Indiana Recovery Audit Contractor (RAC)

Complex Reviews WebinarFebruary 15, 2013

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Webinar Goals

► Provide information

HMS - selected vendor as the Indiana Medicaid RAC

Indiana’s Medicaid RAC Program

► Details on HMS Complex Reviews

Methodology

Approach & Overview

Review Process

► Answer Common Questions

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HMS Presenters

► Jeanine Motsay – HMS Program Director, Indiana

► Joleen Bond-Livingston, VP Recovery Audit

► Glenda Lloyd, Manager, Recovery Audit Coding

HMS OVERVIEW

JOLEENBOND-LIVINGSTON

VICE PRESIDENT, RECOVERY AUDIT

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About HMS

► We provide cost containment services for

healthcare payers

► We help ensure that claims are paid

correctly (program integrity) and by the

responsible party (coordination of

benefits)

► As a result, our clients spend more of

their healthcare dollars on the people

entitled to them

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Background Recovery Audit Contractor

► Medicare Modernization Act of 2003 created a demonstration project to identify Medicare overpayments

● The program was operational from 2005 through 2007

● Following success of the demonstration project, the program was made permanent in 2008

► Section 6411(a) of the Affordable Care Act expanded RAC to Medicaid and required each State to begin implementation by January 1, 2012

● Identification of overpayments and underpayments

● States & RAC vendor must coordinate recovery audit efforts

● RAC vendors reimbursed through contingency model

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HMS- Medicaid RAC Standards

Reduce provider abrasion, provide education, customer service and limit administrative costs.

Possess in depth knowledge of Indiana Medicaid policies, regulations and MMIS process.

Maintain an understanding of the state’s operating environment – political, provider associations, agency goals.

Experienced in coordinating with other state audit entities.

Have established processes for a) Receiving and Formatting Medicaid Data, b) proven provider relations and c) seamless recovery function.

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Overview of Review Process

Analysis

And Targeting

Education,

Process Improvement

Review/Audit

• Program Analysis • Data Mining/Scenario Design• State Approval

Record Request

• Provider Contact• Record Request/Receipt• Tracking/follow up

• RN/Coder Review • Physician Referral• QA and Client Review/Approval

Results and

Communications

• Draft Audit Findings Letter• Reconsideration/Appeal• Support

• Provider Association Meetings• Program Recommendations• Banner/Website

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Analysis and Targeting

► Wrap around existing Indiana Fraud and Abuse Detective

System (FADS) and compliment FSSA/OMPP Surveillance

and Utilization Review (SUR) efforts.

► HMS utilizes data mining techniques to target claims where

the demographics, billing attributes, diagnosis codes,

procedures codes, and/or factors that appears to be

inconsistent with other attributes of the claim.

► OMPP has no immediate plans to utilize extrapolation for

RAC audits.

Analysis

And Targeting

• Program Analysis • Data Mining/Scenario Design• State Approval

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Types of Reviews –Automated / Complex

► Automated Review is applied in scenarios where improper

payments can be identified clearly and unambiguously.

1. Claims are identified with potential findings.

► Complex Review is required when analysis identifies a

potential improper payment that cannot be automatically

validated.

1. Claims are flagged for further review and HMS determines

what documentation is required to determine if an improper

payment exists.

2. Documentation is requested from the provider or appropriate

party and reviewed to determine if an improper payment

exists.

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HMS RAC Support Staff

► Experienced staff performing reviews:

● Certified Coders

● Registered nurses

● Pharmacy staff

● Dental staff

● Therapists

● Review panel of certified board physicians

► HMS has in-depth knowledge of:

● Indiana Medicaid billing & reimbursement

practices

● Claims adjudication process

INDIANA MEDICAID RAC

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Indiana’s Medicaid RAC Program

HMS, as the Recovery Audit Contractor (RAC), audit areas

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Financial Audits Clinical Complex Reviews

Current Clinical Complex

Review DRG Validation Audit

Credit Balance Long Term Care

Provider Types Approved to Date

Acute Care Hospitals Long Term Care (LTC) Nursing Facilities

Acute Care Hospitals Acute Care Hospitals

Medical Record Limits

Not applicable-Financial Audit only

Not applicable-Financial Audit only

Yes - OMPP will set by Provider Type as audits are approved * Note: OMPP may authorize exception on a case-by-case basis.

