Julie Kearney Kearney & Associates, Inc.

Transcription

1 Medicare, Mange Care & Medicaid Changes in the New World We Live In, Julie Kearney Kearney & Associates, Inc. 1

2 Medicaid What are we seeing? 2

3 NEW Medicaid Change MIlogin File Transfer to send information to the State. On May 20 th, 2016, users will access File Transfer through MILogin rather than Single Sign-On. What is MILogin? MILogin is the State of Michigan s new Single Sign-On, or SSO. Very soon you will begin using MILogin to access some of the State of Michigan systems or applications. MILogin will improve overall functionality, security and compliance with Federal and State regulations, such as HIPAA. When will I use MILogin? MILogin will be rolled out in phases. MDHHS DCH Legacy systems and applications that are currently on Single Sign-On will be accessed through MILogin by October, For a listing of the systems and applications currently on MILogin please visit MILogin-Info If I currently use SSO and am a Provider or Advocate, do I need to set up a MILogin account? Current Providers or Advocates who access Single Sign-on (SSO), will not need to create a MILogin account. You will use the same log in information that you currently use to access SSO. MILogin will eventually provide access to all applications needed to conduct business with the State. 3

4 Blueprint for Health Innovation MI Michigan announces pilot regions for the Blueprint for Health Innovation LANSING, Mich. In moving forward to better coordinate care, lower costs, and improve the health of Michigan residents, the Michigan Department of Health and Human Services has selected the five pilot locations for the Blueprint for Health Innovation. The identified regions are: Jackson County; Muskegon County; Genesee County; Northern Region; and the Washtenaw and Livingston counties area. Final boundaries will be determined after working with partners to target investments and impact. Additional development will begin this summer across the five regions over the three-year project period. "Launching the pilot regions this summer will help us affect payment reform and lower costs for our residents" said Tim Becker, chief deputy director of the MDHHS. "Through the pilots MDHHS will work with the healthcare community to find the best ways to implement changes going forward." The phased approach and timelines will be included in the Operational Plan due to Centers for Medicare & Medicaid Services at the end of May The pilot regions will play an important role in developing a stakeholder engagement process to gather feedback on the Operational Plan prior to submission 4

5 Provider Enrollment Electronic Signature Form Submission Process MSA Medicaid 5

6 Provider Enrollment Electronic Signature Form Submission Process In compliance with 42 CFR , the Michigan Department of Health and Human Services (MDHHS) is establishing a new process associated with Medicaid provider screening and enrollment requirements related to program integrity for the Medicaid Fee-for-Service (FFS) program. Providers were previously notified of the changes required under 42 CFR in bulletin MSA This bulletin describes the process for assigning additional domain access rights to the Community Health Automated Medicaid Processing System (CHAMPS) Provider Enrollment (PE) subsystem on a provider's behalf. These forms do not need to be completed if no new domain access rights are needed. Issued 12/30/2015 Effective on 02/01/2016 6

7 Provider Enrollment Domain Administrator Electronic Signature Agreement Form To obtain the required information mandated under 42 CFR , any provider wishing to appoint another person access to their CHAMPS information must submit an Electronic Signature Agreement form (DCH- 1401) and the Electronic Signature Agreement form cover sheet (MDHHS- 5405). The two completed forms must be submitted to the MDHHS Medicaid Provider Enrollment Unit for processing. MDHHS recommends the provider retain a copy of these forms for their records. The Electronic Signature Agreement form is also being updated to include additional language certifying the enrolled provider understands he or she is liable and bound by all information submitted on his or her behalf. 7

8 Medicaid Coinsurance Medicare Advantage Attention Nursing Facility Medicaid Fee for Service Providers, As part of the December 11, 2015 CHAMPS system update, the final phase of the Medicare Advantage Coinsurance Pricing Logic was implemented. For claim dates of service 2010 and prior, please refer to the Medicaid Provider Manual under General Information for Providers Chapter, Section 12.4 Provider Returning Overpayments. For claim dates of service 2011 and forward, MDHHS will be initiating the claim adjustment within the next few weeks. Providers with further questions can contact Provider Support by phone or 8

