NE Home Care Conference: Effective & Efficient Preparation ......1 NE Home Care Conference: Effective & Efficient Preparation for Medicare Audits & Appeals Cheryl Leslie, RN, MPH Director

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NE Home Care Conference: Effective & Efficient Preparation for Medicare Audits & Appeals

Cheryl Leslie, RN, MPH

Director of Home Care & Hospice Services Pamela Meliso, JD, MPH

Director of Consulting & Regulatory Affairs

Healthcare Management Solutions, Inc

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Today’s Objectives

Today’s Objectives 1. Understand all the Department of Health &

Human Services audit types from CMS and OIG for Home Health Agencies and Hospices; jurisdiction; audit protocol

2. Develop sound compliance programs to prevent denials with internal audit and monitoring to identify risk areas and implement corrective plans

3. Learn the basics of how to appeal denials through the Medicare system and when to get help

Healthcare Management Solutions, Inc

Background

Background Why so many audits? ◦ Growth in home health ◦ Top 25 counties in US ◦ Fraud indictments

How are overpayments and fraud discovered? ◦ Multiple agencies working together using data to target agencies

What can you do? ◦ Get ready – today is a good start

Healthcare Management Solutions, Inc 3

Medicare Audit Entities

Audit Agencies and Contractors Medicare Administrative Contractors (MACs) Office of the Inspector General (OIG) Recovery Audit Contractors (RACs) Zone Program Integrity Contractors (zPICs) Other Auditor activities: CERTS, PSCs, proposed

Cert & Survey sanctions and fines coming, F2F, PECOS enrollment (Phase II now enforced), OIG recommending surety bonds and MICs

Focus today on MAC, OIG, RAC, and zPICs


Medicare Administrative Contractors (MACs)

MAC- Jurisdiction K: National Government Services (NGS)

MACs have assumed all the functions of intermediaries and carriers

MACs perform pre-payment medical reviews

Claims processed through a “scrubber” to check them against claim edits

Denial rates calculated using Charge Denial Rate and Claim Denial Rate


Office of the Inspector General (OIG)

Office of Inspector General (OIG)

Protects the integrity of HHS programs as well as the health & welfare of program beneficiaries

Detects & prevents fraud, waste & abuse 2014 Work Plan includes review of: ◦ PPS requirements; ◦ HHA employment of individuals with criminal convictions; ◦ Hospice use of general inpatient care.


Office of Inspector General (OIG)

Office of Inspector General (OIG) 2013 Work Plan Hospices—Marketing Practices and Financial Relationships

with Nursing Facilities Hospices—General Inpatient Care Home Health Face-to-Face Requirement (New) Employment of Home Health Aides With Criminal

Convictions (New) States’ Survey and Certification: Timeliness, Outcomes,

Follow-up, and Medicare Oversight Missing or Incorrect Patient Outcome and Assessment Data Medicare Administrative Contractors’ Oversight of Claims Home Health Prospective Payment System Requirements Trends in Revenues and Expenses


Recovery Audit Contractors (RACs)

Recovery Audit Contractors (RACs) Region A RAC is Performant Recovery SHS also doing RAC audits Issues under review limited to those listed on

web site RACs do post-payment review by data mining of

billing activities to find overpayments (can look back 3 years)

ADRs, recoupment by MAC RACs reimbursed a percentage of overpayments

they collect


Recovery Audit Contractors (RACs)

RAC Program is currently on hold pending CMS awarding new contracts

The last day that the current RAC can send claim adjustment files to the MAC is 6/1/14

As of 6/2/14 only claim closure files may be sent to the MAC by the RAC

Discussion Period requests will be accepted through 6/3/14


Zone Program Integrity Contractors (ZPICs)

Zone Program Integrity Contractor (zPIC) Zone 6 contractor is under protest; until resolved

Program Safeguard Contractor remains in place PSG for Zone 6 is Safeguard Services Responsible for preventing, detecting, and

deterring Medicare fraud Have specific investigative powers & no approval

needed for issues to investigate Uses data analysis; if high level of error sampling

& extrapolation allowed


RAC Process

RAC Process Demand letter issued by RAC Rebuttal and Discussion Period:

Opportunity for the provider to discuss the improper payment determination with the RAC (outside the normal appeal process)

Helpful to obtain clarification of RAC’s rationale & to challenge it

Do not mistake this with a formal appeal


RAC Appeals - Redetermination

RAC Appeal Process: Redetermination After an initial decision, a provider has 120 days

to file a Request for Redetermination Request for Redetermination filed within 30 days

will stop recoupment until a decision is made; if no request recoupment begins on the 41st day after the date of the demand letter

