3/12/2012. DRG Validation, cont. New Challenges and Target Areas RACs. Update on RACs [Recovery Audit Contractors] & Other External Auditors
|
|
- Amie Garrison
- 5 years ago
- Views:
Transcription
1 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 147 Outpatient claims 17 Professional 17 DME 11 DME by supplier 2 DME by physician 1 CSW 1 Total: 196 New Challenges and Target Areas RACs DRG Validation Reviews Audit types as of 3/7/12 Automated: 39 Outpatient 14 Professional 13 DME 10 CSW 1 Inpatient - 1 Complex: 156 Inpatient 146 DME - 4 Outpatient 3 Professional 3 Semi-automated [prof]: 1 Total: 196 Diseases and Disorders of the Blood [12/11] MS-DRG Validation to determine principal diagnosis and secondary diagnoses identified as CCs and MCCs [major complication or comorbidity] are: Present Correctly sequenced Coded and Clinically validated Principal diagnosis - condition established after study found to be chiefly responsible for admission to the hospital The other diagnosis - (MCC/CC) present during admission that impact the stay POA [present on admission] indicator for all diagnoses reported must be coded correctly DRG Validation, cont. Other Diseases of the Respiratory System [12/11] Acute Kidney Failure [11/11] Disorders of Pituitary Gland and Hypothalamic Control [11/11] Excisional Debridement [11/11] Reviewers will validate MS-DRGs with a procedure code of and for diagnoses that affect the MS-DRG assignment Nutritional Disorders [11/11] Medical Necessity Review Examples Acute Inpatient Admission Respiratory Conditions Conditions of the Circulatory System Diseases and Disorders of the Digestive System Infections Musculoskeletal Disorders Surgical Cardiovascular Procedures 1
2 Medical Necessity and DRG Review Examples Chest Pain Esophagitis, Gastroenteritis & Misc Digestive Disorders w/mcc Heart Failure & Shock w/mcc, w CC and w/o CC/MCC Nutritional and Metabolic Disorders Other Circulatory System Diagnoses w MCC Renal Failure Coding Reviews and Miscellaneous Issues Intravenous Infusion Chemotherapy and Nonchemotherapy - Excessive Units Reported Neulasta Outpatient Claims Billed within a PPS Inpatient Admission DME while Inpatient Excessive Billing of Positive Airway Pressure (PAP) and Respiratory Assist Device (RAD) Accessories Hospital to Hospital Transfer New Purchased Power Wheelchairs Other External Auditors Who are They? Power Wheelchairs are covered if the equipment is properly coded and meets coverage criteria/documentation requirements specified in the National Government Services (NGS) Local Coverage Determination (LCD) L27239, Medical records will be reviewed for new, purchased PWC for appropriate coding, documentation requirements and medical necessity criteria Medicaid RACs Medicare Administrative Contractors Medicaid Integrity Contractors Program Safeguard Contractors Office of Inspector General State audits Commercial audits Key Target Areas of Other Auditors Same as RACs in many cases Denials of readmissions due to inadequate discharge plans Tools to Assess Risk and Upcoming Target Areas of Auditors PEPPER reports OIG work plan issues RAC website updates MAC tip of the week info CMS and OIG website 2
3 PEPPER OIG Work Plan Issues [2012 Examples] Provides summary statistics of claims data on CMS target areas payment errors due to billing, DRG/coding and/or admission necessity issues Hospitals can review data for the current quarters and the previous three fiscal years for each of the areas targeted for improvement by CMS, and compare their performance to that of the other acute-care PPS hospitals within their state. Can also compare their own data across years to: identify significant changes in billing practices; pinpoint areas in need of auditing; identify potential DRG under- or over-coding problems; and identify target areas where length-of-stay is increasing. Accuracy of Present-on-Admission Indicators Submitted on Medicare Claims (New) Medicare Inpatient and Outpatient Payments to Acute Care Hospitals (New) Hospital Inpatient Outlier Payments: Trends and Hospital Characteristics Medicare s Reconciliations of Outlier Payments Hospital Claims With High or Excessive Payments Hospital Same-Day Readmissions Acute-Care Hospital Inpatient Transfers to Inpatient Hospice Care (New) Medicare Payments for Beneficiaries With Other Insurance Coverage MAC [CGS] tip of the week Info CMS and OIG Websites Tip of the Week: Make sure all documents are signed by the person providing the service Tip of the Week: Should you receive a request for a signature or attestation because the documentation submitted did not meet the signature requirements you MUST respond within 20 days of the request Tip of the Week: Make sure that all required information is documented in the medical record Tip of the Week: It is important that you comply with CERT requests timely. Not responding or submitting insufficient documentation will result in a CERT denial and recoupment of funds CMS Hospital: OIG Includes in and outpatient services provided by certain hospitals Allegedly about 100 hospitals will be visited OIG uses following to identify billing risk areas computer matching data mining and analysis techniques Also have new audit tool: OIG s Internal Controls Questionnaires OIG audits 7 to 10 error types OIG picks from menu of 30 risk areas Once in a chart OIG can review anything Examples of review areas: physician signatures, bylaw reviews, inpatient short stays, same day discharges and re-admissions - 3
