The Essence of the Problem
|
|
- Cecily Miles
- 6 years ago
- Views:
Transcription
1 Addressing Clinical Documentation, Orders and Case Management Processes to Avoid Recoupment and Win Appeals Presented to: Joan C. Ragsdale, JD Chief Executive Officer Judy Elkourie Clinical Education Manager The Essence of the Problem The Ambiguity of Federal Medicare Law Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury Private Insurers and Medicaid have different rules. Beware! 1
2 Hungry RACs In 2012 fiscal year, RACs collected $2.29 billion in overpayments (3x the 2011 amount). The most common reason for complex denial short-stay medically unnecessary. Hospitals report appealing 40% of all denials. Of claims appealed, 74% were overturned in favor of the provider. 2
3 4 Medicare RACs are growing, with Connolly a leader in growth of charts requested, and recoupment amounts $2.29 billion in overpayments from the RACs 12% of hospitals reported spending more than $100,000 managing the RAC process during the third quarter alone Dramatic increases in medical record requests-68% increase from 1 st to 3 rd qtr. 3
4 Recovery Auditor FY 2012 Update 8 4
5 Other, Scarier Agencies Other Government entities will still investigate and enforce CMS regulations DOJ (Department of Justice) OIG (Office of the Inspector General for HHS) FIs/MACs (Medicare Administrative Contractors) MICs, ZPICs (Medicaid and Program Integrity) PSCs and other Gov t contractors These non-racs are not constrained by the relatively kind RAC audit guidelines Longer statute of limitations Can and will apply extrapolation Can EXCLUDE a provider from Medicare Can criminally prosecute So, Careful Attention to Compliance is a Must Common Problem Areas Inpatient only list and interpretation that a procedure must be done outpatient unless there is a complication Interqual used as definitive arbiter of medical necessity rather than as a screen Inpatient v. Outpatient relative to short stays. (In fiscal 2012, 61% of medical necessity denials were for one-day stays in the wrong setting, not because the care was not medically necessary). 5
6 What Is Level of Care (LOC)? In the good old days, we admitted patients to the hospital; or not. Observation in an inpatient hospital outpatient bed was concocted to help us! Now, forces of evil wield it against us. Orwellian Double- Speak LOC is a patient s status in a hospital Only 2 LOC exist Inpatient ($$$$$) Outpatient ($) Observation ( ) is a service that and MD must order. Inpatient Status Outpatient Status Observation is a service, not a status. 6
7 Painful Semantic Lessons Auditors and Government Agencies Will Attack Based on Simple Wording Errors Payments for Major Surgery and MI Care with PCI have been denied based on lack of a properly written order A doctor s orders must be precise, written eventually, authenticated, dated, and timed. Admit to Inpatient Status (Bed) Or Place in Outpatient Status/bed + Begin observation services now. Mandated Tension Deciding LOC Conditions of Participation Mandates UR screening of Admissions 42CFR Program Integrity Manual Mandates shall use a screening tool PIM section MBPM mandates MD final decision based on complex medical judgment MBPM chapter 1 section 10. CoP mandate MD consent (42CFR482.30(d)(1) CMS transmittal prohibits UR changing inpatient to outpatient without MD concurrence. CMS transmittal 1745 PIM prohibits decisions on LOC based on screening instrument alone ( in all cases reviewer applies clinical judgment ) PIM section
8 So Why Is This Fraud? Hospitals must establish a process to accurately determine inpatient admission versus Outpatient status (aka the level of care (L.O.C)). Federal regs (C.O.P) 42CFR requires hospitals to establish a Utilization Review plan to ensure compliance with Medicare L.O.C. rules. Doctors must order the L.O.C. Ch 1, Section 10, MBPM Doctors certify every code, note, and bill is compliant with all CMS rules. Doctors May Not Default to Inpatient Admission Can t just assign all patients inpatient status and let someone else figure it out later Every change from inpatient to outpatient status is automatically scrutinized. Use of Condition Code 44 is not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians and hospital staff about each hospital s existing policies and admission protocols. As education and staffing efforts continue to progress, the need for hospitals to correct inappropriate admissions and to report condition code 44 should become increasingly rare. Medicare Claims Processing Manual
9 But, Don t Default to Outpatient Obs Technically Violates the Law, plus Carries a Devastating Financial Impact: Inpatient CHF - $4,820 (HSR $5,500) Observation hour stay Estimated reimbursement = $800 Difference approximately $4,000 per case Can add up to REAL $$$ very quickly It May Hurt Patients Too July 7, 2010 The Centers for Medicare & Medicaid Services (CMS) has become increasingly concerned about an increase in outpatient observation services We are unaware of any policies that would cause a hospital to extend observation care for Medicare patients. As it not in the hospital's or the beneficiary's interest to extend observation care rather than either releasing the patient from the hospital or admitting the patient as an inpatient, we are interested in learning more about why this trend is occurring and would appreciate any information you can share to better inform further actions CMS can take on this issue. Sincerely, Marilyn Tavenner Acting Administrator and Chief Operating Office 9
10 CMS rules are really quite simple Or, Maybe Not That Simple The Social Security Act and its regulations promulgated by the Department of Health and Human Services ("HHS") that implements it "present as complex a legislative mosaic as could possibly be conceived by man." City of New York v. Richardson, 473 F.2d (2d Cir. 1973); accord Beverly Community Hospital Ass'n v. Belshe, 132 F.3d 1259,1266 (9th Cir. 1997) (finding that "clarity is recognized as totally absent from the Medicare and Medicaid statutes"), cert denied, 119 S. Ct. 334 (1998); Rehabilitation Ass'n of Va.,Inc. v. Kozlowski, 42 F.3d 1444, 1450 (4th Cir. 1994) (characterizing Medicaid as"among the most completely impenetrable texts within human experience" and "dense reading of the most tortuous kind"). Messier v. Southbury Training School, et al., 1999 WL (D. Conn.) 10
