8/9/2018. What s New with Payment-Related Scrutiny? Current CMS Contractor Audit Activity. What is Driving Payment-Related Scrutiny in Hospice?

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1 What s New with Payment-Related Scrutiny? Carrie Cooley, RN, MSN Principal / Chief Executive Officer Weatherbee Resources Current CMS Contractor Audit Activity Targeted Probe and Educate (TPE) Unified Program Integrity Contractors (UPIC) UPIC contractors have unified review privileges (Medicare and Medicaid) Combine and integrate functions previously performed by ZPIC and MIC contractors Hospices are still seeing some ZPIC activity Office of Inspector General (OIG) What is Driving Payment-Related Scrutiny in Hospice? Data Data Data Data Data CMS has very sophisticated data mining capability and sees problematic trends emerge very quickly Example: The OIG has found that Medicare payments for hospice care in ALFs more than doubled in 5 years totaling $2.1 billion (a 119% increase). What led to this increase? 1

2 NEW OIG Report (July 2018) Vulnerabilities in the Medicare Hospice Program Affect Quality Care and Program Integrity: An OIG Portfolio Web address: Hospice Payment Growth OIG Report Findings, cont d 2

3 OIG Findings, cont d OIG Findings, cont d In 2016, a total of 665 hospice only provided the Routine Home Care level of care (i.e., no General Inpatient or Continuous Home Care levels of care were provided). This is an increase of 55% from 2011 when only 429 hospice did so From 2006 to 2016, about 75% of beneficiaries did not receive did not receive a visit from the hospice physician. OIG Findings, cont d 3

4 OIG Findings, cont d Hospices often provide beneficiaries incomplete or inaccurate information about the hospice benefit due to poor Election of Benefits documents. Some election statements do not mention waiving coverage of certain Medicare services; others do not contain required information regarding the palliative versus curative nature of hospice care. OIG Findings, cont d Inappropriate billing by hospices is rampant. In 2012, hospices billed 1/3 of GIP stays inappropriately, costing Medicare $268 million Hospices were more likely to bill inappropriately for GIP care provided in SNFs than GIP provided in other settings For-profit hospices billed 41% of their GIP stays inappropriately; in comparison, nonprofit hospices billed 27% of GIP stays inappropriately OIG Findings, cont d 4

5 OIG Findings, cont d OIG Findings, cont d Vulnerabilities in the Medicare Hospice Program OIG, July 2018 OIG Recommendations 1. Reform payments to reduce the incentive for hospices to target beneficiaries with certain diagnoses and those likely to have long stays. 2. Target certain hospices for review: a. High percentage of ALF b. High percentage of long lengths of stay c. High percentage of certain diagnoses d. High percentage of beneficiaries who rarely receive hospice visits 5

6 OIG Recommendations, cont d 3. Develop and adopt claims-based measures of quality: Average number of visits/services provided How often physician visits are provided How often hospice provides services provided during the weekend 4. Make hospice data publicly available for beneficiaries (i.e., Hospice Compare website) OIG Recommendations, cont d 5. Provide additional information to hospices to educate them about how they compare to their peers (e.g., PEPPER) The OIG has made it abundantly clear it will continue to focus on and target hospices and payments. Targeted Probe and Educate (TPE) 6

7 Targeted Probe and Educate (TPE) What CMS says about TPE: When Medicare claims are submitted accurately, everyone benefits. CMS s TPE program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help. Purpose of TPE TPE is intended to increase accuracy in very specific areas Medicare Administrative Contractors (MACs) will use data analysis to identify: Providers with high claim error rates or unusual billing practices; and Items and services that have high national error rates and are a financial risk to Medicare. Data Analysis and PEPPER PEPPER Problems = likely Payment-Related Scrutiny 7

8 Data Analysis PEPPER Program for Evaluating Payment Patterns Electronic Report PEPPER is created by TMF Quality Institute and is distributed each April PEPPER does not identify the presence of improper payments, but it can be used as a guide for auditing and monitoring efforts PEPPER and Contractors TMF does not provide PEPPER reports to other contractors, although TMF does provide an access database for the First-look Analysis Tool for Hospice Outlier Monitoring (FATHOM) to MACs and Recovery Auditors. FATHOM can be used to product a PEPPER. TPE Process 3 Rounds 8

