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RELEVENT REIMBURSMENT
CONCERNS
Presented By :The Division of Socioeconomic
Affairs May 23rd. 2010
Socioeconomic Affairs Staff
• Yolanda Doss, MJ, RHIA, DirectorDivision of Socioeconomic Affairs
• Kavin Williams, CPC, CCPHealth Reimbursement Policy Specialist
• Michele Campbell, CPCCoding & Reimbursement Specialist
Yolanda Doss, MJ, RHIA
Responsibilities include:• Helping to secure reimbursement for
osteopathic services• Securing the acceptance of
osteopathic credentials• Addressing Medicare issues• HIPAA compliance• Fraud and Abuse
Kavin T. Williams, CPC, CCPResponsibilities include:• Assists AOA members with
reimbursement and health payment policies.
• Oversees and assists AOA members with coding and payment disputes with carriers.
• Oversees the AOA Coding and Reimbursement Advisory Panel.
• Represents the AOA at national reimbursement policy meetings.
Michele Campbell, CPC
Responsibilities include:• Assists AOA members with accurate
coding.• Assists AOA members with coding
and payment disputes with carriers.• Medical record reviews.• Coordinates AOA’s responses to
AMA CPT coding requests.
The Objective is to Provide Information
on the Following Topics:• Impacts on 2010 Revenue• Elimination of the Consultation Codes• Evaluation &
Management/Documentation • Medicare Audits• Recovery Audit Contractors (RAC)• “Incident To” Services• Federal Trade Commission’s Red Flag
Rule
2010 Medicare Fee Schedule Update • The 2010 Fee Schedule remains at
the same level as 2009 • Physician Quality Reporting
Initiative (PQRI) Bonus Payment 2%• E-Prescribing Bonus Payment 2%
Consultation Codes
• CMS eliminated the consultation codes 99241-99245 and 99251-99255 effective January 1, 2010
• What does this mean for you?• Make sure you and your staff
understand the difference between a new vs. an established patient
Consultation Codes Updates
• Some specialist will end up billing an established patient when they see a “referral” from a PCP unless the patient was not seen in the last three years by one of their partners. In that case this visit would be a new patient visit.
• In the hospital setting, each physician that sees a patient will bill for an “initial hospital service” or sometimes referred to as an “admission”. This physician (admitting) will need to add modifier-AI, defined as Principal physician of record
Consultations Codes Updates
• We will have to wait and see what the private payers do, but the codes are still valid and are in the CPT book for 2010 with new commentary regarding transfer of care.
• United Healthcare has announced that they will reimburse for the consultation codes for their commercial product.
• The question will be how do you handle a claim where a commercial payer is primary and Medicare is secondary?
Consultation Codes Updates
• RVUs have increased 6% for the outpatient office visit codes 99201-99215
• RVUs have increased 2% for the inpatient initial hospital care codes (aka admissions) 99221-99223 and subsequent care for follow up visits
Evaluation & Management (E/M) Coding
• Coding for office visits• New patient visits, 99201-99205• Established Patient visit, 99211-
99215
Documentation
Rule One:If It Was Not Documented It Was Not
Done!!Rule Two:Documentation Must Be Clear & Legible
Chief Complaint (CC)
• The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factors that is the reason for the encounter, usually stated in the “patient’s own” words.
• Documentation Guidelines states that the medical record should clearly reflect the chief complaint
Medical Necessity
• Payers define “Medical Necessity” as services or supplies that are:
• In accordance with standards of good medical practice
• Consistent with the diagnosis• The most appropriate level of care
provided in the most appropriate setting
Chart Documentation
What Is An Audit?
An effective tool used by Medicare and other payors to recover monies lost to fraud and erroneous billings.
Why Audits Are Initiated?• Suspicion (Billing Pattern)• Outlier Physicians• The Senior Patrol• Whistleblowers• Procedure Codes
Who Are The Auditors?
• The Office of the Inspector General (OIG)
• Medicare• The Department of Justice (DOJ)• The Federal Bureau of Investigation
(FBI)• Carriers
Types of Audits
• Prepayment Audits• Post-Payment Audits• Statistical Sampling Method
What Auditors Look For?
• Billing for services or supplies that were not provided.
• Billing for non-allowable or non-covered services.
• Altering claim forms to receive a higher payment amount.
• Unbundling claims.
How To Respond To A Request For Documentation
• Reply to the audit notice in a timely fashion.
• Gather and submit Only the requested documentation.
• Be cooperative.• You may want to conduct an internal
audit.
How to Respond to the Audit Findings
• If the findings are not favorable:• Attempt to discuss the findings with
the reviewer. • If necessary request
redetermination.• If necessary request a level one
appeal.
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Medicare Recovery Audit
Contractors (RACs)
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RAC Legislation
• The RAC program was created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 which pays incentive fees to third-party auditors that identify and correct improper payments paid to healthcare providers in fee-for-service Medicare.
• The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 also requires permanent and nationwide RAC program by no later than 2010
The RAC Demonstration Project
• The RAC demonstration project to place of New York, Florida, and California.
