Medicaid RAC Audit Results

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1 Medicaid RAC Audit Results Clinical Audits: The RAC Clinical audit goal was to review supporting documentation for necessity of admission and continued stay in long term care for Medicaid residents. There was over $2.6M identified in potential PASRR errors in the 32 of 35 facilities that were chose thus far for the clinical audit. Common Errors Identified Include: Form 161 Form missing Lack of Medicaid admit date Facility name missing Lack of SSN or Medicaid ID PASRR/OBRA Lack of completion prior to admission date Not signing as review after admission - RN did not sign the Level I Determination as reviewed on or before the date of admission Form missing Physician Visit Form missing Visits outside of required time frames Financial Audits: The Financial audit goal was to identify improperly billed and paid claims to ensure the Alabama Medicaid Agency is the payer of last resort as required by CFR Chapter 42. Common Errors Identified Include: Dates of Service paid after death or discharge Disallowed hospital bed hold days Home leave days payable by Medicaid exceeded Medicare or MCO covered period Hospice covered period Other insurance covered period Duplicate Medicaid payment Remaining patient funds on facility records for a deceased recipient As a reminder, according to federal regulation the RAC entity must not review claims that are older than 3 years from the date of the claim, unless it receives approval from the State. Providers are reminded that the Alabama Administrative Code and their Provider Agreements require compliance with requests for medical records for Medicaid program audits. Please note that ALL facilities will receive a RAC clinical and financial audit at some point. We encourage you to please conduct chart audits to ensure that all necessary documentation is contained in the medical record to meet the guidelines set forth in federal and state regulations.

2 OBRA Screening PASRR Information What is PASRR? PASRR is a provision at section 1919 (e) (7) of the Social Security Act. It requires that all Medicaid certified facilities neither admit nor retain individuals with mental illness, intellectual disability or related conditions unless a thorough PASRR evaluation indicates that such placement is both appropriate and the individual s total care needs can be met. The state of Alabama uses the Level I Screening Form as an identification tool to classify individuals that may have MI/ID/RC diagnoses. The Social Security Act requires that the Level I Screening Form be completed prior to admission for all applicants seeking admission into a Medicaid certified facility, regardless of their payment source. The statute also requires nursing facilities to submit an updated Level I Screening Form to the OBRA Office for significant changes. An Alabama Preadmission Level I Screening is required for everyone who: Is applying for admission into an Alabama Medicaid certified nursing home Was discharged from an Alabama Medicaid certified nursing home into the community for over 30 days Is transferring from an out of state nursing home to an Alabama Medicaid certified nursing home Out of State Referrals All out of state referrals must complete an Alabama Level I Screening Form and have it submitted to the OBRA PASRR Office for review prior to admission. What is a PASRR Significant Change? Significant Changes are mandated to monitor nursing home residents to ensure their continued eligibility and appropriateness for nursing home level of care; this includes re-admissions and residents that remain in the nursing home. A Level I Significant Change is required for any of the following: (not an exhaustive list) Increased psychiatric, mood-related or behavioral symptoms of individuals with a MI/ID/RC diagnosis OR Individuals without a previous Level II history who obtain a new mental illness diagnosis Has never been evaluated through the PASRR process, but exhibits signs, symptoms and/or behaviors suggesting the presence of a mental disorder A Level I must be updated for a significant change within 14 days of the status change

3 Significant Changes for MI/ID/RC residents can be Medical Improvements (which may result in the resident no longer being medically eligible) Significant Changes can be Medical Declines, where the condition impacts the resident s MI/ID/RC diagnosis (may impact the need for Specialized Services) A Significant Change is required for MI/ID/RC residents who were approved under a 120 Day Time limited Categorical, Convalescent Care Determination and are now expected to stay beyond the approved timeframe. Individuals with MI/ID/RC who have been re-admitted to a nursing home following a hospital stay and have been identified as having a significant change, the significant change Level I Screening must be completed within 14 days of the re-admission What is a Re-admission? A re-admission is a nursing home resident returning to the same nursing home from a hospital stay or a nursing home resident discharged to the community for no more than 30 days and returns to the same nursing home. In these cases, unless the readmission is identified as having a significant change, an updated Level I is not required. What is an Inter-facility Transfer? An inter-facility transfer is a nursing home resident who transfers directly from one Alabama Medicaid Certified Nursing Facility to another Alabama Medicaid Certified Nursing Facility with or without an intervening hospital stay. There can not be a break in institutional care. (E.g. nursing home or hospital) Inter-facility Transfers do not require an updated Level I Screening Form or Determination. However, the discharging nursing home is responsible for ensuring that a copy of the most current PASRR documentation accompanies the resident to the receiving NF. Remember: For inter-facility transfers, always ensure that the PASRR documentation exists and that it is complete and accurate. Important Note: The state of Alabama requires all out of state nursing home residents to complete an Alabama Level I Screening Form prior to admission. PASRR Regulatory Tracking Requirements/Monthly Level II Report You must identify all admissions, discharges, and deceased residents who have a diagnosis of MI/ID/RC as determined by the OBRA PASRR Office on the Monthly Level II Report. The Level II Report is due by the 10th of every month. If there are no changes, an or fax notification must be sent to the OBRA Office by the 10th of the month. The notification

