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October 20, 2014
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
CPAs & ADVISORS
Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
M. Aaron Little, CPA
BKD, LLPManaging [email protected]
Patrick Brown, MBA, MS
Penn Home Care & Hospice ServicesChief Financial [email protected]
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Source: Association of Certified Fraud Examiners Report to the Nations on Occupational Fraud and Abuse, 2014 Global Fraud Studyhttp://www.acfe.com/rttn/docs/2014-report-to-nations.pdf
October 20, 2014
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
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Source: OIG home page, June 2014
Source: OIGhttps://oig.hhs.gov/fraud/enforcement/criminal/index.asp#CEA2014060503
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Source: Times-Picayunehttp://www.nola.com/crime/index.ssf/2014/09/7_indicted_in_50_million_for_m.html
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
Source: 2014 OIG Work Planhttp://oig.hhs.gov/reports-and-publications/archives/workplan/2014/Work-Plan-2014.pdf
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OBJECTIVES6
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
OBJECTIVESIdentify key compliance risk areas influencing revenue cycleIdentify key performance metrics for managing a revenue cycle compliance scorecardDescribe key accountability strategies for managing compliance in revenue cycle
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PROGRAM INTEGRITY CONTRACTORS8
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
Revenue cycle risks
Coverage & billing
compliance
Program integrity
People & process
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Care Documentation
Claims Data
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
PROGRAM INTEGRITY11
PROGRAM INTEGRITY12
MACs • Medicare Administrative Contractors
CERTs • Comprehensive Error Rate Testing contractors
RAs • Recovery Auditors (formerly Recovery Audit Contractors)
ZPICs • Zone Program Integrity Contractors
SMRCs • Specialty Medical Review Contractors
MICs • Medicaid Integrity Contractors
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
MACsMedicare Administrative Contractors (MACs)
CMS authorized contractors responsible for claims processing & other administrative functions for designated HH & hospice jurisdictionsTypically conduct program integrity activities through on pre-payment medical review processes
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Source: CGShttp://www.cgsmedicare.com/hhh/medreview/med_review_edits.html
Home health widespread probe edits for HIPPS codes: 1BGP*, 5CHK*, 5CGK*, 5BHK*, 5AHK*, 5BGK*, 5AGK*, 5BFK*, 5AFK*, 2CGL*, & 2BGL*
Source: Palmetto GBAhttp://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%2011%20Home%20Health%20and%20Hospice~Medical%20Review~General~9NNJBX6701?open&navmenu=Medical^Review||||
Source: Palmetto GBAhttp://www.ngsmedicare.com/ngs/portal/ngsmedicare/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOINvIKdHd1MTQwMfC0NDDwdzYLd3N0NjE1MzPQLsh0VAcOG-IU!/
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
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MACsCMS Change Request 8802
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R541PI.pdf
CERTsComprehensive Error Rate Testing (CERT) Program contractors
Program established by Centers for Medicare & Medicare Services (CMS) to monitor accuracy of Medicare claim payment
Identify errors & assesses error ratesEvaluate performance of MACs
Randomly select statistical sample of paid claims to determine whether claims were paid properly
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
RAsRecovery Auditors (RAs)
Review claims on post-payment basis to identify improper payments
Three years from date claim paid‘Issues’ published & approved by CMS
Contractors paid fee percent of amount recoveredFifth RA being created for to HH, hospice, & durable medical equipment
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ZPICsZone Program Integrity Contractors (ZPICs)
Identify cases of suspected fraud, investigate, & take action to ensure any inappropriate Medicare payments are recouped
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
ZPICs
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Fraud includesBilling for services not furnishedBilling appearing to be deliberate for duplicate paymentAltering claims or medical records to obtain higher paymentSoliciting, offering, or receiving kickbacks or rebates for patient referralsBilling non-covered or non-chargeable services as covered
Actions may includeInvestigating potential fraud & abuseMedical review, typically on post-pay basisData analysisPayment suspensionsPrepayment or auto-denial editsReferring cases to law enforcement for civil or criminal prosecution
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
SMRCsSupplemental Medical Review Contractors (SMRCs)
Contract awarded by CMS in October 2012 to StrategicHealthSolutions (SHS)
Contract covers specialty review for nationPost-payment review determined based on data analysis
Medicare Part A, Part B & DMESHS currently conducting review of Medicare HH compliance with physician face-to-face encounter documentation requirements
Includes all Medicare certified HH agencies
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MICsMedicaid Integrity Contractors (MICs)
Entities with which CMS has contracted to conduct post-payment audits of Medicaid providersGoal is to identify overpayments & decrease inappropriate payments
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
UPICsUnified Program Integrity Contractor (UPIC)
New contractor…coming soon…that consolidates ZPIC & MIC activitiesTo predict, detect, prevent & deter fraud, waste & abuse in Medicare & Medicaid programs
By consolidating Medicare & Medicaid program integrity activitiesSharing & coordinating information among Medicare & Medicaid partnersEmphasizing timely administrative actionsStrengthening data matching across programs to expand view of provider billing patterns
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KEY PERFORMANCE METRICS24
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
OVERVIEW
o Documentation & Billingo Referral Processo Homebound Statuso Plan of Care (CMS Form 485)o Face to Face Encountero Progress Noteso Medical Necessityo Therapy Reassessmento Aide Supervisory Visit o Coding & Documentationo Additional Information
REFERRAL/ADMISSION SCORECARD• Scorecard reviews on a monthly basis the percentage of
patients with an identified Face to Face Physician.• Intake process documents whether the patient has a Face to Face encounter; if not, this
is the trigger for the alert to the clinical team to ensure that the patient has a scheduled follow up visit.
