New initiatives to drive quality outcomes 

Learn about ilumed’s new initiatives aimed at improving the quality of healthcare delivery and improving patient health outcomes. 

Transitional Care Management Quality Review 

Initiative description:  

This initiative recognizes the crucial role that primary care providers play in managing the transition of patients, particularly those with complex medical conditions, from the hospital back to the community. 

ilumed medical directors will review documentation for patients who are discharged from in-patient hospital stays and skilled nursing facilities (SNFs). This will ensure all necessary steps are taken to provide adequate transitional care and meet regulatory documentation requirements.  

Initiative goal:  

Gather valuable insights to help us improve patient outcomes by ensuring all patients receive quality care through a timely and seamless transition.  

Initiative key metrics: 

• Identify gaps in care 

• Track effectiveness of interventions 

• Assess impact of transitional care on readmission rates 

• Meet or exceed regulatory documentation requirements 

How this initiative benefits PCPs:  

You will better understand where and when your processes and documentation are working well or have room for improvement. You’ll have peer-to-peer discussions as needed with our medical directors to help you improve your workflows and documentation efforts. 

How this initiative benefits patients:  

Transitioning back home from an in-patient stay can be overwhelming and confusing, especially for those with complex or chronic needs. When patients have the support they need, they are more likely to have optimal health outcomes and higher satisfaction rates and less likely to be readmitted. 

Sedation Risk Initiative 

Initiative description:  

ilumed medical directors will partner with PharmAssist Consulting Group to determine if medication alternatives are available to lower a patient’s sedation risk. This may include cognitive dysfunction, delirium, frailty, confusion, falls and brain atrophy. Falls are the top preventable adverse drug effect with an average hospitalization cost of $35,365. 

Initiative goal:  

Reduce unplanned hospital admissions (UHAs) and other risks such as falls due to adverse drug effects. 

Initiative key metrics: 

• Total alternatives recommended 

• Number of adverse sedation-related drug events 

• Quantity of UHAs 

How this initiative benefits PCPs:  

You will be able to make recommendations for alternative medications with fewer sedative side effects, improving patient outcomes and delivery of care. 

How this initiative benefits patients:  

Patients should experience fewer negative sedative side effects and improved quality of life. 

Anomalous Billing Review Initiative 

Initiative description:  

ilumed will conduct post-payment comprehensive reviews of medical records and documentation to identify outliers. When ilumed identifies an outlier, we will ask for additional documentation from the provider to support the claim. 

Initiative goal:  

Improve the quality and accuracy of documentation and billing claims. 

Initiative key metrics: 

• Identify, monitor, and track coding and billing trends 

• Ensure provider documentation supports medical necessity 

• Minimal variation in coding practices across providers 

• Accuracy, integrity, and quality in patient data 

How this initiative benefits PCPs:  

Help you and your staff to adhere to appropriate billing and coding practices and improve the quality of documentation in your medical records. 

How this initiative benefits patients:  

Patients will get the appropriate level of care that is medically necessary for their health and well-being. This helps increase equity in the healthcare system and ultimately helps reduce costs. 

Correct Coding Initiative/Supplemental Data Submission 

Initiative description:  

ilumed recognizes that systems or operational errors may occur in claims, which result in truncated or incomplete submission. This initiative allows providers to amend claims within a 12-month period to ensure all diagnoses are accurately reported without duplicating a claim or getting denied by the Centers for Medicare & Medicaid Services (CMS). 

Providers can submit additional medically necessary diagnosis codes on claims within 12 months using the CPT code 99499. 

Important notes: 

• Always use the original date of service. Your submission must follow Medicare fee-for-service timely filing guidelines. Only amend submissions within a 12-month period of the original date of service. 

• This assumes you are not removing or changing the original codes.  

• If you do need to remove or change the original code, a different procedure applies. You must submit corrected claims to CMS directly. 

• Contact coding@ilumed.com with coding-related questions and concerns. 

Initiative goal:  

Provide more flexibility and accuracy in claim submissions. 

Initiative key metrics: 

• Accuracy of claim submissions 

• Quantity of corrected/supplemental claims 

How this initiative benefits PCPs:  

This ensures that all the conditions are accurately captured and reported on the claim, which reflects the complexity and disease burden of the patient.  

How this initiative benefits patients:  

When patients’ claims are accurate, it supports quality, patient-centered care as their providers have a clear and concise picture of their health needs. This also helps coordinate value-based care delivery across the healthcare system, ensuring that relevant information is shared effectively.