MACtoberfest®

The information provided in this presentation was current as of November 7, 2018. Any changes or new information superseding the information in this presentation are provided in articles with publication dates after November 7, 2018 posted on our website at: www.PalmettoGBA.com/medicare

Disclaimer

2

CPT® only copyright 2017 American Medical Association.

All rights reserved.

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2017 American Dental Association (ADA). All rights

reserved.

MACtoberfest®

Medical Review Overview and Targeted Probe and Educate

Presented by: Michael Parrozzo Manager Medical Review

• Medial Review Program Summary

• Targeted Probe and Educate Overview

• Tools to Assist in Provider Self Monitoring

AGENDA

4

Medical Review Program Summary

Designed to reduce/prevent improper payments by preventing payment of claims that do not comply with Medicare’s coverage, coding, payment and billing policies

Medical Review Program

6

Develop Annual Improper Payment Reduction Strategy (IPRS) • Required by CMS • Problem focused, outcome based operational plan that

identifies risks and describes the planned interventions Prioritized problem list is developed by service type after data

analysis has been completed Once prioritized list has been identified, interventions are

implemented to reduce/prevent improper payments

• Palmetto GBA utilizes Define, Measure, Analyze, Improve and Control (DMAIC) process to organize and prioritize the IPRS Well established method of process improvement Root cause analysis for identified errors

Medical Review Program

7

Develop Annual Strategy Analysis Report (SAR)

• Required by CMS

• Midway through the year, assess progress towards achieving the improvement goals outlined in the IPRS

• Based on evaluated results can modify or continue with the IPRS plan

Medical Review Program

8

Define risks • Analysis of data: Provider, service, and beneficiary specific

• Historical claims data

• Utilization trending/patterns High volume/cost

Change in frequency

• Outliers

Comparative Billing Reports (CBR) • National

• Region

• State

Medical Review Program

9

• Evaluation of Other Information Reports from CMS and other Government Agencies

• Office of Inspector General (OIG)

• Government Accountability Office (GAO)

Reports from other Contractors • Comprehensive Error Rate Testing (CERT)

• Recovery Auditor

• Internal Prioritization Reports Incorporates multiple components

• Edit results

• CERT errors

• National data

• Utilization Analysis

Medical Review Program

10

• Measure Once risks are identified medical review of claims may be initiated

• Validate issues

Targeted Probe and Educate (TPE)

• Review of 20-40 claims

• Establish benchmarks

• Analyze Review edit effectiveness reports for reviewed claims once universe of claims in

the selected sample are completed

• Improve/Control One-on-One provider specific education

Providers with moderate and high error rates will continue to a second round, followed by additional education

Based on results, a provider may be advanced to a third round

Medical Review Program

11

Targeted Probe and Educate Overview

• TPE began as a pilot program in June of 2016

• Developed from the Inpatient as well as HH Probe and Educate models Prior models included participation of all providers with smaller

review samples

Current TPE model providers are selected based on data analysis and probe reviews are conducted for 20-40 claims

• Previous success was demonstrated by: Decreased appeals

Increased acceptance of provider education

Background

13

The purpose of TPE is to reduce appeals, decrease provider burden and improve the medical review and education process

Purpose

14

• Service specific and provider specific edits

• Probe with progression to Targeted Medical Review with percent of claims sampled

• Quarterly results reviewed for continuation of edit

• Limited interaction with clinical review staff

Previous Medical Review Process

15

• Providers identified by data analysis when developing IPRS described earlier

• Up to 3 rounds of probe review • Each round consist of a 20-40 claims for review • One-on-one education intervention with clinical staff • Allow 45-56 days between education intervention and

next round • Discontinue review when provider becomes compliant • Monitor for one year via data analysis with follow-up

review if needed

Targeted Probe and Educate Process

16

Targeted Probe and Educate Process

17

Part B

Evaluation and Management

Surgical Services

Drugs and Biological Services

Diagnostic Services

Ambulance Services

Rehabilitation Services

ESRD

Services of Focus

18

Part A

SNF Ultra High/Very High RUG Codes

Inpatient Psychosis

Inpatient Procedure Codes and Coding

IRF

Outpatient

Drugs and Biological Services

HBO

Rehabilitation Services

Home Health and Hospice

Eligibility and Medical Necessity

• If selected for TPE, the provider will receive a notification letter outlining reason for review Notice of Review – Targeted Probe and Education

Letter will be addressed to the Medicare Provider or Compliance Officer

• Please ensure the process for routing this information to the person(s) who should receive the notification is timely and effective

Provider Notification

19

After the notification letter is received, the provider will also receive an individual Additional Documentation Request (ADR) for each claim selected for the probe review

• Providers should respond with records for the claim designated on the ADR

• Please ensure the process for routing these documents to the person(s) responsible for submission is timely and effective

• If the requested documentation is not received within 45 days, the selected claim will be denied

Provider Notification

20

• The interaction between the reviewer and the provider is a key component of the TPE model.

