Medicare Recovery Audit Contractors. Chicago, IL August 1, 2008
|
|
- Caroline Mathews
- 6 years ago
- Views:
Transcription
1 Medicare Recovery Audit Contractors Chicago, IL August 1,
2 Recovery Audit Contractors Demo Summary National Rollout AHA Strategy AHA RACTrac Overview 2
3 Recovery Audit Contractors Medicare Modernization Act (Rx bill) 3-year demonstration project Recover overpayments and identify underpayments Payment made on a contingency fee basis 3 states selected based on highest per capita Medicare utilization: California Florida New York Background + South Carolina Massachusetts Tax Relief and Health Care Act of 2006 Expanded to all states by
4 RAC Three-State Demo Review last four years of provider claims Use automated software programs to identify potential payment errors Types of Payment Review Duplicate payments FI errors Medical necessity Coding errors Hospitals can appeal using the standard Medicare appeals process 4
5 RAC Demo Findings RAC Impact: March 2006 to March 2008 Overpayments Collected: $992.7 m Less Underpayments Repaid: - ($37.8 m) Less $ Overturned on Appeal: Less PRG IRF Re-review: - - ($46.0 m) ($14.0 m) Less Costs to Run Demo: - ($201.3 m) BACK TO TRUST FUNDS $693.6 m* 5
6 Where Did RACs Find Overpayments? Most overpayments were collected from inpatient hospital services for medical necessity and coding Incorrectly Coded 35% Other 17% Outpatient 4% SNF 2% Doc/Ambulance/ Lab/DME/Other 4% Rehab 6% Inpatient Hospital 85% No/Insufficient Documentation 8% 95% from Hospitals Medically Unnecessary 40% 6 Source: CMS, The Medicare Recovery Audit Contractor Program: An Evaluation of the 3-Year Demonstration, June 2008
7 RAC Target Areas Coding Targets: Correct coding for debridement (excisional or not) DRG 263/MSDRG 573 and DRG 217/MS-DRGs 463, 464 and 465 DRGs designated as complicated or having comorbidity with only one secondary diagnosis DRGs 079, 416, 468, 475, 477 and 483 Correct coding of discharge status for PAC transfer Unit Coding grams vs. milligram, number or procedures per day (e.g., appendectomy) Medical Necessity Targets: Inpatient admissions for procedures that are eligible for outpatient surgery (eg. laparoscopy, cholecystectomy) One-day stays Chest pain Back Pain: DRG 243/MS-DRG 551 Three-day stays to qualify for SNF care Inpatient rehabilitation (joint replacement patients) 7
8 RAC Impact on Hospitals Percent of Hospital Revenue Affected by RACs: Fiscal Years 2006 to % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 75.1% 60.1% 53.2% 31.7% 26.3% 19.0% 6.2% 7.3% 2.9% 4.1% 1.4% 2.9% 2.6% 3.5% 1.1% No Offsets 0% to 2.5% 2.5% to 5% 5% to 10% >10% NY & MA FL & SC CA 8 Source: CMS, The Medicare Recovery Audit Contractor Program: An Evaluation of the 3-Year Demonstration, June 2008
9 RAC Impact on Hospitals Overpayments Collected by Quarter: $500 $450 $464.3 $400 in millions $350 $300 $250 $200 $150 $167.7 $146.6 $100 $50 $0 $0.7 $1.8 FY06 Q2 FY06 Q3 $33.0 $39.3 FY06 Q4 FY07 Q1 $52.3 FY07 Q2 $73.5 FY07 Q3 FY07 Q4 FY08 Q1 FY08 Q2 9 Source: CMS, The Medicare Recovery Audit Contractor Program: An Evaluation of the 3-Year Demonstration, June 2008
10 RAC Rollout Schedule RAC Demo ended March 27 Demo evaluation report released July 11 4 new RACs to be announced September 08 CMS/RACs to conduct outreach to hospitals in first round of RAC rollout 4-6 weeks if existing RAC 8-12 weeks if new RAC RAC audits begin 4-6 weeks after CMS/RAC education with state hospital association 10
11 CMS National Rollout Plan A D B C Summer 2008 Fall 2008 Jan 2009 or later 11 Although CA was a RAC demo state, California claims will not be available for RAC review from March Oct due to a MAC transition
12 Hospital View Hospitals strive for accuracy in service, billing, and coding Hospitals support program integrity efforts Lots of overlap by auditors RACs bad behavior unacceptable 12
13 Multiple Medicare contractors perform the same oversight activities Medicare Oversight Activities by Type of Medicare Contractor Activity FIs* Carriers MACs** PSCs*** COB Contractor* NSC* DAC Contractor* Audit Reviewing cost reports for institutional providers Medical Review Reviewing claims to determine whether services provided are medically reasonable and necessary Secondary Payer Identifying primary sources of payment Benefit Integrity Identifying and investigating fraud and abuse and referring cases to law enforcement agencies Provider Education Communicating Medicare coverage policies, billing practices, and issues related to fraud and abuse Source: Avalere Health analysis and adaptation of Government Accountability Office. (September 2006). Medicare Integrity Program: Agency Approach for Allocating Funds Should Be Revised. Washington, DC. *FI = Fiscal Intermediary; MAC = Medicare Administrative Contractor; PSC = Program Safeguard Contractor; COB = coordination of benefits; NSC = National Supplier Clearinghouse; DAC = data analysis and coding. **By 2009, MACs will replace FIs and Carriers, which are being phased out of Medicare. ***Per the Medicare Modernization Act of 2003, PSCs will be replaced by Zone Program Integrity Contractors (ZPICs).