11 915 Total Reviews 11
12 Not InterQual. Not Milliman. No Numbers Chapter 6 of the Program Integrity Manual controls the medical review process for determining the medical necessity of inpatient admissions. RACs and MACs must follow the instructions contained therein (Medicare Program Integrity Manual, Chapter 1, section 1.1). The instructions mandate that, In all cases, in addition to screening instruments, the reviewer applies his/her own clinical judgment to make a medical review determination based on the documentation in the medical record. (Medicare Program Integrity Manual, Chapter 6, section 6.5) REGULATIONS-CMS Inpatient Definition An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Source: Medicare Benefit Policy Manual, Chapter 1 12
13 REGULATIONS-CMS Inpatient Details Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight. Source: Medicare Benefit Policy Manual, Chapter 1 Expected to Need Inpatient Care for 24h Physicians should use a 24-hour period as a benchmark, i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis. Source: Medicare Benefit Policy Manual, Chapter 1, Section 10 13
14 The Actual Time In The Hospital Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital. Source: Medicare Benefit Policy Manual, Chapter 1, Section How MD Forms This Expectation the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient s medical history and current medical needs, the type of facilities available to inpatients and outpatients, the hospital s by-laws and admissions policies, and the relative appropriateness of treatment in each setting. Source: Medicare Benefit Policy Manual, Chapter 1 14
15 Factors Bearing on Inpatient Expectation Factors to be considered when making the decision to admit include such things as: The severity of the signs and symptoms exhibited by the patient; The medical predictability of something adverse happening to the patient; The need for diagnostic studies that appropriately are outpatient (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and The availability of diagnostic procedures at the time when and at the location where the patient presents. Source: Medicare Benefit Policy Manual, Chapter 1 Need an Acute Threat Inpatient care rather than outpatient care is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. The reviewer shall consider, in his/her review of the medical record, any preexisting medical problems or extenuating circumstances that make admission of the beneficiary medically necessary. Medicare Program Integrity Manual Chapter 6 - Intermediary MR Guidelines for Specific Services Medical Review of Acute Inpatient Prospective Payment System (IPPS) Hospital or Longterm Care Hospital (LTCH) Claims A. Determining Medical Necessity and Appropriateness of Admission 15
16 Patient or Family Worry is Not Enough Without accompanying medical conditions, factors that would only cause the beneficiary inconvenience in terms of time and money needed to care for the beneficiary at home or for travel to a physician's office, or that may cause the beneficiary to worry, do not justify a continued hospital stay. Medicare Program Integrity Manual Chapter 6 - Intermediary MR Guidelines for Specific Services Medical Review of Acute Inpatient Prospective Payment System (IPPS) Hospital or Long-term Care Hospital (LTCH) Claims A. Determining Medical Necessity and Appropriateness of Admission What is the Requisite Intensity? Auditors love attacking hospitals with the PIM intensity stick. must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis. Medicare Program Integrity Manual,Chapter 6 - Intermediary MR Guidelines for Specific Services, Medical Review of Acute Inpatient Prospective Payment System (IPPS) Hospital or Long-term Care Hospital (LTCH) Claims (Rev. 264; Issued: ; Effective Date: ; Implementation Date: ) No mention of IV fluid rate, hospital ward v ICU, oxygen minimums etc previously defined as a 24 or more hour physical hospital setting in many institutions there is no difference between the actual medical services provided in inpatient and outpatient observation settings the designation still serves to assign patients to an appropriate billing category. Novitas LCD L27548 AND WPS L32222! 16
17 Surgery NOT on Inpatient-Only List Minor Surgery or Other Treatment When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they are considered outpatients for coverage purposes regardless of the hour they came to the hospital, whether they used a bed, and whether they remained in the hospital past midnight. Source: Medicare Benefit Policy Manual, Chapter 1, Section 10 Exclusions Trump Card Custodial care is excluded from coverage. Custodial care serves to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet, preparation of special diets, and supervision of medication that usually can be selfadministered. Custodial care essentially is personal care that does not require the continuing attention of trained medical or paramedical personnel. In determining whether a person is receiving custodial care, the intermediary or carrier considers the level of care and medical supervision required and furnished. It does not base the decision on diagnosis, type of condition, degree of functional limitation, or rehabilitation potential. Medicare Benefit Policy Manual Chapter Custodial Care (Rev. 1, ) A3-3159, HO , HO-261, B
18 Events and Facts After the Admission Inpatient vs. Observation determination Evidentiary Rules QIOs (and RACs)* consider only the medical evidence which was available to the physician at the time an admission decision had to be made. They do not take into account other information (e.g., test results) which became available only after admission, except in cases where considering the post-admission information would support a finding that an admission was medically necessary. Medicare Benefit Policy Manual,Chapter 1,Page 8, 10 * Sacred Heart v. First Coast, Medicare Appeals Council, Nov. 10, 2009 Practical Application Utilization Review nurses apply screening criteria (normally Interqual or Milliman) Order Supported by Documentation? Physician Advisor consulted Applies CMS criteria May call the attending for additional information Makes a recommendation on level of care (Inpatient vs. Outpatient w/ Observation Services vs. Outpatient Letter of Determination sent back to hospital and physician s office 18