9 TPE Positive Things! Much better audit strategy than previous ADR process (in theory) Providers have a day window between each audit round to implement compliant changes MACs provide direct education to providers between each round if Charge Denial Rate (CDR) is not acceptable TPE Negative Things TPE (by nature of the data analysis) will focus on vulnerable areas for the hospice provider TPE response is burdensome on providers IDG documentation is slow to change (even with good education) Providers who fail to improve after 3 rounds will be referred to CMS for next steps 9

10 What are the Next Steps after a failed TPE Audit CMS may initiate the following: 100% pre-payment review Extrapolation Referral to a Recovery Auditor (RA) Other action TPE Target Areas and PEPPER Correlation PEPPER Target Areas Target areas are identified based on review of the Medicare Hospice Benefit (MHB), analysis of claims data, and coordination with CMS subject matter experts. Claims-based: Summarize statistics for episodes of service. Service-based: Summarize services to beneficiaries. 10

11 PEPPER Target Areas, cont d Live Discharges Not Terminally Ill Live Discharges Revocations Live Discharges LOS Days Long Length of Stay CHC in Assisted Living Facility RHC in Assisted Living Facility RHC in Nursing Facility RHC in Skilled Nursing Facility PEPPER Target Areas, cont d Claims with Single Diagnosis Coded Episodes with no GIP or CHC Long GIP Stays Based on what we are seeing at Weatherbee, TPE Audits are largely driven by hospice providers whose PEPPER Target Areas are at or above the 80 th Percentile when compared by jurisdiction, state, or nationally. TPE Audits and Results Many hospices are currently under TPE Audits that began in early 2018 The focus of the TPE audits is in direct correlation with hospice providers aberrant data (often identified on the PEPPER Report) Results vary, but we have seen only a few providers fair well in TPE round 1. MAC education is helpful, but changing staff documentation is difficult. 11

12 Current TPE Focus Areas Patients with non-cancer diagnosis who reside in a long-term care facility or a skilled nursing facility (location codes Q5003 and Q5004) Long length of stay patients Hospices with a high provision rate of the General Inpatient (GIP) level of care Hospices with a high rate of Alzheimer s disease and non-specific dementia diagnoses Response to Payment Related Scrutiny TPEs should be taken more seriously than the old ADR process due to the 3-round limit and referral consequence for failure to meet CDR threshold (15-20% estimated) Technical denials can invalidate the entire dates of service under review (e.g., Election of Benefits, Certification / Recertification documentation, Face-to-Face Encounter, etc.) Audit Response Submit all requested documentation for the dates of service under review on time and in an organized manner. If deadline is missed, it is an automatic denial Bates stamp (or number) all pages submitted If sending by mail, request tracking and receipt confirmation Keep an exact copy of all documentation submitted with each TPE request. 12

13 Audit Response, cont d Submit a cover letter with response (can be done by the Hospice or an independent expert) Consider including documentation just prior to or after the dates of service under review to further substantiate clinical eligibility Highlight important items; however, do not alter the clinical record Audit Response, cont d Include scholarly articles, if needed Track all TPE activity (EXCEL works well) and reason(s) for denial Take advantage of the MAC education ask challenging questions, if needed. Educate staff on clinical record deficiencies and how to mitigate going forward Audit Response, cont d Consider incorporating deficiencies or opportunities for improvement into the QAPI program If clinical record remediation is needed, consult legal counsel Make prudent appeal decisions (i.e., it is not recommended to appeal simply because you have the right to do so) 13

14 TPE Claim Denials Unified Program Integrity Contractors (UPIC) and Zone Program Integrity Contractors (ZPIC) ZPIC / UPIC Investigations ZPICs are issued by a Zone Program Integrity Contractor; ZPICs are paid on a contractual basis (approx. $67 million) UPICs are issued by a Unified Program Integrity Contractor; UPICs are paid on a contractual basis These are NEW to Hospice! ZPIC / UPIC perform targeted medical review, not random The purpose of ZPIC/UPIC audits is fraud detection and deterrence 14