14 Recovery Audit Contractors add to CMS redundancy and complexity Overlap Between Recovery Audit Contractors (RACs) and Other Contractors Recovery Audit Contractors (RACs) Medicare Administrative Contractors (MACs) Program Safeguard Contractors (PSCs) Comprehensive Error Rate Testing Program (CERT)* Hospital Payment Monitoring Program (HPMP)** Office of Audit Services Audits Annual Work Plan Projects Incorrectly Billed Claims Processing Errors Medical Necessity Incorrect Payment Amounts Non- Covered Services Incorrectly Coded Services Duplicate Services Sources: Centers for Medicare & Medicaid Services. CERT Overview. Hospital Payment Monitoring Program. Government Accountability Office. (September 2006). Medicare Integrity Program: Agency Approach for Allocating Funds Should Be Revised. Washington, DC; Fedor, F. (2005). Recovery Audit Contractors RAC Up Another Challenge for Providers. Healthcare Financial Management, 59(9), 52-56; Stockdale, H. (October 2007). Medicare Program Integrity: Activities to Protect Medicare from Payment Errors, Fraud, and Abuse. Washington, DC: Congressional Research Service; Office of the Inspector General. and * CERT contractors will have new responsibility for medical review of inpatient hospital payments once CMS completes its transition to its new system for review of inpatient hospital prospective payment system claims. ** The QIOs will no longer have responsibility for the functions previously included in the HPMP once CMS completes its transition to its new system for review of inpatient hospital prospective payment system claims.
15 AHA Strategy Push CMS for administrative changes Letters and continual discussions with CMS RAC improvements for permanent program Push Congress for legislative relief Advocacy STOP and Fix-it Capps-Nunes legislation (HR 4105) Member Education Collaboration and education with state, metro and regional hospital associations Member advisories and education RACTrac: Collect data and examples of egregious behavior 15
16 RAC National Rollout 16 CMS Response to RAC New Issue Review Problems CMS will review all new issues proposed for review by the RAC Notification of target areas on RAC website Validation Process Validation Contractor will review a random sample of each RACs completed reviews CMS will release an accuracy score for each RAC on an annual basis
17 RAC National Rollout CMS Response to RAC Problems Limits on the number of medical records a RAC can request per month Requirement for a web-based application by January 1, 2010 Required to have a medical director Yearly Scorecard of RAC performance 17
18 RAC National Rollout CMS Response to RAC Problems No contingency fee when denial is overturned at any level of appeal Three-year look-back period for review No claims with a payment date prior to October 1, 2007 will be reviewed, regardless of the actual start date for the RAC in a state. RAC 3-Year Review Window 10/1/07 10/1/06 10/1/08 10/1/09 10/1/10 18
19 New Medicare Appeals Guidelines 19 No funds recouped during first two stages of appeals process, if denial appealed within the first 40 days to the FI or first 60 days to the QIC Effective Date July 7, 2008 CMS has indicated October 2008 for implementation Transmittal updating timeline timing unknown In 2003, the MMA amended a section of the SSA to limit CMS s recoupment of certain overpayments under the Medicare program and it specifically provides a stay on recoupment during second level of appeals. Unfortunately this statute has not been fully implemented through regulation. Proposed Rule issued in September 2006 and no final rule has been issued. Transmittal 314 and subsequently 322 are the first in a series of Change Requests that are intended to fully implement the MMA provisions along with a pending final rule still to be issued.
20 Appeal RAC denial within 40 days to stop recoupment. Interest Accrues Appeal RAC denial within 60 days to stop recoupment. If provider loses at QIC level, recoupment will commence and interest will be owed. 20
21 AHA Strategy Push CMS for administrative changes Letters and continual discussions with CMS RAC improvements for permanent program Push Congress for legislative relief Advocacy STOP and Fix-it Capps-Nunes legislation (HR 4105) Member Education Collaboration and education with state, metro and regional hospital associations Member advisories and education RACTrac: Collect data and examples of egregious behavior 21
22 RAC Legislation H.R The Medicare Recovery Audit Contractor Program Moratorium Act of 2007 Rep. Lois Capps (D-CA) Rep. Devin Nunes (R-CA) 100 Co-sponsors (23Rs and 77Ds) 1-year Moratorium CMS Report GAO Study Senate Bill?? 22 *Cosponsor list updated as of July 22, 2008
23 Message to CMS and Congress STOP and Fix-it it Slow down Reduce or remove contingency method of payment Exclude medical necessity from RAC review (or more physician involvement) Reduce look-back to 12 months Centralized electronic tracking platform of RAC denials and appeals Exemption from timely billing rules Improved CMS management and transparency of RAC program RAC and Provider education Bigger focus on UNDERpayments 23
24 AHA Strategy Push CMS for administrative changes Letters and continual discussions with CMS RAC improvements for permanent program Push Congress for legislative relief Advocacy STOP and Fix-it Capps-Nunes legislation (HR 4105) Member Education Collaboration and education with state, metro and regional hospital associations Member advisories and education RACTrac: Collect data and examples of egregious behavior 24
25 AHA Resources on RACs SAMPLE LETTER VISIT AHA WEBSITE 25
26 AHA Resources on RACs Upcoming Member Advisories Medicare Appeals Process and how RAC program works Upcoming AHA Summer Call Series Appealing RAC Denials RAC Coding Strategies Maximize RAC Compliance/Minimize RAC Risk 26