19 Practical Application Benefits of Physician Advisors Interpret CMS guidelines in medical terms Takes burden off the attending physician of knowing all the nuances that drive the level of care decision Conversations between attending physician and physician advisor allows transfer of knowledge regarding the CMS regulations Case 1: Acute GI Bleed 85 year old man presented to the ER one hour after vomiting a lot of bright red blood. Medical History: CAD, cardiac stents, and CHF. Taking both aspirin and plavix, plus a beta blocker 19
20 Case 1: GI Bleed Exam: Pulse = 90, BP=120/60 Otherwise unremarkable Hgb/HCT 12/36 (baseline) BUN 28/Creat. 0.8 NG tube aspirated guiac positive coffee ground material Guiac positive normal appearing stool on rectal exam No further complaints or events in the ER Case 1: GI Bleed Milliman recommends observation Interqual recommends observation The Physician Advisor Recommends inpatient admission based on Medicare guidelines. Complex medical judgment supports the expectation of 24 or more hours of hospital care. 20
21 Case 1: Why The Disparity? Scientifically, one can not assess the severity of a GI bleed by the initial Hgb/HCT. Tachycardia is masked here by a beta blocker The patient s cardiac history escalates his risk. His medications escalate his risks. Case 1 is an Inpatient Admission The risk posed by this patient s presenting symptoms and past cardiac history Predict the need for 24 hours of hospital care 21
22 Case 2: Syncope 69 year old man presented to the ER after passing out. Without warning, he went from standing to lying on the ground No memory of how No prodromal symptoms. Case 2: Syncope Past Medical History: HTN, diabetes Medications: ASA, Toprol, Vasotec, lasix, glyburide Exam: Normal exam and vital signs Normal neuro exam EKG: NSR with some PVCs. Lab: glucose 180 at the scene (EMS). Normal CBC and Chemistries. BNP 643. Troponin <.01 22
23 Case 2: Syncope Milliman recommends observation. Interqual recommends observation. The physician advisor recommends inpatient admission. Complex medical judgment supports the expectation of 24 or more hours of hospital care. Why the Disparity? His cardiac history increases his risk of Vtac and Vfib. His history (the absence of any warning symptoms) suggests a sudden ventricular arrhythmia. 23
24 Case 2 is an Inpatient Admission This patient s suspiciously unheralded loss of consciousness plus his high Vtac risk cardiac history.. Support the expectation of needing more than 24 hours of hospital level care Case 3: Chest Pain 49 year old woman presented with severe chest pain for 7 hours. Constant and 10/10 pain Past history of disabling chronic back pain, GERD, smoking, diabetes, and HTN. 24
25 Case 3: Chest Pain EKG and Cardiac Markers were normal. Minimal relief with NTG. Admitted for severe GI related chest pain. Started on IV protonix. GI consult called for planned EGD in am. Case 3: Chest Pain Milliman recommended observation. Interqual recommended observation. The physician advisor recommended observation because the risk for an acute cardiac event was low and the severe pain could have been managed outside a hospital. GI referral could have waited a bit. 25
26 Case 4: Chest Pain! 77 year old man presented to the ER with 4 hours of fluctuating chest pain. Each episode occurred at rest and was aborted with NTG. This is new. He had been CP free for years after a stent. Case 4: Chest Pain! Medical History: 2 prior MI, CABG, stents. Compliant with all Medications Taking Plavix and Aspirin. He was chest pain free on arrival to the ER Troponin was <0.01 EKG was normal All other labs and Exam were normal. 26
27 Case 4: Chest Pain! Milliman recommended observation. Interqual recommended observation. The physician advisor recommended inpatient admission. Complex medical judgment supports the expectation of more than 24 hours of hospital care here. Case 4: Why the Disparity? This is classic unstable coronary syndrome in a known CAD patient. Neither troponin or the EKG can detect intermittent ischemia This patient has been self treating ACS 27
28 Case 4 is an Inpatient Admission This patient had known CAD with prior MI. The unique details of the presentation demonstrate that a high risk for MI and cardiac death remain despite negative testing. Most doctors would expect more than 24 hours of hospital care to cool down the artery and proceed to cath. OIG Review of ALJ Opinions The OIG reviewed the appeals process and recommended that CMS: (1) develop and provide coordinated training on Medicare policies to ALJs and QICs, (2) identify and clarify Medicare policies that are unclear and interpreted differently, (3) standardize case files and make them electronic, (4) revise regulations to provide more guidance to ALJs regarding the acceptance of new evidence, and (5) improve the handling of appeals from appellants who are also under fraud investigation and seek statutory authority to postpone these appeals when necessary. OIG recommended that recommend that the Office of Medicare Hearings and Appeals (OMHA): (6) seek statutory authority to establish a filing fee, (7) implement a quality assurance process to review ALJ decisions, (8) determine whether specialization among ALJs would improve consistency and efficiency, and (9) develop policies to handle suspicions of fraud appropriately and consistently and train staff accordingly, and that CMS: (10) continue to increase CMS participation in ALJ appeals. 28
29 Practical Steps Know who is auditing Know target area by agency Know areas that are ambiguous, and make certain documentation is clear Pay attention to patient complaints or employee concerns Pay attention to PEPPER Reports and other communications showing aberrant practices Processes must be continually updated to address concerns Resources must be allocated to training and education not abstract training but concrete requirements Address documentation requirements in the context of EHRs Create a culture of compliance. Make certain efforts are documented and supported by solution pathways Recognize that there is pressure to reduce success at the ALJ level. Make certain appeals are well documented and supported Provide feedback between recoupment activities, appeals and concurrent processes Make certain that educational efforts are throughout the organization. Questions? 29
