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 & Regulatory Affairs Healthcare Management Solutions, Inc 1
Today s Objectives 1. Understand all the Department of Health & Human Services audit types from CMS and OIG for Home Health Agencies and Hospices; jurisdiction; audit protocol 2. Develop sound compliance programs to prevent denials with internal audit and monitoring to identify risk areas and implement corrective plans 3. Learn the basics of how to appeal denials through the Medicare system and when to get help Today s Objectives Healthcare Management Solutions, Inc 2
Background Why so many audits? Growth in home health Top 25 counties in US Fraud indictments How are overpayments and fraud discovered? Multiple agencies working together using data to target agencies What can you do? Get ready today is a good start Background Healthcare Management Solutions, Inc 3
Audit Agencies and Contractors Medicare Administrative Contractors (MACs) Office of the Inspector General (OIG) Recovery Audit Contractors (RACs) Zone Program Integrity Contractors (zpics) Other Auditor activities: CERTS, PSCs, proposed Cert & Survey sanctions and fines coming, F2F, PECOS enrollment (Phase II now enforced), OIG recommending surety bonds and MICs Focus today on MAC, OIG, RAC, and zpics Medicare Audit Entities Healthcare Management Solutions, Inc 4
MAC- Jurisdiction K: National Government Services (NGS) MACs have assumed all the functions of intermediaries and carriers MACs perform pre-payment medical reviews Claims processed through a scrubber to check them against claim edits Denial rates calculated using Charge Denial Rate and Claim Denial Rate Medicare Administrative Contractors (MACs) Healthcare Management Solutions, Inc 5
Office of Inspector General (OIG) Protects the integrity of HHS programs as well as the health & welfare of program beneficiaries Detects & prevents fraud, waste & abuse 2014 Work Plan includes review of: PPS requirements; HHA employment of individuals with criminal convictions; Hospice use of general inpatient care. Office of the Inspector General (OIG) Healthcare Management Solutions, Inc 6
Office of Inspector General (OIG) 2013 Work Plan Hospices Marketing Practices and Financial Relationships with Nursing Facilities Hospices General Inpatient Care Home Health Face-to-Face Requirement (New) Employment of Home Health Aides With Criminal Convictions (New) States Survey and Certification: Timeliness, Outcomes, Follow-up, and Medicare Oversight Missing or Incorrect Patient Outcome and Assessment Data Medicare Administrative Contractors Oversight of Claims Home Health Prospective Payment System Requirements Trends in Revenues and Expenses Office of Inspector General (OIG) Healthcare Management Solutions, Inc 7
Recovery Audit Contractors (RACs) Region A RAC is Performant Recovery SHS also doing RAC audits Issues under review limited to those listed on web site RACs do post-payment review by data mining of billing activities to find overpayments (can look back 3 years) ADRs, recoupment by MAC RACs reimbursed a percentage of overpayments they collect Recovery Audit Contractors (RACs) Healthcare Management Solutions, Inc 8
RAC Program is currently on hold pending CMS awarding new contracts The last day that the current RAC can send claim adjustment files to the MAC is 6/1/14 As of 6/2/14 only claim closure files may be sent to the MAC by the RAC Discussion Period requests will be accepted through 6/3/14 Recovery Audit Contractors (RACs) Healthcare Management Solutions, Inc 9
Zone Program Integrity Contractor (zpic) Zone 6 contractor is under protest; until resolved Program Safeguard Contractor remains in place PSG for Zone 6 is Safeguard Services Responsible for preventing, detecting, and deterring Medicare fraud Have specific investigative powers & no approval needed for issues to investigate Uses data analysis; if high level of error sampling & extrapolation allowed Zone Program Integrity Contractors (ZPICs) Healthcare Management Solutions, Inc 10
RAC Process Demand letter issued by RAC Rebuttal and Discussion Period: Opportunity for the provider to discuss the improper payment determination with the RAC (outside the normal appeal process) Helpful to obtain clarification of RAC s rationale & to challenge it Do not mistake this with a formal appeal RAC Process Healthcare Management Solutions, Inc 11
RAC Appeal Process: Redetermination After an initial decision, a provider has 120 days to file a Request for Redetermination Request for Redetermination filed within 30 days will stop recoupment until a decision is made; if no request recoupment begins on the 41 st day after the date of the demand letter The Contractor has 60 days from the date of the Redetermination request to issue a decision The decision-making time period is extended 14 days if new evidence is submitted post- Redetermination request RAC Appeals - Redetermination Healthcare Management Solutions, Inc 12