• By 2010 the RAC will cover all 50 states.
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RAC Program Mission
• To detect and correct past improper payments,
• To implement actions that will prevent future improper payments.
•Providers can avoid submitting claims that don’t comply with Medicare rules
•CMS can lower its error rate•Taxpayers & future Medicare beneficiaries are protected
The New RAC’s Are:• Diversified Collection Services, Inc. of Livermore,
California, in Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.
• CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B, initially working in Michigan, Indiana and Minnesota.
• Connolly Consulting Associates, Inc. of Wilton, Connecticut, in Region C, initially working in South Carolina, Florida, Colorado and New Mexico.
• HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.
Additional states will be added to each RAC region in 2009
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Timeframes
D
C
B
A
March 1, 2009 March 1, 2009 March 1, 2009
March 1, 2009 March 1, 2009 March 1, 2009
August 1, 2009 August 1, 2009 August 1, 2009
Provider Outreach Claims Available for Analysis Earliest Correspondence
*RACs may not begin reviewing until there is provider outreach in
the state
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Minimize Provider Burden
• Limit the RAC “look back period” to three years• Maximum look back date is October
1, 2007 • RACs will accept imaged medical
records on CD/DVD • Limit the number of medical record
requests
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Medical Record Limit Example
• Outpatient Hospital • 360,000 Medicare paid services in 2007 • Divided by 12 = average 30,000
Medicare paid services per month • x .01 = 300• Limit = 200 records/45 days (hit the
max)
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Summary of Medical Record Limits (for FY 2009)
• Inpatient Hospital, IRF, SNF, Hospice• 10% of the average monthly
Medicare claims (max 200) per 45 days per NPI
• Other Part A Billers (HH)• 1% of the average monthly Medicare
episodes of care (max 200) per 45 days per NPI
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Summary of Medical Record Limits (for FY 2009) Continued
• Physicians (including podiatrists, chiropractors)
• Sole Practitioner: 10 medical records per 45 days per NPI• Partnership 2-5 individuals: 20 medical records per 45 days
per NPI• Group 6-15 individuals: 30 medical records per 45 days per
NPI• Large Group 16+ individuals: 50 medical records per 45
days per NPI
• Other Part B Billers (DME, Lab, Outpatient hospitals)
• 1% of the average monthly Medicare services (max 200) per NPI per 45 days
RAC Validation Contractor (RVC)
• CMS has contracted with Provider Resources, Inc. of Erie, PA, to work as the Recovery Audit Contractor (RAC) Validation Contractor.
• The RAC Validation Contractor (RVC) will work with CMS and the RAC to approve new issues the RACs want to pursue for improper payments, as well as perform accuracy reviews on a sample of randomly selected claims on which the RACs have already collected overpayment.
• The RVC is another tool CMS will use to provide additional oversight and ensure that the RACs are making accurate claim determinations in the permanent program.
For Additional Information on RAC
• http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6125.pdf
• http://www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf
• http://www.cms.hhs.gov/rac/
Medicare “Incident to” Physician Services
The OIG reviews Medicare services that are “incident to” physicians services to determine the qualifications and appropriateness of the staff who performed them.
Physician Defined The “physician” refers to physician or other practitioner (listed below), who are authorized to receive payment for services “incident to” his or her own services.
• physician assistants• nurse practitioners• clinical nurse specialist• nurse midwife, and• clinical psychologist
Professional Service
• A direct, personal, professional service which is rendered by the physician
• To meet the “incident to” guidelines, the physician must initiate the course of treatment, and
• Conduct subsequent physician services to show ongoing involvement
Coverage Requirements
To be covered, service and supplies must be:
• An integral, though incidental, part of the physician’s or on-physician practitioner’s professional services
• Commonly furnished in a physician’s office or clinic
• Furnished by the practitioner or auxiliary personnel under the physician’s direct supervision
Supervision Requirements Direct physician supervision of auxiliary personnel is required.
Auxiliary personnel:•any individual (employee, leased employee, or independent contractor) who is acting under the supervision of a physician
•Auxiliary personnel include nurses, medical assistants, technicians, etc.
Direct Supervision in the Office
• Physician must be present in the office suite
• Physician must be immediately available to assist if needed
• Does not require that the physician be in the same room
Direct Supervision in the Office Continued
Scenarios that do not meet the direct supervision requirement: • Availability of a physician by telephone• Physician presence somewhere in an institution
Documentation
To support the use of the incident to provision, the documentation should clearly indicate: • Who performed the “Incident to” service• The physician’s presence in the office suite during the service/procedure
Federal Trade Commission (FTC)“Red Flag” Rule
As many as nine million Americans have their identities stolen each year. Identity thieves may drain their accounts, damage their credit, and even endanger their medical treatment. The cost to businesses left with unpaid bills racked up by scam artists can be staggering.
Federal Trade Commission (FTC)“Red Flag Rule” Continued
The “Red Flags” Rule, requires many businesses and organizations to implement a written Identity Theft Program designed to detect the warning signs-or “red flags”- of identity theft in their day-to-day operations, take steps to prevent the crime, and mitigate the damages it inflicts.
