4/20/2015. NE Home Care & Hospice Conference: Strategic Preparation for Medicare Audits & Appeals. Today s Objectives. Background

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1 NE Home Care & Hospice Conference: Strategic Preparation for Medicare Audits & Appeals Cheryl Leslie, RN, MPH Director of Consulting Services Pamela Meliso, JD, MPH Director of Consulting Services Today s Objectives 1. Understand Department of Health & Human Services audit types from CMS and OIG for Home Health Agencies and Hospices; jurisdiction; and audit protocols 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 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 1

2 Audit Agencies & 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, 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 Inspector General (OIG) Protects the integrity of HHS programs as well as the health & welfare of program beneficiaries Detects & prevents fraud, waste & abuse 2015 Work Plan includes review of: PPS requirements; HHA employment of individuals with criminal convictions; Hospice in assisted living facilities Hospice use of general inpatient care. 2

3 Recovery Audit Contractors (RACs) Region A RAC is Performant Recovery Strategic Health Solutions also doing RAC audits as a supplemental medical review contractor (SMRC) Issues under review limited to those listed on web site LOS, no skilled service, outpatient therapy > cap SMRC- F2F 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 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 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 3

4 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 41 st 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 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 Appeal Process: ALJ Hearing Providers must file a request for ALJ hearing within 60 days of the Reconsideration decision AIC must be met ($ ) 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 Currently 2 year delay assigning appeals to ALJ (lawsuit pending) 4

5 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 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 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 5

6 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, 3 rd 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) 6

7 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 3 rd benefit period, F2F, orders, rehab utilization, G codes) Work as a team (see example of 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 ! 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 7

8 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 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 meritbased arguments Use expert opinions/testimony when appropriate. Nurses and therapists are experts 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 8

9 Summary of Audit & Appeals Summary of Audit & Appeals Questions? 9

10 Resources National Government Services OIG Workplan RAC - Performant Recovery SMRC - Strategic Health Solutions zpic (PSC)Safeguard Services Hospice PEPPER Reports d=61 Office of Medicare Hearings & Appeals The Corridor Group Cheryl Leslie, RN, BA, BS, MPH cleslie@corridorgroup.com Pam Meliso, JD, MPH pmeliso@corridorgroup.com 10