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 beneficiaries in a Medicare covered SNF stay be included in a bundled prospective payment made through the fiscal intermediary (FI)/A/B Medicare Administrative Contractor (MAC) to the SNF. These bundled services had to be billed by the SNF to the FI/A/B MAC in a consolidated bill. No longer would entities that provided these services to beneficiaries in a SNF stay be able to bill separately for those services. Medicare beneficiaries can either be in a Part A covered SNF stay which includes medical services as well as room and board, or they can be in a Part B non-covered SNF stay in which the Part A benefits are exhausted, but certain medical services are still covered though room and board is not. Medicare Admission Do they have Dr. appt. Did you verify insurance Yes then verify where No then condnue on with care Was prior authorizadon needed 1
Has Dr. Appt. What is the HCPS Code What is the Fee Screen HCPCS Code TC Oral Busulfan J8510 Treat Leukemia Price: 2.98 Per ML QuesDons What is the Treatment Diagnosis Do you know they are geung Treatment Who is the Outside TreaDng Physician Know the HCPCS Code Only pay the Technical Component fee screen Are you puung the Service on your UB04 Are you CoordinaDng Care What is your treatment Diagnosis 2
Here are the links to find the fee screens Physician Fee Screens http://www.cms.gov/home/medicare.asp Down on the right hand side are the various fee screens. Here is the Pharmacy Fee Screen site. https://www.cms.gov/mcrpartbdrugavgsalesprice/ 01a17_2012ASPFiles.asp#TopOfPage Here is the Consolidated Billing site you also need to know https://www.cms.gov/snfconsolidatedbilling/ Large Computer Network NPI Provider Enrollment Social Security CPE Contract Payment IRS DHS Champs LOCD Medicare Heat Team http://www.stopmedicarefraud.gov/index.html Most doctors, health care providers, suppliers, and private companies who work with Medicare are honest. However, there are a few who are not. The Medicare Program is prioritizing efforts to find and prevent fraud and abuse by working closely with health care providers and strengthening oversight. Detroit Health Care Fraud Summit-March 15, 2011 3
Medicare Part A Medical Review process h[p://www.ngsmedicare.com LCD on NGS h[p://www.ngsmedicare.com/wps/portal/ ngsmedicare/mpc Consolidated Billing Best PracDces (HCPCS) h[p://www.cms.gov/snfpps/ 08_bestpracDces.asp Medicare appeals Process First Level of Appeal: Redetermina>on is an examina>on of a claim by the FI, The appellant (the individual filing the appeal) has 120 days from the date of receipt of the ini>al claim determina>on to file an appeal. Medicare Appeal Process Second Level of Appeal: ReconsideraDon A party to the redeterminadon may request a reconsideradon if dissadsfied with the redeterminadon. A QIC will conduct the reconsideradon. A wri[en reconsideradon request must be filed within 180 days of receipt of the redeterminadon. 4
Medicare Appeal Process Third Level of Appeal: AdministraDve Law Judge Hearing If at least $130* remains in controversy following the QIC s decision, a party to the reconsideradon may request an ALJ hearing within 60 days of receipt of the reconsideradon Medicare Appeal Process Fourth Level of Appeal: Appeals Council Review If a party to the ALJ hearing is dissadsfied with the ALJ s decision, the party may request a review by the Appeals Council. The request for Appeals Council review must be submi[ed in wridng within 60 days of receipt of the ALJ s decision, and must specify the issues and findings that are being contested. Medicare Appeal Process FiNh Level of Appeal: Judicial Review in U.S. District Court If at least $1,260* or more is sdll in controversy following the Appeals Council s decision, a party to the decision may request judicial review before a U.S. District Court judge. The appellant must file the request for review within 60 days of receipt of the Appeals Council s decision. 5
Medicare Common RejecDon Codes h[p://www.ngsmedicare.com/wps/portal/ ngsmedicare/!ut/p/ c4/04_sb8k8xllm9msszpy8xbz9cp0os3gdr2 BnRzdTEwMDX0sDA09Hs2A3d3cDYxMDM_2C bedfaphesmi!/ NaDonal Government Services Connex h[ps://connex.ngsmedicare.com/home/ start.swe? SWECmd=Start&SWEHo=connex.ngsmedicare. com Online system Alert Medicare Pre Payment Probe They have arrived Overview. 6
.. Medicare IACS & PECOS Individuals Authorized Access to the CMS Computer Services (IACS) h[p://www.cms.gov/iacs/ 04_Provider_Community.asp#TopOfPage Medicare Provider- Supplier Enrollment System (PECOS) h[p://www.cms.gov/ MedicareProviderSupEnroll/ 04_InternetbasedPECOS.asp. 7