• Scorecard documents percentage of Patient Consents returned within Seven Days.
• Business Staff sends a weekly report with missing consents listed; project reduced write offs for lack of consent by $25K in past fiscal year.
• Scorecard details the percentage of 485s where the Physician on 485 matches the MD listed in the Referral documentation.
• Any subsequent change to the MD on the 485 may necessitate a countersignature for the Face to Face.
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
ACTIVE PATIENT SCORECARD• Scorecard details percentage of physician orders returned
signed within Thirty Days.• Report designed to ensure compliance with State regulation; report details the number
of days to send both returned and unreturned orders.
• Scorecard reviews number of unlocked visits on a weekly basis.
• Scorecard documents number of patients without activity in past seven days.
• Documentation designed to ensure that clinical staff discharge patients when care is completed and that caseloads are accurate.
• Scorecard details the number of unsent orders by team.• Report designed to ensure that clinical staff complete documentation for any interim
orders-this allows for timely delivery of services, as the interim order is the trigger for staff scheduling.
BILLING SCORECARD• Scorecard reviews the percentage of clean claims.
• This measure is intended to break down the silos between the departments and identify barriers to billing .
• Scorecard documents days to lock OASIS.• Measurement is a proxy for days to RAP.
• Scorecard details days to Final Claim.• Scorecard details audit of patient paper chart.
• Audit to confirm patient consent, all signed orders and all Home Health Aide Plans of Care are present in the chart.
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
HOSPICE SCORECARD• Scorecard documenting percentage of Patient Consents
returned within Seven Days includes Hospice patients.• Plan is to add component that measures compliance with
Notice of Election submission requirement.
Other Measurements:• Daily Report regarding patients in Hospice Inpatient Unit with
length of stay greater than five days.• Ongoing audit of patients in third or more certification period
regarding eligibility:• Although the patient’s clinical condition upon admission to hospice may have
supported the trajectory of decline to be six months or less, it is important to ensure the documentation for patients with long lengths of stay clearly supports an ongoing trajectory of decline versus a chronic stable patient with significant custodial care needs whose trajectory has plateaued.”
PEOPLE AND PROCESS 30
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
Department of Justice HEAT Settlement:
Agency allegedly billed Medicare for nursing and therapy services that were medically unnecessary or provided to patients who were not homebound, and otherwise misrepresented patients’ conditions to increase its Medicare payments. These billing violations were the alleged result of management pressure on nurses and therapists to provide care based on the financial benefits to Agency, rather than the needs of patients.http://www.justice.gov/opa/pr/amedisys-home-health-companies-agree-pay-150-million-resolve-false-claims-act-allegations
COMPLIANCE ORIENTATION
Information Line 215-349-5423
Reporting (Confidential) 215-349-5422
Email [email protected]
Website http://uphsxnet.uphs.upenn.edu/billcomp/
General Counsel 215-746-5200
Reporting & Help Line UPENN Institutional Compliance 215-P-Comply (215-726-6759)
Privacy Questions/Concerns: UPHS Privacy Officer
(215) 662-6232 Each Entity also has a designated Entity Privacy Officer. UPHS Privacy Policies can be found at:
http://uphsxnet.uphs.upenn.edu/policy/hup/admin/admin_catg_medctr.html#admin_hipaa
Security, data breach, laptop thefts, etc. Mike Moran, UPHS Dir. of IT Security
(215) 615-0643
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
CMS TRAINING MATERIALS• Medicare Parts C & D Fraud, Waste, and Abuse Training and
General Compliance• Available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/ProviderCompliance.html• The training module covers both Fraud/Waste/Abuse and General Compliance Training.• Completion of this or comparable program required by one of our contracted Medicare
Advantage Programs
RISK MANAGEMENT34
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
Foster a culture of compliance
Identify at risk areas
Maintain concurrent focused compliance monitoring processes
Maintain objective & accountable tracking systems
Periodically test compliance processes
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Periodically test compliance processes• Define sample
• Time period• Number of claims
• Select random or targeted sample• Gather source documentation• Conduct review
• Paid claim to documentation• Document, track & trend findings• Report results• Act on results
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• Validate physician face-to-face encounter documentation
• Re-score OASIS & validate HIPPS code billed & paid
• Verify all visits billed on claim are supported by documentation
• Verify all visits were performed within physician ordered frequencies
• Verify claim was submitted after receipt of all signed orders
• Review claim coding• Diagnosis & HCPCS
codes, physician information, etc.