9 The State has been paying the wrong coinsurance amount for Medicare Advantage since Per below they will be doing a claim adjustment in the next few weeks for dates of service 2011 going forward. If you have refunded the State by a check watch and make sure they do not double recover the money. If they do you will have to get your check and list of people you refunded and send it to providersupport@michigan.gov. They have stated they have fixed the pricing logic to pay it correctly going forward. Watch and make sure they are paying the correct amount if not you will have to again pull the information from the coinsurance payer and send it to providersupport@michigan.gov. For dates of service prior to 2011 you will have to return the Money per the Medicaid manual Medicaid providers performing self audits may discover an overpayment situation and wish to return the Medicaid overpayment to MDHHS. This process should only be used when the provider is unable to claim adjust or it is not practical to claim adjust. Sending in a check will not correct the underlying claim(s) data. Providers must: Document why the money is being returned (i.e., provider self audit) and identify provider NPI information, address, dates of service, and specialty area (i.e., durable medical items, pharmacy, physician practice, hospital, etc.) and include a basic information letter. Attach an excel spreadsheet document with the Tax ID, billing NPIs, and associated amounts (if multiple IDs exist for the entity) for the MDHHS Accounting Office to apply credit to. Make check payable to "State of Michigan" and mail to the MDHHS/Cashier s Unit - Attn: Bureau of Finance-MCU. (Refer to the Directory Appendix for contact information.) 9

10 Lawsuit DHS Changes on Caregivers A recent Michigan Court of Appeals decision has played havoc on the rules surrounding payments to non-family caregivers. DHS rules regarding payments to caregivers state that payments are divestment in two situations: 1) prospective payments made to any caregiver (family or non-related) before care is provided, and 2) payments to family caregivers absent a Medicaid qualified caregiving contract. The Court of Appeals decision, Jensen v. Department of Human Services, confuses the rules and applies the family caregiving contract requirements to all caregivers, even professional caregiving agencies. The result of the case is that payments to non-family caregivers may be divestment unless the Medicaid applicant has a contract with the caregiver meeting the extremely specific rules found in the Medicaid manual. 10

11 TPL Medicaid Change Attention Providers, Effective October 26, 2015, the MDHHS Third Party Liability (TPL) Update Other Insurance Now! Online form will be updated. You will now receive a confirmation number when you submit your request. If an address is added within the Requestor Information section, once TPL completes your request, you will receive an with the confirmation number and the status of your request. Please allow up to 10 business days for information to be verified and updated in the system. Please check your spam or junk folders if you do not receive the after 10 business days. Providers with further questions can contact Provider Support by phone or ProviderSupport@michigan.gov. 11

12 CHAMPS Member Screen Attention Providers, Effective September 25, 2015, a change was made to the CHAMPS system. This change modified the provider view for the Member Eligibility Inquiry screen. If a member no longer has active Medicaid, the hyperlink to view Commercial/Other Third Party Liability (TPL) information is disabled. Because TPL does not always maintain TPL/Other Insurance information for members that do not have active Medicaid coverage, this information was disabled to prevent inaccurate information from being reported. 12

13 LOC dropping off Not Due to MI Health If, after 30 days the county hasn t processed the 2565 that you have send via the central scan ( ) AND other methods you choose to use you can the 2565 to Ardene Martin At the following mailbox. I ask that you put the beneficiaries name in the subject line. MSA2565@michigan.gov 13

14 Issues PPA going all over the place LOC 02 dropping off not related to MI Health LOCD tons of money written off Must check CHAMPS member screen all the time and you must check pending 14

15 Secure Information The State of Michigan asked me to remind you when you are communicating with them regarding residents to not send Resident names, Birthdates or Social security numbers in those s. What you send is the Medicaid ID and they can look it up. Or if it is a billing issue send them the TCN and the Medicaid ID. We have been in the practice of ing DHS, Ardene Martin, Integrated Health, and Provider Support with all the resident name and such. 15

16 Medicaid & Hospice LOC 07 Manage Medicaid Hospice included so plan would pay provider and not switch to a LOC 16 LOC 02 Medicaid (Regular Medicaid) Hospice not included so switch to 16 Hospice and Hospice pays provider LOC 11 Healthy Michigan is included in plan so plan would pay provider and not switch to LOC 16 LOC 005 & 015 MI Health is up in the air waiting for CMS. Currently Hospice is now included. LOC 16 is Hospice when they switch from Regular Medicaid only and Hospice pays provider. 16

