New England HC-HANDOUTS SEIDMAN Billing Compliance ......Robin N. Seidman, RN, BSN, MSN, MBA, LNCC, HCS-D Director, Compliance Consulting Division Simione Consultants, LLC 1 ... •

Billing Compliance Essentials: Strategies to Minimize Reimbursement Risk

New England Home Care Conference Trade Show

May 2011

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BILLING COMPLIANCEESSENTIALS:

Strategies to Minimize Reimbursement Risk

Presented by:Robin N. Seidman, RN, BSN, MSN, MBA, LNCC, HCS-D

Director, Compliance Consulting DivisionSimione Consultants, LLC 1

Billing Compliance Essentials

• Be Aware of the Regulatory Trends &Be Aware of the Regulatory Trends & Government Activities

• Know the Compliance Risk Areas

• Know the Regulations & where to find them

• Identify and Recognize Your Agency’sIdentify and Recognize Your Agency s Compliance Pitfalls

• Have & USE a Compliance Program

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May 2011

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Regulatory Trends

HEALTHCARE REFORM • Focus on Fraud & Abuse• Focus on Fraud & Abuse

• Patient Protection and Affordable Care Act• Joint efforts to expand combating fraud, waste & abuse

– Health Care Fraud Prevention & Enforcement Action Team (HEAT)

C bi t DOJ & HHS• Cabinet DOJ & HHS

– Increase of Oversight and Resources• MACs, MICs, RACs, ZPICs, HEAT

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Regulatory Trends

TECHNOLOGY – more data…..

• Real-time data access (HEAT)

• Automated Reviews (RACs)

• Data Mining – all Medical Review

– Measurable data

• Coding-Diagnosis, OASIS

• Utilization

– Benchmarks

• Outcome Reporting

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May 2011

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Government Activities

• Recent Investigations (OIG)– OIG Reportsp

– Corporate Integrity Agreements

• The “Enforcers” (RACs, MACs, PSCs / ZPICs)

• Annual OIG Work Plan– http://oig.hhs.gov/publications/workplan/2011/WP01-

M di A B dfMedicare_A+B.pdf

• Visit your MAC/RHHI Website

– Visit www.ngsmedicare.com for up to date information.

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Recent Investigations

• US Senate Committee on Finance (5/13/10)

I ti ti ft d t t HHA– Investigation after data suggests HHA intentionally increased visit frequency to trigger higher reimbursement rates.

– 4 Agencies: Almost Family, Amedisys, Gentiva Health Services and LHC Group

• TherapyTherapy• Physician Care Plan Oversight• Survey Deficiencies• Hospice – Nursing Facilities

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May 2011

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CIAs

• OIG Corporate Integrity Agreementsh // i hh /f d/ i / i li– http://oig.hhs.gov/fraud/cia/cia_list.asp

• Result of “Whistleblowers”– Admission of ineligible patients– Billing without supporting documentation– Backdating &/or alteration of documentationg– Offering free goods & services

• 5 years + IRO + payback

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2011 OIG WORK PLAN - HH

• Home Health Agency Profitability TrendsReview Cost Reports to determine whether payment– Review Cost Reports to determine whether payment methodology should be adjusted.

• HHRG & OASIS Data Accuracy– Examine episodes from 2008 for claims meeting

Medicare billing criteria including homebound status d l f iand plan of care requirements.

– Review CMS’s process for ensuring HHAs submit accurate and complete data.

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May 2011

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2011 OIG WORK PLAN - HH

• Payment Controls– Examine billing Utilization Trends

L i f S i # f l i• Location of Service, # of claims,

# visits, ownership info.

• Part B Payments– Examine adequacy of controls to prevent inappropriate

payments to outside suppliers for services & medical supplies included in HHA PPS payment

• Enrollment– Determine if program integrity efforts identify

questionable HHA applicants9

2011 OIG WORK PLAN - Hospice

• Focus on Hospice and Nursing Facilities– OIG recent report: 82% hospice claims for patients in

NF did t t M di i tNF did not meet Medicare coverage requirements

• Hospice Utilization in Nursing Facilities– Examine characteristics of nursing facilities with high

utilization patterns of Medicare hospice care.