RAC Appeal Process: Reconsideration A provider has 180 days from the Redetermination decision to file a Request for Reconsideration If filed within 60 days, recoupment delayed until decision. If no Reconsideration request, recoupment begins on day 76 following the Redetermination decision RAC Appeals - Reconsideration Healthcare Management Solutions, Inc 13
RAC Appeal Process: ALJ Hearing Providers must file a request for ALJ hearing within 60 days of the Reconsideration decision AIC must be met ($140-2014) ALJ hearings conducted by VTC or phone Recoupment occurs during this stage even if appeal requested ALJ has 90 days from hearing request to issue a decision in writing RAC Appeals ALJ Hearing Healthcare Management Solutions, Inc 14
RAC Appeal Process: Appeals Council Provider must request MAC appeal within 60 days of ALJ decision MAC will only consider new evidence if it was not available at the time of the ALJ hearing No time limit for MAC to issue decision RAC Appeals Appeals Council Healthcare Management Solutions, Inc 15
Corporate Compliance Program 7 Elements (FR Vol 63, No 152 August 7, 1998) Voluntary 1. Develop written standards of conduct and policies create zero tolerance culture 2. Name a Compliance Officer reporting to the CEO 3. Develop education for all employees 4. Develop an anonymous reporting system (hotline) for complaints 5. Develop a response team and investigate and take action on findings including disciplinary actions 6. Develop monitoring and auditing of compliance 7. Develop a plan to remediate findings including refunding Objective #2: Compliance Programs Healthcare Management Solutions, Inc 16
Corporate Compliance Program Develop program with existing resources Target the program to known risk areas such as the TMR edits, OIG 6 criteria and 2014 Workplan Keep it Simple and Smart (KISS) combining audit activities where possible Think like the auditors by anticipating audit targets Learn to data mine and analyze to fix problems to stay off the radar screen Benchmark your claims data to others Corporate Compliance Program Healthcare Management Solutions, Inc 17
Corporate Compliance Program Don t assume just because you have a compliance plan it s effective. Test it. Conduct gap analysis to find the holes in operations, coding, OASIS, billing practices Learn how to extract data from the agency software see handout Put a team together that shapes the Compliance Program with an audit Champ Corporate Compliance Program Healthcare Management Solutions, Inc 18
Corporate Compliance Program: Risk Assessment Operations review Coding and OASIS scoring and transmission practices Billing practices, RAC metrics Home Health TMR on LUPA, low HHRG early and late claims Hospice: TMR on short LOS, 3 rd benefit period; diagnosis screen non-ca, Alzheimer's, debility, COPD Corporate Compliance Program Healthcare Management Solutions, Inc 19
Corporate Compliance Program: Education Train all employees who have anything to do with a claim (clinicians, office support, finance/billing) Chose topics wisely - bang for the buck (financial risk and clinician time) Pick topics from audit findings, newsletters, listservs, benchmark data Use tools to train on coverage, utilization, appeals, coding using a variety of sources (HCA listservs, newsletters, webinars, consultants) Corporate Compliance Program Healthcare Management Solutions, Inc 20
Corporate Compliance Program: Monitoring & Auditing Develop an audit schedule and stick to it: risk assessment dictates if 100% pre-bill review Target risk areas (low HHRG, hospice 3 rd benefit period, F2F, orders, rehab utilization, G codes) Work as a team (see example of email alert) Work it into existing audits (QCRR) Data mine using reports to analyze what to audit (see handout of sample report) What would be a reasonable response to the data? Take action to correct errors before MAC does!! Corporate Compliance Program Healthcare Management Solutions, Inc 21
Corporate Compliance Program: ADR Response Team Develop response team for ADRs that includes who opens the snail mail and email! Respond to ADRs timely (don t wait the 30 days) and do a QA check of the ADR documents Draft a cover letter with arguments for coverage including other claims periods Send the OASIS Validation Report since the state archives the OASIS quickly and cover letter Appeal all denials even small ones to get credit toward your claim/charge denial rate calculation Corporate Compliance Program Healthcare Management Solutions, Inc 22
Corporate Compliance Program: Suggested Home Health audit Run data on your claims histories against the TMR edits, 6 OIG criteria and determine if you are at risk Do prospective and concurrent reviews of the claims, not just retrospective reviews Review documentation of skilled and homebound criteria; consider cancelling claims before the MAC sends an ADR. Then it s too late Educate staff on qualifying conditions skilled and FRED homebound documentation Monitor OASIS and coding accuracy: how many corrections with upcodes; with downcodes Benchmark your agency with others in US and NE Corporate Compliance Program Healthcare Management Solutions, Inc 23