17 Medicaid Going forward please make sure that your Champs ID & NPI on your member screen matches your facility CHAMPS ID & NPI for each resident and matches for all new admissions or new approved Medicaid going forward. The edit will be turned on soon to stop the payment of these claims if the CHAMPS ID and NPI do not Match your facility on the Medicaid member screen. Make sure you are putting the information correct on the 2565 you send in to DHS 1. I attached a When you fill this out for new people make sure in box 12 a you put your NPI and 12 b you put your CHAMPS ID. This will help the DHS case workers assign the person to your facility. 2. I would check all your residents CHAMPS member screens and make sure the NPI and CHAMPS ID are your facilities. If not you will have to work with the DHS worker to fix this. The DHS worker is the only one that can fix this. 3. We are having some issues where the DHS case workers will not change this NPI and CHAMPS ID to your facilities. You have to get them to change it or you just will not get paid. 4. We situations where the resident is in a facility in Kent County (as an example) but the family lives in Livingston County and completes the applications in Livingston County. You will have to get the DHS worker in Livingston to fix it not the local DHS worker in Kent County where your facility is. 17

18 Medicaid Medicare Buy In Based on the information from the Office of Personnel Management, Federal Employee s employed as of January 1, 1983 are eligible for Medicare Part A.(see page 5 of attached document) This was also confirmed with our Social Security liaison. If the beneficiary did not retire before 1983, he can enroll in Medicare Part B and pay the premium and then he can enroll in Medicare Part A and pay that premium as well, or may qualify for Medicare Buy in of Part A. If a beneficiary has an SSA document stating they are not eligible for Medicare as they do not have enough work credits the beneficiary/beneficiary representative needs to go to SSA and let them know that while they know they are not eligible for Medicare Part A free or reduced, however they are eligible for Medicare Part B and would like to enroll. Once the beneficiary enrolls in Medicare Part B (enrollment period January 1 st March 31 each year) and pays the premium, then the beneficiary is eligible to either pay for Medicare Part A, or that beneficiary may qualify for Medicare Part A buy in through Medicaid. Once the beneficiary is enrolled in Medicare Part A and Medicare Part B, Medicaid will begin to make payments on claims. 18

19 Manage Medicaid Where are we? 19

20 Healthy Michigan Residents 20

21 Healthy Michigan Medicaid Days 21

22 McLaren Health Plan 22

23 Manage Medicaid Plans January 1 Region 1 Upper Peninsula Health Plan Region 2 McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, UnitedHealthcare Community Plan Region 3 McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, UnitedHealthcare Community Plan Region 4 Blue Cross Complete of Michigan, McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, Priority Health Choice, UnitedHealthcare Community Plan Region 5 McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, UnitedHealthcare Community Plan Region 6 Blue Cross Complete of Michigan, HAP Midwest Health Plan, McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, UnitedHealthcare Community Plan Region 7 Blue Cross Complete of Michigan, McLaren Health Plan, Meridian Health Plan, UnitedHealthcare Community Plan Region 8 Aetna Better Health of Michigan, McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, Priority Health Choice, UnitedHealthcare Community Plan Region 9 Aetna Better Health of Michigan, Blue Cross Complete of Michigan, McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, UnitedHealthcare Community Plan Region 10 Aetna Better Health of Michigan, Blue Cross Complete of Michigan, Harbor Health Plan, McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, Total Health Care, UnitedHealthcare Community Plan 23

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25 MI Health Link Where are we? 25

26 MI Health Link 2565 This notification is being sent to providers of long term care services including nursing facilities, county medical care facilities, and hospital long term care units to provide clarification on the process involved with the submission of the Facility Admission Form (MSA-2565-C) for an individual enrolled in the MI Health Link program. The MI Health Link program covers the custodial/long term nursing facility service benefit. When an individual who is enrolled in the MI Health Link program is admitted to a nursing facility for custodial/long term nursing services, a disenrollment from the Integrated Care Organization (MI Health Link health plan) is NOT REQUIRED. The Facility Admission Form (MSA-2565-C) should NOT be sent to the Michigan Department of Health and Human Services (MDHHS) Enrollment Services Section for a disenrollment to be processed. 26

27 What are the Names Started as Integrated Health Then called MMP (Medicare Medicaid Program) Duals (Also Known as Duals as in Dual Eligible) Now called MI Health Link Total confusion 27

28 MI Health Dual Eligible 28

29 MI Health LOC 29

30 LOC Medicaid We have the new pilot program which started on March 1, 2015 in Southwest Michigan Region 4 Counties, Macomb, Wayne and the UP. You could see these patients they are dual eligible in the Pilot program in counties surrounding the pilot. MHL-LOC 005 (All other Facilities) or LOC 015 (County Care). These residents have to call Michigan Enrolls to disenroll toll-free at (TTY: ) Monday-Friday from 8 AM to 7 PM. Once they dis-enroll they will go to a LOC 02 you have to do a new LOCD. 30