Justifying Medicare Inpatient Admissions RAC Response and Appeals Tactics
Justifying Medicare Inpatient Admissions RAC Response and Appeals Tactics Gregory Palega, MD JD MedManagement LLC Medical Director of Regulatory Affairs gpalega@medmanagementllc.com Objectives Learn the
More informationUsing Clinical Criteria for Evaluating Short Stays and Beyond. Georgeann Edford, RN, MBA, CCS-P. The Clinical Face of Medical Necessity
Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford, RN, MBA, CCS-P The Clinical Face of Medical Necessity 1 The Documentation Faces of Medical Necessity ç3 Setting the Stage
More informationUsing Clinical Criteria for Evaluating Short Stays and Beyond
Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford I. History A. Social Security Act Medical Necessity and Utilization Review 1. Items or services necessary for the diagnosis
More informationCMS Observation vs. Inpatient Admission Big Impacts of January Changes
CMS Observation vs. Inpatient Admission Big Impacts of January Changes Linda Corley, BS, MBA, CPC Vice President Compliance and Quality Assurance 706 577-2256 Cellular 800 882-1325 Ext. 2028 Office Agenda
More informationAdapting Your Medical Necessity Compliance Program In An Evolving Regulatory Environment
Adapting Your Medical Necessity Compliance Program In An Evolving Regulatory Environment Joydip Roy MD Vice President of Compliance and Physician Education Adapting Your Medical Necessity Compliance Program
More informationATTACHMENT I. Outpatient Status: Solicitation of Public Comments
ATTACHMENT I The following text is a copy of the Federation of American Hospitals ( FAH ) comments in response to the solicitation of public comments on outpatient status that was contained in CMS-1589-P;
More informationFY 2014 Changes to Medicare Inpatient Admission and Reimbursement Standards: CMS s Two Midnight Rule and the Revised Part A to Part B Rebilling Policy
FY 2014 Changes to Medicare Inpatient Admission and Reimbursement Standards: CMS s Two Midnight Rule and the Revised Part A to Part B Rebilling Policy Mark Polston King & Spalding In Fiscal Year 2014,
More informationCentral Ohio HFMA Fall Education Hot Topics: Maintaining Compliance in Times of Change. November 22, 2013
Central Ohio HFMA Fall Education Hot Topics: Maintaining Compliance in Times of Change November 22, 2013 Agenda IPPS Final rule inpatient status changes Proposed OPPS changes to reporting hospital evaluation
More informationReviewing Short Stay Hospital Claims for Patient Status: Admissions On or After October 1, 2015 (Last Updated: 11/09/2015)
7 Reviewing Short Stay Hospital Claims for Patient Status: Admissions On or After October 1, 2015 (Last Updated: 11/09/2015) Medical Review of Inpatient Hospital Claims Starting on October 1, 2015, the
More informationChanges to Medicare Inpatient Admission and Reimbursement Standards: CMS s Two Midnight Rule and the Revised Part A to Part B Rebilling Policy
Changes to Medicare Inpatient Admission and Reimbursement Standards: CMS s Two Midnight Rule and the Revised Part A to Part B Rebilling Policy Mark Polston King & Spalding In Fiscal Year 2014, the Centers
More informationWhat is an Inpt & How to get it right. The Challenges of Coverage and Compliance Why is it so hard?
What is an Inpt & How to get it right The Challenges of Coverage and Compliance Why is it so hard? 1 From the pt: AARP Jan-Feb 2010 issue Hospital Stays are Under Observation Ruth Way fell, was admitted
More informationExecutive Summary, December 2015
CMS Revises Two-Midnight Rule to Allow An Exception for Part A Payment for Hospital Services Provided to Patients Requiring Inpatient Care for Less Than Two Midnights Executive Summary, December 2015 Sponsored
More informationAAPC Webinar 3/28/2016
Short Stays for the Coder Where Are We Now? Heather Greene, MBA, RHIA, CPC, CPMA AHIMA Approved ICD-10 CM/PCS Trainer Copyright 2016 AAPC Agenda The Two-Midnight Rule Supportive documentation Observation
More information2 Midnight Case Examples and Documentation Tips. Ralph Wuebker, MD Executive Health Resources, Inc. All rights reserved.
2 Midnight Case Examples and Documentation Tips Ralph Wuebker, MD AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance
More informationCMS IPPS 2014 Final Rule: Overview & Best Practice Recommendations
CMS IPPS 2014 Final Rule: Overview & Best Practice Recommendations Ralph Wuebker, MD, MBA Chief Medical Officer AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for
More informationCMS IPPS 2014 Final Rule: Physician Education on Observation Status and 2-Midnight Rule
CMS IPPS 2014 Final Rule: Physician Education on Observation Status and 2-Midnight Rule John Zelem, MD, FACS Executive Medical Director Audit, Compliance and Education (ACE) AHA Solutions, Inc., a subsidiary
More informationOutpatient Observation Services
Outpatient Observation Services Presented by: Gina Hobert, MBA, CHC, CPC-I, CPMA, CEMC, CRC Sr. Manager, Baker Newman Noyes Definition MCR Benefit Policy Manual, CMS 100-02, Chapter 6, 20.6 A. Outpatient
More informationRecovery Audit Contractors: AHA Perspective. Elizabeth Baskett, Policy, AHA February 23, 2012
Recovery Audit Contractors: AHA Perspective Elizabeth Baskett, Policy, AHA February 23, 2012 Agenda Lay of the Land = Audit Overload RACs (Medicare & Medicaid) MACs ZPICs and OIG and DOJ, oh my! AHA and
More information9/18/2014. Agenda. Final IPPS 2015 AKA CMS 1607-F (Published in Federal Register on August 22, 2014)
2015 Inpatient Prospective Payment Services (IPPS) and Insights on Best Practices John Zelem, MD, FACS Executive Medical Director, Client Relations and Education Agenda 2014/2015 IPPS Final Rule 2015 proposed
More informationLESSONS LEARNED FROM THE PROBE AND EDUCATE AUDIT K. CHEYENNE SANTIAGO, RN
LESSONS LEARNED FROM THE PROBE AND EDUCATE AUDIT K. CHEYENNE SANTIAGO, RN Created on 6/2/2014 DISCLAIMER DISCLAIMER: WPS Medicare has produced this material as an informational reference. Every reasonable
More informationTwo Midnight Rule What does it mean for Coders?
