Audits & Appeals What you need to know

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Audits & Appeals What you need to know Financial Disclosure The instructor acknowledges a financial interest in the subject matter of this presentation. Kirk A.

Office of Inspector General (OIG) Comprehensive Error Rate Testing (CERT) Recovery Auditors (RA) aka Recovery Audit Contractors (RAC) Medicare Secondary Payer Recovery Contractor (MSPRC) Zone Program

1 Audits & Appeals What you need to know Financial Disclosure The instructor acknowledges a financial interest in the subject matter of this presentation. Kirk A. Mack, COMT, COE, CPC, CPMA Senior Consultant Corcoran Consulting Group Objective Discuss targets for scrutiny Appeal process Case Studies Who s watching? Office of Inspector General (OIG) Comprehensive Error Rate Testing (CERT) Recovery Auditors (RA) aka Recovery Audit Contractors (RAC) Medicare Secondary Payer Recovery Contractor (MSPRC) Zone Program Integrity Contractors (ZPIC) Program Safeguard Contractors (PSC) Who s watching? Supplemental Medical Review Contractor (SMRC)* The SMRC is conducting medical review based on the analysis of national claims data versus data that is limited to a specific jurisdiction as performed by Medicare Administrative Contractors (MACs). Who s watching? Supplemental Medical Review Contractor (SMRC)* Strategic is currently performing medical record review on the following projects: Y2P18 Home Health Agency (HHA) Y2P24 Diabetic Testing Strips Y2P29 Home Health Agencies Y2P33 Electrodiagnostic Testing Y2P34 Clinician Services Y2P39 Inpatient Psychiatric Facility Services Y3P69 Diagnostic Radiology Services

2 Who s watching? Y2P34 Clinician Services The OIG reported that of the 303 clinicians who each furnished more than $3 million of Part B services during CY 2009, MACs and Zone Program Integrity Contractors (ZPICs) identified 104 clinicians (34 percent) for improper payment reviews. As of December 31, 2011, the MACs and ZPICs had completed reviews of 80 of the 104 clinicians and identified $34 million in overpayments. The OIG states the results of these reviews suggest that identifying clinicians who are responsible for high cumulative payments could be a useful means of identifying improper payments. Agenda OIG issues Modifier 25 Drug Inventory DMEPOS RAC issues POS errors New vs Est. patient Global surgery rules CCG s observations HPI attestation Diagnostic Test requirements OIG Strategic Plan Goals 1. Fight Fraud, Waste, and Abuse 2. Promote Quality, Safety, and Value 3. Secure the Future 4. Advance Excellence and Innovation Each goal has a list of 3 to 4 priorities OIG Work Plans ( ) Issue Place of Service errors x x x x x Payment for Drugs x x x x x (Lucentis/Avastin) Office visits in Global x x x x periods DME Claims x x x Ophthalmological Svcs x x x Strategic-Plan pdf Source: OIG work plans (2011, 2012, 2013, 2014, 2015) Recovery Audit Contractors Performant Recovery of Livermore, California, in Region A, working in CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, and VT. CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B, working in MN, WI, MI, OH, IN, IL, KY. Connolly Consulting Associates, Inc. of Wilton, Connecticut, in Region C, working in AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV, and Puerto Rico and U.S. Virgin Islands. HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D, working in AK, AZ, CA, HI, IA, ID, KS, MO, MT, ND, NE, NV, OR, SD, UT, WA, WY, and Guam, American Samoa, Northern Marianas. Source: CMS website Overpayments Collected Underpayments Collected Recovery Audit Program FY 2010 Oct 2009 Sept 2010 FY 2011 Oct 2010 Sept 2011 FY 2012 Oct 2011 Sept 2012 FY 2013 Oct Sept 2013 Total National Program $75.4M $797.4M $2,291.3M $3,656.8M $6.8B $16.9M $141.9M $109.4M $167.2M $435.4M Total Corrections $92.3M $939.3M $2,400.7M $3,823.8M $7.26B Source: CMS Medicare Fee-for Service RAC Program FY 2013

RAC Issue Name: Blepharoplasty Eyelid Lifts Number: A008142013 Description: Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle,