31 Medicaid Redetermination and MHL Enrollment At the time of re-determination for Medicaid financial eligibility, the MI Health Link (MHL) program will not be sending beneficiaries information about this program. Beneficiaries who previously opted out will not be passively enrolled according to an from the MHL staff. The MHL staff wrote: There is currently no MI Health Link enrollment letter sent to beneficiaries when eligibility is re-determined. A person who becomes eligible for MI Health Link enrollment may opt-in at any time. When Medicaid re-determination takes place the beneficiary remains in the same ICO, unless that beneficiary lost Medicaid coverage. If the enrollee loses Medicaid coverage and later regains it, they are not passively enrolled into MI Health Link. The beneficiary may choose to opt back in to the program at that time if desired. MHL staff did state that about 1500 beneficiaries will be passively enrolled effective January 1, These specific individuals were given normal notice of 60 and 30 days in which to opt-in or opt-out if they so chose. No other large scale passive enrollment is scheduled according to the MHL staff. 31

32 MI Health Link Portals Meridian Health Plan Amerihealth Aetna/Coventry Molina HAP/Midwest Fidelis/Centene 32

33 MI Health Authorizations We need to watch these authorization that the plans are giving us for the MI Health program. Some plans are assigning a diagnosis for residents in their prior authorizations. They are assigning diagnosis that the residents do not even have. You need to make sure these are correct diagnosis and if not you need to work with the case managers of the plans to fix the issue. The authorization numbers do change. Make sure that any resident that is in a MI Health plan that you have a prior authorization. All plans are giving different periods authorizing the residents stay in the facility. You need to set up a system to make sure you always have a authorization for the period of time you are rendering the service. Here is an example of time frame of authorizations: Meridian is authorizing 12 months Aetna is authorizing 3 months. Molina is authorizing 6 months The authorization numbers need to go on your claims to the payer. You need to put the authorizations in your software and track the dates. 33

34 MI Health Issues We are seeing some issues with MI Health where the resident does not have the correct LOC or it shows up correct on CHAMPS but ancillary providers such as Dentist and such cannot see it. I think we still have some issues with the information crossing between Bridges DHS system, CMS and CHAMPS. It in return is creating some access of care issues. If it is a true LOC issues Facilities with LOC issues need to submit the Medicaid ID numbers to the MSA-MHL-Enrollment@Michigan.gov box with the subject line: Nursing home LOC Issue so they may work to resolve the issues. If it becomes an access to care issue the information to INTEGRATEDCARE@michigan.gov. Remember in these s only send the Medicaid ID and explain the situation. The State will work with the plans to try to fix the process, or improve the process. We are also seeing with new admission with LOC 015 or 005 that the plans are stating they have 14 days to authorize admission. These are resident in the emergency room and possibly be admitted to you for Rehab. The hospital will not keep the resident in ER for 14 days and you cannot admit the resident until you have a prior authorization. I would recommend when you are told this by the plan that you need to ask to speak to a manager. We will have to work through this. Ancillary Provider: You need to work with your ancillary providers such as Lab, Pharmacy, X-Ray, Physician and such to get the to be credentialed with the plans. We are hearing that some of the pharmacies are not participating with the plans this will create issues for you so I would continue to ask these groups to participate. 34

35 LOC 02 dropping MI Health Issues The passive enrollments have occurred in Macomb & Wayne for Medicaid dual eligible. We are having the same issue we did as in the Southwest MI & UP with the passive enrollments. I am starting to hear from facilities who are checking there CHAMPS member screens that those residents that have opted out (some residents not all) have lost there 02. Make sure you are checking your CHAMPS member screen both for those that were passively enrolled and those that might have lost there 02 Medicaid that opted out. Facilities with LOC issues need to submit the Medicaid ID numbers to the (Only MI Health)MSA-MHL-Enrollment@michigan.gov box with the subject line: Nursing home LOC Issue so they may work to resolve the issues. 35

36 PPA Offset There are no co-pays, deductibles or premiums in MI Health Link, so there should be no need to offset the PPA with code 25. MI Health Link enrollees can continue to offset their PPA for non-program covered medical expenses (like Vision-Code 27, Dental-Code 28, and Hearing- Code 26) and use the appropriate codes to offset the PPA when billing the health plan for nursing facility services. Resident pay PPA when Medicare/Medicaid coinsurance. 36

37 LOCD Nursing Facility Level of Care Determination (NFLOCD) The MI Health Link health plan will be responsible for conducting the Michigan Medicaid NFLOCD tool for enrollees seeking admission to a nursing facility. For existing residents at the time of enrollment, the existing NFLOCD will be adopted for capitation payment purposes. The health plan will complete a new NFLCOD tool within the first 90 days of enrollment. If a nursing facility resident is disenrolled from MI Health Link, the nursing facility will be responsible for conducting a new NFLOCD tool in accordance with published Medicaid policy. 37