• Services Provided to Hospice Beneficiaries pResiding in Nursing Facilities– Review services provided by hospices to patients in

nursing facilities (CoPs 42 CFR part 418)

• Services by Hospice Aides• Plans of Care 10



May 2011

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RACS

• Recovery Audit Contractors– Diversified Collection Services (DCS) Healthcare ( )

Services of Livermore, CA in Region A consists of the following states: CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, & VT.

• Paid on contingency basis (9-12%)

M t t i d t i• Must get issues approved to review:– Active: Region D – 2 hospice related issues

• DME while in hospice

• Hospice related services (Medicare A&B)11

RACS• RACs review claims on a post-payment basis • Two types of review:

– Automated (no medical record needed)– Complex (medical record required)

• RACs will not be able to review claims paid prior to October 1, 2007 – RACs will be able to look back 3 yrs date claim

paidpaid • Record Request:

– Hospice: 10% (max 200 to reach max – 2000 claims/mo)

– Can NOT review claims already under scrutiny

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May 2011

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ZPICS

• Zone Program Integrity ContractorsC lid i f PSC– Consolidation of PSCs

– Perform pre & post audit reviews with ability to refer to law enforcement entities• e.g. OIG, DOJ, CMS, State AgenciesAgencies

• Refer quality issues to QIOs– Use of claim sampling & extrapolation

MACS - Medical Review

• MAC / National Government Services– Additional Development Requests (ADRs)

– Probe audits• Provider specific• Widespread

– Target Medical Review • >10% payment error rate

CERT A dit• CERT Audits– CMS Independent Contractor – not part of Palmetto

– Processed claims – test error rate of FI

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May 2011

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BILLING COMPLIANCE STRATEGIESSTRATEGIES

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Take Advantage of Technology

• FISS is a process that allows remote users online connectivity to the Fiscal Intermediary S d d S ( SS) i f dStandard System (FISS), or mainframe, used by RHHI to process Medicare claims.

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May 2011

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Through FISS you can...

• Enter UB92 claims • View check number date &• Enter UB92 claims

• Correct electronic claims

• Correct paper claims

• Track all claims through the processing system

A th C

• View check number, date, & amount of your last 3 payments

• Review files for inquiry purposes, i.e. diagnosis codes, revenue codes

• Access the Common Working File (CWF) through HIQH (Health Insurance Query for HHAs

• View claims selected for additional review & information requests

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May 2011

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Claims Summary Inquiry

• Weekly check of the Claims Summary Inquiry screenq y– Displays specific claim history information for

all pending and processed claims.

– Check for claims in pending status:Return to Provider (RTP)

Medicare Secondary Payer (MSP)Medicare Secondary Payer (MSP)

Medical Review claims

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Additional Development Request (ADR)

• Definition: a billing transaction that fails a medical review edit while processing in FISSBill d t S/LOC SB6001• Bill suspends to S/LOC SB6001

• Documentation requested to support services billed• Medicare medical review nurse will review

documentation to make payment determination.• Print ADR letter and forward to the clinical

department per your agency proceduresdepartment per your agency procedures.• Documentation must be submitted within 45 days or

the bill is automatically denied.• Check for ADR requests at least weekly

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May 2011

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COMPLIANCE ESSENTIAL:Responding to ADRs…..

• Define process:– Identify ADRs

– Assign responsibilities

– Timelines

– Review

– Write summary of key points to support claimWrite summary of key points to support claim

– Return receipt

– Accountability and reporting (trend data)

– Action Plan21

Adjusting Medically Denied Services

• “It is never appropriate to adjust denied i l f ll i llservices or cancel a fully or partially

(downcoded) denied claim and resubmit that claim for payment. These activities could be viewed as an attempt to circumvent the formal appeal process or manipulate denial statistics and could be considered fraudulent.”

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May 2011

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COMPLIANCE ESSENTIAL:What to Do…..

