Reimbursement Audits: How to Prepare for Them. Andrea Stark, MiraVista LLC DMEPOS Consultant & Reimbursement Specialist

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1 Reimbursement Audits: Understanding the Trends & How to Prepare for Them Andrea Stark, MiraVista LLC DMEPOS Consultant & Reimbursement Specialist

2 Top 5 Things to Know for CE: Make sure your BADGE IS SCANNED each time you enter a session, to record your attendance. Carry the Evaluation Packet you received on registration with you to EVERY session. If you re not applying for CE, we still want to hear from you! Your opinions about our conference are very valuable. Pharmacists, Pharmacy Technicians and Nurses need to track their hours on the Statement of Continuing Education Certificate form as they go. FOR CE: At your last session, total the hours and sign both pages of your Statement of Continuing Education Certificate form. Keep the PINK copies for your records. Place the YELLOW and WHITE copies in your Evaluation packet. Make sure an evaluation form from each session you attended is completed and in your Evaluation packet (forgot to pick up an evaluation form at a session? (Extras are available in an accordion file near the registration desk.) Put your name and unique member ID number (six digit number on the bottom of your badge) on the outside of the packet, seal it, and drop it in the drop boxes in the NHIA registration area at the convention center.

3 Disclosures Andrea Stark is Consultant/Owner of ClaraVista, LLC & miravista, LLC. The conflict of interest was resolved by peer review of slide content. Clay Stribling, Esq is President of HC Comply. The conflict of interest was resolved by peer review of slide content. Clinical trials and off-label uses will not be discussed during this presentation.

4 Agenda Why Would I Be Audited? Hot Audit Triggers Who is Auditing Right Now? RACs, ZPICs, CERT, DME MACs Overcoming Documentation Challenges Obtaining i Documentation ti 4

5 Why Would I Be Audited?

6 Infusion is On the Audit Radar Top 6 DME Most Frequently Billed Incorrectly (per CERT Task Force 05/20/10): Oxygen Diabetic Supplies Power Mobility Devices / Wheelchairs Nebulizers & Drugs Enteral Nutrition Positive Airway Pressure (Pap) Devices & Supplies 6

7 Infusion is on the OIG s Radar Enteral/Parenteral Nutrition is Specifically Being Reviewed by the OIG in 2011 for: Improper Payments (Focus on High Volume Areas). Claims with GA, GY and/or KX Modifiers. Medicare s Parenteral Fee Schedule vs. Other Insurers Rates Is Medicare Paying Too Much? 7

8 Hot Audit Triggers Billing Patient Without a Valid ABN Duplicate Billing Upcoding Unbundling Items Billing Before Receiving a Detailed Order Billing Without a DIF Improper Use of the KX Modifier Routinely Waiving 8 Deductibles/Coinsurance

9 Who is Auditing Right Now?

10 RAC Reviews Recovery Audit Contractors (RACs): Review Medicare Part A and Part B 3-Year Look-Back Period All Issues Approved By CMS All Issues Posted to RAC Website Types of Reviews: Automated Complex 10

11 Automated Reviews Decision Made Without Requesting Records Overpayment = Payment Demand Letter. 11

12 On-going Reviews Name Pharmacy Supply & Dispensing Fees Parenteral Nutrition Additives with Premix Solutions Q4099 Formoterol fumarate (perforomist) Description Pharmacy supply and dispensing fees when billed by a DME supplier are required to be accompanied with an oral anti-cancer, oral anti-emetic, immunosuppressive drug or inhalation drug. When premix parenteral nutrition solutions are used there may not be separate billing for the carbohydrates, amino acids or additives. Patients are allowed a maximum of two vials of formoterol (20 micrograms each) per day. Jurisdictions Auditing A, C, D A C 12

13 On-going Reviews Name J7605 Arformoterol, (Brovana) Budesonide - Dose vs.billed Units PEN supplies more than 1 time a day Infusion Pump Denied/ Accessories & Drug Codes should be denied Description Patients are allowed a maximum of two vials asof arformoterol oeo (15 micrograms) coga s)per day. Budesonide should be billed one unit of service for each vial dispensed regardless of vial dose for a maximum of 62 units per month. The description or the billing guidelines state t parenteral/enteral t l nutrition codes are allowed once a day. When the infusion pump is denied, then the infusion accessories and infusion drug codes are also denied. Jurisdictions Auditing C B, C D D 13

14 Complex Reviews RAC Must Request Medical Records Limits Imposed on the Number of Requests Max of 10% of Records for Average Number of Monthly Services, per 45-days. Capped at 250 Records, per 45-days. Respond Within 45-Days From the Date on the Letter. Infusion NOT Currently Under Complex Review. 14

15 Complex Reviews RACs Have 60 Days to Respond. Review Results Letter Will Include: RACs Decision Regulation Violated Information on Appeals Rights Overpayment Determination = Additional Payment Demand Letter 15

16 ZPICs Zone Program Integrity Contractors (ZPICS): Formerly Program SafeGuard Contractors (PSCs) Review Parts A, B, C, D, Home Health and Medi-Medi. Audits Unannounced or Limited Notice Payment Demand Letters Come From Your MAC. Follow Standard Appeals Process. 16

17 ZPIC Jurisdictions Zone 1 CA, NV, American Samoa, Guam, HI, and the Mariana Islands. Zone 2 AK, WA, OR, MT, ID, WY, UT, AZ, ND, SD, NB, KS, IA and MO. Zone 3 MN, WI, IL, IN, MI, OH, and KY. Zone 4 CO, NM, OK, and TX (Health Integrity, LLC effective 2/1/09). Zone 5 AL, AK, GA, LA, MS, NC, SC, TN, VA and WV (AdvanceMed Corporation effective 1/1/10). Zone 6 PA, NY, MD, Washington DC, DE, ME, MA, NJ, CT, RI, NH, and VT. Zone 7 FL, Puerto Rico and Virgin Islands (SafeGuard Services, LLC effective 2/1/09). 17