38 MI Health Issues-New with Insurance Plan issues, Case Manager Issues 38

39 ACO What are they? 39

40 Families Receiving Letters for ACO 40

41 ACO What is It? What's an ACO? Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. 41

42 Payroll Based Journal Mandatory on July 1, 2016 Internet Explorer Version Internet Explorer v 10 and v 11 will need to operate in compatibility mode 42

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44 If you submit data manually, should you also submit it through the XML? Now, you have three options: Submit Manually only Submit through the XML only You are able to submit manually and using the XML. 44

45 Staffing Submission Frequently Asked Questions Who are direct care staff? (Who do we submit data for?) Submission of data for contract staff Medical directors and consultants Staff switching roles or tasks throughout the day Hours paid vs. hours worked Must be verifiable Public posting/quality Measures/Five Star Enforcement Voluntary submission risks (none...so register now!) 45

46 CMS defines 37 job title codes that are required to match employees to the number of hours each direct care function was performed. It is important to work with your teams to define the workers that contribute to each job type and how those daily worked hours are recorded and converted to a PBJ submission The PBJ does include some more specific job descriptions than the 671. For example, the PBJ system includes job descriptions for RNs with administrative duties and LPNs with administrative duties, versus the 671 s more general Nurses with Administrative Duties. Page 46

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48 PBJ Medical Director Role Physician Leadership Help the facility ensure that patients have appropriate physician coverage and ensure the provision of physician and health care practitioner services; and Help the facility develop a process for reviewing physician and health care practitioner credentials; Provide specific guidance for physician performance expectations; Help the facility ensure that a system is in place for monitoring the performance of health care practitioners; and Facilitate feedback to physicians and other health care practitioners on performance and practices. Patient Care - Clinical Leadership Participate in administrative decision-making and the development of policies and procedures related to patient care; Help develop, approve, and implement specific clinical practices for the facility to incorporate into its care-related policies and procedures, including areas required by laws and regulations; Develop procedures and guidance for facility staff regarding contacting practitioners, including information gathering and presentation, change in condition assessment, and when to contact the medical director; Review, consider and/or act upon consultant recommendations, as appropriate, that affect the facility's resident care policies and procedures or the care of an individual resident Review, respond to and participate in federal, state, local and other external surveys and inspections; and Help review policies and procedures regarding the adequate protection of patients' rights, advance care planning, and other ethical issues. 48

49 PBJ Medical Director Role Quality of Care Help the facility establish systems and methods for reviewing the quality and appropriateness of clinical care and other health-related services and provide appropriate feedback; and Participate in the facility's quality improvement process; Advise on infection control issues and approve specific infection control policies to be incorporated into facility policies and procedures; Help the facility provide a safe and caring environment; Help promote employee health and safety; and Assist in the development and implementation of employee health policies and programs. Education, Information, and Communication Promote a learning culture within the facility by educating, informing, and communicating; Provide information to help the facility provide care consistent with current standards of practice (defined as "approaches to care, procedures, techniques and treatments that are based on research and /or expert consensus and that are contained in current manuals textbooks and or publications, or that are accepted, adopted or promulgated by recognized organizations or national bodies.") Help the facility develop medical information and communication systems with staff, patients, and families and others; Represent the facility to the professional and lay community on medical and patient care issues; Maintain knowledge of the changing social, regulatory, political, and economic factors that affect medical and health services of long term care patients; and Help establish appropriate relationships with other health care organizations. 49

50 Dietician When the dietary or food services supervisor is other than a registered dietitian, the supervisor shall receive routine consultation and technical assistance from a registered dietitian (R.D.). Consultation time shall not be less than 4 hours every 60 days. Additional consultation time may be needed based on the total number of patients, incidence of nutrition-related health problems, and food service management needs of the facility. 50

51 Pharmacy Consultant At least once per month, a licensed pharmacist must perform a drug regimen review (DRR) for each resident. The pharmacist must report any irregularities to the attending physician or director of nursing. Furthermore, these reports must be acted upon 51

52 What are the names for the Medicare Number OSCAR -Online Survey, Certification and Reporting PTAN-PTAN number is assigned by Medicare to authenticate the provider when using the local Medicare Administrative Contractor s (MAC) self-help tools like the IVR, internet portal, on-line application status, etc. Provider Transactions Access Number CCN- CMS Certification Number Medicare Number- example 23-???? All of the above mean the same thing. 52