3 RAC Issue Name: Blepharoplasty Eyelid Lifts Number: A Description: Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will denied. Issue Type: Complex Provider: Physician Source: Appeal Process Review occurs RAC or other entity sends Overpayment letter Rebuttal (RAC only) 15 days to notify the RAC Redetermination 120 days to appeal 30 days to stop recoupment Reconsideration 180 days to appeal 60 days to stop recoupment Administrative Law Judge (ALJ) 60 days to appeal Recoupment begins Source: Network-MLN/MLNProducts/downloads/MedicareAppealsprocess.pdf Appeal Process Rebuttal unlikely to stop to the process Under our existing regulations 42 CFR Sections , providers and other suppliers will have 15 days from the date of this demand letter to submit a statement of opportunity to rebuttal. The rebuttal process provides the debtor the opportunity to submit a statement and/or evidence stating why recoupment should not be initiated. The outcome of the rebuttal process could change how or if we recoup. We will review your documentation. Our office will advise you of our decision in 15 days from receipt of your request. However, this is not an appeal of the overpayment determination and it will not delay recoupment before a rebuttal response has been rendered. Appeal Process Redetermination If you disagree with this overpayment decision, you may file an appeal. An appeal is a review performed by people independent of those who have reviewed your claim so far. The first level of appeal is called the redetermination. You must file your request for redetermination within 120 days from the date of this letter. However, if you wish to avoid recoupment from occurring you need to file your request for redetermination within 30 days from the date of this letter as described above. Appeal Process Reconsideration to Qualified Independent Contractor (QIC) If the redetermination decision is 1) unfavorable we can begin to recoup no earlier than the 60 th day from the date of the Medicare redetermination notice (Medicare Appeal Decision Letter), or 2) if the decision is partially favorable we can be begin to recoup no earlier than the 60 th day from the date of the Medicare revised overpayment Notice/Revised Demand Letter. Therefore, it is important to act quickly and decidedly to limit recoupment by requesting a valid and timely reconsideration within 60 days of the appropriate notice/letter. Reference: AHA Regulatory Advisory: The Medicare Appeals Process March 27, 2009

Levels of Appeal Process Days to File Time Limit AIC 1 Redetermination 120 days 60 days $0 Reconsideration 180 days 60 days $0 ALJ 60 days 90 days $150 Department Appeals 60 days 90 days $0 Board

4 Levels of Appeal Process Days to File Time Limit AIC 1 Redetermination 120 days 60 days $0 Reconsideration 180 days 60 days $0 ALJ 60 days 90 days $150 Department Appeals 60 days 90 days $0 Board Federal District Court 60 days NA >$1,460 Level 1 - Redetermination File within 120 days of receipt of initial demand letter. However, to avoid recoupment a provider must file an appeal within 30 days following the initial denial letter. Provider may submit new evidence to support claims. 1 Amount in controversy; ALJ increased $10 from 2013; Federal Court increased $30 from 2014 Source: Grievances/OrgMedFFSAppeals/index.html Level 1 - Redetermination Provider may submit new evidence to support claims Use designated reconsideration form(s) Submit everything to support/defend denied services Chart notes Patient history form(s) Dictated letters Diagnostic tests (i.e., photographs, interpretations) Practice specific abbreviation lists Operative reports Preoperative information Activities of daily living questionnaires Applicable policies, LCDs, CPT, standard of care Level 1 - Redetermination CMS Form Forms/downloads/CMS20027.pdf Level 2 - Reconsideration Filed with Qualified Independent Contractor (QIC) Must be filed within 180 calendar days of receipt of the Redetermination Notice However, in order to extend the stay of recoupment through this level, a provider must file an appeal within 60 calendar days of the date of the Redetermination Decision

Level 2 - Reconsideration Provider may submit new evidence to support claims Use designated redetermination form(s) Request detailed explanation for denials Request source documents used for review