• MONITOR & AUDIT:K h i i– Know where previous improper

payments have been found

– Know if you are submitting claims

with improper payments

• Know the Documentation Requirementsq

• Prepare to respond to medical record requests– Automated tracking system

– Multiple government agencies

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FOCUS AUDITS

• Government & MAC Focus Areas:– Medical Review “Hot Spots”

• Conduct Routine Pre & Post Billing Audits– Coverage: conditions of payment NOT conditions

of participation (COPs)

– Definitive Billing Risk • “Black & White” or Technical error• Black & White or Technical error

– OASIS HHRG Items that Impact $$• Diagnosis Coding

• Clinical M items (pain, wounds)

• Functional M items (ambulation, bathing)24



May 2011

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The AUDIT TOOL

• Customize Audit Tool− Billing

− Identified problem areas

− Don’t under estimate historical compliance issues

• Collect data specific to the issue &/or “red flags”

• Results:d h− Trend the Data

− Action Plan and Follow-Up

• Avoid this Mistake: Don’t collect ALL data in one big audit tool

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MAC Focus Areas: Home Health

• Utilization– High therapyg t e apy– 5-7 visit episodes– Outliers (DM, Wounds)

• Medical Necessity– Re-Certs, Long Length of Stay (LLOS)

• Homebound Status*– ZPICs – “big bang for the review buck”

• Diagnosis– HTN, Cardiac, Parkinson’s, Dementia

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May 2011

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Top Home Health Claim Denials

• Medical Review Down-Code

• Lack of response to ADR

• Documentation does not support medical necessity

• Denials related to Physician Orders– POC/Verbal Orders not signed and/or dated timely

– No physician orders for services provided

– Incomplete Orders• Discipline, Frequency/Duration, Treatment, PRN

• Homebound status27

MAC Focus Areas: Hospice

• Eligibility– Admission & Re-Cert (LLOS)

• Terminal diagnosis– Non-cancer diagnoses– Ill-defined diagnoses (AFTT,

Debility)

• Location & Level of CareLocation & Level of Care– Nursing Home– Inpatient care (GIP)– Continuous Home Care (CHC)

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May 2011

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Top Hospice Claim Denials

• Documentation does not support Six-month terminal prognosis

• Missing/Incomplete/Untimely physician certification or recertification

• Missing/Incomplete/Untimely Notice of Election

• Reduced Level of Care

• No response to ADRs

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GBILLING COMPLIANCE

ESSENTIAL

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May 2011

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HAVE A PLAN…..

• Establish a Compliance Plan & USE IT

• Implement 7 Fundamental Elements

• Need to coordinate your P & P with appropriate training & educational programs

• Identify All Risk Areas:– Clinical, Billing, Financial, Administrative,

HR• Home Health: 31 OIG Risk Areas

• Hospice: 29 OIG Risk Areas

* Refer to Handouts 31

OIG Billing Risk Areas

• Claim Development and Submission PProcess– MOST FREQUENT RECOVERIES

• Many have resulted in CIAs in addition to paying $$$$.

• MUST have a process in place for reviewing basic billing requirements– Pre-and-Post Submission Reviews

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May 2011

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Use Your Compliance Plan

• Establish Strong gCorporate Culture

• Support the culture

• Provide Checks & BalancesBalances

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May 2011

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Corporate Culture

• Code of Conduct– Verbal/Written expression of your

organizational culture

• Education and Buy-in of Board & Top Management– PoliciesPolicies

– Responsibilities

• The message needs to be clear:“Do the Right Thing”

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Systems to Support Culture

• Adequate Staffing– Oversight of case management– Avoid the desire to cut corners

• TOOLS to do the job efficiently• Documented Procedures

– Train to a procedure

• On-going EducationOn going Education– Training on new regulations– Re-training on existing regulations

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May 2011

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Checks & Balances

• Data Analysis– Monitor trends

– Utilize accepted benchmarks for “early warning”

• Internal Audits– Clinical record review

– Cross departmental audit

• Employee Reporting– Open lines of communication

• Supervision

• Exit Interviews 37

THANK YOU!THANK YOU!

Contact Information:[email protected]

1-800-653-4043 38

Documents

New England HC-HANDOUTS SEIDMAN Billing Compliance ......Robin N. Seidman, RN, BSN, MSN, MBA, LNCC, HCS-D Director, Compliance Consulting Division Simione Consultants, LLC 1 ... •