53 QTSO Once you are logged in the QTSO site You will have a state login to the site to access the various site specific to your facility Installing you will need administrator rights to your network 53

54 Medicare Update What are we seeing? 54

55 CMS Final Rule On Returning Credits 55

56 Over Payment Rule Medicare payments for non covered services Medicare payments in excess of the allowable amount for an identified covered service Errors and non reimbursable expenditures in cost reports Duplicate payment Receipt of Medicare payments when another payor had the primary responsibility for payment 56

57 Questions to MAC Does the Medicare credit balance report change with this overpayment rule? No, Medicare Credit Balances are still required at the end of each quarter. Will that still be the communication to let CMS or the MAC know that we have received an overpayment? Submission of Medicare Credit Balance is one form of communicating overpayments to CMS. Other methods include submitting a voluntary refund with required claim information or the submission of a standard overpayment form. 57

58 Questions to MAC Will the MAC still deduct from a future RA? If the recovery of the overpayment includes adjusting a claim then the overpayment would be netted against future claims payments and reflected on the RA. Or will that process change with this new rule? Process will remain the same. Will NGS send communication out on this? Yes, NGS will communicate this once the final rule is communicated to the MACs by CMS. However, this could change depending on final CMS instructions. 58

59 Final Rule on Returning Credits Providers will want to immediately update their current policies governing overpayments in order to comply with this new rule, which will take effect on March 14, Providers and suppliers are required to use reasonable diligence to investigate credible information regarding overpayments through both proactive compliance efforts and reactive investigations. If an overpayment is identified, then it must be repaid within 60 days. An overpayment is identified when a person has or should have, through the exercise of reasonable diligence, determined that the person received an overpayment and quantified the amount. Providers and suppliers have a maximum of 8 months to report and return overpayments up to 6 months to investigate and quantify the overpayment (i.e., to identify it) and up to 60 days to report and return the overpayment. 59

60 Final Rule on Returning Credits Providers and suppliers are required to report and return all overpayments within a 6-year lookback period. The cause and amount of the overpayment is irrelevant for the determination, e.g., it was due to a mistake, it was someone else s fault, it is a minor amount. An overpayment is an overpayment and must be returned. Providers and suppliers must make their own determination to which entity to report and return the overpayment, i.e., to the Medicare contractor or using the OIG Self Disclosure Protocol or the CMS Self Referral Disclosure Protocol. 60

61 Final Rule on Returning Credits Providers and suppliers may use the claims adjustment, credit balance, self-reported refund process, or another appropriate process to report and return overpayments. At this time, there is no standard refund form to use. Failure to report and return an overpayment could subject the provider or supplier to False Claims Act liability, Civil Monetary Penalties Law liability, and exclusion from federal health care programs. 61

62 P S & R-Accountants will be asking for this information The location you login into has changed it is now on EIDM. EIDM is the acronym for CMS' Enterprise Identity Management system which includes Identity Verification, Access Management, Authorization Assistance Workflow Tools, and Identity Lifecycle Management functions Login.html Go down the page and click on the PS&R/STAR This will take you to the login page will look the same as the old P S & R did. Changes Affecting PS&R System Access (Please Read) (posted 01/29/2015) (Updated 5/26/2015) is changing? The system which controls your PS&R user ID (currently IACS) The new system is referred to as EIDM This will result in a different way to create new accounts or change passwords to existing accounts If you already have an account in EIDM, you may have to use that account for accessing PS&R after the transition When is the change effective? June 13, 2015 What is staying the same? The internet address for accessing PS&R remains the same. The PS&R system/functionality is NOT changing 62

63 Medicare Advantage Payors Medicare Advantage payors are pulling/denying payments on admissions if the patient was readmitted within 30 days after discharge. The client believes that the payors systematically denying payments for all readmissions within 30 days. They believe this practice denies them due process to address whether the readmissions were justified and not due to a "premature discharge of patient." The payors seem to want to "act" like a QIO without having the same accountabilities of the QIO related to determinations of non-payment. Here's the QIO process under section 4240 of the QIO Manual Readmission Review - (Rev. 2, ) Readmission review involves admissions to an acute, general, short-term hospital occurring less than 31 calendar days from the date of discharge from the same or another acute, general, short-term hospital (see 1154(a)(13) and 42 CFR (a)(8)(ii)). Neither the day of discharge nor the day of admission is counted when determining whether a readmission has occurred. A. Medical Review Procedures Obtain the appropriate medical records for the initial admission and readmission. Perform case review on both stays. Analyze the cases specifically to determine whether the patient was prematurely discharged from the first confinement, thus causing readmission. Perform an analysis of the stay at the first hospital to determine the cause(s) and extent of any problem(s) (e.g., incomplete or substandard treatment). Consider the information available to the attending physician who discharged the patient from the first confinement. Do not base a determination of a premature discharge on information that the physician or provider could not have known or events that could not have been anticipated at the time of discharge. Review both the initial admission and the readmission at the same time unless one of them has previously been reviewed. In these cases, use, at a minimum, the PRAF case summary of the other admission in addition to the medical record of the case under review. C. Denials Deny readmissions under the following circumstances: If the readmission was medically unnecessary; If the readmission resulted from a premature discharge from the same hospital; or If the readmission was a result of circumvention of PPS by the same hospital (see 4255). With the QIO process, there is an appeal within the QIO, here the hospital is getting no opportunity to challenge the denials. 63