Two Midnight Rule What does it mean for Coders? Heather Greene, MBA, RHIA, CPC, CPMA Vice President, Compliance Services AHIMA Approved ICD-10 CM/PCS Trainer 1 Agenda The Two-Midnight Rule Supportive documentation
More informationComplex Challenges/Financial Impact Medical Necessity Compliance Role of the Physician Advisor. NJHFMA Finance for Clinicians Session March 24, 2016
1 Complex Challenges/Financial Impact Medical Necessity Compliance Role of the Physician Advisor NJHFMA Finance for Clinicians Session March 24, 2016 Complex Challenges 2 Declining Inpatient Admissions
More informationHCCA South Central Regional Annual Conference November 21, 2014 Nashville, TN. Post Acute Provider Specific Sections from OIG Work Plans
HCCA South Central Regional Annual Conference November 21, 2014 Nashville, TN Kelly Priegnitz # Chris Puri # Kim Looney Post Acute Provider Specific Sections from 2012-2015 OIG Work Plans I. NURSING HOMES
More informationBest Practices to Avoid Medicare Denials
Best Practices to Avoid Medicare Denials Ralph Wuebker, MD Chief Medical Officer Executive Health Resources AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the
More informationPATIENT STATUS DEFINITIONS, 2 MIDNIGHT RULE AND 96 HOUR RULE
PURPOSE It is the policy of Mason General Hospital and Family of Clinics (MGH&FC) that based on the Patient Status Definitions, all placements concerning the use of observation beds, or placements made
More information2014 Hospital Admission Criteria
2014 Hospital Admission Criteria Created on 11/20/2013 Audio and/or Video Recording of this Educational Session is Prohibited Agenda Inpatient vs. observation 2-midnight benchmark and presumption Admission
More informationRESOURCE GUIDE TO CASE MANAGEMENT Optum Executive Health Resources
RESOURCE GUIDE TO CASE MANAGEMENT Optum Executive Health Resources Table of contents Pages 2-8 Pages 9-12 Pages 13-16 Pages 17-20 Reviewing your utilization review program Learn how to evaluate your admissions
More informationAHLA. Z. New Rules: Hospital Patient Status, Observation, Part B Billing for Denied Inpatient Admissions
AHLA Z. New Rules: Hospital Patient Status, Observation, Part B Billing for Denied Inpatient Admissions Timothy P. Blanchard Blanchard Manning LLP Orcas, WA Joan C. Ragsdale CEO MedManagement LLC Vestavia,
More informationCigna Medical Coverage Policy
Cigna Medical Coverage Policy Subject Observation Care Table of Contents Coverage Policy... 1 General Background... 2 Coding/Billing Information... 4 References... 5 Effective Date... 10/15/2014 Next Review
More informationObservation Coding and Billing Compliance Montana Hospital Association
Observation Coding and Billing Compliance Montana Hospital Association Sue Roehl, RHIT, CCS sroehl@eidebaill.com 701-476-8770 IP versus Observation considerations Severity of patient s signs and symptoms
More informationBenefit Criteria for Outpatient Observation Services to Change for Texas Medicaid
Benefit Criteria for Outpatient Observation Services to Change for Texas Medicaid Information posted on October 8, 2010 Effective for dates of service on or after December 1, 2010, the benefit criteria
More information10/7/2014. Agenda. Big picture Internal Medicine Update. The Two Midnight Rule: One Year Later
2014 Internal Medicine Update SC Chapter Scientific Meeting The Two Midnight Rule: One Year Later Nick Ulmer, MD CPC VP Clinical Services and Medical Director of Case Management, SRHS Agenda Define status
More informationBecoming a Champion of Physician and Hospital Alignment: Focusing on Length of Stay, Discipline and Standards of Care
Becoming a Champion of Physician and Hospital Alignment: Focusing on Length of Stay, Discipline and Standards of Care Marc Tucker, DO Senior Director Audit, Compliance & Education AHA Solutions, Inc.,
More information10/2/2015. Agenda. Medicare Compliance DOJ OIG Contractors 2016 OPPS Best Practices Physician buy-in Summary
Medicare Compliance Updates and Best Practices for Providers Joe Crea, DO, MHA Vice President, Clinical and Regulatory Agenda Medicare Compliance DOJ OIG Contractors 2016 OPPS Best Practices Physician
More informationTopics. Overview of the Medicare Recovery Audit Contractor (RAC) Understanding Medicaid Integrity Contractor
RACS, ZPICS & MICS John Falcetano, CHC-F, CCEP-F, CHPC, CHRC, CIA Chief Audit and Compliance Officer University Health Systems of Eastern Carolina jfalceta@uhseast.com Topics Overview of the Medicare Recovery
More informationThe In and Out of the Medicare Two Midnight Rule. Disclaimer. Objectives 3/31/2014
The In and Out of the Medicare Two Midnight Rule Brenda Keeling, RN, CPHQ, CCM Patient Response, Inc. 1 Disclaimer Information enclosed was current at the time it was presented. Medicare policy changes
More information4/20/2015. NE Home Care & Hospice Conference: Strategic Preparation for Medicare Audits & Appeals. Today s Objectives. Background
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
More informationCopyright ht 2012 Executive Health lthresources, Inc. All rights iht reserved. The Perfect Storm
Medicare Compliance Challenges in the Age of Healthcare Accountability Marc Tucker, DO Senior Director Audit, Compliance & Education AHA Solutions, Inc., a subsidiary of the American Hospital Association,
More informationSee page 16. Drug diversion in healthcare facilities, Part 1: Identify and prevent. Erica Lindsay
Compliance TODAY May 2015 a publication of the health care compliance association www.hcca-info.org From the courtroom to Compliance one lawyer s journey and the lessons learned an interview with Tracy
More informationUTILIZATION MANAGEMENT Section 4. Overview The Plan s Utilization Management (UM)
Overview The Plan s Utilization Management (UM) Program is designed to meet contractual requirements and comply with federal regulations while providing members access to high quality, cost effective medically
More informationUsing PEPPER and CERT Reports to Reduce Improper Payment Vulnerability
Using PEPPER and CERT Reports to Reduce Improper Payment Vulnerability Cheryl Ericson, MS, RN, CCDS, CDIP CDI Education Director, HCPro Objectives Increase awareness and understanding of CERT and PEPPER