27 27 RACTrac
28 RACTrac Goals PRIMARY purpose is to support advocacy efforts Tell the Hospital Story RACTrac will help the field better understand the nature of RAC activities 28
29 Why RACTrac? Study Shows Inappropriate Medicare Payment Denials Reduce Access to Inpatient Medical Rehabilitation Services 29
30 63% of claims that have completed their appeals process have been overturned Claims Data from 72 Inpatient Rehabilitation Facilities, July Claims where initial FI review is complete 20% Approved 652 Claims where the appeals process up to level 3 is complete 12% Claims never appealed or withdrawn by the provider 25% Denial Upheld or Time Expired Before Appeal Could Move Forward 80% Denied 63% of denials overturned on appeal 30 More than $25 Million in Medicare Payment Withheld from IRFs Nearly $6 Million Returned to IRFs
31 What is RACTrac? Web-based survey collecting RAC experience data from hospitals DATA COLLECTION TO BEGIN POST RAC AUDITS Solicitation via and fax Quarterly data collection (open and close time period) Unit of analysis is the hospital i.e. ONE Medicare provider number per data entry General Med/Surge (including CAH s) LTAC Inpatient Rehabilitation Psyche Collect summary information on RAC experience to date Overpayments (automated and complex) Underpayments Appeals information Administrative Burden 31
32 RACTrac will give us trends in RAC activity Sample Talking Point: 80% of hospitals experienced denials in their inpatient services in Quarter 1 Hospitals cited medical necessity as their top reason for RAC denials in Quarter 1 Total dollars reported to have been recouped by hospitals responding in RAC TRAC to date is $XXX million or $XXX per hospital. 32
33 AHA RACTrac Survey ( Data Entry on website Data Upload (CSV file) AHA Claim Level Excel Template (& CSV File) Vendor Provided CSV file 2 Ways to Report RAC Experience Data to AHA RACTrac 33
34 Vendors in the Marketplace AHA is currently working with several vendors who have developed claim level RAC audit tracking tools and would like to make their tools RACTrac compatible. Ask your vendor Is your tool AHA RACTrac compatible? AHA will work with others in order to ensure that its easy for you to report data back to AHA List of vendors available at Under RACTrac 34
35 Top 5 Reasons to Report to RACTrac Internally tracking RAC audit activity is essential for minimizing financial risk, identifying areas for improvement and surviving the RACs Data on the impact of the RACs on hospitals is essential for a successful advocacy effort. Participation in RACTrac will provide AHA and the State Association the data they need to advocate on your behalf. Participation in RACTrac will allow AHA to identify trends in reasons for denials across the RAC regions or at the national level. This information can be used to educate the field. RACTrac provides a basic tool to organize your data 35
36 National RACTrac Rollout and Timeline COMING SOON! Estimated national release of RACTrac is currently scheduled for summer 2008 RACTrac Claim level tracking guide RACTrac Member Advisory AHA News and News Now Letters and s to all CEOs Following Member Advisory with Security Codes for Registering in RACTrac RACTrac Webinar Series Data collection to officially begin post RAC audits 36
37 Prepare for RACs Today! Establish internal RAC team Interdisciplinary Team: Coders, Finance, Clinical, Utilization Review, Case Management Identify RAC point of contact for internal and external RAC communications Develop a central tracking mechanism for all RAC correspondence Incoming and Outgoing Conduct a self audit to identify potential problems Participate in RAC trainings Know the rules for you and for the RACs and remember the program is a WORK IN PROGRESS! 37
38 QUESTIONS Alyssa Keefe Senior Associate Director, Policy Questions on RACs 38
Recovery Audit Contractors: AHA Perspective. Elizabeth Baskett, Policy, AHA February 23, 2012
Recovery Audit Contractors: AHA Perspective Elizabeth Baskett, Policy, AHA February 23, 2012 Agenda Lay of the Land = Audit Overload RACs (Medicare & Medicaid) MACs ZPICs and OIG and DOJ, oh my! AHA and
More informationCACS, MACS & RACS WHAT TO EXPECT IN 2009
. CACS, MACS & RACS WHAT TO EXPECT IN 2009 Presented to GASCO University December 3, 2008 1 Presented by: Karen Beard Director Georgia Society of Clinical Oncology 2 Medicare Carrier Advisory Committee
More informationRecovery Audit Contractors (RACs) and Medicare. The Who, What, When, Where, How and Why?
Recovery Audit Contractors (RACs) and Medicare The Who, What, When, Where, How and Why? 1 Agenda What is a RAC? Will the RACs affect me? Why RACs? What does a RAC do? What are the providers options? What
More informationComplex Challenges/Financial Impact Medical Necessity Compliance Role of the Physician Advisor. NJHFMA Finance for Clinicians Session March 24, 2016
1 Complex Challenges/Financial Impact Medical Necessity Compliance Role of the Physician Advisor NJHFMA Finance for Clinicians Session March 24, 2016 Complex Challenges 2 Declining Inpatient Admissions
More information6/25/2013. Knowledge and Education. Objectives ZPIC, RAC and MAC Audits. After attending this presentation, the attendees will be able to :
Objectives ZPIC, RAC and MAC Audits Approach After attending this presentation, the attendees will be able to : 1. Understand the different types of audits related to reimbursement: ZPIC, RAC, and MAC
More informationCMS Observation vs. Inpatient Admission Big Impacts of January Changes
CMS Observation vs. Inpatient Admission Big Impacts of January Changes Linda Corley, BS, MBA, CPC Vice President Compliance and Quality Assurance 706 577-2256 Cellular 800 882-1325 Ext. 2028 Office Agenda