4 OIG s Internal Controls Questionnaires St. Vincent Medical Center in Conn. Had OIG audit Results were as follows: 60 outpatient 138 inpatient claims which risk for error Result: 38 inpatient and 3 outpatient claims had billing errors Total $284,773 And OIG asks for parking, fax machines, internet access, etc Asks specific questions about provider processes in an attempt to identify root causes for errors Areas reviewed include: Processes and internal control mechanisms Contracts for billing and payment processing vendors Determination of accuracy of clinical orders Safeguards for correct coding and record documentation Results of current and previous internal and external audits of coding, billing and documentation processes Inpatient Transfer Claim Example Examples of the types of claims at risk for noncompliance included the following: inpatient claims for short stays inpatient transfer claim inpatient claims with high severity level DRG codes inpatient claims for blood clotting factor drugs outpatient claims billed prior to and during inpatient stays outpatient claims billed with modifier -59 (indicating that a procedure or service was distinct from other services performed on the same day) inpatient and outpatient claims paid in excess of charges, and inpatient and outpatient claims involving manufacturer credits for replaced medical devices A discharge of inpatient is a transfer if patient is readmitted same day to another hospital unless readmission is unrelated to initial discharge* A discharge of inpatient is also a transfer when the patient s discharge is assigned to one of the qualifying DRGs and the discharge is to a home under a written plan of care for the provision of home health services from a home health agency and those services begin within 3 days after the date of discharge** Under the above circumstances hospital is paid a graduated per diem rate for each day of the patient s stay in that hospital, not to exceed the full DRG payment that would have been paid if the patient had been discharged to another setting*** * 42 CFR 412.4(b) ** 42 CFR 412.4(c) ***42 CFR 412.4(f) Inpatient Transfer Claim Example How can Case Managers assist in evaluating high risk areas and establish processes to prevent loss of revenue? In review done of a specific hospital OIG found that in a majority of the claims they should have coded the discharge as transfer to another facility instead of discharge to home Hospital should have received per diem payment instead of full DRG payment For 1 of 26 claims, the entire Medicare payment was in error - Medicare was subsequently determined to be the secondary payer Hospital stated errors occurred because coding staff did not identify disposition status information in the discharge plans and physician orders Appeals process Review based on criteria [Interqual or Milliman] Remember these are guidelines Include arguments of medical necessity Patient co-morbidities Physician clinical judgment According to Highmark Medicare Services, Inc., the Medicare Administrative Contractor ( MAC ) for Jurisdiction I, a person is considered an inpatient if: he is formally admitted based on the physician s expectation of a need for an appropriate inpatient stay justification for an inpatient stay is based on the information available at the time of admission Subsequent information may support a physician s hunch that the patient needed inpatient care, but never serves to refute that original determination. 4