More information50938 Federal Register / Vol. 78, No. 160 / Monday, August 19, 2013 / Rules and Regulations
50938 Federal Register / Vol. 78, No. 160 / Monday, August 19, 2013 / Rules and Regulations The quality, utility, and clarity of the information to be collected. Recommendations to minimize the information
More informationMedicare Recovery Audit Contractors. Chicago, IL August 1, 2008
Medicare Recovery Audit Contractors Chicago, IL August 1, 2008 1 Recovery Audit Contractors Demo Summary National Rollout AHA Strategy AHA RACTrac Overview 2 Recovery Audit Contractors Medicare Modernization
More informationRiding Herd on Fraud, Waste and Abuse
Riding Herd on Fraud, Waste and Abuse Dan McCullough Judi McCabe Juanita Henry Kim Hrehor 1 Taking Stock: Surveying the Landscape of Fraud, Waste and Abuse 2 How Big is the Problem? The simple truth is
More informationGoal of the Audit Culture
Inpt vs. Observation Why is it so hard? It is all about the patient s story Presented By: Day Egusquiza, President AR Systems, Inc. 1 Goal of the Audit Culture To ensure billed services are reflected in
More informationMobile Medical Review Team Observation Services & the 2 Midnight Rule. The Audio and/or Video Recording of this Educational Session is Prohibited
Mobile Medical Review Team Observation Services & the 2 Midnight Rule The Audio and/or Video Recording of this Educational Session is Prohibited National Government Services, Inc. Medicare Part A & Part
More informationREGULATION, ACCREDITATION, AND PAYMENT PRACTICE GROUP (June, July, August 2004)
REGULATION, ACCREDITATION, AND PAYMENT PRACTICE GROUP (June, July, August 2004) Lester J. Perling Broad and Cassel Fort Lauderdale, Florida I. Case Summaries CMNs Document Medical Necessity In Maximum
More informationClinical Documentation Improvement Programs and Physician Advisors: Working Together to Improve Effectiveness. October 12, 2009
Clinical Documentation Improvement Programs and Physician Advisors: Working Together to Improve Effectiveness October 12, 2009 Betty B. Bibbins, MD, CHC, FACOG, C-CDI, C CDI, CPEHR, CPHIT President & Chief
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: observation_room_services 2/1997 3/2013 3/2014 3/2013 Description of Procedure or Service Observation services
More informationHospice House Network Inpatient Conference
Hospice House Network Inpatient t Conference Trends & Recent Developments in Hospice General Inpatient Care Policy and Enforcement June 7, 2013 1 www.morganlewis.com Presented by Howard J. Young, Esq.
More informationAugust 14, 2013 COF Bi- Monthly Call. Questions or comments? Contact Ivy Baer: or
August 14, 2013 COF Bi- Monthly Call Questions or comments? Contact Ivy Baer: ibaer@aamc.org or 202-828-0499 OPPS Comment Period Is NOW Comments Due 9/6 Hospital Outpatient Services Proposal (OPPS) On
More informationCMS IPPS 2014 Final Rule: Overview & Best Practice Recommendations. Agenda
CMS IPPS 2014 Final Rule: Overview & Best Practice Recommendations Ralph Wuebker, MD, MBA Chief Medical Officer AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for
More informationMedical Necessity Certification 3/4/2014. CMS IPPS 2014 Final Rule: Overview & Best Practice Recommendations. Agenda. Valid Admissions What Changed?
CMS IPPS 2014 Final Rule: Overview & Best Practice Recommendations Ralph Wuebker, MD, MBA Chief Medical Officer AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for
More informationThe Two-Midnight Rule: Practical Strategies for Hospital Compliance Officers
AIS s Management Insight Series The Two-Midnight Rule: Practical Strategies for Hospital Compliance Officers Adapted from an AIS webinar presented by Abby Pendleton, Esq. Founding Partner The Health Law
More informationAHLA. GG. Physician Orders. Timothy P. Blanchard Blanchard Manning LLP Orcas, WA
AHLA GG. Physician Orders Timothy P. Blanchard Blanchard Manning LLP Orcas, WA Institute on Medicare and Medicaid Payment Issues March 26-28, 2014 Physician Orders Timothy P. Blanchard, MHA, JD Medicare
More informationCombatting Denials. NJ HFMA January 10, 2017
Combatting Denials NJ HFMA January 10, 2017 1 Denial Challenges PAYER INDUCED Aggressive Commercial Payer Denials (Concurrent and Retrospective) Pre-Payment Review Denials for Medicare Unilateral Payer
More informationCREATING AN AUDIT PLAN FOR PHYSICIAN OFFICES. Katherine Abel, CPC, CPB, CPMA, CPPM, CPC-I, AAPC Fellow Director of Curriculum AAPC
CREATING AN AUDIT PLAN FOR PHYSICIAN OFFICES Katherine Abel, CPC, CPB, CPMA, CPPM, CPC-I, AAPC Fellow Director of Curriculum AAPC OIG Compliance Guidance Implementing written policies, procedures and standards
More informationLove Letters to and from CMS: Responding to Audits and Overpayments and Making Voluntary Refunds
Love Letters to and from CMS: Responding to Audits and Overpayments and Making Voluntary Refunds By: David Glaser and Katie Ilten February 14, 2018 2 You Have Mail Request for records: MAC PSC, ZPIC,
More informationCMS New Standards for Hospital Inpatient Admissions October Physician Admission Order Check List Detail
Providing technologically supported physician advisory and case management services to healthcare providers and payors CMS New Standards for Hospital Inpatient Admissions October 2013 Physician Admission
More informationHealth Management Policy
Health Management Policy Policy Number: 0101 Effective Date: 4/1/18 Policy Title: Circumvention of PPS/Readmission Review Applies To: Generations Advantage Purpose: The Martin s Point Health Care Medicare
More informationMedicare s Impact on Cardiology Drugs and Devices During Clinical Research
Medicare s Impact on Cardiology Drugs and Devices During Clinical Research Ryan Meade, JD Meade & Roach, LLP July 15, 2008 Baltimore, Maryland University of Maryland School of Medicine 1 Overview Theme:
More informationMedicare Fraud & Abuse: Prevention, Detection, and Reporting ICN
Medicare Fraud & Abuse: Prevention, Detection, and Reporting ICN 908103 1 Disclaimers This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently
More informationNE Home Care Conference: Effective & Efficient Preparation for Medicare Audits & Appeals
NE Home Care Conference: Effective & Efficient Preparation for Medicare Audits & Appeals Cheryl Leslie, RN, MPH Director of Home Care & Hospice Services Pamela Meliso, JD, MPH Director of Consulting &