18 CERT Comprehensive Error Rate Testing (CERT): Always Requests Additional Documentation. Requests Identify Patient and Records Under Review. Requests NOT Limited to LCD. Documents From Other CMS Manuals May be Requested. Respond Within 75-Days of the Date on the Letter. Respond via Fax or Mail. 18

19 DME MACs Jurisdictions Auditing for Enteral Nutrition: A NHIC Prepay: B9000, B9002 (Pumps) C CIGNA Prepay: B4150, B4154 (Formula) D NAS: CERT Error Rate at 65.13% 19

20 Overcoming Documentation Challenges

21 Insufficient i Documentation ti (Nutrition) Diagnosis Codes ALONE Dispensing or Prescription Orders ALONE Supplier Generated Forms NOT a Substitute for Physician Records! Stamped Signatures Illegible Signatures 21

22 Ensure You Have (Nutrition): Dispensing/Verbal Order Detailed Written Order Listing Each Item Billed Supplier Signed and Dated DIF (Form 10126) Clinical Records Supporting Coverage Criteria Permanent non-function or disease of the structures that normally permit food to reach the small bowel, or Disease of the small bowel which impairs digestion and absorption of an oral diet. Justification for Pump or Special Formulas Proof of Delivery Contractors Must Be Able to Determine Who, What and Where. 22

23 For Pumps Pumps (B900-B9002): Physician Must Document Conditions That Justify Need, such as: Gravity feeding is not satisfactory due to reflux and/or aspiration, Severe diarrhea, Dumping syndrome, Administration rate less than 100 ml/hr, Blood glucose fluctuations, Circulatory overload. 23

24 For Pumps Pumps (B900-B9002): If Discontinued For Two Consecutive Months And Later Resumed, A New Initial DIF Is Required If Nutrition is Changed from Syringe/Gravity to a Pump A New Initial DIF Is Required (for Pump) A Revised DIF Is Required (for Nutrition) 24

25 For Specialty Nutrients Specialty Nutrients (B4149, B4153-B4157, B4161 and B4162): Covered For Patients With Specific Diseases Requires Additional Documentation Identifying The Specific Condition And Need For The Nutrient Auditors Expect Evidence Of Failure On Standard d Formulas 25

26 For Nutrients Revised DIF Needed for ALL Nutrients If: Number of Calories Per Day Changes, Number of Days Per Week the Nutrient Is Administered Changes, Method of Administration Changes Between Syringe, Gravity, or Pump, Route of Administration Changes From Feeding Tubes to Oral Tubes (If Billing For A Denial). 26

27 Obtaining Documentation Myth: HIPPA Prevents Physicians From Supplying Requested Documents. Truth: HIPPA Allows Disclosure of PHI for: Treatment, Payment, or Health Care Operations. 27

28 Obtaining Documentation SSA Mandates Physicians Comply with Documentation Requests. Section 1842(p)(4): [i]n case of an item or service ordered by a physician or a practitioner but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that t the item or service is ordered by the physician or practitioner. 28

29 Educating Physicians Check Your DME MAC s Website: Physician Documentation Request Letters Enteral Nutrition Dear Physician Letter Include Cover Letters Quoting LCD Coverage Requirements. 29

30 Refills and Supplies Patient Must be Contacted Prior to Delivery. Contact No More Than 7 Days Before Expected Depletion. May Deliver 5 Days Early (NOT Routinely). Confirm Supply is Nearly Depleted. Obtain Information on Frequency of Utilization. Are You the Only Supplier? 30

31 Refills and Supplies For Telephone Contact, Document: The Patient s Name The Person Contacted (Patient or Caregiver) General Description of Items Requested Statement That Refill is Requested Date of Contact 31

32 Refills and Supplies For Written Contact, Document: The Patient s Name General Description of Items Requested Statement That Refill is Requested Patient or Caregiver s Signature and Date 32

33 Maintaining Documentation Documentation Must Be on File For 7- years. Cut Back on Paper Files. Consider a Scanning Solution. Maintain Electronic Copies. Faster Recall of Old Documents, More Organized, Less Storage Space. 33

34 Infusion Billing Vulnerabilities: Proof of delivery for parenteral nutrition (typical 7 day shipments) Justification for TPN Protocol for date stamping documentation Request for refills High calorie diets (exceeding 2000 calories) Physical therapy Oncologist Notes Cal/kg requirements Dietition Specialty nutrients failure on standard nutrients, hospital records Change in Infusion drug after pump has capped 34

35 Infusion Billing Vulnerabilities: Use of the JB modifier for subcutaneous immune globulin, and pump E0779. Removal of least costly alternative for E0781/E0791 for subcutaneous immunoglobulin (must bill E0779 only). 35

36 Questions & Answers Andrea Stark Consultant/Reimbursement Specialist x 240 andrea@miravistallc.com 36

37 Disclaimer These materials and links to other sources are provided d for informational purposes only and are not intended to be and should not be construed as legal advice. MiraVISTA does not guarantee or warrant that t the materials are without error or present a complete explanation of all aspects of coverage or billing. Laws and procedures res change frequently entl and are subject to differing interpretations. Content and information is subject to change without notice. 37

Reimbursement Audits: Understanding the Trends & How to Prepare for Them. Andrea Stark, Consultant/Owner, miravista,llc, Columbia, SC

Reimbursement Audits: Understanding the Trends & How to Prepare for Them Andrea Stark, Consultant/Owner, miravista,llc, Columbia, SC Top 4 Things to Know for CE 1. Make sure your BADGE IS SCANNED each