5 How CM s Can Help Understand How CM s Can Help - Understand On average, Medicare pays about $4,500 to $5,000 more for a DRG than for an APC with its bundled observation fee. Billing one legitimate inpatient admission as an outpatient observation claim every day adds up to about $1.7 million in lost revenue annually. * Hospitals need to ensure there is a process in place to identify the correct patient status preferably before the patient is discharged from the hospital *Health Care Compliance Association Inpatient Short Stay Admissions Enforcement Developments April 18-21, 2010, p.5 By: William R. Mitchelson, Jr. & Lisa Barry Frist The physician or other practitioner responsible for a patient s care at the hospital is also responsible for determining whether the patient should be admitted as an inpatient By state law, only physicians can order the admission of a patient to a hospital Nurses (including care managers) are not legally qualified to make that decision, which is outside their scope of practice How CM s Can Help Understand How CM s Can Help Understand The MBPM sets forth the following factors that should be considered by the physician in determining whether to admit a patient as an inpatient: The severity of the signs and symptoms exhibited by the patient The medical predictability of something adverse happening to the patient The need for diagnostic studies that appropriately are outpatient services and The availability of diagnostic procedures at the time CMS created Condition Code 44 which allows the hospital to change the patient s status from inpatient to observation after the patient has been admitted but before the patient is discharged from the hospital. Even though Condition Code 44 may help to catch errors prior to discharge, it is better to assign the correct patient status when the patient presents at the hospital (often in the emergency room) Early communication between the utilization review nurses, the emergency room physician, and the treating physician facilitate this process How can you be proactive with documentation, monitoring, and communications? Ensure the documentation addresses: Problems identified in the history and physical Treatment initiated Patient s response to treatment Major changes in the patient s condition and action taken Status of unresolved problems Discharge planning and follow-up How can you be proactive with documentation, monitoring, and communications? Use case examples to educate providers Consult with peers in the community to see how they have been successful with appeals Realize at the ALJ level you may have more success Need to ensure appeal is tailored to audience Don t appeal all cases credibility Be organized and succinct Utilize physician advocates to assist in writing appeals and presenting evidence to ALJ 5
6 Saint Joseph s Health System in Atlanta settled False Claims Act allegations with the federal government in December 2007 Hospital paid $26 million to settle claims that it improperly admitted patients to the hospital that did not meet medical necessity for inpatient admission Government s investigation focused on the medical necessity for claims submitted for short inpatient stays: one-day & two-day inpatient stays three-day stays followed by a discharge to a skilled nursing facility one-day stays ESRD patients receiving urgent dialysis after missing scheduled maintenance dialysis as a result of needing to repair blocked or nonfunctioning access sites September 2009 six Indiana and Alabama hospitals resolved allegations the hospitals overcharged Medicare related to kyphoplasty procedure government alleged that kyphoplasty is a minimally-invasive procedure that should have been performed on an outpatient basis rather than admitting the patients as inpatients Hospitals agreed to pay the United States more than $8 million to settle the allegations July 2009, Yale-New Haven Hospital in Connecticut settled claims with the government related to medically unnecessary inpatient hospital admissions. Hospital paid $885,953 to settle the allegations Allegations related to a Gamma Knife stereotactic radiosurgery procedure which is generally used to treat malignant and benign tumors, vascular abnormalities, and other neurological conditions. Government contended this procedure was non-invasive and should have been performed on an outpatient basis without general anesthesia rather than admitting the patients as inpatients January 2010, Wheaton Community Hospital in Minnesota agreed to pay $846,461 to settle allegations that their hospital admission practices violated the False Claims Act. Government alleged that the hospital admitted some patients and kept others admitted to acute care when doing so was not medically necessary. Hospital then billed Medicare for the inpatient hospital admissions that were not medically necessary. Investigation of Wheaton Community Hospital began with a lawsuit filed in federal court in Minnesota under the qui tam provisions of the False Claims Act Whistleblower in this case was a physician who formerly practiced at the hospital Recommended Actions Recommended Actions Education and ongoing training for emergency room physicians, treating physicians, and utilization review/care management nurses regarding the differences between inpatient and observation status as well as Condition Code 44 Use of up-to-date InterQual (or other screening