More informationZone Program Integrity Program & Recovery Audit Contractors
Zone Program Integrity Program & Recovery Audit Contractors Advance Planning and Responsive Tools. AHLA Long Term Care and the Law Program Feb 26, 2013 Presented by: Brain Daucher Esq. Sheppard Mullin
More informationEMTALA: Taking the high road BRANDON LEWIS, DO, MBA, FACOEP, FACEP
EMTALA: Taking the high road BRANDON LEWIS, DO, MBA, FACOEP, FACEP Objectives Provide a better understanding of the background and definitions of EMTALA Provide a better understanding of how these regulations
More informationCurrent Status: Active PolicyStat ID: Effective: 08/2001 Approved: 12/2016 Last Revised: 12/2016 Expiration: 12/2019
Current Status: Active PolicyStat ID: 3023748 Effective: 08/2001 Approved: 12/2016 Last Revised: 12/2016 Expiration: 12/2019 Owner: Department: References: DeAnna Read: Dir. Case Management Case Management
More informationUnitedHealthcare Medicare Readmission Review Program for Medicare Advantage Plans General Clinical Guidelines for Payment Review
UnitedHealthcare Medicare Readmission Review Program for Medicare Advantage Plans General Clinical Guidelines for Payment Review Introduction The UnitedHealthcare Medicare Readmission Review Program is
More informationFlorida Health Care Association 2013 Annual Conference
Florida Health Care Association 2013 Annual Conference The Westin Diplomat Resort & Spa Session #51 Navigating Health Care Reform: Creating a Road Map for Success Thursday, August 8 8:15 to 9:45 a.m. Regency
More informationInpatient orders and Physician Certification MUST BE authenticated PRIOR to discharge No EXCEPTIONS.
2 Midnight Rule for InPatient Admission On August 2, 2013 the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS- 1599-F) updating Medicare payment policies which modifies and clarifies
More informationClaims Denial Management: What Are Third Party Payers Really Telling You about Your Documented Quality-of-Care and Compliance?
Claims Denial Management: What Are Third Party Payers Really Telling You about Your Documented Quality-of-Care and Compliance? Betty Bibbins, MD, CHC, CPEHR, CPHIT President & Chief Medical Officer Website:
More informationIn this course, we will cover: The Two Midnight Rule and the rule s documentation requirements Medical Necessity standards Inpatient Order and
In this course, we will cover: The Two Midnight Rule and the rule s documentation requirements Medical Necessity standards Inpatient Order and Certification requirements for physicians Outpatient Observation
More informationMLN Matters Number: MM6699 Related Change Request (CR) #: 6699
News Flash Medicare will cover immunizations for H1N1 influenza also called the "swine flu." There will be no coinsurance or copayment applied to this benefit, and beneficiaries will not have to meet their
More informationCertified Ophthalmic Executive (COE) Review Day
Certified Ophthalmic Executive (COE) Review Day Compliance Plan & Chart Audits Financial Disclosure The instructor acknowledges a financial interest in the subject matter of this presentation. Presented
More informationEMERGENCY DEPARTMENT CASE MANAGEMENT
EMERGENCY DEPARTMENT CASE MANAGEMENT By Linda Sallee, Haley Rhodes, Sapna Patel, Cathleen Trespasz Healthcare consumers are becoming more empowered to have healthcare on their terms. With telemedicine,
More informationResponding to Today s Health Care Regulatory Environment
Responding to Today s Health Care Regulatory Environment St. Joseph s Health Michael R. Holper SVP, Compliance and Audit Services October 26, 2016 2014 Trinity Health. All Rights Reserved. 1 We operate
More informationLearning Objectives. It Starts With an Order and an Expectation
1 Under What Condition: Understanding Condition Codes 44 and W2 Debbie Mackaman, RHIA, CPCO, CCDS Regulatory Specialist HCPro, an H3.Group Brand Middleton, MA Learning Objectives At the completion of this
More informationEmergency Department Update 2010 Outpatient Payment System
Emergency Department Update 2010 Outpatient Payment System ED Facility Level Guidelines: Still No National Guidelines Triage Only Services Critical Care Requires CMS Documentation E/M Physician of Payment
More informationAre they coming to get you! Todd Thomas, CCS-P
Are they coming to get you! Todd Thomas, CCS-P Who is coming for you? Medicare Administrative Contractors (MACs) Recovery Audit Contractors (RACs) Medicaid Recovery Audit Contractors (MACs) Comprehensive
More informationSection 4 - Referrals and Authorizations: UM Department
Section 4 - Referrals and Authorizations: UM Department Primary Care Referral Process 1 Referrals to In-Network Specialists 1 Referrals to Out-Of-Network Specialists 2 Consultation Referral Forms 2 Consultation
More informationQuarterly CERT Error Findings Report WPS GHA Part B J8 MAC ~ Indiana and Michigan ~
Quarterly CERT Error Findings Report WPS GHA Part B J8 MAC ~ Indiana and Michigan ~ This report provides details of Comprehensive Error Rate Testing (CERT) errors assessed April 1, 2017, through June 30,
More informationObservation vs. Inpatient: How to Get it Right. November 5, 2013
Observation vs. Inpatient: How to Get it Right November 5, 2013 Learning Objectives Understand how the Inpatient Prospective Payment System (IPPS) Final Rule impacts your facility Integrate leading practice
More informationCAH PREPARATION ON-SITE VISIT
CAH PREPARATION ON-SITE VISIT Illinois Department of Public Health, Center for Rural Health This day is yours and can be flexible to the timetable of hospital staff. An additional visit can also be arranged
More informationMedicare Consolidate Billing & Overview
Medicare Consolidate Billing & Overview Julie Kearney, Kearney & Associates Consolidated Billing The Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to
More informationCCT Exam Study Manual Update for 2018
CCT Exam Study Manual Update for 2018 This document reflects updates made to the instructional content from the CCT Exam Study Manual 2017 to the 2018 version of the manual. This does not include updates
More informationRecovery Audit Contractors (RACs) and Medicare. The Who, What, When, Where, How and Why?