More informationTopics. Overview of the Medicare Recovery Audit Contractor (RAC) Understanding Medicaid Integrity Contractor
RACS, ZPICS & MICS John Falcetano, CHC-F, CCEP-F, CHPC, CHRC, CIA Chief Audit and Compliance Officer University Health Systems of Eastern Carolina jfalceta@uhseast.com Topics Overview of the Medicare Recovery
More informationUsing PEPPER and CERT Reports to Reduce Improper Payment Vulnerability
Using PEPPER and CERT Reports to Reduce Improper Payment Vulnerability Cheryl Ericson, MS, RN, CCDS, CDIP CDI Education Director, HCPro Objectives Increase awareness and understanding of CERT and PEPPER
More informationMDCH Office of Health Services Inspector General
MDCH Office of Health Services Inspector General Recovery Audit Contract (RAC) Provider Outreach & Education Spring 2014 Background Recovery Audit Contractor Medicare Modernization Act of 2003 created
More informationCAH SWING BED BILLING, CODING AND DOCUMENTATION. Lisa Pando, Sr. Consultant GPS Healthcare Consultants
CAH SWING BED BILLING, CODING AND Lisa Pando, Sr. Consultant GPS Healthcare Consultants Learning Objectives: 1. Review Medical Necessity documentation specific to swing bed patients 2. Reasons to use the
More informationMedicare and Medicaid Audit Defense & Appeals: From RACs to ZPICs September 7, 2012 Skokie, IL
Midwest Home Health Summit Best Practices Conference Series Medicare and Medicaid Audit Defense & Appeals: From RACs to ZPICs September 7, 2012 Skokie, IL Michael T. Walsh Principal Kitch Attorneys & Counselors
More informationState Medicaid Recovery Audit Contractor (RAC) Program
State Medicaid Recovery Audit Contractor (RAC) Program Section 6411 of the Patient Protection and Affordable Care Act 2010 (ACA) requires by December 31, 2010 each state Medicaid program to contract with
More informationResults of Best Practice Research on Hospital RAC Management Preventing and Redressing Audit-Generated Takebacks
Results of Best Practice Research on Hospital RAC Management Preventing and Redressing Audit-Generated Takebacks Our Work To Date Bringing Best Practice Insight to Hospitals and Health Systems Advisory
More informationBest Practices to Avoid Medicare Denials
Best Practices to Avoid Medicare Denials Ralph Wuebker, MD Chief Medical Officer Executive Health Resources AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the
More informationHospices Under the Microscope: Are You Prepared for ZPICs? Medicare Integrity Programs. Objectives. Fraud or Abuse? 3/3/2014
Hospices Under the Microscope: Are You Prepared for ZPICs? Paula G. Sanders, Esquire Principal & Chair Health Care Practice Post & Schell, PC Diane Baldi, RN CHPN Chief Executive Officer Hospice of the
More information4/20/2015. NE Home Care & Hospice Conference: Strategic Preparation for Medicare Audits & Appeals. Today s Objectives. Background
NE Home Care & Hospice Conference: Strategic Preparation for Medicare Audits & Appeals Cheryl Leslie, RN, MPH Director of Consulting Services Pamela Meliso, JD, MPH Director of Consulting Services Today
More informationAlabama Rural Health Conference 03/25/2010
1 This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although every reasonable effort has
More informationUniversity of California Health Science Compliance Program Executive Summary*
1. Introduction The UC Academic Medical Centers (AMC) continued to encounter a complex regulatory environment. The Office of Inspector General (OIG) of the Department of Health and Human Services (DHHS)
More informationThe following is a summary of each of the updates from the meeting.
This week, National Government Services (NGS) conducted a home health advisory meeting in the Centers for Medicare and Medicaid Services (CMS ) Region V office in Chicago for the State Associations in
More informationATTACHMENT I. Outpatient Status: Solicitation of Public Comments
ATTACHMENT I The following text is a copy of the Federation of American Hospitals ( FAH ) comments in response to the solicitation of public comments on outpatient status that was contained in CMS-1589-P;
More informationUsing SNF Data to Manage Federal & State Audit Initiatives
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
More informationRiding Herd on Fraud, Waste and Abuse
Riding Herd on Fraud, Waste and Abuse Dan McCullough Judi McCabe Juanita Henry Kim Hrehor 1 Taking Stock: Surveying the Landscape of Fraud, Waste and Abuse 2 How Big is the Problem? The simple truth is
More informationReview of Claims Affected by Temporary Suspension of BFCC-QIO Short Stay Reviews Q&As
Review of Claims Affected by Temporary Suspension of BFCC-QIO Short Stay Reviews Q&As INTRODUCTION On May 4, 2016, the Centers for Medicare & Medicaid Services (CMS) temporarily paused the Beneficiary
More informationMedicare Consolidate Billing & Overview
Medicare Consolidate Billing & Overview Julie Kearney, Kearney & Associates Consolidated Billing The Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to
More informationNE Home Care Conference: Effective & Efficient Preparation for Medicare Audits & Appeals
NE Home Care Conference: Effective & Efficient Preparation for Medicare Audits & Appeals Cheryl Leslie, RN, MPH Director of Home Care & Hospice Services Pamela Meliso, JD, MPH Director of Consulting &
More informationCertified Ophthalmic Executive (COE) Review Day
Certified Ophthalmic Executive (COE) Review Day Compliance Plan & Chart Audits Financial Disclosure The instructor acknowledges a financial interest in the subject matter of this presentation. Presented
More informationCCT Exam Study Manual Update for 2018
CCT Exam Study Manual Update for 2018 This document reflects updates made to the instructional content from the CCT Exam Study Manual 2017 to the 2018 version of the manual. This does not include updates