64 Medicare Provider Enrollment Fee Provider Enrollment Application Fee Amount for CY 2016 On December 3, CMS issued a notice: Provider Enrollment Application Fee Amount for CY 2016 [CMS 6066 N]. Effective January 1, 2016, the CY 2016 application fee is $554 for institutional providers that are: Initially enrolling in the Medicare or Medicaid program or the Children's Health Insurance Program (CHIP) Revalidating their Medicare, Medicaid, or CHIP enrollment Adding a new Medicare practice location This fee is required with any enrollment application submitted from January 1 through December 31,

65 Medicare MAC-Higlas Effective 1/4/2016, CMS has implemented a change to begin netting (offsetting) provider money across workloads within a single organization. What this means is that any related providers conducting business in two different workloads (example: New York and Maine) will have their money applied to any account receivables (AR) with a remaining balance owed to Medicare within both workloads. For example: Provider ABC is located in New York and is scheduled to receive a payment of $1,000 on today's remittance advice. Provider XYZ is related to provider ABC but is located in Maine and has ARs with a balance owed of $200. Provider ABC's $1,000 payment will have the $200 applied against provider XYZ's ARs resulting in a net payment of $800. This will be reflected on the remittance advice by the same PLB code as seen today for offsets for the $

66 Two Midnight Rule Change January 1, Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices- Items/CMS-1633-FC.html 66

67 Two Midnight Rule However, effective January 1, 2016, CMS will allow exceptions to the Two-Midnight Benchmark to be determined on a case-by-case basis by the physician responsible for the care of the beneficiary, subject to medical review. Said differently, Part A payment may be appropriate in some circumstances even though there is no expectation by the physician (or qualified ordering practitioner) of a two-midnight stay and one of the two pre-existing categorical exceptions (CMS inpatient only list and newly initiated mechanical ventilation) does not apply. CMS has indicated that this change to the Two Midnight Rule is in response to stakeholder concern and CMS s continued efforts to develop the most appropriate standard for determining Medicare Part A payment. 67

68 Two Midnight Rule A new 42 C.F.R (a) provides that a patient "is considered an inpatient of a hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner." The physician orders inpatient status when he or she "expects the patient to require a stay that crosses at least 2 midnights."[10] Stays expected to be shorter than at least two midnights "are generally inappropriate for inpatient admission and inpatient payment under Medicare Part A," unless the surgical procedure is "specified by Medicare as inpatient only under (n)."[11] The physician's "expectation should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event."[12] The physician order is part of "physician certification of the medical necessity of hospital inpatient services."[13] 68

69 InPatient Vs Observation Cont Physician certification, which begins with an order for inpatient admission, requires the physician to certify the reasons for the hospitalization, the estimated time the patient will remain in the hospital, and "plans for posthospital care, if appropriate."[14] The certification "must be completed, signed, and documented in the medical record prior to discharge."[15] A physician's admission order has "no presumptive weight" and both the admission order and the physician certification "will be evaluated in the context of the evidence in the medical record."[16] CMS intends to provide additional information about what "evidence in the medical record" means in future instructions and manual revisions.[17] 69

70 Two Midnight Rule Although the new case-by-case exception appears to be inherently subjective to a certain extent, CMS states that the following factors (among others) would be relevant to determining whether a patient requires inpatient admission under the expanded policy: The severity of the signs and symptoms exhibited by the patient; The medical predictability of something adverse happening to the patient; and The need for diagnostic studies that appropriately are outpatient services (that is, their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more). CMS also notes that an inpatient admission (and Part A payment) should be rare and unusual for minor surgical procedures or other treatment that is expected to keep the patient in the hospital for only a few hours or for a period of time that does not span at least overnight (thus, a subset of stays not meeting the Two Midnight Benchmark). CMS indicates that such cases will be prioritized for medical review. 70