Cheer Onward, and Upward she shall prevail. We are here to care for the residents, and provide a wonderful service. www.facebook.com/kearneyassociates.julie.kearney h[p://twi[er.com/kearneyjk jkearney@kearneyassociates.com www.kearneyassociates.com References www.cms.hhs.gov CMS www.ngsmedicare.com NaDonal Government Services h[p://www.stopmedicarefraud.gov/ heatsuccess/index.html US Health and Human Services and US Department of JusDce h[p://www.cms.gov/snfconsolidatedbilling h[p://www.cms.gov/snfpps/ 08_bestpracDces.asp 8
Many Government Auditors Defined Julie Kearney Kearney & Associates, Inc. 1 National Government Services New Round of Prepayment Probes Pulling 20-40 claims Send Medical records in 30 days Review in 45 days KX Physical Therapy Medicare Part B 2 CERT CERT-Comprehensive Error Testing CMS implemented to measure improper payment to Medicare FFS (Fee For Service) program Comply with Improper Payments Elimination and Recovery Act of 2010 Random and pull a random electronic sample of claims CMS outline of records requested https://www.cms.gov/apps/er_reports 3 1
DOJ DOJ- Department of Justice Collaborates with OIG (Office of Inspector General) Collaborates with HHS (Department of Health and Human Services) DOJ can perform other audits if requested by other government agencies Use other agencies to work on civil fraud cases and health care fraud 4 DOJ Cont Federal and state investigative agency identifies cases in multiple states information is sent to the DOJ. DOJ website: http://www.justice.gov http://www.justice.gov/archive/opd/appendixa.htm 5 HEAT HEAT-Health Care Fraud Prevention and Enforcement Action Team Prevent fraud and abuse in the Medicare and Medicaid program Focuses on people who prey on Medicare and Medicaid beneficiaries. Increased HEAT audits Partnership with DOJ, HHS and other departments to recover tax dollars 6 2
HEAT CONT HEAT website: http://www.stopmedicarefraud.gov Appendix B HEAT task force results online http://oig.hhs.gov 7 MAC MAC- Medicare Administrative Contractors Michigan will be MAC J8 Contracted to do Prepayment Medical reviews Verify Medicare beneficiaries are covered and medically necessary. All claims submitted are put through a scrubber check against claim edits and ensure payments are made to certified providers. 8 MAC Cont Once claim passes edit, MAC calculates the payment amount based on fee schedules, formulas, geographical adjustments, provider characteristics, and beneficiary copayments. MAC audits are expected to be combined with RAC audits MAC generally review on prepayment basis RAC review on a retrospective review 9 3
MAC Cont.. Organization receives a MAC review If they identify billing or coding error has occurred It is best to self-report regarding past discharges Self-reporting could stop a potential RAC retrospective Review Could also stop a full medical necessity review in addition to a RUG review 10 MIP & MIC Deficit Reduction Act of 2005 created the Medicaid Integrity Program (MIP) under section 1936 of the Social Security Act MIP is the first comprehensive federal strategy to prevent and reduce provider fraud Medicaid program CMS two broad responsibilities under MIP Hire contractor to review provider activities Support states in their efforts to combat fraud and abuse 11 MIP & MIC cont Social Security Act requires CMS develop the five year comprehensive Medicaid Integrity Plan in conjunction with internal and external partners. Medicaid Integrity Group oversees MIP through Medicaid Integrity Contractors (MIC) and State Program Integrity Operations 12 4
MIP & MIC Three Primary MIC types Review MIC analyze Medicaid claims data to determine potential provider fraud waste or abuse. Audit MIC audit provider claims and identify overpayments Education MIC provide education to providers and others on payment integrity and quality of care Issues 13 Medicaid RAC Medicaid Recovery Audit Contractors Supplemental to make sure states make proper payments to providers Tasked to identify and recovering Medicaid overpayments and identifying underpayments Programs designed so Medicaid RAC report instances of fraud and criminal activity 14 Medicaid RAC States were expected to submit a Medicaid State Plan Amendment to CMS by December 31, 2010 They had to address the elements of there programs Proposed date for states to have their RAC fully implemented was delayed through CMS bulletin CP-B 11-03 on February 1, 2011 CMS expects to announce the implementation deadline sometime in 2011 15 5