15 ZPIC / UPIC Investigations Hospice notified by letter from ZPIC / UPIC or in person by agent Providers generally have 15 to 30 days to provide requested documentation; Both will generally grant a day extension It is advised to engage legal counsel with a ZPIC and UPIC Investigation ZPIC/UPIC Investigations, cont d ZPIC /UPIC audits often include a clinical record review and rigorous data analysis Statistical sampling methodology and extrapolation of damages (example on later slide) ZPIC/UPIC audits are often the result of whistleblower activity or sophisticated data mining ZPIC/UPIC Investigations, cont d Any overpayments are referred to the MAC for payment recoupment (Appeal rights then kick in) Damages can be catastrophic to a provider due to extrapolation, which is why legal counsel is strongly advised with ZPIC/UPIC audits 15

16 Extrapolation Example ABC Hospice ZPIC/UPIC Audit (2018) Look back Period = 5 years ( ) Medicare payment from = $5,000,000 Review of 100 claims (statistically valid sample) Results: 55% of claims did not contain documentation to support a terminal prognosis 55% of $5,000,000 = Overpayment = $2,750,000 * * Does not include penalty multiplier Consequences of a ZPIC/UPIC Audit with Negative Findings Extrapolation of findings Suspension of payment Revocation of Medicare provider number Referral to MAC for recoupment of overpayments (Appeal rights, as outlined in previous slide, kick in) What to do NOW to Mitigate Risk 16

17 Up Your Regulatory Game! Review and improve documentation systems Ensure a robust and real-time QAPI and Compliance Program Review and Improve Documentation Systems Conduct a pre-billing clinical record review on high-risk / high-volume patients (LLOS, noncancer diagnosis patients in a SNF/ALF) PRINT OUT the clinical record (Does the printed version fully demonstrate the patient s clinical eligibility?) Disable all copy/paste or cloning features Review and Improve Documentation Systems, cont d Audit clinical records for patients who received the GIP or CHC to ensure the medical necessity is supported Ensure technical compliance on certification / recertification of terminal illness Ensure eligibility determinations are thoroughly documented by your physicians 17

18 Review and Improve Documentation Systems, cont d Address deficient documentation practices of all IDG members (physicians, nurses, social workers, chaplains, hospice aide, volunteers) Utilize the full pre-billing capabilities of your EMR Implement processes to avoid billing if technical or clinical deficiencies exist during the claim period Ensure a Robust and Real-time QAPI and Compliance Program How does your Compliance Program directly mitigate payment-related scrutiny? How does your hospice close the loop on identified weaknesses / challenges? How does your QAPI program address employee-identified compliance concerns? Are you preventing or creating whistleblowers? Does your Compliance Officer act more like A FIREMAN? SMOKEY THE BEAR? OR 18

19 Act Now Implement a corporate compliance plan ASAP (if you don t already have one) Ensure staff coverage for the CHC level of care GIP ensure 24-hour RN coverage and evaluate the facilities documentation to ensure support for the GIP level of care Learn to read and utilize your hospice s PEPPER report NOW! Take necessary steps to mitigate risk, if present Act Now, cont d Avoid putting undue pressure on hospice staff to increase census to aggressive or unrealistic levels Avoid allowing anyone to overrule/pressure physicians regarding clinical eligibility decisions Don t delay live discharges! Utilize an outside consulting firm to assess your hospice s compliance and act on the findings Act Now, cont d Ensure IDG meetings and processes are robust Avoid allowing hospice physicians to over-rely on hospice staff for eligibility assessments Monitor frequent discharges for hospitalizations and readmissions If you have suspected compliance issues, address them NOW Keep comprehensive documentation of all compliance issues and resolution(s) 19

20 Questions / Answers Carrie Cooley, RN, MSN Principal / CEO Weatherbee Resources (866)

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