The Contractor has 60 days from the date of the Redetermination request to issue a decision

The decision-making time period is extended 14 days if new evidence is submitted post-Redetermination request


RAC Appeals - Reconsideration

RAC Appeal Process: Reconsideration A provider has 180 days from the

Redetermination decision to file a Request for Reconsideration ◦ If filed within 60 days, recoupment delayed until decision. If no Reconsideration request, recoupment begins on day 76 following the Redetermination decision


RAC Appeals – ALJ Hearing

RAC Appeal Process: ALJ Hearing Providers must file a request for ALJ

hearing within 60 days of the Reconsideration decision

AIC must be met ($140 - 2014) ALJ hearings conducted by VTC or phone Recoupment occurs during this stage even

if appeal requested ALJ has 90 days from hearing request to

issue a decision in writing


RAC Appeals– Appeals Council

RAC Appeal Process: Appeals Council Provider must request MAC appeal within

60 days of ALJ decision MAC will only consider new evidence if it

was not available at the time of the ALJ hearing

No time limit for MAC to issue decision


Objective #2: Compliance Programs

Corporate Compliance Program 7 Elements (FR Vol 63, No 152 August 7, 1998) Voluntary 1. Develop written standards of conduct and policies –

create zero tolerance culture 2. Name a Compliance “Officer” reporting to the CEO 3. Develop education for all employees 4. Develop an anonymous reporting system (hotline) for

complaints 5. Develop a response team and investigate and take action

on findings including disciplinary actions 6. Develop monitoring and auditing of compliance 7. Develop a plan to remediate findings – including

refunding


Corporate Compliance Program

Corporate Compliance Program Develop program with existing resources Target the program to known risk areas such as

the TMR edits, OIG 6 criteria and 2014 Workplan Keep it Simple and Smart (KISS) combining audit

activities where possible Think like the auditors by anticipating audit

targets Learn to data mine and analyze to fix problems

to stay off the radar screen Benchmark your claims data to others



Corporate Compliance Program Don’t assume just because you have a

compliance plan it’s effective. Test it. Conduct gap analysis to find the holes in

operations, coding, OASIS, billing practices

Learn how to extract data from the agency software – see handout

Put a team together that shapes the Compliance Program with an audit Champ



Corporate Compliance Program: Risk Assessment Operations review Coding and OASIS scoring and transmission

practices Billing practices, RAC metrics Home Health TMR on LUPA, low HHRG early and

late claims Hospice: TMR on short LOS, 3rd benefit period;

diagnosis screen non-CA, Alzheimer's, debility, COPD



Corporate Compliance Program: Education Train all employees who have anything to do with a claim (clinicians, office support, finance/billing)

Chose topics wisely - bang for the buck (financial risk and clinician time)

Pick topics from audit findings, newsletters, listservs, benchmark data

Use tools to train on coverage, utilization, appeals, coding using a variety of sources (HCA listservs, newsletters, webinars, consultants)



Corporate Compliance Program: Monitoring & Auditing Develop an audit schedule and stick to it: risk

assessment dictates if 100% pre-bill review Target risk areas (low HHRG, hospice 3rd benefit

period, F2F, orders, rehab utilization, G codes) Work as a team (see example of email alert) Work it into existing audits (QCRR) Data mine using reports to analyze what to audit

(see handout of sample report) ◦ What would be a reasonable response to the data? ◦ Take action to correct errors before MAC does!!



Corporate Compliance Program: ADR Response Team Develop response team for ADRs that includes

who opens the snail mail and email! Respond to ADRs timely (don’t wait the 30 days)

and do a QA check of the ADR documents Draft a cover letter with arguments for coverage

including other claims periods Send the OASIS Validation Report since the state

archives the OASIS quickly and cover letter Appeal all denials even small ones to get “credit”

toward your claim/charge denial rate calculation



Corporate Compliance Program: Suggested Home Health audit Run data on your claims histories against the TMR edits, 6 OIG

criteria and determine if you are at risk Do prospective and concurrent reviews of the claims, not just

retrospective reviews Review documentation of skilled and homebound criteria;

consider cancelling claims before the MAC sends an ADR. Then it’s too late

Educate staff on qualifying conditions skilled and “FRED” homebound documentation

Monitor OASIS and coding accuracy: how many corrections with upcodes; with downcodes

Benchmark your agency with others in US and NE



Corporate Compliance Program: Suggested Hospice Audit Program for Evaluating Payment Patterns

Electronic Report (PEPPER Report) Numerator (N): count of beneficiaries discharged alive with occurrence code "42"

(date of termination of hospice benefit) and with a length of stay (LOS) < 25 days Denominator (D): count of all beneficiaries discharged (by death or alive) with a LOS

