Using SNF Data to Manage Federal & State Audit Initiatives

Transcription

1 Using SNF Data to Manage Federal & State Audit Initiatives 2012 OIG & GAO Reports In 2009 OIG estimated that 47% of claims had misreported information on the MDS that caused significant errors in Billing $ 25% of all claims had billing errors of over $1.5B Over 20% Up coded Less than 3% Down coded Over 2% Did not meet coverage requirements FY 2011 was budgeted as Budget Neutral but increased by $2.1 B or 16% Medicare Payment Advisory Commission concerns about SNF payments in FY 2012 of $32.2 B for Medicare ZIMMET HEALTHCARE SERVICES GROUP, LLC 1

2 More Concerns About Error Rates & Overpayments SNFs increased volume of higher paying RUGs from 2006 to 2008 even though beneficiary characteristics remain the same Volume of Ultra High Therapy RUGS increased by nearly 90% For profit SNFs more likely to bill for higher paying RUGs More than $23B returned to the Medicare Trust Fund since 1997 through audit efforts What Is An Overpayment? Any funds that a person receives or retains under Title XVIII to which the person, after applicable reconciliation, is not entitled to. Payment for non covered services Payment in excess of the amount allowed Incorrect coding resulting in a higher reimbursement Services provided by an unlicensed or excluded individual Duplicate payments Errors and non reimbursable expenditures in cost reports ZIMMET HEALTHCARE SERVICES GROUP, LLC 2

3 UB 04 Errors: Sources of Overpayments Eligibility and Financial verification, Identity Qualifying stay, benefit period, Physician Certification, Condition treated as part of hospital stay MDS Assessments including : RUG data and ARD, Diagnosis coding, services provided including treatments and therapies, ADLs, physician exams and orders Financial Information including identity, Clinical record Omissions and Invalid Entries: Orders, certifications, supportive documentation Worthless services Cost Reports, Census Data Errors: ZHSG Medicare RDA: 10/1/12 04/30/13 Indicator ZHSG Avg. % Rehab + ES 1.7% % Rehab (w/o ES) 88.9% Total Rehab % 90.6% % Hx2, Lx2, Cx2 18.2% % lower % Rehab Intensity Distribution Ultra High 52.2% Very High 29.5% High 11.3% Medium 6.9% Low 0.1% Rehab ADL Distribution Rehab "X" 55.6% Rehab "L" 44.4% Rehab "C" 34.8% Rehab "B" 39.7% Rehab "A" 25.6% ZIMMET HEALTHCARE SERVICES GROUP, LLC 3

4 OIG on Part B Therapy 2010 report to Congress indicated that Medicare expenditures for Part B therapy increased 133% in 2009 while the number of people receiving services increased 26% Improper use of KX modifier Exceeding the therapy cap (with exceptions ) Failure of tracking systems to identify people who received multiple therapy services from different providers What Part B Therapy Activity Audited? KX Modifier $$ per claim Length of time in program Intensity of program Functional Limit Reporting Beneficiary Proposal to have MACs audit ALL claims over $3,700 payment limitation being challenged by industry Manual Medical Review in certain states Post pay review for balance of states ZIMMET HEALTHCARE SERVICES GROUP, LLC 4

5 Outpatient Therapy Spending & Usage (2011) Therapy Users Total Spending Share of Spending Mean Spending per User Mean Visits per User Users Above the Cap Mean Spending on Users Who Exceed Cap PT 4.3M $4.1B 71% $ % $3,013 ST 0.6M $0.5B 10% $ OT 1.1M $1.1B 19% $1, % $3,026 Total 4.9M $5.7B $1, Totals reflect the number of individual beneficiaries, some of whom received multiple disciplines Source: MedPAC 9 Request for Repayments OIG reported in June 2013 that a local provider of therapy services overbilled Medicare $3.1M Decision was based on a random sample of claims (100) out of 40,000 claims billed Errors found in 83 claims (some had multiples) No physician CERT (45) No treatment notes (36) Therapist did not perform any of the services Services not R&N (21) Therapy plan did not meet Medicare requirements NYS OMIG and AG investigating psychologists and other SNF Part B professional providers ZIMMET HEALTHCARE SERVICES GROUP, LLC 5

6 2012 Top Reasons for Medicare SNF Audits RUA on Any Assessment (FI/MAC, ZPIC) Disproportionate Number of RUB, RUC Days Compared to Peers (FI/MAC, ZPIC) RU anything over 60 days (FI/MAC, ZPICs) Excessive Length of Stay Compared to Peers (FI/MACs) Disproportionate $ Paid to a Provider Compared to Peers (FI/MAC, ZPIC, OIG) Part B Therapy Claims with Ill defined Diagnosis Codes (719.7, 728.9, 780.7, 290.0) (FI/MAC) Part B Therapy with CCI Modifier or Units Errors (RAC) Claims with 042 Diagnosis (FI/MAC) Auditing the Part A SNF Claims CMS has been directed by the OIG to train Federal and State surveyors on the accuracy of MDS assessments and ensure same Multiple entities (MAC, ZPIC, CERT, RAC) all sending ADRs via the MAC for medical records MAC has authority to flag the claims identified by the audit group MAC will adjust (cancel) all claims found to be invalid by the audit group Claim cancels result in an Overpayment debt which is due in 60 days APPEALS must be filed within 30 days to stop interest payments from accumulating ZIMMET HEALTHCARE SERVICES GROUP, LLC 6