5 Level 2 - Reconsideration Provider may submit new evidence to support claims Use designated redetermination form(s) Request detailed explanation for denials Request source documents used for review (if not provided) LCDs, Policies, Sources, NCCI edits, etc. Challenges with Reconsideration appeal Carefully review each denial the denial may not be for the same reason as the original denial All information from Redetermination should be forwarded to the QIC (assume nothing) send everything needed to appeal remaining claims Be thorough, last chance to submit new information Level 2 - Reconsideration Use designated reconsideration form Only appeal those items not overturned Strengthen rebuttal for each item Review remaining denied claims for outstanding/new issues If necessary include physician affidavits for clarification Level 2 - Reconsideration CMS Form Forms/downloads/cms20033.pdf Level 3 Administrative Law Judge ( ALJ ) Claim must meet established threshold for 2014 = $ Filed within 60 calendar days from date of receipt of the QIC s reconsideration decision. ALJ has 90 calendar days of receipt of the request for a hearing to render a decision. There are a host of reasons that the ALJ s 90-day deadline may be extended. They will contact you to discuss your options Conference call or Video conference call Level 3 Administrative Law Judge ( ALJ ) Form Request for Medicare Hearing by an ALJ Forms/Downloads/CMS20034AB.pdf

Case #1 Following a RAC review of 12 blepharoplasty charts, an overpayment letter from the RAC is received for all 12 charts. The RAC is questioning medical necessity.

6 Case #1 Following a RAC review of 12 blepharoplasty charts, an overpayment letter from the RAC is received for all 12 charts. The RAC is questioning medical necessity. Rebuttal Submit a SHORT rebuttal within 15 days Direct response stating medical records will be submitted Do not expect much Case #1 Following a RAC review of 12 blepharoplasty charts, an overpayment letter from the RAC is received for all 12 charts. The RAC is questioning medical necessity. Step 1 Submit the 12 redeterminations Summary/Cover letter Redetermination discussion Patient Complaint Exam findings VF results describing degrees of improvement Describe photographs Operative report(s) Cite LCD (if applicable) Case #1 because: The chart notes support medical necessity. 7. Additional Information Medicare Should Consider: See attached chart notes. What is wrong with this response? Case #1 because: A. In the attached clinic note dated 3/3/13 the patient complained of heavy lids with skin irritation, trouble reading, and constant brow ache. B. The clinical exam on 3/3/13 shows a Margin Reflex Distance (MRD) of less than 1.0 mm. C. The un-taped VF shows an obstruction to within 5 degrees of fixation. The taped VF improves the VF to 55 degrees for a 50 degree improvement. D. The photographs show the lid covering part of the pupil in each eye, skin resting on the lashes of both eyes, and red inflamed eyelid skin. 7. Additional Information Medicare Should Consider: See attached chart notes. Case #1 Following the redetermination of 12 cases, 3 cases were denied due to lack of medical necessity Step 2 Submit the 3 reconsiderations Summary/Cover letter Reconsideration form (focus on reason for denial) Clarify Patient Complaint (highlight in notes) Clarify Exam findings (highlight in notes) VF results describing degrees of improvement (taped/untaped and improvement) Describe photographs Cite LCD (if applicable) May be very similar to reconsiderations

