Audit to Protect Your Margins

Transcription

1 Audit to Protect Your Margins An IRF Year to Remember 2010 Don t Let it Come Back to Haunt You Darlene L. D Altorio-Jones, PT., MBA-HCM Strategist, Program Improvement/Rehab Mgmt.

2 Agenda Significance of 2010 for IRF s Leaving the past behind 11 Life Changing Criteria 155 Clarifications to date that guide 2010 Regulation Expectations! Protecting the Medicare Trust Fund ON Steroids What you don t know CAN HURT YOU! Audit Criteria - Step by Step & WHY Audit Checklist and do it yourself guidance Determine YOUR RISKS SET YOUR UNIQUE PLAN Continuous Quality Improvement It s YOUR DUTY COP, Compliance, Utilization Review Defend using 2010 Specific Formula Audit & Return! 2

3 Objectives: Objectives Participants will grasp the serious consequences in understanding the conditions of participation (C.O.P.) in an IRF as defined in the 2010 Guidelines and how they are monitored for Medicare Part A patients. Participants can clarify expected baselines for measurement and adherence to medically necessary admissions and how documentation must support compliance to refute denial audits. Participants will be provided tools and skills to enable self-audit at a level expected by either their FI/MAC, RAC auditors/contractors. Attendees will be able to state time deadlines and documentation requirements that must be supported in the Medical Record and to apply a 1-5 rating Risk to presence of criteria. Participants will be empowered to complete meaningful self-audits of the entire IRF throughput; admit to billing and demonstrate resources that back up measurement clarity. Tools and Resources will be provided 3

4 Objectives Attendees will be exposed to how electronic documentation systems can/should provide discrete elements to track success in meeting clinical and physician charting mandates for more than just a % of population. Attendees will be provided a format for Plan, Do, Check, Act Process improvement and will be able to utilize that format to plan and guide performance improvement toward 2010 mandates. AFTER completing the detailed audit, participants will be able to utilize the information gathered in a RETURN WEBINAR that will demonstrate HOW TO format a rebuttal upon an additional development request (ADR) HOW TO gather documented evidence to support Medical Necessity HOW to utilize that information to write a rebuttal that demonstrates REASONABLE & NECESSARY care was provided in line with expected regulations HOW to IMPROVE the PRE-ADMISSION PROCESS so that detailed evidence/rationale is supported beginning to end in the documentation process. 4

5 Hospital s Biggest Regulatory Headache: Compliance HEALTHLEADERSMEDIA.COM /INTELLIGENCE, December 2012 Regulatory Strategies: From Medicare to Meaningful Use

6 IRF Admission: Prior Basis Medical Necessity Prior to 2010 Federal Regulations HCFA 85-2 Ruling was the standard defense for medically necessary IRF Care. Statements that represented guidelines but without specific measurement criteria toward expectations of process. HUGE RAC Denial demonstration using these criteria was hugely debated and somewhat nonsticky resulting in over turned decisions.

7 HCFA Ruling 85-2 (OLD) EIGHT CRITERIA, when satisfied conclusively established IRF stay as MEDICALLY NECESSARY The patient must require and receive close medical supervision by a physician with specialized training or experience in rehabilitation. The patient must require and receive 24-hour rehabilitation nursing. The patient must require and receive a relatively intense level of rehabilitation services. The patient must require and receive a multidisciplinary team approach to delivery of program.

8 HCFA Ruling 85-2 (OLD) The patient must require and receive a coordinated program of care. The patient must be likely to achieve a significant practical improvement. The patient s goals must be realistic. The length of the rehabilitation program must be reasonable. LOOK FAMILIAR??? CMS REDEFINED Placed parameters and called it REASONABLE & NECESSARY no longer must defend that a SNF stay WOULD have been possible as long as criteria met.

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11 Final 2012 SNF 1351F Regulations page 48499

12 RAC Program Myths?

13 Process Changing Regulations 13

14 Grasp Reality Clearly comprehend THEN & NOW Treat the Pre-Admission Assessment Accordingly. TAKE TIME Defensible Medically Reasonable RATIONALE = Reasonable & Necessary. Once Criteria is pronounced ALL documentation continues to defend that decision for all merits rendered. Take the Disconnect CHALLENGE? Extract rationale bullets find them in your staff s documentation - If you can you are doing it RIGHT!