More informationPharmacy Compliance: Beyond Med Errors. Overview
Pharmacy Compliance: Beyond Med Errors Daniel P. Fitzgerald, Senior Attorney Litigation & Regulatory Law Department Walgreen Co. James S. Mathis, Esq., Nashville, TN Overview Med Errors & Controlled Substances
More informationUsing the Inpatient Psychiatric Facility (IPF) PEPPER to Support Auditing and Monitoring Efforts: Session 1
Using the Inpatient Psychiatric Facility (IPF) PEPPER to Support Auditing and Monitoring Efforts: Session 1 March, 2016 Kimberly Hrehor Agenda Session 1: History and basics of PEPPER IPF PEPPER target
More informationCombatting Denials. NJ HFMA January 10, 2017
Combatting Denials NJ HFMA January 10, 2017 1 Denial Challenges PAYER INDUCED Aggressive Commercial Payer Denials (Concurrent and Retrospective) Pre-Payment Review Denials for Medicare Unilateral Payer
More information10/2/2015. Agenda. Medicare Compliance DOJ OIG Contractors 2016 OPPS Best Practices Physician buy-in Summary
Medicare Compliance Updates and Best Practices for Providers Joe Crea, DO, MHA Vice President, Clinical and Regulatory Agenda Medicare Compliance DOJ OIG Contractors 2016 OPPS Best Practices Physician
More informationThe Fifth National Medicare RAC Summit
The Fifth National Medicare RAC Summit How to Evaluate the Effectiveness of Your RAC Appeal Strategies Are You Maximizing Defense Strategies? Marriot Wardman Park Hotel March 9 11, 2011 Washington, DC
More informationOne Year Later THE IMPACT OF HEALTH CARE REFORM on Health Care Provider Audits and Compliance Programs
24 Health Care Law One Year Later THE IMPACT OF HEALTH CARE REFORM on Health Care Provider Audits and Compliance Programs By Andrew B. Wachler, Jennifer Colagiovanni, and Christopher J. Laney FAST FACTS:
More informationAdapting Your Medical Necessity Compliance Program In An Evolving Regulatory Environment
Adapting Your Medical Necessity Compliance Program In An Evolving Regulatory Environment Joydip Roy MD Vice President of Compliance and Physician Education Adapting Your Medical Necessity Compliance Program
More informationResponding to Today s Health Care Regulatory Environment
Responding to Today s Health Care Regulatory Environment St. Joseph s Health Michael R. Holper SVP, Compliance and Audit Services October 26, 2016 2014 Trinity Health. All Rights Reserved. 1 We operate
More informationPublic Policy HCA Public Policy No
Public Policy HCA Public Policy No.2-2014 TO: FROM: RE: HCA CHHA & LTHHCP PROVIDER MEMBERS PATRICK CONOLE, VICE PRESIDENT, FINANCE & MANAGEMENT UPDATES FROM NGS HOME HEALTH ADVISORY MEETING DATE: MARCH
More informationObjectives. The Alphabet Soup Of Hospice Scrutiny
Leadership And The Interdisciplinary Group: Overcoming Organizational Challenges In A Time of Change Alphabet Soup For The Hospice Soul: Understanding The Impact Of RHHI, MAC, RAC, CMS, OIG, FBI and DOJ
More informationThe Latest on Medicare RACs
The Latest on Medicare RACs This roundtable discussion is brought to you by the Regulation, Accreditation, and Payment (RAP) and is sponsored by Horne LLP. February 13, 2012 12:00 1:00 pm Eastern Presenter:
More informationIMAGES & ASSOCIATES O UR S ERVICES OPERATIONAL REVIEW AND ENHANCEMENT
O UR S ERVICES OPERATIONAL REVIEW AND ENHANCEMENT The Prospective Payment System (PPS) for Inpatient Rehabilitation Facilities creates both opportunities and challenges for facilities that provide comprehensive
More informationREGULATION, ACCREDITATION, AND PAYMENT PRACTICE GROUP (June, July, August 2004)
REGULATION, ACCREDITATION, AND PAYMENT PRACTICE GROUP (June, July, August 2004) Lester J. Perling Broad and Cassel Fort Lauderdale, Florida I. Case Summaries CMNs Document Medical Necessity In Maximum
More informationGetting Ready for RAC Part II: Prepare & Defend 2009 Arent Fox LLP. Background Resulting in RACs
Getting Ready for RAC Part II Prepare & Defend Presented by Connie A. Raffa, J.D., LL.M. raffa.connie@arentfox.com 212.484.3926 Thomas E. Jeffry, Jr., J.D. jeffry.thomas@arentfox.com 213443-7520 October
More informationAgenda. OIG Medicare Compliance Reviews: A Compliance Officer s Guide to Survival. Introduction History and Purpose Facility Selection Evolution
OIG A Compliance Officer s Guide to Survival Shannon DeBra Bricker & Eckler LLP sdebra@bricker.com Linn Swanson UPMC swansonlm@upmc.edu Agenda Introduction History and Purpose Facility Selection Evolution
More informationFlorida Health Care Association 2013 Annual Conference
Florida Health Care Association 2013 Annual Conference The Westin Diplomat Resort & Spa Session #51 Navigating Health Care Reform: Creating a Road Map for Success Thursday, August 8 8:15 to 9:45 a.m. Regency
More informationCombating Medicaid Fraud & Abuse NCSL New England Fiscal Leaders Meeting February 22, 2013
Combating Medicaid Fraud & Abuse NCSL New England Fiscal Leaders Meeting February 22, 2013 Kavita Choudhry State Health Care Spending Project Pew Charitable Trusts Pressure on state and local budgets Source:
More information9/18/2014. Agenda. Final IPPS 2015 AKA CMS 1607-F (Published in Federal Register on August 22, 2014)
2015 Inpatient Prospective Payment Services (IPPS) and Insights on Best Practices John Zelem, MD, FACS Executive Medical Director, Client Relations and Education Agenda 2014/2015 IPPS Final Rule 2015 proposed
More informationZone Program Integrity Program & Recovery Audit Contractors
Zone Program Integrity Program & Recovery Audit Contractors Advance Planning and Responsive Tools. AHLA Long Term Care and the Law Program Feb 26, 2013 Presented by: Brain Daucher Esq. Sheppard Mullin
More informationRECOVERY AUDIT CONTRACTORS
RECOVERY AUDIT CONTRACTORS RAC SUBSCRIPTION SERVICE What are We Learning? May 24, 2011 2011 Aegis Compliance & Ethics Center, LLP 1 Faculty Brian Annulis, JD Partner, Meade & Roach, LLP 773.907.8343 bannulis@meaderoach.com