criteria) guidelines by the utilization review/care management nurses Early communication among members of the treating team including physicians and utilization review/care management nurses Ensure hospital has an up-to-date UR Plan and UR Committee to review short stay admissions and unnecessary admissions Develop plan of action if high percentage of one-day stays or unnecessary admissions Emphasize importance of clear documentation in admission orders (e.g., physician order to admit is not clear; physician order should specify inpatient, outpatient, and observation and should include the admitting diagnosis) Use physician advisors Involve utilization review staff, coding/billing department, Health Information Management department, finance department, and compliance team regarding compliance with Medicare rules and regulations 6
7 Questions? 7
Topics. 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 informationCompleting the Circle: The Importance of CDI Specialist Participation in the Denial Management Process
Completing the Circle: The Importance of CDI Specialist Participation in the Denial Management Process Sarah Mendiola, Esq., LPN, CPC Senior Associate & Director of Clinical Services Washington & West,
More informationUsing Clinical Criteria for Evaluating Short Stays and Beyond
Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford I. History A. Social Security Act Medical Necessity and Utilization Review 1. Items or services necessary for the diagnosis
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 informationRAC Targets, Bullseyes and Near Misses: What Your CDI Program Should Know
RAC Targets, Bullseyes and Near Misses: What Your CDI Program Should Know Barbara Flynn, RHIA, CCS, Certified AHIMA ICD-10-CM/PCS Trainer, ICD10 Ambassador Vice President for Health Information Management
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 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 informationTHE PEPPER AND YOUR CDI PROGRAM. Kat McFarland, RN, MN, ACM Director Care Management Providence Regional Medical Center Everett 9/28/2018
THE PEPPER AND YOUR CDI PROGRAM Kat McFarland, RN, MN, ACM Director Care Management Providence Regional Medical Center Everett 9/28/2018 https://pepperresources.org/training-resources/short-term-acute-care-hospitals/pepper-review
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 information* HFMA staff and volunteers determined that this product has met specific criteria developed under. endorse or guaranty the use of this product.
Latest Updates to the PEPPER: Utilizing New Report Data and Benchmarks to Support Your Compliance Efforts John Zelem, MD Senior Director, Audit, Compliance & Education Executive Health Resources * HFMA
More informationUser s Guide Tenth Edition
Long-term Acute Care Program for Evaluating Payment Patterns Electronic Report User s Guide Tenth Edition Prepared by Long-term Acute Care Program for Evaluating Payment Patterns Electronic Report User
More informationClinical Documentation Improvement (CDI) Programs: What Role Should Compliance Play?
Clinical Documentation Improvement (CDI) Programs: What Role Should Compliance Play? June 17, 2016 Agenda Clinical Documentation Improvement (CDI) Perspective An Effective CDI Program Core Focus: Compliance
More informationRecovery 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 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 informationAAPC Webinar 3/28/2016
Short Stays for the Coder Where Are We Now? Heather Greene, MBA, RHIA, CPC, CPMA AHIMA Approved ICD-10 CM/PCS Trainer Copyright 2016 AAPC Agenda The Two-Midnight Rule Supportive documentation Observation
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 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 informationDevelop a Taste for PEPPER: Interpreting
Develop a Taste for PEPPER: Interpreting Your Organizational Results Cheryl Ericson, MS, RN Manager of Clinical Documentation Integrity, The Medical University of South Carolina (MUSC) Objectives Increase
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 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 informationCigna Medical Coverage Policy
Cigna Medical Coverage Policy Subject Observation Care Table of Contents Coverage Policy... 1 General Background... 2 Coding/Billing Information... 4 References... 5 Effective Date... 10/15/2014 Next Review
More informationCAH PREPARATION ON-SITE VISIT
CAH PREPARATION ON-SITE VISIT Illinois Department of Public Health, Center for Rural Health This day is yours and can be flexible to the timetable of hospital staff. An additional visit can also be arranged
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 informationWhat is an Inpt & How to get it right. The Challenges of Coverage and Compliance Why is it so hard?
