LOGAN GENERAL HOSPITAL, Defendant . . NO. fr- 14D1- CIVIL ~ftM NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the fOllowing pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a jUdgment may be entered against you by the Court without further notice for any money claimed in the Complaint or fo~ any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 Liberty Avenue CarliSle, PA l701J 717-249-3166 NOTICIA Le han demandado a usted en la corte. Si usted quiere defende se de estas demandas expuestas en las paginas siguientes, usted tiene viente (20) dias de partir de la fecha de la demanda y la notifcacion. Usted debe presentar una apariencia escrita 0 en persona 0 por abodago y archivar en la corte en forma escrita sus defensas 0 sUs objeciones alas demandas en contra de su persona. Sea avisado que si usted no se defiende, la corte tomara medidas y peude entrar una orden contra usted sin previo adviso 0 notificacion y por cualquier queja 0 alivio que es pedido en la peticion de demanda. Usted puede perder dinero 0 sus propiedades 0 ostros derechos importantes para usted. I I \ I I /ii., I,; 1', '/ i; ; i I I I' ); i ~ :' r IJ. I ' I .... ., -.:.:-...- .~.. ;.... , , . " NATIONAL HEALTH SYSTEMS, INC. , Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION v. LOGAN GENERAL HOSPITAL, Defendant , (,1 c.'. I '10 \ NO. r CIVIL 199B COMPLAINT NOW COMES Plaintiff and makes the following Complaint against Defendant: l. plaintiff is a Pennsylvania business corporation, with its principal place of business at 1104 Fernwood Avenue, Fourth Floor, Camp Hill, Cumberland County, Pennsylvania. 2. Defendant is a not-for-profit hospital organized and existing under the laws of the state of West virginia with its principal place of business at 20 Hospital Drive, Logan, West Virginia. 3. Plaintiff is in the business, inter alia, of providing hospitals with expertise in the areas of DRG coding, Laboratory and Radiology coding, and medical bill auditing services. 4. On or about September 23, 1996, plaintiff and Defendant entered into an Agreement under which Plaintiff agreed to provide to Defendant DRG Quality Validation Assessment services. 5. On or about November 21, 1996, Plaintiff and Defendant entered into an Agreement under which Plaintiff agreed to provide to Defendant'a Prospective DRG Quality Validation Review. .. .-: . .. 6. On or about April 2B, 1997, Plaintiff and Defendant entered into an Agreement under which Plaintiff agreed to provide to Defendant a DRG Quality Validation Assessment. 7. All three of these Agreements were accepted by Plaintiff in Camp Hill, Cumberland County, Pennsylvania. B. Plaintiff performed all of its duties and obligations under the Agreements, and Defendant received the services as outlined in the Agreements. 9. Plaintiff submitted the following statements for services to Defendant, in accordance with the Agreements: January 2B, 1997 February 10, 1997 February lO, 1997 February 14, 1997 March 5, 1997 June 9, 1997 August 7, 1997 $6,350.00 2,900.00 4,000.00 3,300.00 4,675.00 5,000.00 5,000.00 The statements are attached hereto collectively as Exhibit "D". lOt To date, Defendant has paid Plaintiff none of the above-referenced amounts. ll. Even after repeated requests for payment, Defendant refused to make payment to Plaintiff. l2. Defendant is in breach of its obligations under the Agreements in that it has not made proper payment to Plaintiff. The Agreements are attached hereto as Exhibits "A", "an, and "COO and incorporated herein by reference. l3. Defendant owes Plaintiff $3l,225.00 to date, plus interest and costs of suit. '", . . Record Selection and Review Methodology Logan General Hospital is requesting a prospective review of those cases reimbursed under the DRG payment system. These include reviewing all Medicare, Medicaid, Workmen's Compensation and Public Employee third party payer charts, NHS will review these cases to determine the quality and accuracy of the coded data and its initial ORG assignment by the hospital coding staff, Each medical record will be reviewed by an experienced medical record professional. Each inpatient medical record will be reviewed to verify the ICO-9-CM coding, ensure assignment of the most optimal DRG assignment and the r.esulting reimbursement while focusing on the following criteria: . Correct selection and sequencing of principal and secondary diagnoses and procedures . Identification of comorbid and complicating conditions . Correct