More informationCRCE Exam Study Manual Update for 2017
CRCE Exam Study Manual Update for 2017 This document reflects updates made to the instructional content from the Certified Revenue Cycle Executive (CRCE-I, CRCE-P) Exam Study Manual - 2016 to the 2017
More informationRegulatory Compliance Risks. September 2009
Rehabilitation Regulatory Compliance Risks September 2009 1 Agenda - Rehabilitation Compliance Risks Understand the basic requirements for Inpatient Rehabilitation Facilities (IRFs) and Outpatient Rehabilitation
More informationCentral Ohio HFMA Fall Education Hot Topics: Maintaining Compliance in Times of Change. November 22, 2013
Central Ohio HFMA Fall Education Hot Topics: Maintaining Compliance in Times of Change November 22, 2013 Agenda IPPS Final rule inpatient status changes Proposed OPPS changes to reporting hospital evaluation
More information50938 Federal Register / Vol. 78, No. 160 / Monday, August 19, 2013 / Rules and Regulations
50938 Federal Register / Vol. 78, No. 160 / Monday, August 19, 2013 / Rules and Regulations The quality, utility, and clarity of the information to be collected. Recommendations to minimize the information
More informationJune 2, Dear Secretary Sebelius:
Ms. Kathleen Sebelius Secretary U.S. Department of Health and Human Services Hubert H. Humphrey Building, Suite 120F 200 Independence Avenue S.W. Washington, D.C. 20201 Dear Secretary Sebelius: On behalf
More informationMEDICARE FFY 2017 PPS PROPOSED RULES OVERVIEW OHA Finance/PFS Webinar Series. May 10, 2016
MEDICARE FFY 2017 PPS PROPOSED RULES OVERVIEW 2016 OHA Finance/PFS Webinar Series May 10, 2016 Spring is Medicare PPS Proposed Rules Season Inpatient Hospital Long-Term Acute Care Hospital Inpatient Rehabilitation
More informationSTATE OF NORTH CAROLINA
STATE OF NORTH CAROLINA DEPARTMENT OF PUBLIC SAFETY DIVISION OF ADULT CORRECTION FINANCIAL RELATED AUDIT MAY 2012 OFFICE OF THE STATE AUDITOR BETH A. WOOD, CPA STATE AUDITOR DEPARTMENT OF PUBLIC SAFETY
More informationGeneral Inpatient Level of Care: Managing Risks
General Inpatient Level of Care: Managing Risks THE CAROLINAS CENTER, 2015 1 Presenter Annette Kiser, MSN, RN, NE-BC Director of Quality & Compliance The Carolinas Center akiser@cchospice.org THE CAROLINAS
More informationGoal of the Audit Culture
Inpt vs. Observation Why is it so hard? It is all about the patient s story Presented By: Day Egusquiza, President AR Systems, Inc. 1 Goal of the Audit Culture To ensure billed services are reflected in
More information3/19/2014 RAC TEAM UM TEAM FINANCE HIM
Karen Stoll, BSN, RN, CPC-H, Manager-Payor Services/Recovery Audit, Wheaton Franciscan Healthcare & Catlin Scheppler, BSN, RN, Recovery Audit and Appeals Nurse Analyst, Recovery Audit and Appeals Department,
More informationHighlights of Program Integrity Provisions Managed Care Delivery System Subcommittee June 9, 2011
Patient Protection and Affordable Care Act: Highlights of Program Integrity Provisions Managed Care Delivery System Subcommittee June 9, 2011 1 Provider Screening and Other Enrollment Requirements Provider
More informationImproving Medicaid Program Integrity: State Strategies to Combat Fraud and Abuse
Improving Medicaid Program Integrity: State Strategies to Combat Fraud and Abuse March 6, 2013 Overview New York's Experience Role of Medicaid Program Integrity: Florida s Approach Medicaid Anti-Fraud
More informationDiane Meyer, CHC (650) Agenda
The Road Ahead and How to Navigate It Kevin D. Lyles, Esq. kdlyles@jonesday.com (614) 281-3821 Diane Meyer, CHC DMeyer@stanfordmed.org (650) 724-2572 Frank E. Sheeder, Esq. fesheeder@jonesday.com (214)
More informationAddressing Documentation Insufficiencies
Objectives Addressing Documentation Insufficiencies ICAHN June 9,2015 Glenn Krauss, BBA, RHIA, CCS, FCS, PCS,CCS-P, CPUR, C-CDI, CCDS, C- DAM Understand and appreciate physician frustrations with the EHR
More informationRFI /14 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION REQUEST FOR INFORMATION
RFI 002-13/14 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION REQUEST FOR INFORMATION Medicaid Recovery Audit Contractor (RAC) to provide on a contingency fee basis recovery audit services for the
More informationAnnual Leadership Institute August 25, Triple Check: A Process for Preventing False Claims
Annual Leadership Institute August 25, 2016 Triple Check: A Process for Preventing False Claims 1 Your presenter today is: Sophie A. Campbell, MSN, RN, CRRN, RAC-CT, CNDLTC Director, Clinical Advisory
More informationNHPCO Regulatory Recap for Activity from August 2011 Volume 1, Issue No.8
NHPCO Regulatory Recap for Activity from August 2011 Volume 1, Issue No.8 To: NHPCO Membership From: NHPCO Regulatory Team IN THIS ISSUE: CMS Help Prevent Fraud Campaign CMS Provider Compliance Group Outreach
More informationMassHealth Provider Billing and Services Updates & Upcoming Initiatives. Massachusetts Health Care Training Forum July 2011
MassHealth Provider Billing and Services Updates & Upcoming Initiatives Massachusetts Health Care Training Forum July 2011 Agenda I. MassHealth Updates/Resources & Upcoming MassHealth Initiatives II. Paper
More informationClinical Documentation Improvement Programs and Physician Advisors: Working Together to Improve Effectiveness. October 12, 2009
Clinical Documentation Improvement Programs and Physician Advisors: Working Together to Improve Effectiveness October 12, 2009 Betty B. Bibbins, MD, CHC, FACOG, C-CDI, C CDI, CPEHR, CPHIT President & Chief
More informationUsing the Hospice PEPPER to Support Auditing and Monitoring Efforts: Session 1
Using the Hospice PEPPER to Support Auditing and Monitoring Efforts: Session 1 March, 2016 Kimberly Hrehor Agenda Session 1: History and basics of PEPPER PEPPER target areas Percents and percentiles Comparison