What is an Inpt & How to get it right The Challenges of Coverage and Compliance Why is it so hard? 1 From the pt: AARP Jan-Feb 2010 issue Hospital Stays are Under Observation Ruth Way fell, was admitted
More informationRECOVERY AUDIT CONTRACTORS
RECOVERY AUDIT CONTRACTORS RAC ROUND-UP SUBSCRIPTION SERVICE Being Proactive Kyphoplasty, CMS Clarifies Effective and Implementation Dates & Changes to Carotid Artery Stenting Coverage January 11, 2011
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 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 informationMedicare Recovery Audit Contractors. Chicago, IL August 1, 2008
Medicare Recovery Audit Contractors Chicago, IL August 1, 2008 1 Recovery Audit Contractors Demo Summary National Rollout AHA Strategy AHA RACTrac Overview 2 Recovery Audit Contractors Medicare Modernization
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 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 informationUnitedHealthcare Medicare Readmission Review Program for Medicare Advantage Plans General Clinical Guidelines for Payment Review
UnitedHealthcare Medicare Readmission Review Program for Medicare Advantage Plans General Clinical Guidelines for Payment Review Introduction The UnitedHealthcare Medicare Readmission Review Program is
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 informationBecoming a Champion of Physician and Hospital Alignment: Focusing on Length of Stay, Discipline and Standards of Care
Becoming a Champion of Physician and Hospital Alignment: Focusing on Length of Stay, Discipline and Standards of Care Marc Tucker, DO Senior Director Audit, Compliance & Education AHA Solutions, Inc.,
More informationHealth Management Policy
Health Management Policy Policy Number: 0101 Effective Date: 4/1/18 Policy Title: Circumvention of PPS/Readmission Review Applies To: Generations Advantage Purpose: The Martin s Point Health Care Medicare
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 information2013 OIG Work Plan. Scott McBride Baker & Hostetler LLP 1000 Louisiana, Suite 2000 Houston, Texas
2013 OIG Work Plan Scott McBride Baker & Hostetler LLP 1000 Louisiana, Suite 2000 Houston, Texas 77002 713.646.1390 smcbride@bakerlaw.com Webinar Essentials * Session is currently being recorded, and will
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 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 informationPolling Question #1. Denials and CDI: A Recovery Auditor s Perspective
1 Denials and CDI: A Recovery Auditor s Perspective Tim Garrett, MD Medical Director Barb Brant, RN, CCDS, CDIP, CCS Sr. Clinical Trainer/DRG Auditors Cotiviti, Atlanta, GA 2 Polling Question #1 Does inpatient
More informationWound Care Reimbursement. Things Are A-Changing!