7 Case #1 Reconsideration form CMS (or other form): 5. I do not agree with the determination of my claim. MY REASONS ARE: A. In the attached clinic note dated 3/3/13 the patient complained of heavy lids with skin irritation, trouble reading, and constant brow ache. (see highlights) B. The clinical exam on 3/3/13 shows a Margin Reflex Distance (MRD) of less than 1.0 mm. (see highlights) C. The un-taped VF shows an obstruction to within 5 degrees of fixation. The taped VF improves the VF to 55 degrees for a 50 degree improvement. (add labels/arrows) D. The photographs show the lid covering part of the pupil in each eye, skin resting on the lashes of both eyes, and red inflamed eyelid skin. (add labels/arrows) 7. Additional Information Medicare Should Consider: See attached chart notes. Case #2 Following a redetermination for the practice received an unfavorable ruling stating 8 visits were incorrectly coded. All 8 were found unfavorable due to: The documentation does not support the level of ophthalmological service billed. A comprehensive visit requires 8 or more of the ten elements and always includes a fundus exam with pupils dilated. Case #2 Step 2 Submit the 8 reconsiderations Response (likely same for each of the 8): The Vision Manual, Page 2 stipulates: The physical examination elements of an ophthalmologic examination are ten (10) in number and include: 1) Confrontation visual fields, 2) Ocular mobility, 3) Cornea, 4) Lens, 5) Retina (vitreous, macula, periphery, and vessels), 6) Eyelids and adnexa, 7) Pupils/iris, 8) Anterior Chamber, 9) Intraocular pressure, and 10) Optic disc. See attached documentation of examination of right eye, handwritten clinic note dated 3/28/xx and dictated note dated 3/29/xx. These combined notes represent a comprehensive eye exam (CPT 92014) satisfying all 10 elements including a dilated fundus exam as listed in the Vision Manual. Case #3 Following a review by the ZPIC of five (5) and claims the auditor made the following remarks: The documentation provided is insufficient to support the service billed. CPT for fluorescein angiogram and for Fundus photography require an interpretation and report. The documentation for and does not include an interpretation and report. Case #3 Step 1 Submit the redeterminations Responses: A. The interpretation and report for the fluorescein angiogram (FA) (CPT RT and LT) is located on the attached chart note dated 5/1/xx. It is identified by the initials FA. The interpretation and report reads: Right Eye: Increased Subfoveal Choroidal Neovascularization (CNV) with temporal leakage as seen in frames 8, 12. Significatly worse than 3 months ago. Left Eye: Macular staining as seen in frames 11, 14, showing new leakage. Case #3 Step 1 Submit the redeterminations Responses: B. The interpretation and report for Fundus Photography (CPT 92250) is located on the attached chart note dated 5/1/xx. It is identified by label Color Photos. The interpretation and report reads: Right Eye: Increased RPE (retinal pigment epithelium) changes with significant edema. Increased edema from previous photos. Left Eye: Macular drusen with increased RPE changes.

8 Case #3 Step 1 Redetermination denied for and Step 2 Reconsideratoin denied for and Step 3 requested ALJ hearing. Cover letter describing the scenario and previous submissions. Re-submitted all documents from Step 1 and 2. Opportunity to discuss each case Present to the ALJ Each party is allowed to testify. Case #4 Following a review by the carrier of 5 cataract surgery claims, the reviewer made the following observation: The patient must undergo assessment of his/her vision function status using ADL scale or VF-14 or other standard measurement tools. Visual impairment must decrease ability to carry out ADLs. Snellen acuity of 20/50 or worse or with 20/40 or better vision documentation of glare or other factors adversely impacting ADLs. Appropriate evaluation and measurements. One or more of these items were not met. Case #4 The attached documentation from 3/10/xx contains the following documentation: 1. Operative report for cataract extraction surgery left eye on 4/5/xx. 2. The comprehensive eye exam with dilated fundus exam on 3/10/xx demonstrating best corrected vision of 20/50 reduced to 20/400 by glare testing. 3. The exam on 3/10/xx includes the patient life style complaints of difficulty reading and watching television for 2 years. The ADL assessment form lists difficulty watching television, blurred/foggy vision, and problems reading and cooking. The form is signed and dated by the patient on 3/10/xx. Case #5 During a pre-payment review by the carrier (MAC) for 8 Evaluation/Management claims for CPT 99204, the MAC down coded all 8 visits to and Case #5 because: My chart notes support Additional Information Medicare Should Consider: See attached chart notes. Case #5 because: According to the 1997 Evaluation and Management guidelines CPT requires the following; Comprehensive History Comprehensive Exam Moderate Medical Decision Making What is wrong with this response?

9 Case #5 because: In the attached note a comprehensive history showing 4 elements in the History of Present Illness, a Review of Systems of 10 systems, Personal/family/Social History. A comprehensive exam listing the 12 exam elements described in the 1997 E/M guidelines. Moderate Medical Decision Making is supported by the new diagnosis codes for cataracts needing surgery, and glaucoma suspect. See attached 1997 E/M guidelines. Take Away Points Demand clear explanations for unfavorable decisions Locate all applicable payer policies used by the reviewer(s). Use FOIA request if needed Submit standard abbreviation list with appeal Eliminate any room for misinterpretation by providing a detailed response, labeled/highlighted documents Use the facts (no emotion) Appeal, Appeal, Appeal (after all it's your money) Throw everything at the QIC (or have a good excuse for the ALJ) Organization is key More help For additional assistance or confidential consultation, please contact us at: (800) or Kmack@CorcoranCCG.com

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