use of ICD-9-CMIDRG principles to classify diagnoses and procedures . Reference Coding Clinic regulations, as needed . Verify medical record documentation to support the reported diagnoses and procedures, Our DRG specialist will be on-site at the facility three days per week to avoid any delays in billing the charts. Once the hospital coder has coded a chart being reimbursed under the ORG payment system, the coder will then flag the chart for review and not bill the case, After the chart is reviewed by our specialist it is immediately returned to the coder for final billing if there are no recommendations for DRG adjustments. If a DRG change is made, our specialist will prepare a DRG Review Findings worksheet for each discrepancy identified during the assessment. Hospital staff will receive a copy of the worksheet. The worksheet is designed to document all relevant infonnation developed during the review process, Copies of the worksheets will be provided to appropriate hospital personnel for review, comment, and fmal billing on a daily basis to eliminate any cash flow delays, Exit Interview NHS will discuss all discrepancies identified during the review process at the time of the exit interview to be held on a bi-weekly basis. The exit interview is welcome to all coders and any other personnel the hospital wishes to involve, It is to be used as a forum for educating the key staff on coding principles which impact the day to day coding process. All discrepancies identified during the previous two weeks will be discussed for educational purposes. It will focus on any coding patterns identified, specific coding principles and optimization techniques to facilitate the learning process for the coders. 2 Exhibit "B" . . Record Selection and Review Methodology NHS suggests a retrospective review of selected cases to determine the quality and accuracy of the coded data for Medicare, Medicaid, Workmen's Compensation and Public Employee cases or all third party payers reimbursing under the DRG system for inpatient medical records. Under existing Medicare regulations, hospitals have an opportunity to review and resubmit DRG coding information within 60 days following reimbursement from the Fiscal Intermediary. NHS will identify accounts for review from remittance advices falling within the 60 day "window of opportunity." NHS will also review remittance advices for case seleciion for Medicaid, Workmen's Compensation and Public Employee third party payers. The selection process will take into account DRGs that traditionally have been undercoded by the facility and/or other facilities or have shown increased potential for review by third party payers. The number of records reviewed will vary and be dependent on the hospital's caseload at the time of review. Each medical record will be reviewed by an experienced medical record professional. Each inpatient medical record will be reviewed to verify the ICD-9-CM coding, ensure assignment of the most optimal DRG and the resulting reimbursement while focusing on the following criteria: . Correct selection and sequencing of principal and secondary diagnoses and procedures . Identification of comorbid and complicating conditions . Correct use of ICD-9-CM/DRG principles to classify diagnoses and procedures . Reference Coding Clinic regulations, as needed . Verify medical record documentation to support the reported diagnoses and procedures. NHS will prepare a DRG Review Findings worksheet for each discrepancy identified during the assessment. The worksheet is designed to document all relevant information developed during the review process. Copies of the worksheets will be provided to appropriate hospital personnel for review. comment, and rebilling at the exit interview. Exit Interview NHS will discuss all discrepancies identified during the review process at the time of the exit interview. The exit interview is welcome to coders and any other personnel the hospital wishes to involve. It is to be used as a forum for educating the key staff on coding principles which impact the day to day coding process. 