4 must include the facility name, contact person, fax & telephone number, and the terms, "Level II Report, NO CHANGES" When MI/ID/RC Categorical Convalescent Care residents are discharged from the nursing home prior to 120 days, these discharges must be included on the Monthly Level II Report. Categorical Convalescent Care Rules (MI/ID/RC) In order to meet the regulatory criteria for a Categorical Convalescent Care admission, you must have a minimum of OT/PT/ST 5x a week by a licensed therapist, be a direct admission from a hospital (can not be in home/community setting) and must not be a danger to the safety or welfare of self or others. Convalescent Care admissions are timed stays. They are valid for up to 120 days. If the PT/OT/ST is discontinued prior to the 120 day period, the categorical convalescent care determination is no longer valid. Also, if the PT/OT/ST frequency is reduced from 5x a week, the determination is also invalid. In these cases, you must either discharge the resident from your facility or submit a new Level I Screening Form to the OBRA Screening Office for a Significant Change in order to remain compliant. If a MI/ID/RC Convalescent Care resident is expected to reside in your facility past the 120 day timed stay and needs additional PT/OT/ST, you must submit a Level I Form to the OBRA Screening Office for a Significant Change prior to the expiration date. If not, your determination is invalid and you are in violation of PASRR regulations. When a Convalescent Care resident discharges from a Nursing Facility before the 120 day period expires, you must indicate this discharge on the Monthly Level II Report. This is a Federal Tracking Requirement.

5 Medicaid Clinical RAC Audit Resident Name: Dates of Service: 1. Resident Assessment Instrument (MDS) pertinent section which the facility deems necessary to establish medical need a. Include the comprehensive assessment prior to the requested dates of service as well as the quarterly assessment that covers the dates of service request b. Include the CAAs c. Reminder: As in accordance with F273 the comprehensive assessment must be completed within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident s physical or mental condition. d. Reminder: As in accordance with F274 the comprehensive assessment must be completed within 14 days after it has been determined that a significant change has occurred in the resident s physical or mental condition. e. Reminder: As in accordance with F275 a comprehensive assessment must be done not less than once every 12 months (< 366 days). f. Reminder: As in accordance with F276 a quarterly assessment must be done not less frequently than once every 3 months (< 92 days). g. Reminder: As in accordance with F287 the facility must encode and transmit the MDS to the state within 7 days after completion. 2. Form XIX LTC-9 (Form 161) and assessment documentation (unstable) a. The entire form must be completed. b. Reminders: i. There are up to 5 dates required on page 1: Date, Medicare Admission Date, Medicaid Admission Date, Medicaid Discharge Date, Date of Death ii. The top of page 2 and 3 must be completed. This requires the name, Medicaid number, and date to be filled in at the top of the page. iii. The bottom of page 2 requires the physician address and telephone number. iv. Documentation must be included to support the criterion checked on the form 1. If criterion g is checked then the supporting documentation must contain information to support the condition and the active treatment rendered within 60 days prior to admission 2. If criterion k is checked then you should submit at least 1 week of nurse s notes or ADL flow sheets approximately 1 week prior to the Medicaid admission 3. Criterion a and k cannot be used together it is one or the other. 4. Criterion g and k9 cannot be used together it is one or the other 5. Multiple items checked in k will only count as one criterion v. Two (2) criterion are required for admission vi. One (1) criterion is required for readmission. If the resident is out in the community greater than 30 days, then this is considered a new admission and the resident will have to meet two (2) criterion. vii. Signatures and dates are required for the physician viii. An RN signature is required

6 3. PASRR Screening Information a. MUST be completed PRIOR TO ADMISSION b. An updated Level I must be submitted within 14 days of the status change for residents that have a significant change c. Make sure a Level II is completed on those residents whose Level I indicates the need for a Level II d. The form requires signatures and dates that must be completed 4. Physician Progress Notes a. Must be written, signed, and dated at each visit b. May want to consider reviewing F386 which indicates that the physician must review the resident s total program of care, including medications and treatments at each visit c. Physician visits must be made in accordance with F387: The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. d. Physician visits can be made by a physician extender is accordance with F388. The initial visit must be made by the physician and the other visits maybe alternated between the physician extender and the physician. 5. Physician Orders a. Must be signed and dated b. Must contain language similar to I certify the need for admission and continuing stay 6. Rehabilitative Plan and Treatment Notes (e.g., SP, PT, and OT) a. Must be signed and dated 7. Nurses Notes a. Must be signed and dated 8. History and Physical 9. Discharge and Transfer Summaries 10. Lab Reports 11. Radiology Reports 12. Interdisciplinary Team Notes a. This includes social services, activities, and dietary/nutrition assessments b. If no notes were done during the dates of service requested, then a copy of the quarterly notes prior to the dates of service requested should be sent 13. Intake and Output Log a. This could include ADL s, MARs, Catheter output, etc.) 14. Vital Sign Log 15. Weight Records 16. Treatment sheets 17. Therapy Re-evaluations (e.g., SP, PT, and OT) 18. Care Plans