Understanding the New OMIG Audit Protocol for Assisted Living Programs

Transcription

1 Understanding the New OMIG Audit Protocol for Assisted Living Programs NYSCAL Audio Conference January 23, 2014 David R. Ross, Esq. O Connell and Aronowitz, Attorneys at Law (518) dross@oalaw.com DISCLAIMER: FOR EDUCATIONAL PURPOSES ONLY. THIS IS NOT LEGAL ADVICE. PLEASE CONSULT WITH YOUR OWN ATTORNEY. Albany Plattsburgh Saratoga (518)

2 Following up This audio conference is following up from the NYSHFA/NYSCAL Conference in Troy, NY on November 13, 2012 where I, along with Medicaid Inspector General James Cox, presented on Office of the Medicaid Inspector General (OMIG) Assisted Living Program (ALP) audits Albany Plattsburgh Saratoga (518)

3 Following up (cont d) ALP audit protocol was being worked on by the OMIG at that time ALP audit protocol released on November 22, Albany Plattsburgh Saratoga (518)

4 Basics: How are ALPs reimbursed? The State s Medicaid program reimburses ALPs for services furnished to Medicaid-eligible residents at a capitated per diem rate Albany Plattsburgh Saratoga (518)

5 Basics: Services included in the ALP rate (1) personal care services (2) home health aide services (3) personal emergency response services (4) nursing services (5) physical therapy Albany Plattsburgh Saratoga (518)

6 Basics: Services included in the ALP rate (cont d) (6) occupational therapy (7) speech therapy (8) medical supplies and equipment not requiring prior authorization (9) adult day health care Albany Plattsburgh Saratoga (518)

7 OMIG s basic ALP rule Medicaid will only pay for goods or services once, so Items included in the ALP per diem rate will only be paid for once Albany Plattsburgh Saratoga (518)

8 ALPs and the OMIG What has the OMIG been looking for in their audits of ALPs? Review OMIG s published documents (Annual Reports and Work Plans) Review past OMIG Final Audit Reports Albany Plattsburgh Saratoga (518)

9 Historical OMIG ALP audit categories We have seen 4 basic findings: (1) Durable Medical Equipment and Supplies not Requiring Prior Approval Billed During an ALP Stay Albany Plattsburgh Saratoga (518)

10 Historical OMIG ALP audit categories (cont d) (2) Physical, Speech and/or Occupational Therapy Billed During an ALP Stay Albany Plattsburgh Saratoga (518)

11 Historical OMIG ALP audit categories (cont d) (3) Home Health Aide, Personal Care and/or Personal Emergency Response Services Billed During an ALP Stay Albany Plattsburgh Saratoga (518)

12 Historical OMIG ALP audit categories (cont d) (4) ALP Per Diem Billed during Medicaid Recipient Inpatient Hospital Stay Albany Plattsburgh Saratoga (518)

13 Primary form of OMIG disallowances Goods and services delivered to ALP residents by other providers and billed to the Medicaid program but which were also included in the ALP payment rate, resulting in the Medicaid program having paid twice for these services Albany Plattsburgh Saratoga (518)

14 Potential OMIG disallowances Service documentation issues Documentation of care given to ALP residents, focusing on timely medical evaluations, interim assessments, plans of care, functional assessments, and the presence of relevant evidence of service provision Albany Plattsburgh Saratoga (518)

15 What is the OMIG looking for now? According to the OMIG s Work Plan: Duplicate payments for goods and services already paid for in the ALP rate Service documentation issues Albany Plattsburgh Saratoga (518)

16 Inappropriate Fee-for-Service Billings for Assisted Living Program Residents Medicaid will not pay for any items furnished to an ALP when the cost of these items is included in the facility's rate. OMIG will identify goods and services delivered to ALP residents by other providers and billed to the Medicaid program but had also been included in the ALP payment rate, resulting in the Medicaid program having paid twice for these services. (source: OMIG Work Plan, p. 17.) Albany Plattsburgh Saratoga (518)

17 Fee for Service Reviews of Assisted Living Program Resident Care OMIG may conduct reviews which are concerned with the documentation of care given to ALP residents. These reviews would focus on timely medical evaluations, interim assessments, plans of care, functional assessments, and the presence of relevant evidence of service provision. (source: OMIG Work Plan, p. 17.) Albany Plattsburgh Saratoga (518)

18 What are audit protocols? Set of standards governing the criteria by which audit findings will be determined Shows the types of things that will result in a disallowance OMIG audit protocols are not exhaustive There may be additional disallowances Albany Plattsburgh Saratoga (518)