The Red Flags Rule: An OverviewThe Red Flags Rule sets out how certain businesses and organizations must develop, implement, and administer their Identity Theft Prevention Programs. Your Program must include four basis elements, which together create a framework to address the threat of identity thief.
First,• Your program must include reasonable
policies and procedures to identify the “red flags” of identify theft you may run across in the day-to-day operation of your business.
• Red flags are suspicious patterns or practices, or specific activities, that indicate the possibility of identify theft.
• For example, if a new patient arrives at your office and you request the insurance cards along with identification and the ID looks like it might be fake would be a “red flag” for your practice.
Second,
• Your program must be designed to detect the red flags you’ve identified.
• For example, if you’ve identified fake IDs as a red flag, you must have procedures in place to detect possible fake, forged, or altered identification.
Third,
• Your program must spell out appropriate actions you’ll take when you detect red flags
Lastly,
• Because identity theft is an ever-changing threat, you must address how you will re-evaluate your program periodically to reflect new risks from this crime.
• The Red Flags Rule gives you the flexibility to design a program appropriate for your practice, its size and potential risks of identify theft.
Who Must Comply With The Red Flags Rule?
• Financial Institutions• Creditors• Covered Accounts• The determination of whether a
business or organization is covered by the Red Flags Rule isn’t based on the industry or sector, but rather on whether the activities of the business fall within the relevant definition.
Financial Institution: The Red Flags Rule defines a “financial institution” as a state or national bank, a state or federal savings and loan association, a mutual savings bank, a sate or federal credit union, or any other person that, directly or indirectly, hold a transaction account belonging to a consumer.
Creditor:• According to the final rule, a creditor is “any
person who regularly extends, renews, or continues credit; any person who regularly arranges for the extension, renewal of continuation of credit; or any assignee of an original creditor who participates in the decision to extend, renew or continue credit.”
• The FTC has taken the position that physicians are creditors, if they do not require full payment upfront at the time they see patients, but bill patients after the services are rendered.
Covered Accounts:
• Once you have concluded that your business or organization is a financial institution or creditor, you must determine if you have any covered accounts.
Covered Account Continued:• Two categories of accounts are covered:• The first is a consumer account you offer
your customers that’s primarily for personal, family, or households purposes that involves or is designed to permit multiple payments or transactions
• The second kind of “covered account” is any other account that a financial institution or creditor offer or maintains for which there is a reasonable foreseeable risk to customers or to the safety and soundness of the financial institution or creditor from identify theft
How To Comply
• Identify relevant red flags• Detect red flags• Prevent and mitigate identify
theft• Update your program
Identify Relevant Red Flags• What are “Red Flags”?. They’re
the potential patters, practices, or specific activities indicating the possibility of indentify theft
Identify Relevant Red Flags Continued
• Consider the following when identifying relevant red flags:
• Risk Factors• Sources of Red Flags• Categories of Common Red Flags
Detect Red Flags
Once you’ve identified the red flags of indentify for your business, it time to lay out procedures for detecting them in your day-to-day operations. Sometimes using identity verification and authentication is taking place in person or at a distance – say, by telephone, mail, internet, or wireless system
Prevent and Mitigate Identify Theft
When you spot a red flag, be prepared to respond appropriately. Your respond will depend upon the degree of risk posed. In determining your response, consider whether any aggravating factors heighten the risk of identify theft.
Update The Program
The rule recognizes that new red flags emerge as technology changes or identity thieves change their tactics. Therefore, it requires periodic updates to your program to ensure that it keeps current with identity theft risks.
Red Flag Rule Resources• Fighting Fraud with the Red Flag
Rules http://ftc.gov/redflagsrule
Division Website
• Go to www.do-online.org and sign onto DO-Online. • First time users will need their AOA
member number to sign up.• On DO-Online, click on Practice
Management for the division website.• There is also a Division email address:
What the DO-Online Practice Management Website has for
You• Billing and Coding• E/M documentation• ICD-9-CM code
updates• OMT information• Legal• Litigation fund• Updates on class
action suits
• CMS/Medicare• Links to local carrier
information• Information on each
CPT code• Enrollment information• CMS Medlearn• CCI link• Fee schedules, new and
prior
What the DO-Online Practice Management Website has for You
• Preventive health services
• Demonstration projects
• CERT- fraud and abuse information
• HIPPA• Managed care• Osteopathic
Advocacy Resources
Division CME Seminars
• Conducted in conjunction with state associations and specialty colleges.
• Seminars available include Medicare Compliance, HIPAA Privacy Compliance, and Documentation Guidelines and Coding Reimbursement.
• Call Yolanda Doss, MJ, RHIA at 800-621-1773 ext. 8187 or [email protected] for info.
My Contact Information
• Kavin T. Williams, CPC, CCP, Health Reimbursement Policy Specialist
1-800-621-1773 X 8194 Toll Free1-312-202-8194 Direct