Medicaid MAC State requirement under proposed rule required to report to CMS regarding the effectiveness of there program Effectiveness elements included Contract periods of performance, contractor names and program metrics 16 MFCU MFCU- Medicaid Fraud Control Unit Single identifiable entity of state government annually certified by the secretary of HHS MFCU responsible for conducting a state initiative aimed at investigating and prosecuting providers that defraud the Medicaid program 17 MFCU MFCU may also review complaints of abuse or neglect of nursing home residents or misappropriation of patients private funds The Ticket to Work and Work Incentives Improvement Act of 1999 extended MFCU jurisdiction to include fraud investigation North Dakota received a waiver from federal government leaving MFCU in 49 states and District of Columbia 18 6
MFCU Cont Most are located in state attorney general s office It is not a requirement Certification by HHS require MFCU are required to employ attorneys experience in investigation, and fraud 19 OIG OIG-Office of Inspector General Since 1993 investigating fraud and abuse Mandated by amended Public Law 95-452, OIG mission is to protect the integrity of HHS program All activities by OIG lie within the authority of the US Inspector General 20 OMIG OMIG-State offices of Medicaid Inspector General Independent agencies within individual state department of health. Purpose to improve the integrity of state Medicaid programs coordinate fraud and abuse activities Many work with agencies such as Department of Mental Health, Office of Children and Family services 21 7
PERM PERM-Payment Error Rate Measurement Program Measure improper payments in the Medicaid program and Children s Health Insurance Program (CHIP) PERM is designed to comply with Improper Payments Information Act of 2002 Executive Order 13520 intensified Perm Efforts to eliminate fraud, waste and abuse. 22 RAC RAC-Recovery Audit Contractor Mission is to reduce Medicare improper payment Use detection and collection of overpayments Data mining activities based on billing information Tax Relief and Health Care Act of 2006 Mandates CMS implement Medicare RAC auditors in all states 23 RAC CMS awarded contract to four regional RAC s Michigan RAC-CGI Federal Region B http://racb.cgi.com Recent change increased RAC record request to 500 records every 45 days The contingency fee nature of RAC payments will ensure audits remain a top risk for providers 24 8
MAC What Should Providers Do Specifically, Medicare providers and suppliers should enact systems to address the following: Responding to record requests within the required timeframes; Internally monitoring protocols to better identify and monitor areas that may be subject to review; Implementing compliance efforts, including, but not limited to, documentation and coding education; and Properly working up appeals to challenge denials in the appeals process. 25 ZPICS ZPICS-Zone Program Integrity Contractors Located in 7 zones ZPICS scope of work will similar to previous groups Auditors perform wide range of medical review, data analysis, policy auditing for fraud, abuse and waste These audits are most concerning because they use statistical data sampling and extrapolation methods 26 ZPICS Cont ZPICS should not be taken lightly Should be handled with due diligence Michigan is in Zone 3 (Also included are MN, WI, IL, OH, and KY) Pursuant to the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) 27 9
MPRO Michigan Peer Review Organization QIO (Quality Improvement Organization) LOCD Medical Reviews (Level of Care Determination Medicaid) Random Medical review audits Medicare appeal 28 Cheer Onward, and Upward she shall prevail. We are here to care for the residents, and provide a wonderful service. 29 www.facebook.com/kearneyassociates.julie.kearney http://twitter.com/kearneyjk jkearney@kearneyassociates.com www.kearneyassociates.com 30 10
American Hospital Association Recovery Audit Contractor (RAC) Program www.aha.org/ aha/issues/rac Centers for Medicare and Medicaid Services (CMS) Demonstration to work toward Assuring Accurate Medicare Payments Press release. March 28, 2004 www.cms.gov CMS. Final Scope of work. www.cms.gov/rac /downloads final CMS. The Medicare Recovery Audit Contractor (RAC) Program: An evaluation of the 3 year demonstration. June 2008. www.cms.gov/recovery-audit-program/downloads/ appealupdatethrough63008ofraceevalrept.pdf References 31 CMS. MMA-The centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) Initiative MLN Matters SE)469.https://www.cms.gov/ MLNmattersarticles/downloads/SE0469.pdf CMS. Recovery Audit Contractor Overview. www.cms.gov/rac Johnson, Kathy m., et al. RAC ready: How to prepare for the Recovery Audit Contractor Program. Journal of AHIMA 80 no. 2 (Feb. 2009): 28-31 Journal of AHIMA July 2011 page 50-55 References 32 11