Corporate Compliance Program: Suggested Hospice Audit Program for Evaluating Payment Patterns Electronic Report (PEPPER Report) Numerator (N): count of beneficiaries discharged alive with occurrence code "42" (date of termination of hospice benefit) and with a length of stay (LOS) < 25 days Denominator (D): count of all beneficiaries discharged (by death or alive) with a LOS < 25 days excluding discharge patient status code "30" (still a patient) Long Length of Stay N: count of beneficiaries receiving hospice services whose combined days of service at the hospice during the cap year (November 1 through October 31) is greater than 180 days (obtained by considering all claims billed for a beneficiary during the cap year) D: count of all beneficiaries receiving hospice services at the hospice at any point during the cap year (beneficiaries must have at least one claim for service from the hospice) The Hospice PEPPER will be distributed in hard copy format via Federal Express, addressed to the Hospice Administrator/Chief Executive Officer March 2013 Corporate Compliance Program Healthcare Management Solutions, Inc 24
Appeal Strategies Submit additional evidence as soon as possible, good cause must be shown for evidence submitted at the ALJ level of appeal In general, for an ALJ to find good cause the evidence must have been unavailable earlier or there was no reason to know it was needed Be prepared to raise legal defense arguments as well as merit-based arguments Use expert opinions/testimony when appropriate. Nurses and therapists are experts! Objective #3: Appeal Strategies Healthcare Management Solutions, Inc 25
Appeal Strategies When possible, utilize VTC technology for hearings rather than telephone hearings Know the clinical record well and support your argument with references to the record Be prepared to answer questions about the record In general just answer the question asked; if unsure of answer ask for time post-hearing to respond Objective #3: Appeal Strategies Healthcare Management Solutions, Inc 26
Auditing Agencies Jurisdictional Scope Process Risk Mitigation Strategies Medicare Administrative Contractors (MAC S) Office of the Inspector General (OIG) Oversee claim completion and accuracy Anticipated to revive the comprehensive error rate testing program (CERT) who test the accuracy of the MAC! Promoting efficiency and effectiveness Protect the integrity of HHS programs as well as the health and welfare of beneficiaries of those programs Prepayment medical review All claims put through a scrubber to check claims against claim edits ADR sent electronically Letter/email requesting information/records Work plan issues 2013 targeted areas 2014 targeted areas Data mine and analyze risk areas Prebilling auditing of high risk claims Process ADRs promptly Monitor denial rate Appeal denials Know the OIG Workplan and audit risk areas Respond promptly to OIG requests Summary of Audit & Appeals Healthcare Management Solutions, Inc 27
Auditing Agencies Jurisdictional Scope Process Risk Mitigation Strategies Recovery Audit Contractors (RAC s) 4 Regions (A, B, C, D) NE Region A contractor Performant Recovery Paid based on what they recover (bounty hunters) Confined to investigate only issues identified by CMS with website notice Overpayment issues not kick backs or Stark violations Issues investigated posted to web site Ex: dup claims, radiology and diagnostic testing Can look back 3 years!! Data mining based on billing activities Post payment review Issue ADR or complex review Denial issued through MAC who recoups with appeal within 30 days; QIC RC in 60 days; ALJ in 60 days; Appeals Council; Federal Court Know the RAC audit issues on RAC website Audit risk areas Respond promptly to ADRs Appeal Zone Program Integrity Contractors (zpics) NE Zone 6 Paid a fixed fee with bonus incentives Agency selected based on data not size Overpayments and Uncovering fraudulent practices No approval needed to investigate Data analysis of aberrant billing patterns within a homogeneous group using combined sources of data (hospital, SNF claims) Identify the need for a local coverage decision (LMRC) Prepayment medical review/data analysis - No appeals process!! Post payment audits Unannounced visits and records requests Data mining EXTRAPOLATION authority Summary of Audit & Appeals Implement Corporate Compliance Program at the level of risk Know your billing profile and practices Healthcare Management Solutions, Inc 28
Questions? Q&A Healthcare Management Solutions, Inc 29
National Government Services www.ngsmedicare.com OIG Workplan https://oig.hhs.gov/reports-andpublications/workplan/index.asp RAC Performant Recovery www.performantrac.com zpic (PSC)Safeguard Services http://www.safeguard-servicesllc.com Hospice PEPPER Reports http://pepperresources.org/linkclick.aspx?fileticket=gm n4md7nl3s%3d&tabid=61 Resources Healthcare Management Solutions, Inc 30
HMS Healthcare Management Solutions www.hmsabc.com 203-269-4667 Cheryl Leslie, RN, BA, BS, MPH cleslie@hmsabc.com Pam Meliso, JD, MPH pmeliso@hmsabc.com Resources Healthcare Management Solutions, Inc 31