• The notification letter will contain a form for providers to designate a point of contact (POC) for the reviewer to contact by phone for any education calls. This form should be returned with the ADR response

Provider Notification

21

• During the probe review, the reviewer may contact the designated POC for any missing information or to provide education on a specific claim or issue identified

• If a review results in the denial of a claim, the provider will receive an individual MR Claim Review Decision and Education Letter for that specific claim

Results and Education

22

MR Claim Review Decision and Education Letter

23

MR Claim Review Decision and Education Letter

24

MR Claim Review Decision and Education Letter

25

• Upon completion of the 20-40 claim sample, the clinical reviewer will then contact you to schedule a 1:1 educational session via teleconference regarding any errors noted during the claim review

• Medical Review will also provide you written notification at the end of the review to include your results. This letter will include the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part and education on the results

Results and Education

26

Past TPE Teleconference Questions and Answers and other information related to TPE are posted at palmettogba.com

TPE Questions and Answers

27

Examples of data analysis that may trigger selection for TPE • Data is analyzed to identify services that have a high

payment error probability and/or present the greatest risk

• These services may be identified via previous review activity conducted by the MAC, the CERT contractor, the OIG and other CMS contractors

• Once the services are identified, additional data analysis includes (but is not limited to) establishing a baseline to identify unusual trends such as provider’s rank against peers and changes in utilization over time

Common TPE Questions and Answers

28

When were the first TPE notification letters mailed?

• Initial TPE notification letters were mailed back in October 2017

• As new providers and topics are identified, additional notifications are mailed

• TPE probes and rounds are specific to a provider and each provider is treated independently

Common TPE Questions and Answers

29

Who conducts the TPE reviews at Palmetto GBA?

• Registered Nurses

• Certified Coders

• Physical Therapists

Common TPE Questions and Answers

30

Is there a documented threshold to determine if the provider should move to the next round?

• TPE probe claim denial or charge denial rate of 20% or above may result in progression to the next round

Common TPE Questions and Answers

31

Who should participate in the 1:1 education?

• There are no requirements for who should participate

• Anyone the organization chooses to participate in the call is welcome

• Recommend including participant(s) that can benefit from the education and can facilitate implementation of any necessary changes

Common TPE Questions and Answers

32

Can we designate where the notification or results letters are mailed to?

• Letters are mailed to the correspondence address as listed on the Provider 855A or 855B

Common TPE Questions and Answers

33

What is the process to appeal a TPE denial?

• The appeal’s process has not changed due to TPE

• If you have a review determination during TPE that results in a claim denial, we encourage you to review the medical records you submitted, and if you disagree with that determination - you should follow the established appeal’s process

Common TPE Questions and Answers

34

Tools to Assist in Provider Self-Monitoring

• eCompare

• eReview

• eCBR eServices: Learn More About eCBR Video

• eUtilization eServices eReview: eUtilization and eAudit Video

• eAudit eServices eReview: eUtilization and eAudit Video

Tools to Assist in Provider Self-Monitoring

36

• eCompare Smart Edit Message will Inform provider of potential issue with their billing pattern

Provides a link to eCBR and accompanying education material for more information on their billing pattern

• Sent back in 277CA for each claim hitting the edit

• eCompare does not stop the claim from processing, only educational for the provider

eCompare Smart Edit

37

277CA Report Format Claim Information

38

• eReview is a tab available on eServices

• The suite of tools is designed to: Help providers self-audit

Increase self-awareness of how their data are being used

eServices eReview

39

• 7 topics currently available

• Data are updated monthly

• Providers can pull for multiple time periods (last 3, 6, 12, or 18 months)

• Comparisons are made to the state and JM for the specialty

eCBR

40

• Topics currently available JM: Topic 1: E/M – Established Patient 99211-99215

Topic 2: Chiropractic Services 98940-98942

Topic 3: Initial Hospital Visit 99231-99233

Topic 4: Non-Cancer Length of Stay (NCLOS) Hospice Providers

Topic 5: E/M – Initial Visit 99201-99205

Topic 6: Drugs of Abuse Lab Services

Topic 7: ER Services 99281-99285

• Topics currently available JJ: • Topic 1: E/M – Established Patient 99211-99215

• Topic 2: E/M – Initial Visit 99201-99205

eCBR

41

Two functions are available: • Currently available for JM and will be available soon in JJ Ordering/Referring – enter a NPI and see all providers that have the

NPI listed as the ordering/referring physician for a claim • Offers a detail drill down to identify the specific service provided and

number rendered

Rendering – enter a NPI and see all the PTANs and their utilization for that NPI • Available for multiple time periods just like eCBR

• Gives providers the ability to monitor where their numbers are being used

• Offers a detail drill down to identify the specific service provided and number rendered by each PTAN

eUtilization

43

44

45

Three functions are available:

• CERT

• MAC MR

• MAC Appeals

eAudit

46

• This tool offers a dashboard with: Total claims sampled

Summary of denials

Drilldown capabilities to claim line

• Shows pending CERT reviews and gives current status of reviews

• Status is updated monthly

eAudit

47

48

49

• CMS Internet Only Manuals: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html

• CR 10249: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1919OTN.pdf

• TPE Flowchart: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/TPE-Pilot-Flow-chart06-20-17v9-final.pdf

• CMS TPE Strategy Article: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

Resources

50

MACtoberfest®

Questions?