< 25 days excluding discharge patient status code "30" (still a patient) Long Length of Stay N: count of beneficiaries receiving hospice services

whose combined days of service at the hospice during the cap year (November 1 through October 31) is greater than 180 days (obtained by considering all claims billed for a beneficiary during the cap year)

D: count of all beneficiaries receiving hospice services at the hospice at any point during the cap year (beneficiaries must have at least one claim for service from the hospice) ◦ The Hospice PEPPER will be distributed in hard copy format via Federal Express,

addressed to the Hospice Administrator/Chief Executive Officer March 2013


Objective #3: Appeal Strategies

Appeal Strategies Submit additional evidence as soon as possible,

good cause must be shown for evidence submitted at the ALJ level of appeal

In general, for an ALJ to find good cause the evidence must have been unavailable earlier or there was no reason to know it was needed

Be prepared to raise legal defense arguments as well as merit-based arguments

Use expert opinions/testimony when appropriate. Nurses and therapists are experts!


Objective #3: Appeal Strategies

Appeal Strategies When possible, utilize VTC technology for

hearings rather than telephone hearings Know the clinical record well and support your

argument with references to the record Be prepared to answer questions about the

record In general just answer the question asked; if

unsure of answer ask for time post-hearing to respond


Summary of Audit & Appeals

Auditing Agencies Jurisdictional Scope Process Risk Mitigation Strategies

Medicare Administrative Contractors (MAC’S)

Oversee claim completion and accuracy Anticipated to revive the comprehensive error rate testing program (CERT) who test the accuracy of the MAC!

Prepayment medical review All claims put through a “scrubber” to check claims against claim edits ADR sent electronically

Data mine and analyze risk areas Prebilling auditing of high risk claims Process ADRs promptly Monitor denial rate Appeal denials

Office of the Inspector General (OIG)

Promoting efficiency and effectiveness Protect the integrity of HHS programs as well as the health and welfare of beneficiaries of those programs

Letter/email requesting information/records Work plan issues 2013 targeted areas 2014 targeted areas

Know the OIG Workplan and audit risk areas Respond promptly to OIG requests


Summary of Audit & Appeals

Auditing Agencies Jurisdictional Scope Process Risk Mitigation Strategies

Recovery Audit Contractors (RAC’s) 4 Regions (A, B, C, D) NE Region A contractor Performant Recovery Paid based on what they recover (bounty hunters)

Confined to investigate only issues identified by CMS with website notice Overpayment issues not kick backs or Stark violations Issues investigated posted to web site Ex: dup claims, radiology and diagnostic testing Can look back 3 years!!

Data mining based on billing activities Post payment review Issue ADR or complex review Denial issued through MAC who recoups with appeal within 30 days; QIC RC in 60 days; ALJ in 60 days; Appeals Council; Federal Court

Know the RAC audit issues on RAC website Audit risk areas Respond promptly to ADRs Appeal

Zone Program Integrity Contractors (zPICS) NE Zone 6 Paid a fixed fee with bonus incentives Agency selected based on data not size

Overpayments and Uncovering fraudulent practices No approval needed to investigate Data analysis of aberrant billing patterns within a homogeneous group using combined sources of data (hospital, SNF claims) Identify the need for a local coverage decision (LMRC)

Prepayment medical review/data analysis - No appeals process!! Post payment audits Unannounced visits and records requests Data mining EXTRAPOLATION authority

Implement Corporate Compliance Program at the level of risk Know your billing profile and practices


Q&A

Questions?


Resources

National Government Services ◦ www.ngsmedicare.com

OIG Workplan ◦ https://oig.hhs.gov/reports-and-publications/workplan/index.asp

RAC Performant Recovery ◦ www.Performantrac.com

zPic (PSC)Safeguard Services ◦ http://www.safeguard-servicesllc.com

Hospice PEPPER Reports ◦ http://pepperresources.org/LinkClick.aspx?fileticket=Gm

n4md7nl3s%3D&tabid=61


https://oig.hhs.gov/reports-and-publications/workplan/index.asp

https://oig.hhs.gov/reports-and-publications/workplan/index.asp

Resources

HMS Healthcare Management Solutions www.hmsabc.com

203-269-4667 Cheryl Leslie, RN, BA, BS, MPH

[email protected] Pam Meliso, JD, MPH

[email protected]


http://www.hmsabc.com/

mailto:[email protected]

mailto:[email protected]

Documents

NE Home Care Conference: Effective & Efficient Preparation ......1 NE Home Care Conference: Effective & Efficient Preparation for Medicare Audits & Appeals Cheryl Leslie, RN, MPH Director