15 Clarifications Guide SPECIFIC EXPECTATIONS

16 Immense Leadership Challenges Post Acute Care CMS Protecting the Medicare Trust Fund Prospective Payment Systems- Extremely prescriptive payment criteria IRF areas high mandated timeframes/expectations In addition to 60% rule enforcement of Rehab 13 Demonstrate preponderance compliance Saves ability to operate as an IRF and not be subject to EXTRAPOLATION of findings increased liability! However each chart stands on it s own to defend payment one by one! All 11 criteria add up to more than 44 items that must be monitored initially and then ONGOING for each record. PROCESS IS KEY STAFF must ADHERE

17 IRF REGULATIONS: HOW MANY BEDS DO YOU SERVE? 10 Beds x 44 = Whopping 440 indicators in a continuous vigilant cycle 20 Beds x 44 = 880 continuous indicators 30 Beds x 44 = 1,320 continuous indicators 40 Beds x 44 = 1,760 continuous indicators HOW MANY FACILITIES ADDED STAFF to COMPLY? HOW MANY ADDED STAFF JUST TO MONITOR 2010 Regulations?

18 RAC Demo REAL RAC REFORM

19 What s at Stake? Fiscal Yr Review 19

20 Fiscal Yr Review 20

21 RAC Contractor Activity Comparison July Sept 2011 Over payments Collected: Million Underpayments Returned: 76.6 Million FYTD Corrections: Million July Sept 2012 Over payments Collected: Million Underpayments Returned: 46.5 Million FYTD Corrections: 2,400.7 Billion 21

22 Why Audit? To participate in the Medicare Program you must participate in Utilization Review of your program against regulatory mandated practice Auditing practice to expected standards should IDEALLY occur in REAL TIME; in order to set priorities you need to develop your RISK potential and then specifically improve workflow & expectations to mitigate areas that fall short of expectation 22

23 IRF Benefit Designed to provide: Intensive rehabilitation therapy In a resource intensive hospital environment For patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary approach to the delivery of rehabilitation care. 23

24 Patient Type Patients must be able to fully/actively participate in and benefit from intensive rehabilitation therapy program prior to transfer from the referring hospital. Patients who are still completing their course of treatment in the referring hospital and cannot tolerate an intensive therapy program are not appropriate for IRF admission. 24

25 Consequences are High

26 Reasonable at the START Reasonable & Necessary vs. Medically Necessary

27 Who is Looking? Why? Network- MLN/MLNProducts/downloads/ContractorEntityGuide_ICN pdf 27

28 Office of Inspector General Safeguarding the integrity of the Medicare and Medicaid programs and the health and welfare of their beneficiaries. THE OFFICE OF AUDIT SERVICES (OAS) THE OFFICE OF EVALUATION AND INSPECTIONS (OEI) THE OFFICE OF INVESTIGATIONS (OI) THE OFFICE OF COUNSEL TO THE INSPECTOR GENERAL (OCIG) 28

29 OIG Work Plan Heads Up 29

30 The greatest risk to any organization is leadership s failure to know the current status of all key expectations IF YOU DON T AUDIT YOU REALLY DON T KNOW YOUR RISKS!

31 Numerous COP to Track! RACs have become the focus of our industry sort of like driving by looking in the rear view mirror. * ALL Conditions of Participation are important: In the new era of healthcare reform and accountable care, successful IRFs must not only focus upon defending critical dollars from RAC auditors, but also address the entire spectrum of revenue integrity and compliance issues threatening their bottom line. *Bob Habasevich (MediServe blog 02/12/2013)

32 Sample Population & Risk Each limit is based on the provider s prior calendar year Medicare claims volume. The maximum number of requests per 45 days is 400. Limit is = to 2% of all claims submitted for the previous calendar year divided by 8. The Recovery Auditors may go more than 45 days between record requests but may not make requests more frequently than every 45 days. IF Provider (TIN) billed 156,253 Medicare claims last year. 2% of the claims volume is 3,125. The limit is calculated by dividing 3,125 by 8. The provider s limit is no more than 390 requests every 45 days. IF 1,200 claims last year. (Free standing IRF perhaps). Math is 1,200 x.02% = 24/8 = 3 claims in any 45 day period 365/45 days = 8.1 request per year possible.