19 What is the new OMIG ALP audit protocol? Released November 22, areas of potential disallowances Remember: additional disallowances are possible Albany Plattsburgh Saratoga (518)

20 New OMIG ALP audit protocols We will go through each of the 22 areas of audit findings Questions and answers at the end Albany Plattsburgh Saratoga (518)

21 #1: Missing Patient Record If the provider is unable to produce the patient record, the paid claim will be disallowed. The nature of the facts surrounding the missing record should be evaluated for additional action. Albany Plattsburgh Saratoga (518)

22 #2: Missing Medical Evaluation The medical evaluation is the equivalent of the medical order for service. If the medical evaluation is missing or the document presented is more than 12 months prior to the date of service, the medical evaluation will be deemed as missing and the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

23 #3: Missing/Invalid Signature on Medical Evaluation A medical evaluation may be dated and signed by a physician, physician s assistant or a nurse practitioner. However, a medical evaluation signed by a physician s assistant or nurse practitioner is not effective unless and until a physician co-signs the document. The lack of the physician s signature will result in the paid claim being disallowed. Albany Plattsburgh Saratoga (518)

24 #4: Missing Interim Assessment The Interim Assessment is a follow up examination which occurs 6 months after the medical evaluation. It is the equivalent of the medical order for service. The document is required when the medical evaluation has not been conducted in the previous 6 months. If the Interim Assessment is missing when required, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

25 #5:Missing/Invalid Signature on Interim Assessment An Interim Assessment must be dated and signed by a physician, physician s assistant or a nurse practitioner. However, an Interim Assessment signed by a physician s assistant or nurse practitioner is not effective unless and until a physician co-signs the document. The lack of a signature and or date will result in the disallowance of the paid claim. Albany Plattsburgh Saratoga (518)

26 #6:Missing Plan of Care If the Plan of Care is missing, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

27 #7:Missing Nursing/Functional/Social Assessment If the Nursing/Functional/Social Assessment is missing, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

28 #8:Missing Date and/or Signature on Plan of Care The Plan of Care must be dated and signed by an RN. If it is not, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

29 #9:Missing Date and/or Signature on Nursing/Functional/Social Assessment If the Nursing/Functional/Social Assessment is not dated and signed, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

30 #10:Missing Patient Review Instrument (PRI) If the Patient Review Instrument applicable for the claim under review is missing, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

31 #11:Missing Date and/or Signature on Patient Review Instrument If the Patient Review Instrument applicable for the claim under review is not dated and signed by a qualified assessor, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

32 #12:Incorrect PRI Level Claimed Determined by PRI Certified Nurse If the PRI Level is not supported by the record, the correct level will be determined from the information in the record. The difference between the appropriate claim amount and the paid claim amount will be disallowed. Albany Plattsburgh Saratoga (518)

33 #13:No Service Rendered If the Medicaid-covered service required by the Plan of Care is not supported by the patient record, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

34 #14:Missing Service Documentation The service must be documented in the record. The paid claim will be disallowed if this documentation is missing. Albany Plattsburgh Saratoga (518)

35 #15:Incorrect Rate Code Billed If the rate code billed is not the correct rate code for the services provided, the difference between the appropriate claim amount and the paid claim amount will be disallowed. Albany Plattsburgh Saratoga (518)

36 #16:Billed for Services While Inpatient at Another Facility Services paid when the patient was an inpatient at another facility will be disallowed. Albany Plattsburgh Saratoga (518)

37 #17:Failure to Complete Minimum Training Requirements If a review of the personnel folder has found that the mandatory training was not documented in the caregivers chart, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

38 #18:Missing Certificate of Immunization If a review of the personnel folder has found that the mandatory certificate of immunization was not in the caregivers chart, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

39 #19:Failure to Complete Required Health Assessment If documentation that the caregiver has met the requirement of a yearly health assessment is missing, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

40 #20:Missing Documentation of a PPD (Mantoux) Skin Test or Follow- Up If documentation that the caregiver has met the requirement of a yearly PPD (Mantoux) skin test is missing, or if the required follow-up is missing, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

41 #21:Missing Personnel Record(s) If the requested personnel records are missing, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

42 #22:Failure to Complete Annual Performance Evaluation If the annual performance evaluation is missing or incomplete, the paid claim will be disallowed. Albany Plattsburgh Saratoga (518)

43 Conclusion Closing comments Questions? Albany Plattsburgh Saratoga (518)

44 Contact information David R. Ross, Esq. O Connell and Aronowitz Attorneys at Law (518) dross@oalaw.com CONNECT WITH US: (our blog) & aronowitz Albany Plattsburgh Saratoga (518)