Wound Care Reimbursement Things Are A-Changing! Kathleen D. Schaum, MS President Kathleen D. Schaum & Assoc., Inc. kathleendschaum@bellsouth.net 561-964-2470 Disclosure No relevant financial relationships
More informationRoadmap. AAH Best Practices and Mobility Documentation. Policy History. History Continued. History Understanding Documentation
Roadmap AAH Best Practices and Mobility Documentation May 2008 History Understanding Documentation MAE NCD Key Concepts Audits The WHY of MR CMS Requirements 1 2 Policy History Original National Policy
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 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 informationReviewing Short Stay Hospital Claims for Patient Status: Admissions On or After October 1, 2015 (Last Updated: 11/09/2015)
7 Reviewing Short Stay Hospital Claims for Patient Status: Admissions On or After October 1, 2015 (Last Updated: 11/09/2015) Medical Review of Inpatient Hospital Claims Starting on October 1, 2015, the
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 informationOutpatient Observation Services
Outpatient Observation Services Presented by: Gina Hobert, MBA, CHC, CPC-I, CPMA, CEMC, CRC Sr. Manager, Baker Newman Noyes Definition MCR Benefit Policy Manual, CMS 100-02, Chapter 6, 20.6 A. Outpatient
More informationLESSONS LEARNED FROM THE PROBE AND EDUCATE AUDIT K. CHEYENNE SANTIAGO, RN
LESSONS LEARNED FROM THE PROBE AND EDUCATE AUDIT K. CHEYENNE SANTIAGO, RN Created on 6/2/2014 DISCLAIMER DISCLAIMER: WPS Medicare has produced this material as an informational reference. Every reasonable
More informationAre they coming to get you! Todd Thomas, CCS-P
Are they coming to get you! Todd Thomas, CCS-P Who is coming for you? Medicare Administrative Contractors (MACs) Recovery Audit Contractors (RACs) Medicaid Recovery Audit Contractors (MACs) Comprehensive
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 informationBenefit Criteria for Outpatient Observation Services to Change for Texas Medicaid
Benefit Criteria for Outpatient Observation Services to Change for Texas Medicaid Information posted on October 8, 2010 Effective for dates of service on or after December 1, 2010, the benefit criteria
More informationCourse Module Objectives
Course Module Objectives CM100-18: Scope of Services, Practice, and Education CM200-18: The Professional Case Manager Case Management History, Regulations and Practice Settings Case Management Scope of
More informationInpatient Psychiatric Facility (IPF) Coverage & Documentation. Presented by Palmetto GBA JM A/B MAC Provider Outreach and Education September 7, 2016
Inpatient Psychiatric Facility (IPF) Coverage & Documentation Presented by Palmetto GBA JM A/B MAC Provider Outreach and Education September 7, 2016 1 Disclaimer This information is current as of August
More informationChanges to Medicare Inpatient Admission and Reimbursement Standards: CMS s Two Midnight Rule and the Revised Part A to Part B Rebilling Policy
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, the Centers
More informationOIG Medicare Compliance Audits: Tactical Tips for Surviving One from the Battlefield
OIG Medicare Compliance Audits: Tactical Tips for Surviving One from the Battlefield Catherine R. McCarthy, CPC-H Billing Compliance Director Brigham & Women's Faulkner Hospital, Brigham & Women s Hospital
More informationObservation Coding and Billing Compliance Montana Hospital Association
Observation Coding and Billing Compliance Montana Hospital Association Sue Roehl, RHIT, CCS sroehl@eidebaill.com 701-476-8770 IP versus Observation considerations Severity of patient s signs and symptoms
More informationUsing Clinical Criteria for Evaluating Short Stays and Beyond. Georgeann Edford, RN, MBA, CCS-P. The Clinical Face of Medical Necessity
Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford, RN, MBA, CCS-P The Clinical Face of Medical Necessity 1 The Documentation Faces of Medical Necessity ç3 Setting the Stage
More informationThank you for joining us!
Thank you for joining us! We will start at 1:00 p.m. CT. You will hear silence until the session begins. Audio Options: Recommended: Audio broadcast using your computer speakers (automatically join the
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 informationEmerging Outpatient CDI Drivers and Technologies
7th Annual Association for Clinical Documentation Improvement Specialists Conference Emerging Outpatient CDI Drivers and Technologies Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA Outpatient Payment
More informationThe presenter has owns Kelly Willenberg, LLC in relation to this educational activity.
