BILLING COMPLIANCE ESSENTIALS: Strategies to Minimize Reimbursement Risk Presented by: Robin N. Seidman, RN, BSN, MSN, MBA, LNCC, HCS-D Director, Compliance Consulting Division Simione Consultants, LLC 1 Billing Compliance Essentials Be Aware of the Regulatory Trends & Government Activities Know the Compliance Risk Areas Know the Regulations & where to find them Identify and Recognize Your Agency s Compliance Pitfalls Have & USE a Compliance Program 2 1
Regulatory Trends HEALTHCARE REFORM Focus on Fraud & Abuse Patient Protection and Affordable Care Act Joint efforts to expand combating fraud, waste & abuse Health Care Fraud Prevention & Enforcement Action Team (HEAT) Cabinet DOJ & HHS Increase of Oversight and Resources MACs, MICs, RACs, ZPICs, HEAT 3 Regulatory Trends TECHNOLOGY more data.. Real-time data access (HEAT) Automated Reviews (RACs) Data Mining all Medical Review Measurable data Coding-Diagnosis, OASIS Utilization Benchmarks Outcome Reporting 4 2
Government Activities Recent Investigations (OIG) OIG Reports Corporate Integrity Agreements The Enforcers (RACs, MACs, PSCs / ZPICs) Annual OIG Work Plan http://oig.hhs.gov/publications/workplan/2011/wp01- Mdi Medicare_A+B.pdf AB df Visit your MAC/RHHI Website Visit www.ngsmedicare.com for up to date information. 5 Recent Investigations US Senate Committee on Finance (5/13/10) Investigation after data suggests HHA intentionally increased visit frequency to trigger higher reimbursement rates. 4 Agencies: Almost Family, Amedisys, Gentiva Health Services and LHC Group Therapy Physician Care Plan Oversight Survey Deficiencies Hospice Nursing Facilities 6 3
CIAs OIG Corporate Integrity Agreements http://oig.hhs.gov/fraud/cia/cia_list.asp Result of Whistleblowers Admission of ineligible patients Billing without supporting documentation Backdating &/or alteration of documentation Offering free goods & services 5 years + IRO + payback 7 2011 OIG WORK PLAN - HH Home Health Agency Profitability Trends Review Cost Reports to determine whether payment methodology should be adjusted. HHRG & OASIS Data Accuracy Examine episodes from 2008 for claims meeting Medicare billing criteria including homebound status and plan of care requirements. Review CMS s process for ensuring HHAs submit accurate and complete data. 8 4
2011 OIG WORK PLAN - HH Payment Controls Examine billing Utilization Trends Location of Service, # of claims, # visits, ownership info. Part B Payments Examine adequacy of controls to prevent inappropriate payments to outside suppliers for services & medical supplies included in HHA PPS payment Enrollment Determine if program integrity efforts identify questionable HHA applicants 9 2011 OIG WORK PLAN - Hospice Focus on Hospice and Nursing Facilities OIG recent report: 82% hospice claims for patients in NF did not meet Medicare coverage requirements Hospice Utilization in Nursing Facilities Examine characteristics of nursing facilities with high utilization patterns of Medicare hospice care. Services Provided to Hospice Beneficiaries Residing in Nursing Facilities Review services provided by hospices to patients in nursing facilities (CoPs 42 CFR part 418) Services by Hospice Aides Plans of Care 10 5
RACS Recovery Audit Contractors Diversified Collection Services (DCS) Healthcare Services of Livermore, CA in Region A consists of the following states: CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, & VT. Paid on contingency basis (9-12%) Must get tissues approved to review: Active: Region D 2 hospice related issues DME while in hospice Hospice related services (Medicare A&B) 11 RACS RACs review claims on a post-payment basis Two types of review: Automated (no medical record needed) Complex (medical record required) RACs will not be able to review claims paid prior to October 1, 2007 RACs will be able to look back 3 yrs date claim paid Record Request: Hospice: 10% (max 200 to reach max 2000 claims/mo) Can NOT review claims already under scrutiny 12 6
ZPICS Zone Program Integrity Contractors Consolidation i of PSCs Perform pre & post audit reviews with ability to refer to law enforcement entities e.g. OIG, DOJ, CMS, State Agencies Refer quality issues to QIOs Use of claim sampling & extrapolation MACS - Medical Review MAC / National Government Services Additional Development Requests (ADRs) Probe audits Provider specific Widespread Target Medical Review >10% payment error rate CERT Audits CMS Independent Contractor not part of Palmetto Processed claims test error rate of FI 14 7
BILLING COMPLIANCE STRATEGIES 15 Take Advantage of Technology FISS is a process that allows remote users online connectivity to the Fiscal Intermediary Standard System (FISS), or mainframe, used by RHHI to process Medicare claims. 16 8
Through FISS you can... Enter UB92 claims View check number, date, & Correct electronic claims amount of your last 3 Correct paper claims payments Track all claims through Review files for inquiry the processing system purposes, i.e. diagnosis codes, revenue codes Access the Common Working File (CWF) View claims selected for through HIQH (Health additional review & Insurance Query for HHAs information requests 17 18 9