33 Calculate Denial Risk If a CMI of 1.0 is $14,343* X 24 pts. = $344, of defensible risk. If your CMI is higher so is your RISK! If your CMI is closer to x that amount would need to be defended. IF YOUR unit is part of a LARGE hospital system using the same TAX ID NUMBER you could experience an audit of your ENTIRE annual volume in the same 45 day period or within just a couple of 45 day periods. The audit contractors do not have to use ONE level of service for volume %.

34 Likert Scale (1 5) Indicator Presence 5 = Meets Evidence Explicitly to Regulation Detail 4 = Adequate Evidence - Good, Most Details Present 3 = Obvious - Not Strongly Represented, Some Details 2 = Poor Evidence - Inconsistent to Expectation 1 = Unable to Find - Absent Expectation Details

35 What is Your RISK Strategy? Must AUDIT RECORDS and DETERMINE AREAS of Strengths & Weaknesses

36 REGULATIONS SPELL OUT CMS does not believe that patients should be transferred to IRF s before their medical conditions are sufficiently stable to enable them to participate in the intensive rehabilitation program provided by the IRF. (CFR42 part 112 pg ) This was ALWAYS intended but not specifically spelled out and sometimes was used to demonstrate lack of acute care stay criteria.

37 Treatment Goals per CMS Generally, the goal of IRF treatment should be the patient s safe return to the home or community-based environment. IRF patients do not have to be expected to achieve complete independence in the domain of self-care nor do they have to be expected to be able to return to their prior level of function. 37

38 Medical Necessity 11 Results 38

39 Documentation Requirements Pre-Admission Screening Physician Orders Post-Admission Physician Evaluation Individualized Overall Plan of Care Intensive Level of Services Weekly Team Meetings Substantial updates functional/medical by Rehab Physician no less than 3x/weekly IRF Patient Assessment Instrument (PAI) included in medical record 39

40 Foundation Starting Right How much time is just right for Pre-Admission Screening Assessment? Generally I hear it takes.5 to 1.5 hours of work! However; 5 10 Hours additional personnel work per denied claim to review, tag, refute information at the chart level makes this level of due diligence well worth it! An appeal takes far greater than 1.0 to 1.5 hrs. to defend record reasonable & necessary prior to the admission. TAKE THE TIME, it is the most important step next to patient s plan of care because THIS INFORMATION DRIVES the patient s expected plan of care. 40

41 Pre-Admission Screening Prior level of function Expected level of improvement Expected length of time to achieve that level of improvement Risk for clinical complications Conditions that caused the need for rehabilitation Combinations of treatments needed Expected frequency and duration of treatment in the IRF Anticipated discharge destination Any anticipated post-discharge treatments Other information relevant to the patient s care needs 41

42 Pre-Admission 35 Clarifications 42

43 Definition of Timely Conducted within the 48 hours immediately preceding the IRF admission, or Documentation updated (within the 48 hour time period) if a comprehensive screening containing all of the required elements was conducted > 48 hours prior to the admission. Must be signed, dated, and timed by a rehabilitation physician. The rehabilitation physician has to document his or her concurrence with the findings and results of the preadmission screening after the preadmission screening is completed and before the IRF admission. Should support the admission decision if they CONCUR with documentation that defends an IRF level of care. 43

44 Pre-Admission Assessment Screening 44

45 Post-Admission Physician Evaluation Ensure that a rehabilitation physician sees the patient in the first 24 hours of admission. Checks whether the patient s status validates pre-admission screening documentation. (changes) Begin development of the patient s expected course of treatment as soon as possible (within 24 hours of admission). Review the patient s prior and current medical and functional conditions and comorbidities. (Intended Repeat) Provide H&P and provide medical necessity for IRF level of care 45