More informationFY 2014 Changes to Medicare Inpatient Admission and Reimbursement Standards: CMS s Two Midnight Rule and the Revised Part A to Part B Rebilling Policy
FY 2014 Changes to Medicare Inpatient Admission and Reimbursement Standards: CMS s Two Midnight Rule and the Revised Part A to Part B Rebilling Policy Mark Polston King & Spalding In Fiscal Year 2014,
More informationSTATE HOSPICE ORGANIZATION AND PALMETTO GBA COALITION MEETING SUMMARY
STATE HOSPICE ORGANIZATION AND PALMETTO GBA COALITION MEETING SUMMARY For meeting held on August 19, 2010 Included in this report: NCLOS audits update on status Various other audit types (ZPIC) Palmetto
More informationToday s presentation
Centers for Medicare & Medicaid Services Update Healthcare Enforcement Compliance Institute October 31, 2017 Kim Brandt, J.D., M.A. Principal Deputy Administrator for Operations, Centers for Medicare &
More informationAHLA. Z. New Rules: Hospital Patient Status, Observation, Part B Billing for Denied Inpatient Admissions
AHLA Z. New Rules: Hospital Patient Status, Observation, Part B Billing for Denied Inpatient Admissions Timothy P. Blanchard Blanchard Manning LLP Orcas, WA Joan C. Ragsdale CEO MedManagement LLC Vestavia,
More information3M Health Information Systems. A case study in coding compliance: Achieving accuracy and consistency
3M Health Information Systems A case study in coding compliance: Achieving accuracy and consistency A case study in coding compliance: Achieving accuracy and consistency The challenge Coding compliance
More informationDecember 5, C.F. Moore Deputy Chief Administrative Law Judge
December 5, 2012 C.F. Moore Deputy Chief Administrative Law Judge Office of the Chief Judge Office of Medicare Hearings and Appeals Arlington, VA http://www.hhs.gov/omha/ OMHA Organization (Cont.) Office
More informationPROPOSED POLICY AND PAYMENT CHANGES FOR INPATIENT STAYS IN ACUTE-CARE HOSPITALS AND LONG-TERM CARE HOSPITALS IN FY 2014
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 FACT SHEET FOR IMMEDIATE RELEASE Contact: CMS Media Relations
More informationAN ANALYSIS OF TITLE VI TRANSPARENCY AND PROGRAM INTEGRITY
AN ANALYSIS OF TITLE VI TRANSPARENCY AND PROGRAM INTEGRITY Summaries of Key Provisions in the Patient Protection and Affordable Care Act (HR 3590) as amended by the Health Care and Education Reconciliation
More information10/7/2014. Agenda. Big picture Internal Medicine Update. The Two Midnight Rule: One Year Later
2014 Internal Medicine Update SC Chapter Scientific Meeting The Two Midnight Rule: One Year Later Nick Ulmer, MD CPC VP Clinical Services and Medical Director of Case Management, SRHS Agenda Define status
More informationCopyright ht 2012 Executive Health lthresources, Inc. All rights iht reserved. The Perfect Storm
Medicare Compliance Challenges in the Age of Healthcare Accountability Marc Tucker, DO Senior Director Audit, Compliance & Education AHA Solutions, Inc., a subsidiary of the American Hospital Association,
More informationPayment Policy: 30 Day Readmission Reference Number: CC.PP.501 Product Types: ALL
Payment Policy: 30 Day Readmission Reference Number: CC.PP.501 Product Types: ALL Effective Date: 01/01/2015 Last Review Date: 04/28/2018 Coding Implications Revision Log See Important Reminder at the
More informationHospice House Network Inpatient Conference
Hospice House Network Inpatient t Conference Trends & Recent Developments in Hospice General Inpatient Care Policy and Enforcement June 7, 2013 1 www.morganlewis.com Presented by Howard J. Young, Esq.
More informationToday s Presenters & Agenda
EHR s Accelerated Compliance Training (ACT) Series: Updates on Regulatory Developments and Audit Activity February 25, 2015 Today s Presenters & Agenda Presenters: Ralph Wuebker, MD, MBA, Chief Medical
More informationChanges in the School Based Access Program (SBAP)
Pennsylvania Association of School Business Officials Changes in the School Based Access Program (SBAP) April 23, 2013 Webcast (9:30-11:00 AM) Listen to audio over your computer speakers (If you prefer
More informationCONTRACT YEAR 2011 MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLAN MODEL TERMS AND CONDITIONS OF PAYMENT
CONTRACT YEAR 2011 MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLAN MODEL TERMS AND CONDITIONS OF PAYMENT Table of Contents 1. Introduction 2. When a provider is deemed to accept Flexi Blue PFFS terms and
More informationMDS Accuracy and Compliance: Where There s Smoke
MDS Accuracy and Compliance: Where There s Smoke November 2014 1 Objectives List the current trends in the Long Term Care industry that are driving scrutiny into the MDS assessment process Identify the
More informationCh COUNTY NURSING FACILITY SERVICES CHAPTER COUNTY NURSING FACILITY SERVICES
Ch. 1189 COUNTY NURSING FACILITY SERVICES 55 1189.1 CHAPTER 1189. COUNTY NURSING FACILITY SERVICES Subchap. Sec. A. GENERAL PROVISIONS... 1189.1 B. ALLOWABLE PROGRAM COSTS AND POLICIES... 1189.51 C. COST
More information3/12/2012. DRG Validation, cont. New Challenges and Target Areas RACs. Update on RACs [Recovery Audit Contractors] & Other External Auditors
Update on RACs [Recovery Audit Contractors] & Other External Auditors Presented by: Mary Legerski, RN, Esq., CHC, CPC, MBA, MPA New Challenges and Target Areas RACs CGI Targets as of 3/7/12 Inpatient claims
More informationSurviving Targeted Probe & Educate
Surviving Targeted Probe & Educate PRESENTED BY: MELINDA A. GABOURY, CEO HEALTHCARE PROVIDER SOLUTIONS, INC. TARGETEDPROBEANDEDUCATE.COM INFO@HEALTHCAREPROVIDERSOLUTIONS.COM CMS expansion on Probe & Educate
More informationIf you want to subscribe to the provider only listserv, please with subscribe as the subject line.