Kelly M Willenberg, MBA, BSN, CCRP, CHC, CHRC 1 The presenter has owns Kelly Willenberg, LLC in relation to this educational activity. 2 1 Medical Necessity when you submit claims Coding for qualifying
More informationCMS IPPS 2014 Final Rule: Physician Education on Observation Status and 2-Midnight Rule
CMS IPPS 2014 Final Rule: Physician Education on Observation Status and 2-Midnight Rule John Zelem, MD, FACS Executive Medical Director Audit, Compliance and Education (ACE) AHA Solutions, Inc., a subsidiary
More informationEvaluation and Management Auditing Back to the Basics. Objectives. Audit Start with the benchmarks CMS MEDPAR by specialty 4/22/2013
Evaluation and Management Auditing Back to the Basics E&M Audit Sonda Kunzi, CPC, CPMA, CPPM, CPC-I Associate Director, Cohen Healthcare Consulting Ltd. Objectives Discuss good basic audit techniques Review
More informationCompliant Documentation for Coding and Billing. Caren Swartz CPC,CPMA,CPC-H,CPC-I
Compliant Documentation for Coding and Billing Caren Swartz CPC,CPMA,CPC-H,CPC-I caren@practiceintegrity.com Disclaimer Information contained in this text is based on CPT, ICD-9-CM and HCPCS rules and
More informationTwo Midnight Rule What does it mean for Coders?
Two Midnight Rule What does it mean for Coders? Heather Greene, MBA, RHIA, CPC, CPMA Vice President, Compliance Services AHIMA Approved ICD-10 CM/PCS Trainer 1 Agenda The Two-Midnight Rule Supportive documentation
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 informationThe Two-Midnight Rule: Practical Strategies for Hospital Compliance Officers
AIS s Management Insight Series The Two-Midnight Rule: Practical Strategies for Hospital Compliance Officers Adapted from an AIS webinar presented by Abby Pendleton, Esq. Founding Partner The Health Law
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 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 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 informationOptima Health Provider Manual
Optima Health Provider Manual Supplemental Information For Ohio Facilities and Ancillaries This supplement of the Optima Health Ohio Provider Manual provides information of specific interest to Participating
More informationimplementing a site-neutral PPS
WEB FEATURE EARLY EDITION April 2016 Richard F. Averill Richard L. Fuller healthcare financial management association hfma.org implementing a site-neutral PPS Congress is considering legislation that would
More informationInnovating Predictive Analytics Strengthening Data and Transfer Information at Point of Care to Improve Care Coordination
Innovating Predictive Analytics Strengthening Data and Transfer Information at Point of Care to Improve Care Coordination November 15, 2017 RRHA Healthcare Innovations Conference Agenda Arnot Health Overview
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 informationOutpatient Hospital Facilities
Outpatient Hospital Facilities Chapter 6 Chapter Outline Introduce students to 1. Different outpatient facilities 2. Different departments involved in the reimbursement process 3. The Chargemaster 4. Terminology
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 informationRESOURCE GUIDE TO CASE MANAGEMENT Optum Executive Health Resources
RESOURCE GUIDE TO CASE MANAGEMENT Optum Executive Health Resources Table of contents Pages 2-8 Pages 9-12 Pages 13-16 Pages 17-20 Reviewing your utilization review program Learn how to evaluate your admissions
More informationQuarterly CERT Error Findings Report WPS GHA Part B J8 MAC ~ Indiana and Michigan ~
Quarterly CERT Error Findings Report WPS GHA Part B J8 MAC ~ Indiana and Michigan ~ This report provides details of Comprehensive Error Rate Testing (CERT) errors assessed April 1, 2017, through June 30,
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 informationExamining Compliance from an Internal Audit Perspective
Examining Compliance from an Internal Audit Perspective Beth A. Schindler, CPA, CIA, CISA, CHC April 19, 2016 0 Houston Methodist Who We Are About Houston Methodist A leading Academic Medical Center 7
More informationBundled Payment Primer
Bundled Payment Primer CMS Opened Application February 14, 2014 Why this matters to you! Bundling is a New Business Model Bundling is a focused opportunity to manage risk and achieve gain Control of a
More informationRE: Two-Midnight Policy and Potential Short Stay Payment Solutions
Sean Cavanaugh Deputy Administrator & Director Centers for Medicare & Medicaid Services Hubert H. Humphrey Building 200 Independence Avenue, S.W., Room 445-G Washington, DC 20201 RE: Two-Midnight Policy
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 informationOffice of Inspector General Hospital Compliance Audit
Office of Inspector General Hospital Compliance Audit HCCA Desert Southwest Regional Annual Conference November 16, 2012 Marc Tatarian, MBA, RN, CHC Regional Compliance Officer, Sutter Health DISCLAIMER
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 informationReducing Readmissions: Potential Measurements
Reducing Readmissions: Potential Measurements Avoid Readmissions Through Collaboration October 27, 2010 Denise Remus, PhD, RN Chief Quality Officer BayCare Health System Overview Why Focus on Readmissions?