46 Post Admission Physician Eval 17 Results

47 H&P & Post Admission Evaluation 47

48 Individualized Interdisciplinary POC Must demonstrate individualization & unique care needs of the patient as it correlates to the Pre-Admission Screening, Post-Admission Evaluation & H&P & Clinical Assessments Therapy/Nursing. Must be synthesized by a rehabilitation physician Must be completed by end of day 4 - IRF admission Can be done with the PAE/H&P but recommended to be collaborative after other discipline evaluations. 48

49 POC Required Information Estimated length of stay Medical Prognosis Functional Outcomes Anticipated interventions Predicted Discharge Destination Expected therapy intensity (# of hours per day) by discipline, frequency (# of days per week), and duration (total number of days during the IRF stay) 49

50 Clarification from 05/31/2012 Call 50

51 Individualized POC 15 Results 51

52 Plan of Care & Intensity of Services 52

53 Intensive Level Rehabilitation 33 Results

54 No Less Than 3- Rehab Physician Visits 54

55 Weekly Team Meeting Purpose of the interdisciplinary team is to foster frequent, structured, and documented communication among disciplines to Establish, Prioritize, and Achieve treatment goals. Weekly Meetings Must Focus on: Assessing progress towards the rehabilitation goals; Considering resolutions to problems that could impede progress towards the goals; Reassess validity of goals previously established; and Monitoring and revising the treatment plan, as needed. 55

56 Team Meetings 16 Results 56

57 TEAM MEETINGS define Reasonable & Necessary :

58 Last Page 58

59 Reasonable & Necessary :

60 Finally Check the Uniform Bill Also review to see how the ancillary charges are itemized on the bill. (Total by Revenue code) See blog on this topic. 60

61 IRF-PAI The IRF-PAI must be contained in the patient s medical record at the IRF. The information in the IRF-PAI must correspond with all of the information provided in the patient s IRF medical record. Signed/Dated. Helpful to state time of transmission to CMS as required for Occurrence code 50 on the UB Form. 61

62 Managing 2010 Compliance Timelines Admission date & time 48 hr Pre- Admission Assessment Physician concurred/ signed off before admitted (ADT system date/time) Therapies start within 36 hrs of midnight admission day POC completed by end of day 4

63 First 4 Day Report

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65 Current 7 Day Cycle - Scheduling 65

66 Regulatory Compliance FI/MAC and RAC audits can occur simultaneously. Given these stringent guidelines/timelines. Are you prepared for an audit for each of the checklist items provided?

67 RAC Collection Process Same as FI/MAC identified overpayments A Remittance Advice notice is issued: Remark Code N432: Adjustment Based on Recovery Audit Carrier; FI/MAC recoups by offset unless provider has submitted a check or a valid appeal within the time lines provided.

68 Comply - Consequences What will happen? Could lose Exempted Status to bill as an IRF PPS. (DRG based payment instead) If Decertified require written Regional Office approval & full 12 month cost report lapse to add back into service. CFR Must follow Conversion of Bed Rules to reinstate 68

69 Extrapolation Medicare Auditors may use statistical sampling and extrapolation. By utilizing statistical sampling and extrapolation techniques, Medicare Auditors may actually review only a relatively small number of claims of a certain type of procedure (the sample). Then, if certain requirements are met, including the finding of a high error level in the sample, the Medicare Auditors are permitted to extrapolate the error rate onto a much larger universe of claims of the same type of procedure when determining the overpayment amount. CR Transmittal 114 Extrapolation 69

70 Strengths & Weaknesses in YOUR IRF:

71 Protecting Self - Risk Management Upon audit, you discover a significant lapse in any of the coverage requirements. Secure a written retainer agreement to ensure that attorney-client privilege extends to all information shared should you work with an attorney. If through chart audits you find that an area is predominantly at risk; discuss with compliance officer of your organization then attach performance improvement and surveillance to the quality initiatives within your organization. ENSURE appropriate change of practice! 71