2 Exhibit "e" . . . NHS will provide copies of the DRG Review Finding worksheet indicating proposed coding changcs and relatcd Issues. Workshcets will be providcd to key staff involved in the coding process at Logan Gencral Hospital for discussion and rcview for educational and rebilling purposcs. Any coding patterns identified during the review process will also be discussed. It will focus on specific coding principles and reimbursement optimization techniques to facilitate the learning process for the coders. The methodology and results of the review process will be incorporated into the exit interview. DRG Validation Review Summary Report DRG Review Summary Reports will be provided to Logan General Hospital at the conclusion of the review. The report will be designed to provide a quantitative project fmding recap and medical record specific detail. The detailed written report may contain the following: . Detailed report outlining specific DRG changes and the Relative Weight differences per case . Forecast the fmancial impact as identified through the overall discrepancies . Summary of the individual case fmdings . Recommend solutions where coding problems exist, whether the problem is within the coding area itself, or an interdepartmental issue . Recommend solutions to facilitate timeliness of coding, in terms of changing a process or utilizing reports to enhance coding . Identify problems which may be attributed to technical errors, documentation problems, and/or process issues. Re-Submisslon of Claims For each discrepancy identified, NHS will compare the payment difference from the original to the revised DRG to assess the fmancial impact. No claim will be re-billed without Logan General Hospital's adminigtrative approval. Logan General Hospital will have fmal responsibility for the re-submission of claims. Any claim being re-billed will adhere to each individual third party payer policies on rebilling procedures. NHS will also assist the hospital in drafting any correspondence to third party payers to justify claim re-submission, as needed, or to request any DRG changes. Under this engagement, NHS will provide appropriate support to Logan General Hospital for cases reviewed under this engagement where DRG issues are raised by the state Peer Review Organization. We will also be available to offer advise for DRG coding issues that may arise on records not included in this engagement. 3 Exhibit "e" ~ .. . ,. , , \,~-' ~Qx ?-D ~~? ,., ~ ~ . ~'_. ;..J ('"'I v.J ~ ~:~ t! ': -','I ~ .., ~ Uj ;) ~ ." "" c. 'f-:':' -:111 I ~ i:..... c', '0 '^, } , \,)..I I ." ~-: .,e) () -.::':' ;'.c.~ t ,'. I ~;J ~ ~,? ~c) ~ '."'rn ....1 1 :-1 :..) ;:! ~ I)' :q ~ -, ~ .... C l.\~ (") c- ::,) " I 'r~. ;;.J ,. .-.0:.' ;;: "" ;"; ~-n Ij:: ('.} .f'"l '" U. .-4 ....'j.J .- C.J{) ~~; '. -'":0"1 ::;1-'1 ,. ~:j:~ 2[j : G5 '''I rl1 :::) ....:'t ;':;1 ~. \!:1 .... ~ ..... - , I I J I ! ..- ....' NATIONAL HEALTH SYSTEMS, INC. , Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION v. LOGAN GENERAL HOSPITAL, Defendant NO. 98-1405 CIVIL PRAECIPE TO ENTER JUDGMENT BY DEFAULT TO THE PROTHONOTARY: Please enter judgment by default in favor of Plaintiff, National Health Systems, Inc., and against Defendant, Logan General Hospital, for its failure to plead to the Complaint in this action within the required time. The Complaint contains a Notice To Defend within twenty (20) days from the date of service thereof. Defendant, Logan General Hospital, was served with the Complaint on March 23, 1998, and its Answer was due to be filed on April 13, 1998. Attached as exhibit "A" is a copy of Plaintiff's written notice of praecipe to enter judgment by default, which I certify was mailed by regular mail to Defendant, Logan General Hospital, at its last known address on April 14, 1998, which is at least ten (10) days prior to the filing of this Praecipe. I have not been notified by any attorney that an appearance has been entered of record on behalf of Defendant, Logan General Hospital. Please assess damages in the amount of $31,225.00, plus interest at the legal rate of eighteen percent (18%), which is the interest rate pursuant to contract. C'"' \IJ (1 f OJ -'-1 :::- --( ""1:' i , - -n ~l:-n 1], , , ;'J n'i~ ~c: " >",1"":'1 l N "-,l.:J c', '-. '.~~~~ . E":, " -n ,~. -"J . , ( -';. \)() .< " ~ ::.~lhl >. ~: . :~:..! , -:':'1 U~ :.:~ -~ (::> ~, ,i (") \0 0 F c.:J -n y.-:-. .-1 -c'.',' --:J :J.1:r1 fI ,. ::::..J ,. '" ~ ;t~ 'J 1'-' '''''1,.n jJ\:":l L"~' '- oA -< '-J" r:::l:.:- -:J .--, -,I -,:::-.,\ C';.; ("; -' ~_-!;:''i r~ - is' ..0;:: rr\ .).'" ~~-; ~~ ~- :~ ~.) 2~ -, c, ~ ~~ C.' 1.1'7' n ~ c- C..! "" ..,.., :'1' *..J ~ o ~. -'oJ ;:; ; 11~:J ,>..; j"..) .?::J ~ S\ ~ ~ ,..; !;; ,~. ~~~ t~~, ~ ~' ~ ~::.'- ::~ ?~:~ ! ~ "- . ....~. ". ~5 .:-:'CJ .r*(- : i:)I.l ~ ~ -, ::7..J :~, :::~ ~ VJ .~ t:J ~..rJ ~. -...J t