7 Auditing Under What Authority? Center for Program Integrity (CPI) Created by CMS to monitor Medicare payments to ensure validity of the claim (billing and coverage decisions) To identify improper billing, and recover monies paid in error Fraud Prevention System (FPS) Created by Small Business Jobs Act Analyzes Medicare data to detect fraudulent behavior Investigated by Program Integrity analysts Once FPS is successfully blended into the claims system, it will strengthen efforts to stop improper payments Regulatory Framework for Audit & Reviews Social Security Act Code of Federal Regulations CMS Claims Manual NUBC Billing Guide Fiscal Intermediary Directions Local Medical Review Policies Proposed Rule 02/2012: Reporting & Returning Overpayments to the Medicare Program ROI: Return on Investment by Federal Government is $7+ for every $1 spent ZIMMET HEALTHCARE SERVICES GROUP, LLC 7

8 Meet Your Auditors Medicare FIs/MACs The CERT The RAC The OIG ZPIC Benefit Integrity Unit Insurance Company Auditors (MSP Payments) Medicaid The MIC The PERM OMIG Medicaid RAC Who are These Audit Groups? MAC (Medicare Administrative Contractor) FKA FI or Medicare retains the responsibility to medically audit your claims Data driven on topics set by CMS or by their own criteria If you stand out from your peers, you will likely be audited CERT (Comprehensive Error Rate Testing) Medical review to check the accuracy of payment by MAC YOUR claim is independently reviewed and can be denied Denials cannot be deemed fraud by this audit group ZIMMET HEALTHCARE SERVICES GROUP, LLC 8

9 Who are These Audit Groups? MIC (Medicaid Integrity Contractor) Arm of Office of the Medicaid Inspector General Responsible to validate accuracy of Medicaid payments PERM (Payment Error Rate Measurement) CMS uses a 17 state rotation for PERM. Each state is reviewed once every three years. This rotation allows states to plan for the reviews as they know in advance when they will be measured Audit measures payment accuracy rate in fee for service (FFS), managed care, and eligibility for Medicaid and CHIP New RA Audit Focus RAs (RACS) are now approved for complex medical review (pre and post pay) Performant Recovery of CA is the auditor for the Northeast states including NYS, Penn In April 2013 the designated RA contractors were approved to audit episodes of care Medical records can now be solicited for an entire covered period Denials are much more likely to happen when all dates of service are audited compared to the review of with an isolated claim RAs are now also responsible for all pre pay review of Part B therapy claims over the $3700 threshold ZIMMET HEALTHCARE SERVICES GROUP, LLC 9

10 ZPICs Fraud and abuse arm of Medicare program Not a simple medical review to validate coverage and payment They are looking for reasons to deny claims and pursue fraud allegations 2012 saw increase in on site audit visits by ZPIC s (FL, CA, LA, VA) although they are active in all states Thus far, results of the ZPIC investigations have not been published ZPIC Audits Currently ZPICs are finding reasons to deny based on technical and clinical reasons which make your claims invalid (pre & post pay): Incomplete or incorrectly signed and dated CERTS, ORDERS, PLANS of CARE Missing treatment records, progress notes, Inadequate PLOF on therapy records (SNF cannot justify need for services) Medically unnecessary services or level of service provided ZIMMET HEALTHCARE SERVICES GROUP, LLC 10

11 ZPIC Power Because of their mission to uncover fraud, ZPIC findings can result in immediate suspension of payment Demand overpayments be refunded DME providers can lose their Accrediting Organization (AO) certification withdrawn Cases may be forwarded to the Department of Justice for resolution Results in legal action, penalties and possible incarceration Watch Your Mail for PEPPER Program for Evaluating Payment Patterns Electronic Report starting in August 2013 for Medicare providers SNF specific report summarizing Medicare claims data in areas considered at risk for improper payment Will include facility stats for Episodes of Care ending between October 2009 through September 2012 Looking at Outliers: Percents & Percentiles At or above 80 percentile for over coding At or below 20 percentile for under coding ZIMMET HEALTHCARE SERVICES GROUP, LLC 11

12 PEPPER Will Examine Billing Patterns Will help providers to understand how they compare to others using Target Areas as determined by CMS Therapy RUGs with high ADLs Non therapy RUGs with High ADLs Change of Therapy Assessments within an episode of care Ultrahigh Therapy RUGS 90+ Day Episodes of care Contractor is TMF Health Quality Institute Therapy Documentation Continues To Be The #1 Review Target in SNFs Resident Goals and documentation of services must support Utilization Levels Attendance logs, daily treatment notes Progress notes including measurements Evidence of Skilled care and interventions If a therapy aide can provide it isn t skilled Motivation & participation of resident Ability to follow instruction/carryover Tolerance/response to exercise regimen Outcomes ZIMMET HEALTHCARE SERVICES GROUP, LLC 12