72 MONITOR Ongoing Assessment HOW? Track Time of Recorded Admission to ADT Pre-Admission Screen Timely/Thorough H&P / Post-Admission Physician Evaluation Who, What, Why, When, How Completion of Therapy Intensity (Noon 3 rd day) Plan of Care Timeliness Content CRITICAL Pre-Admission & FIRST 4 DAYS 72

73 Five Levels of Appeal NEXT!!! / Medicare /Original Medicare Appeals 1 Redetermination 2 Reconsideration 3 Administrative Law Judge Hearing 4 Review by Medicare Appeals Council 5 Judicial Review in US District Court 73

74 Uphold Reasonable & Necessary Avoid Appeal steps 2-5! IRF s have prescriptive guidelines Demonstrate Adherence Personable Factual 74

75 Cover Letter Coverage Criteria Facts 75

76 Rebuttal

77 Step by Step Rules Met expectations conditions are present in record. 77

78 Resources: Code of Federal Regulations; IRF Final Rule 2012; 1538F Final Rule, CMS.gov and Government Printing Office GPO. Rehabilitation Facility Prospective Payment System (PPS) for Federal Register / Vol. 74, No. 151 / Friday, August 7, 2009 / Rules and Regulations Payment/InpatientRehabFacPPS/Coverage.html (Coverage Requirements for IRF October 2010, cms.gov) Clarification for Post-admission Physician Evaluation [PDF, 20KB] IRF PPS Coverage Requirements November 12, 2009 National Call - Follow-up, Series 4 [PDF, 145KB] cms.gov IRF PPS Coverage Requirements November 12, 2009 National Call - Follow-up, Series 3 [PDF, 62KB] 78

79 Resources: IRF PPS Coverage Requirements November 12, 2009 National Call - Follow-up, Series 2 [PDF, 90KB] IRF PPS Coverage Requirements November 12, 2009 National Call - Follow-up, Series 1 [PDF, 94KB] IRF PPS Coverage Requirements November 12, 2009 National Provider Conference Call Transcript and Audio File [ZIP, 25MB] Presentation Material for November 2 and 12, 2009 Call [PDF, 3MB] Follow-up Information [PDF, 45KB] MediServe Blog Article: Reasonable & necessary, Darlene L. D Altorio-Jones, PT., MBA-HCM, April 16th, 2012: 79

80 Resources: MediServe Blog Article: Reasonable & necessary, Darlene L. D Altorio-Jones, PT., MBA-HCM, December 12th, 2011: MediServe Blog Article: Reasonable & necessary, Darlene L. D Altorio-Jones, PT., MBA-HCM, April 24th, 2012: Medicare On Line Manuals; ; Chapter 1, Section 110. Inpatient Rehabilitation IRF Services Guidance/Guidance/Manuals/Downloads/bp102c01.pdf Transmittal 119; Covering guidance of , Chapter 1, Section 110 instructions. Guidance/Guidance/Transmittals/downloads//R119BP.pdf Medicare Claims Processing Manual; Financial Liability Protections; Information/BNI/downloads//CMS4105FINALRULEQsandAs2007.pdf; Chapter

81 Resources: Medicare Learning Network: Contractor Entities At A Glance: Who May Contact You About Specific Centers for Medicare & Medicaid Services (CMS) Activities. NetworkMLN/MLNProducts/downloads//ContractorEntityGuide_ICN pdf Recovery Audit Program : Section 302 of the Tax Relief and Health Care Act of Programs/recovery-audit-program/index.html?redirect=/RAC Statement of Work, Recovery Audit Contractor Program: Programs/Recovery-Audit-Program/Downloads/090111RACFinSOW.pdf Appeals Process Brochure: Medicare Learning Network; MLN/MLNProducts/Downloads/MedicareAppealsProcess.pdf Recovery Audit Contractors: Who, What, Where, When, How? ; Programs/Recovery-Audit-Program/Downloads/RACSlides.pdf Compliance Matters / Gayle Lee, JD; Filing Medicare Appeals, PT in Motion July

82 Thank You 82