71 Health Data Insights & Medicare Plus Blue RAC (Retrospective Audits) 71

72 HDI Health Data & Med Plus Blue Blue Cross Medicare Advantage Audits Facilities seeing 10 to 15 requests for Medical Records In January & Feburary Selected Health Data Insights because they were a premier Audit Vendor for CMS Recovery Audit Contractor (RAC) demonstration Project. They are a audit vendor for Humana Providers not sending Medical Record will get technical denial and lose payments. 72

73 Health Data InSight In 2010 they began the Hospital Review Medicare Advantage encounter data CMS oversight of data integrity OIG 2016 We will review CMS's oversight of MA encounter data validation and assess the extent to which CMS s Integrated Data Repository contains timely, valid, and complete MA encounter data. In 2012, CMS began collecting from MA organizations a more comprehensive set of encounter data reflecting the items and services provided to MA plan enrollees. Prior CMS and OIG audits have indicated vulnerabilities in the accuracy of data reporting by MA organizations. Realizing the potential benefits of the MA encounter data for payment and program integrity oversight is contingent upon the data s completeness, validity and timeliness. (OEI; ; expected issue date: FY 2017). 73

74 Pepper Reports Program for Evaluating Payment Patterns Electronic Report ( PEPPER) Annually, on or about April 18, 2016 will be released Pepper Portal 74

75 CGI Technologies and Solutions, Inc. Indiana Michigan Minnesota Illinois Kentucky Ohio Wisconsin CGI Technologies and Solutions, Inc. For general and administrative questions regarding client service, outreach, quality assurance, or project-specific issues, contact: RACB (7222) Tamara Tate

76 CGI Federal RAC CGI Federal RAC Region B racb@cgi.com Phone: RACB (7222) Mailing Address Send medical records as follows: Medical records for Indiana, Illinois, Kentucky, Michigan, Ohio, Wisconsin, Minnesota, DME and Home Health: CGI Federal Inc. Attn: RACB Imaging Dept 1001 Lakeside Ave., Suite 800 Cleveland, OH If submitting paper records, please send medical records as follows: For Therapy Reviews: CGI Federal Inc. Attn: RACB Imaging 1001 Lakeside Avenue, Suite 800 Cleveland, OH

77 How to survive RAC Audit National health expenditures totaled $1,679 Billion in 2003 National health expenditures were 15.3% of GROSS Domestic Product (GDP) in 2003 Health care cost increasing at +9% per year Doomsday predictions of Medicare running out Congressional Action 77

78 RAC Audits Medicare Modernization Act (MMA) of 2003 Mandated a three year audit demonstration project Appoint audit contractors to review Medicare billings for proper coding, DRG assignment and medical necessity Audits will apply to all health care providers (hospitals, physicians, homecare, dme, etc.) Audit contractors to be paid on a contingency basis, a percentage of overpayments recovered 78

79 How Did we get here Overpayments collected due to errors in: Medically Unnecessary Services 40% Incorrectly Coded 35% Other 17% No/Insufficient Documentation 8% 79

80 Where are we now All RAC s completed required provider outreach. Access to Medicare billing data base given to all RAC RAC review methodology Automated Review-Black & White Issues (current) DRG Validation-complex review (current) Complex Review for coding errors (current) DME Medical Necessity Reviews complex review (calendar year 2010) Medical Necessity Reviews-complex review (calendar year 2010) 80

81 RAC Reviews Responsibilities of the Team Leader Must learn each insurance provider participating in a RAC or RAC type program What are their operating rules? What is their appeal process? Time limits? May be different process for each insurance provider Develop a response team Identify who does what, when, why and alternate individual Build and develop a manual process Review of computerized system 81

82 Priority Health SCIO Health Analytics Claims for Medicare members treated at Skilled Nursing Facilities are reimbursed based on the patients RUG (Resource Utilization Group) score, which is determined using the Minimum Data Set (MDS). Using SCIO's robust analytics, claims and/or providers that merit review are selected for audit. SCIO's auditors conduct a detailed review of the complete medical record and associated MDS to determine if the billed RUG score is valid. In the event the review determines that an incorrect RUG score was billed, SCIO provides the valid score, reports the reason the change was necessary, and calculates the resulting overpayment. 82

83 + Cheer Onward, and Upward she shall prevail. We are here to care for the residents, and provide a wonderful service

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85 References Priority Health Blue Cross Medicaid Medicare 85