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
CHART AUDIT SCORECARD• Chart Audit Focuses on Four Key Elements:
• ICD Coding• Homebound Status, Medical Necessity• Therapy Reassessment• Home Health Aide Supervisory Visits
• Chart Audits selected for patients with Five to Seven visits (LUPA Avoidance population), patients with Fourteen or More therapy visits (High Therapy Population), and patients with six or more Home Health Aide visits (HHA population).
• Chart audits separate from Medical Record review.
CODING COMPLIANCE
• Vendor Audit to Ensure compliance with ICD-9:• Verify following coding guidelines when assigning primary
(OASIS M1020) and secondary diagnoses (OASIS M1022) • Review Sequencing requirements
• List secondary diagnoses in the order which best reflects the seriousness of the patient’s condition
• Coding Documents:• Diagnoses that are unresolved• Relevant medical diagnoses• Diagnoses supported by the patient’s medical record
documentation
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
HOMEBOUND STATUS/MEDICAL NECESSITY
• Review progress notes for documentation of homebound status and medical necessity:• Ensure that the Intake/Admission documentation details
patient need for service• Review gaps in service• Confirm skilled service in last visit(s)• Macro-look
• Is episode appropriate for Medicare coverage
• Micro-look• Does documentation of each visit support reasonable and
necessary medical necessity
THERAPY REASSESSMENT• Performed to ensure therapy services are effective,
required at defined points during a course of treatment, for each therapy discipline for which services are provided
• Medicare Benefits Policy Manual Chapter 7 Section 40.2
• Must include:• Date of functional reassessment
• Patient’s functional measurement with comparison to prior assessment
• Effectiveness of therapy, or lack thereof
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
LESSONS LEARNED• Ensure that you are:
• Timely in performance of reassessments
• Aware of reassessment due dates– If services are outsourced,
provide this information to the covering therapist(s)
• Compliant by: – Reviewing your progress note
to confirm that it is complete and addresses the CMS documentation requirements
AIDE SUPERVISION REQUIREMENTS
• Supervisory onsite visits:o When patient is receiving skilled services:
• Must be performed at least every 2 weeks by RN and aide does not need to be present
• If patient is not receiving nursing care but is receiving home therapy, then the appropriate therapist performs the supervisory visit
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
UNFAVORABLE AUDIT FINDINGSIntake referral:• Lacks detail regarding: Point of referral Patient current condition Current HC needs Homebound status
• Progress notes:• Incomplete notes
– Computer syncing• Frequent cut / paste• Template statements
– Lacks patient specific detail
SUMMARY46
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
Failure of process, personnel or
product?
Non-compliant documentation
received
Documentation accepted into
software system/medical
record
Pre-billing compliance
audit completed
Claim billed & paid
‘Compliance audit’
completed
Compliance error identified
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SUMMARYIdentify key compliance risk areas influencing your agency’s revenue cycleIdentify key performance metrics for managing your agency’s revenue cycle compliance scorecardDescribe key accountability strategies for managing compliance in your agency’srevenue cycle
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Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
QUESTIONS49
CPAs & ADVISORS
Session 303How to Use Scorecards to Manage Revenue Cycle Compliance
M. Aaron Little, CPA
BKD, LLPManaging [email protected]
Patrick Brown, MBA, MS
Penn Home Care & Hospice ServicesChief Financial [email protected]