Claims Summary Inquiry Weekly check of the Claims Summary Inquiry screen Displays specific claim history information for all pending and processed claims. Check for claims in pending status: Return to Provider (RTP) Medicare Secondary Payer (MSP) Medical Review claims 19 Additional Development Request (ADR) Definition: a billing transaction that fails a medical review edit while processing in FISS Bill suspends to S/LOC SB6001 Documentation requested to support services billed Medicare medical review nurse will review documentation to make payment determination. Print ADR letter and forward to the clinical department per your agency procedures. Documentation must be submitted within 45 days or the bill is automatically denied. Check for ADR requests at least weekly 20 10
COMPLIANCE ESSENTIAL: Responding to ADRs.. Define process: Identify ADRs Assign responsibilities Timelines Review Write summary of key points to support claim Return receipt Accountability and reporting (trend data) Action Plan 21 Adjusting Medically Denied Services It is never appropriate to adjust denied services or cancel a fully or partially (downcoded) denied claim and resubmit that claim for payment. These activities could be viewed as an attempt to circumvent the formal appeal process or manipulate denial statistics and could be considered fraudulent. 22 11
COMPLIANCE ESSENTIAL: What to Do.. MONITOR & AUDIT: Know where previous improper payments have been found Know if you are submitting claims with improper payments Know the Documentation Requirements Prepare to respond to medical record requests Automated tracking system Multiple government agencies 23 FOCUS AUDITS Government & MAC Focus Areas: Medical Review Hot Spots Conduct Routine Pre & Post Billing Audits Coverage: conditions of payment NOT conditions of participation (COPs) Definitive Billing Risk Black & White or Technical error OASIS HHRG Items that Impact $$ Diagnosis Coding Clinical M items (pain, wounds) Functional M items (ambulation, bathing) 24 12
The AUDIT TOOL Customize Audit Tool Billing Identified problem areas Don t under estimate historical compliance issues Collect data specific to the issue &/or red flags Results: Trend the Data Action Plan and Follow-Up Avoid this Mistake: Don t collect ALL data in one big audit tool 25 Utilization High therapy 5-7 visit episodes Outliers (DM, Wounds) Medical Necessity MAC Focus Areas: Home Health Re-Certs, Long Length of Stay (LLOS) Homebound Status* ZPICs big bang for the review buck Diagnosis HTN, Cardiac, Parkinson s, Dementia 26 13
Top Home Health Claim Denials Medical Review Down-Code Lack of response to ADR Documentation does not support medical necessity Denials related to Physician Orders POC/Verbal Orders not signed and/or dated timely No physician orders for services provided Incomplete Orders Discipline, Frequency/Duration, Treatment, PRN Homebound status 27 MAC Focus Areas: Hospice Eligibility Admission & Re-Cert (LLOS) Terminal diagnosis Non-cancer diagnoses Ill-defined diagnoses (AFTT, Debility) Location & Level of Care Nursing Home Inpatient care (GIP) Continuous Home Care (CHC) 28 14
Top Hospice Claim Denials Documentation does not support Sixmonth terminal prognosis Missing/Incomplete/Untimely physician certification or recertification Missing/Incomplete/Untimely Notice of Election Reduced Level of Care No response to ADRs 29 BILLING COMPLIANCE ESSENTIAL 30 15
HAVE A PLAN.. Establish a Compliance Plan & USE IT Implement 7 Fundamental Elements Need to coordinate your P & P with appropriate training & educational programs Identify All Risk Areas: Clinical, Billing, Financial, Administrative, HR Home Health: 31 OIG Risk Areas Hospice: 29 OIG Risk Areas * Refer to Handouts 31 OIG Billing Risk Areas Claim Development and Submission Process MOST FREQUENT RECOVERIES Many have resulted in CIAs in addition to paying $$$$. MUST have a process in place for reviewing basic billing requirements Pre-and-Post Submission Reviews 32 16
Use Your Compliance Plan Establish Strong Corporate Culture Support the culture Provide Checks & Balances 33 34 17
Corporate Culture Code of Conduct Verbal/Written expression of your organizational culture Education and Buy-in of Board & Top Management Policies Responsibilities The message needs to be clear: Do the Right Thing 35 Systems to Support Culture Adequate Staffing Oversight of case management Avoid the desire to cut corners TOOLS to do the job efficiently Documented Procedures Train to a procedure On-going Education Training on new regulations Re-training on existing regulations 36 18
Data Analysis Checks & Balances Monitor trends Utilize accepted benchmarks for early warning Internal Audits Clinical record review Cross departmental audit Employee Reporting Open lines of communication Supervision Exit Interviews 37 THANK YOU! Contact Information: rseidman@simione.com 1-800-653-4043 38 19