Provider Type 01(acute care): • 300 records per audit• 600 records per CY• Maximum freq ofrequest-every 90 days

Type of Audit On-site or desk reviews Desk reviews Desk reviews Desk reviews; few could become on-site

Audit Notification HMS letterhead FSSA/OMPP letterhead FSSA/OMPP letterhead FSSA/OMPP letterhead

Types of Records • Aged Trial Balance/ATB•Credit Balance Report•Debit adjustment reports• Other claim documentation

• Census reports• Detailed Aging Report• Detailed Financial History Rpt

• Medical records• Varies by audit

• Medical records For example:Discharge summaryPhysician ordersLabs, x-raysMedication Records

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Indiana’s Medicaid RAC Program

Additional comparisons by audit area

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Credit Balance Audit

LTC Audit Complex Reviews CurrentComplex Review DRG Validation

Audit

Who to Contact? NY, TX, IN field staff CT TX, Indiana licensed MD TX, Indiana licensed MD(Notification includes Contact Information)

Source of Audits and Frequency

All acute care hospitals: variable based on audit results

All LTC nursing facilities: 2 year cycle

Data mining and algorithms: variable based on audit results

Data mining and algorithms: variable based on audit results

Claim Selection Claim-by-claim Claim-by-claim Varies per audit. May use sampling in the future.

Claim-by-claim

Entrance Conference

Yes on-site or by conference call

Yes by conference call No, but provider may contact HMS Provider Services anytime

No, but provider may contact HMS Provider Services anytime

Exit Conference Yes on-site or by conference call to review worksheets

No, but HMS will maintain open communication with provider

No, but provider may contact HMS Provider Services anytime

No, but provider may contact HMS Provider Services anytime

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Complex Reviews

Methodology

► Perform a comprehensive review of fee-for-service claims where data mining/analysis identifies a potential improper payment that cannot be automatically validated.

► The audits will cover a three-year review period adjusted by a one-year look-back period from the date when each audit commences.

● For the ongoing DRG Validation Audits, the time period is July 1, 2008 to June 30, 2011. As we initiate more audits, that time period will be adjusted based on the audit start date and direction from OMPP.

► In the first phase of DRG Validation Audits, 42 hospitals were selected and HMS is currently working with the first 20. The remaining first phase hospitals will receive notification letters in the coming month.

► Audits for additional phases of DRG Validation and approved scenarios to follow first phase.

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Record Request

► Contact updates from Credit Balance Audits and HMS Provider

Services record of contacts.

► The State and HMS jointly issue a notification letter to Provider,

which includes:

● Attachment of selected claims for review.

● Examples of the DRGs and procedure codes that HMS will audit.

● Letter outlines supporting documentation required for submission.

● Submit within 30 days from the date the notification received.

● Instructions for paper, CD/DVD or Electronic Data Interchange (EDI).

● Provider must not submit adjustments/voids for the claims identified.

● Provider Services contact for questions or follow up requests.

Record Request• Provider Contact• Record Request/Receipt• Tracking/follow up

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Review / Audit

► HMS’ Complex Review process is tailored to meet the State’s

policy and procedure requirements.

● OMPP set RAC audit medical record limits for Provider Type

01 (Hospital) and communicated that decision in banner

BR201231 dated July 31, 2012.

► Audits will be conducted as desk reviews by experienced

certified coders with access to a panel of physicians.

● HMS Medical Director, Dr. Peter Gurk, is an Indiana licensed

physician responsible for clinical review operations.

► During this period, HMS may be in contact with the provider

to ask questions or to request additional information. The

provider may contact HMS at any time to discuss their review.

Review/Audit

• RN/Coder Review • Physician Referral• QA and Review/Approval

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HMS Responsibilities

► Send Draft Audit Findings Letter with results of review.

► HMS works one-on-one with the provider to resolve any disputed cases, if provider requested reconsideration.

► When signed appeal waiver is received, coordinate processing of provider claim adjustment requests with Hewlitt Packard.

► Send Final Calculation of Overpayment letter to provider indicating remaining interest owed after claim adjustment requests have been processed. Amount of overpayment is net difference between original claim payment and payment indicated on adjusted claim plus applicable interest.