13 On the State Side the OMIG Due to budget constraints, all states are ramping up their audit efforts Auditing style, frequency and penalties for Medicaid CMI is determined by States Pennsylvania UMR visits quarterly and keeps statistics on errors NJ gearing up with audit policies NYS Office of Medicaid Inspector General (OMIG) is already in our SNFs investigating the validity of MDSs MDS Case Mix audits are focused on SNFs whose had an increase of 5% or greater between 2011 and 2012 NYS Model for National Compliance Programs 18 NYCRR (a) Compliance Programs shall be applicable to: (1) Billings; (2) Payments; (3) Medical necessity and quality of care; (4) Governance; (5) Mandatory reporting; (6) Credentialing; and (7) Other risk areas that are or should with due diligence be identified by the provider. ZIMMET HEALTHCARE SERVICES GROUP, LLC 13

14 You ve Been Notified! Carefully review the letter or the online notification to determine: Who is asking? What do they want? When and Where must it be submitted? Assign staff for responsibility of How to comply Gathering the clinical and financial records Organize record to tell the story with orders, certs and any other information to demonstrate appropriateness and accuracy of claim Make an exact copy of the record to retain at facility Submit with dated tracking number Consider clinical and/or legal assistance to review documentation prior to submission After the Audit All Medicare audit findings of overpayment and denials are channeled through the Medicare claims processing contractor (FI/MAC) Deny any pre pay claims found to be non payable by auditors Holds the authority to mark claims identified as containing overpayments Facilitates the process of notification Cancels previously processed claims Handles all collection efforts Handles all initial appeals ZIMMET HEALTHCARE SERVICES GROUP, LLC 14

15 Appeals Guidance Check reason for EACH denial (FI/MAC letter) Check medical record to establish if claim can be defended Do NOT appeal a claim you cannot support (it will keep your denial stats high and continue focus on your operations) Appeal ALL claims that you believe are valid KEEP GOING (Redetermination, Reconsideration, ALJ, Appeals Council, Federal Court) Check Yourself Before The Feds & State Audit Groups Do! Every SNF should self audit the following: Qualifying Hospital Stay for all admissions Was it ACUTE stay? Was it an observation stay? Resident Eligibility Other Insurance (MSP questionnaire) MDS Accuracy (does the MDS agree with the chart?) Therapy DOC Claims coding (does the claim reflect the correct diagnosis/units/rev codes/ancillaries?) Consult with legal counsel about reporting and overpayments 60 day repayment rule after discovery ZIMMET HEALTHCARE SERVICES GROUP, LLC 15

16 Bottom Line for SNFs: It Starts Facility Standards of Practice Medicare meetings: Review of services related to Hospital stay and meets requirements for Skilled Care on a Daily basis Clinical documentation to support payment drivers Accuracy of MDS Assessments Resident function including Quality of Life, Quality of Care Utilization of CAAs for identification of problems, risks, strengths to develop Care Plans Accuracy of Facility QM, QIS, Survey, Five Star Discharge, Re Hospitalizations, End of life Tracking Accuracy of Reimbursement Avoidance of audit and false claims Review of Worthless Services Compare the MDS to the UB 04 Clinical staff have the responsibility to validate clinical documentation and the MDS Billing staff have the responsibility to match the MDS to the claim that is submitted to Medicare Billers should not be traffic cops ; standing at the intersection of multiple software systems and merely waving data (claims) out the door If clinical staff does not have background to review a claim, billing staff should be (at a minimum) allowed to review info with clinical team (Medicare meetings?) to insure accuracy of data ZIMMET HEALTHCARE SERVICES GROUP, LLC 16

17 What Do Your Claims Say About You? What are Your Risks? How does your Data compare to Benchmarks in Part A, Part B & Medicaid Claims RUG levels ADL LOS Types of Assessments, COT Discharge Destinations ADRs, Denials, Billing Errors Your Audit findings? Good Clinical Practices Require SNFs to provide all services necessary to help residents achieve their highest level of functioning Requires coordination of clinical services and documentation Requires accurate and timely reporting of care and services provided Requires accurate billing of services provided within appropriate reimbursement framework Requires positive outcomes for resident care ZIMMET HEALTHCARE SERVICES GROUP, LLC 17

18 Conclusion Proactive Analysis Internal : Ongoing Auditing and Monitoring Identify Trends & Outliers External: Provider Profile Updates & modifications in response to Regulatory changes On going Training and Implementation Utilize structured reporting mechanisms including QAPI, QI, Five Star Utilize legal counsel when necessary ZIMMET HEALTHCARE SERVICES GROUP, LLC 18