Recovery Audit Contractors (RACs) and Medicare The Who, What, When, Where, How and Why? 1 Agenda What is a RAC? Will the RACs affect me? Why RACs? What does a RAC do? What are the providers options? What
More informationPassport Advantage Provider Manual Section 5.0 Utilization Management
Passport Advantage Provider Manual Section 5.0 Utilization Management Table of Contents 5.1 Utilization Management 5.2 Review Criteria 5.3 Prior Authorization Requirements 5.4 Organization Determinations
More informationDiane Meyer, CHC (650) Agenda
The Road Ahead and How to Navigate It Kevin D. Lyles, Esq. kdlyles@jonesday.com (614) 281-3821 Diane Meyer, CHC DMeyer@stanfordmed.org (650) 724-2572 Frank E. Sheeder, Esq. fesheeder@jonesday.com (214)
More information3/12/2012. DRG Validation, cont. New Challenges and Target Areas RACs. Update on RACs [Recovery Audit Contractors] & Other External Auditors
Update on RACs [Recovery Audit Contractors] & Other External Auditors Presented by: Mary Legerski, RN, Esq., CHC, CPC, MBA, MPA New Challenges and Target Areas RACs CGI Targets as of 3/7/12 Inpatient claims
More informationCLINICAL MEDICAL POLICY
Policy Name: Policy Number: Responsible Department(s): CLINICAL MEDICAL POLICY Cardiac Event Detection Monitoring (L34953) MP-054-MC-PA Medical Management Provider Notice Date: 05/01/2018 Issue Date: 06/01/2018
More informationTHE INVISIBLE DENIAL: A Closer Look at Commercial Denials and Appeals Strategies
THE INVISIBLE DENIAL: A Closer Look at Commercial Denials and Appeals Strategies Marc Tucker, DO, FACOS, MBA Sr. Medical Director ACE AHA Solutions, Inc., a subsidiary of the American Hospital Association,
More informationIMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY
Global Surgery Policy Number GLS03272013RP Approved By UnitedHealthcare Medicare Committee Current Approval Date 04/09/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare
More informationMedicare Inpatient Admission Standards: Two Midnight and Physician Certification Rules
Ohio Hospital Association Medicare Inpatient Admission Standards: Two Midnight and Physician Certification Rules Christa Nordlund cfn1@fuse.net Jeri Rose West Chester Hospital 7700 University Drive West
More informationCompliant Documentation for Coding and Billing. Caren Swartz CPC,CPMA,CPC-H,CPC-I
Compliant Documentation for Coding and Billing Caren Swartz CPC,CPMA,CPC-H,CPC-I caren@practiceintegrity.com Disclaimer Information contained in this text is based on CPT, ICD-9-CM and HCPCS rules and
More informationCurrent Hospital Issues in the Medicare Program
Current Hospital Issues in the Medicare Program submitted for the record to the Committee on Ways & Means Subcommittee on Health U.S. House of Representatives by the Association of American Medical Colleges
More informationReview of Claims Affected by Temporary Suspension of BFCC-QIO Short Stay Reviews Q&As
Review of Claims Affected by Temporary Suspension of BFCC-QIO Short Stay Reviews Q&As INTRODUCTION On May 4, 2016, the Centers for Medicare & Medicaid Services (CMS) temporarily paused the Beneficiary
More informationMEDICARE FINAL RULE Related to INPATIENT Hospital Status Effective
MEDICARE FINAL RULE Related to INPATIENT Hospital Status Effective 10-1-13 TIMELINE August 2, 2013 Final rule published August 19, 2013 CMS holds open door forum. Many questions raised Sept 5, 2013 CMS
More informationValorie Sweigart, DNP g, Samuel Shartar, RN, CEN Emory Healthcare
Valorie Sweigart, DNP g, Samuel Shartar, RN, CEN Emory Healthcare Why build Principles of observational medicine ROI ED Hospital Clinical implications Define intended d use Open, closed or mixed use Impact
More informationCAH SWING BED BILLING, CODING AND DOCUMENTATION. Lisa Pando, Sr. Consultant GPS Healthcare Consultants
CAH SWING BED BILLING, CODING AND Lisa Pando, Sr. Consultant GPS Healthcare Consultants Learning Objectives: 1. Review Medical Necessity documentation specific to swing bed patients 2. Reasons to use the
More informationTELECOMMUNICATION SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL
TELECOMMUNICATION SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL NOVEMBER 2017 CSHCN PROVIDER PROCEDURES MANUAL NOVEMBER 2017 TELECOMMUNICATION SERVICES Table of Contents 38.1 Enrollment......................................................................
More informationHospices Under the Microscope: Are You Prepared for ZPICs? Medicare Integrity Programs. Objectives. Fraud or Abuse? 3/3/2014
Hospices Under the Microscope: Are You Prepared for ZPICs? Paula G. Sanders, Esquire Principal & Chair Health Care Practice Post & Schell, PC Diane Baldi, RN CHPN Chief Executive Officer Hospice of the
More information