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 informationMEDICARE FINAL RULE Related to INPATIENT Hospital Status Effective
MEDICARE FINAL RULE Related to INPATIENT Hospital Status Effective 10-1-13 TIMELINE August 2, 2013 Final rule published August 19, 2013 CMS holds open door forum. Many questions raised Sept 5, 2013 CMS
More informationJustifying Medicare Inpatient Admissions RAC Response and Appeals Tactics
Justifying Medicare Inpatient Admissions RAC Response and Appeals Tactics Gregory Palega, MD JD MedManagement LLC Medical Director of Regulatory Affairs gpalega@medmanagementllc.com Objectives Learn the
More informationChapter 6 Section 3. Hospital Reimbursement - TRICARE DRG-Based Payment System (Basis Of Payment)
Diagnostic Related Groups (DRGs) Chapter 6 Section 3 Hospital Reimbursement - TRICARE DRG-Based Payment System (Basis Of Payment) Issue Date: October 8, 1987 Authority: 32 CFR 199.14(a)(1) 1.0 APPLICABIITY
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 informationAmbulatory-care-sensitive admission rates: A key metric in evaluating health plan medicalmanagement effectiveness
Milliman Prepared by: Kathryn Fitch, RN, MEd Principal, Healthcare Management Consultant Kosuke Iwasaki, FIAJ, MAAA Consulting Actuary Ambulatory-care-sensitive admission rates: A key metric in evaluating
More informationChapter. CPT only copyright 2008 American Medical Association. All rights reserved. 30Radiation Therapy Services
Chapter 30Radiation Therapy Services 30 30.1 Enrollment...................................................... 30-2 30.2 Benefits, Limitations, and Authorization Requirements...................... 30-2
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 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 informationCompliance Objectives
Eyeing Coding Compliance and CDI Compliance Programs What Compliance Officers Need to Know or Should Know By Diana Adams, RHIA (adamsrra@tx.rr.com) Compliance Objectives Discovering who are the healthcare
More informationFor Vanderbilt Medical Center Carolyn Buppert, NP, JD Law Office of Carolyn Buppert
For Vanderbilt Medical Center Carolyn Buppert, NP, JD Law Office of Carolyn Buppert www.buppert.com Describe the services in critical care that nurse practitioners perform that are billable Discuss what
More informationChapter. CPT only copyright 2009 American Medical Association. All rights reserved. 31Radiation Therapy Services
Chapter 31Radiation Therapy Services 31 31.1 Enrollment...................................................... 31-2 31.2 Benefits, Limitations, and Authorization Requirements...................... 31-2
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 informationCompliance. TODAY June High-level stress: Remembering the first OIG Medicare Compliance Review an interview with Tessa Lucey.
Compliance TODAY June 2013 a publication of the health care compliance association www.hcca-info.org High-level stress: Remembering the first OIG Medicare Compliance Review an interview with Tessa Lucey
More information