► Support appeals process when applicable.

Results and

Communications

• Draft Audit Findings Letter• Reconsideration/Appeal• Support

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Provider Responsibilities

► Review Draft Audit Findings and respond within 45 calendar days of signed receipt of letter and:● If provider is in agreement with findings, complete Audit Reconsideration and

Appeal Waiver form along with completed claim adjustment requests as indicated in Draft Audit Findings letter. Completed adjustment request form(s) along with corrected claim form(s) must be directed to the OMPP SUR Department. The SUR Department will facilitate the necessary corrections with Hewlett Packard (HP) to allow claims adjustments beyond one-year look back period for claims covered by the audit, or

● If provider is not in agreement with findings, submit a Request for Administrative Reconsideration and provide supporting documentation. (Not submitting a Request for Administrative Reconsideration within the required 45-day timeframe means the provider forfeits their appeal rights.)

► Review Final Calculation of Overpayment letter and:● Agree and proceed with repayment, or

● File a timely appeal (would not apply if appeal rights are waived or forfeited through Draft Audit Findings process). (Not filing timely appeal within the required 60-day timeframe forfeits appeal rights.)

Results and

Communications

• Draft Audit Findings Letter• Reconsideration/Appeal• Support

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Process Improvement

► Work one-on-one with provider to identify process

improvements and educate staff to reduce future billing

errors.

► IHCP publications for updates on Statewide program.

► Program Integrity Web site for general information such as

FAQs.

(Web site address available at end of today’s presentation.)

► CMS reporting for information on outcomes.

Education,

Process Improvement

• Provider Association Meetings• Program Recommendations• Banner/Website

DIAGNOSIS RELATED GROUP

(DRG) AUDITS

GLENDALLOYD, MBA, BS, RHIA

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DRG Validation

► The purpose of DRG validation

is to ensure that diagnostic

and procedural information

and the discharge status of

the member, as coded and

reported by the hospital on its

claim, matches both the

attending physician's

description and the

information contained in the

member’s medical record.

► Refer to IHCP banner page

BR201242 dated October 16,

2012.

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Current Validation Set

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1. Septicemia: Reviews will be conducted

to validate all information affecting the

assignment of AP-DRGs 416

(Septicemia, age greater than 17), 417

(Septicemia, age less than 18), and 584

(Septicemia with major CC).

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Current Validation Set

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2. Operating Room Procedure

Unrelated to Principal Diagnosis:

Reviews will be conducted of AP-

DRGs 468 (Extensive O.R.

procedure unrelated to principal

diagnosis), 476 (Prostatic O.R.

procedure unrelated to principal

diagnosis), and 477 (Non-extensive

O.R. procedure unrelated to

principal diagnosis) to validate if the

principal diagnosis is correct as well

as address any other coding or

compliance issues identified.

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Current Validation Set

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3. Excisional Debridement: Excisional

debridement of wound, infection, or

burn is defined as the “surgical

removal or cutting away of

devitalized tissue, necrosis, or

slough.”* HMS will audit excisional

debridement procedure code 86.22

to validate the proper use of this

code.

* AHA Coding Clinic, Fourth Quarter, 1988, page 5

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Current Validation Set

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4. Tracheostomy: Reviews will be

conducted of AP-DRGs 482

(Tracheostomy for face, mouth, and

neck diagnoses), 483 (Tracheostomy

except for face, mouth and neck

diagnoses), 700 (Tracheostomy for

HIV infection), and procedure codes

31.1 (temporary tracheostomy) or

31.29 (other permanent

tracheostomy).

CONTACT RESOURCES

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indianamedicaid.com 1-800-457-4515 www.in.gov/fssa

Contact Information

Only formal responses to questions asked through the www.in.gov/fssa inquiry process will be considered official and valid by the State. No participant shall rely upon, take any action, or make any decision based upon any verbal communication with any State employee including responses in today’s presentation.

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WEBSITE - WWW.IN.GOV/FSSA

‘Contact Us’

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SCROLL DOWN…

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After the Webinar

► Providers can refer to the Program Integrity Web site for additional information regarding RAC audits.

● http://provider.indianamedicaid.com/about-indiana-medicaid/program-integrity/medicaid-rac.aspx

Q & AComplex Reviews Webinar

February 15, 2013