From: Sent: CMS ROCHI_Prov_Outreach Tuesday, March 06, 2012 1:48 PM Subject: CMS Medicare FFS Provider e News for Thu Mar 1 If you want to subscribe to the provider only listserv, please email: ROCHIFM@cms.hhs.gov
More informationHB 254 AN ACT. The General Assembly of the Commonwealth of Pennsylvania hereby enacts as follows:
PUBLIC WELFARE CODE - DEPARTMENT OF PUBLIC WELFARE POWERS, DETERMINING WHETHER APPLICANTS ARE VETERANS, MEDICAL ASSISTANCE PAYMENTS FOR INSTITUTIONAL CARE AND STATEWIDE QUALITY CARE ASSESSMENT Act of Jul.
More informationMedicare Fraud & Abuse: Prevention, Detection, and Reporting ICN
Medicare Fraud & Abuse: Prevention, Detection, and Reporting ICN 908103 1 Disclaimers This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently
More informationRAC Audits and Denials Management WHCA Fall Conference September 9, 2014
JoLynn Munro, MS,OTR/L, Regional Vice President Infinity Rehab Carolyn Staples, CCC/SLP, Area Rehab Director Infinity Rehab RAC Audits and Denials Management WHCA Fall Conference September 9, 2014 Objectives
More informationGeneral Documentation Compliance. Review for Provider Reappointment
U N C U H N E C A L H T E H A L C T A H R E C A S R Y E S T E M General Documentation Compliance Review for Provider Reappointment May 2018 Objectives 1 2 Review the principles of compliant billing and
More informationHOME HEALTH CARE TABLE OF CONTENTS. OVERVIEW TRANSITIONAL... CARE... SERVICES . MEMBERS... MANAGED... BY... EVICORE
TABLE OF CONTENTS. OVERVIEW............................................................................................. 452..... TRANSITIONAL................. CARE...... SERVICES......................................................................
More informationREPORT 5 OF THE COUNCIL ON MEDICAL SERVICE (I-09) Radiology Benefits Managers (Reference Committee J) EXECUTIVE SUMMARY
REPORT OF THE COUNCIL ON MEDICAL SERVICE (I-0) Radiology Benefits Managers (Reference Committee J) EXECUTIVE SUMMARY At the 00 Annual Meeting, the House of Delegates adopted as amended Resolution, which
More informationMedi-Cal APR-DRG Updates. Medi-Cal Updates. Agenda. Medi-Cal APR-DRG Updates Quality Assurance Fee (QAF) Program
Medi-Cal Updates Amber Ott California Hospital Association Agenda Medi-Cal APR-DRG Updates Quality Assurance Fee (QAF) Program Current QAF Law (SB239) Prop 52 Medicaid Managed Care Final Rules QAF 5 Development
More informationSNF Determinations of Non-Coverage Denial Letters, ABNs & Expedited Determinations
SNF Determinations of Non-Coverage Denial Letters, ABNs & Expedited Determinations for clients of: www.teamtsi.com 800.765.8998 Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240
More informationCOMPLIANCE ROUND-UP. December 13, Aegis Compliance & Ethics Center, LLP 1
COMPLIANCE ROUND-UP December 13, 2011 2011 Aegis Compliance & Ethics Center, LLP 1 Today s Faculty Brian Annulis, JD, CHC Partner, Meade & Roach, LLP 773.907.8343 bannulis@meaderoach.com Ryan Meade, JD,
More informationHealthStream Regulatory Script. Corporate Compliance: A Proactive Stance. Version: [February 2007]
HealthStream Regulatory Script Corporate Compliance: A Proactive Stance Version: [February 2007] Lesson 1: Introduction Lesson 2: Importance of Compliance & Compliance Programs Lesson 3: Laws and Regulations
More information2014 Hospital Admission Criteria
2014 Hospital Admission Criteria Created on 11/20/2013 Audio and/or Video Recording of this Educational Session is Prohibited Agenda Inpatient vs. observation 2-midnight benchmark and presumption Admission
More informationUsing the New Home Health Agency (HHA) PEPPER to Support Auditing and Monitoring Efforts
Using the New Home Health Agency (HHA) PEPPER to Support Auditing and Monitoring Efforts July 30, 2015 Kimberly Hrehor 2 Agenda History and basics of PEPPER HHA PEPPER target areas Percents, rates and
More information[Document Identifiers: CMS-10341, CMS-10538, CMS-R-153, CMS and CMS-10336]
This document is scheduled to be published in the Federal Register on 03/27/2018 and available online at https://federalregister.gov/d/2018-06081, and on FDsys.gov DEPARTMENT OF HEALTH AND HUMAN SERVICES
More information