What s New with the NYS OMIG Audit Process NYSHFA Nurse Leadership Conference April 23, 2015 Disclosure Information contained in this program has been collected and collated by Zimmet Healthcare Services Group in consultation and conversation with diverse facilities in NY State and several NYS SNF Associations It is the attempt of the speaker to present objective information and provide resources that may be useful to facility staff when completing MDS assessments utilized for Resident Care and Reimbursement programs Individual SNF audit experiences and audit findings are welcome as part of the program. Conversations to improve processes for accurate Resident assessment, delivery of care and appropriateness of payment for services provided under Medicaid and Medicare programs are always appreciated! 2 ZIMMET HEALTHCARESERVICESGROUP 1
OMIG (Office of the Medicaid Inspector General) Established in 2006 as an independent integrity entity within the New York State Department of Health Their mission is to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high quality patient care To insure it is paid correctly and appropriately specific to clinical and financial elements of the SNF reimbursement process 3 OMIG Mission Statement To educate, assist and assess Medicaid program providers in meeting their obligation to establish and operate effective compliance programs that will prevent or in the alternative detect and address fraud, waste and abusive practices within the Medicaid program. NYS Compliance regulations includes 8 elements for insuring payments for care, services or supplies have ongoing policies and procedures.. New York Codes, Rules and Regulations NYCRR 18 521. 4 ZIMMET HEALTHCARESERVICESGROUP 2
PRI to CMI Collections & OMIG Audits 2006-2015 2006 was the last PRI collection that was utilized for SNF payments thru the MDS CMI phase in utilizing 2009-2010 MDS CMI scores Rates established from 2006 collections were heavily audited (years later) based on significant increase in PRI acuity scores OMIG audits & final appeals for 2006 now (almost) complete PRI had explicit rules and policies that provided parameters for auditing; however, there were multiple lawsuits specific to subjective interpretations of PRI language Many PRI items initially thrown out by OMIG nurses during early audits were successfully appealed and dismissed thru judicial reviews eg: Hemiplegia, Dementia Concern that OMIG nurses utilize PRI definitions for MDS audits eg: Rehab services, Physician Exams, Hemiplegia 5 ZHSG Benchmarks: January 28, 2009 Picture Date Simple average MA data from 63 SNFs enrolled 6 ZIMMET HEALTHCARESERVICESGROUP 3
ZHSG Benchmarks: July 2014 Picture Date Simple Average MA data from 125 SNFs ZHSG Avg. Top 25% Q2 Q3 Low 25% CMI 1.1270 1.2990 1.1700 1.0862 0.9902 Rehab + Extensive 4.0% 5.3% 5.0% 4.6% 1.8% Rehab 40.7% 66.9% 48.2% 31.7% 25.1% Extensive Services 4.4% 3.5% 3.8% 6.5% 3.9% Special Care 7.9% 6.0% 7.1% 11.0% 7.2% Clinically Complex 25.9% 11.1% 24.7% 30.8% 34.2% Impaired Cognition 4.7% 1.1% 4.4% 4.3% 9.0% Behavior 0.3% 0.1% 0.2% 0.7% 0.5% Physical Function 11.9% 6.0% 6.7% 10.1% 18.3% Restorative Nursing 14.3% 42.1% 15.9% 11.5% 8.4% CC w/ Depression 21.9% 20.3% 40.1% 13.9% 16.6% 7 Federal OIG Reports on MDS Accuracy Fuels Audits 272 claims in sample Premise: were 108 MDS reimbursement drivers consistent with medical record & documentation? 26% of RUGs were NOT supported 83% of these were upcoded ; 17% were downcoded These findings are inconsistent with ZHSG audits $542M+ in potential Medicare overpayments Sections P & G responsible for majority of errors The NY PRI audit results and the above Federal findings are driving NYS OMIG audits 8 ZIMMET HEALTHCARESERVICESGROUP 4
Where Are We Now? Minimal rules or clarifications specific to NYS RUG/CMI policies exist in writing Utilize RUG 54 for Medicaid payment acuity Most recently completed (non Medicare) MDS for all inhouse Medicaid residents on Picture Date Picture date for CMI is the last Weds in January and July MDS completion for CMI utilizes Federal manual guidelines and policies including definitions, supporting documentation and timeframes NYS Section S clarifications issued April 2015 9 What We Know DOH with School of Public Health conducted webinar training on New York s Common MDS Coding Errors in December & January It was supposed to highlight common MDS coding errors identified through audit by the OMIG and offer strategies for providers to improve accuracy It spent a significant amount of time on MDS coordinator job descriptions, reporting responsibilities, organizational diagrams, competencies and resource manuals It covered Sections S, C, D, E, G, I, J, K, O Utilized MDS manual references and clarifications and did not provide specific NYS OMIG findings MDS is not a source document for items and supportive information for all RUG drivers must have information in the clinical record Documentation references highlighted ARD and Care Planning requirements in addition to self facility auditing to improve documentation processes but not NYS OMIG findings 10 ZIMMET HEALTHCARESERVICESGROUP 5
What We Think We Know Using CMI reports run by DOH including targeting of: Facilities with more than 0.5 increases in CMI Facilities with high proportions of Rehab Services Residents being continued or renewed on Therapy services Facilities with high volume of Clinical Categories including Physician exams and orders to determine what type of Physicians and timing (looking at Podiatry and routine Dental in collection windows) Facilities with high (?) proportion of Residents receiving 2 person assist Are specialty units (Vents) to validate ADL and other services 11 What We Think We Know DOH and OMIG have not disclosed the amount of audits or financial concerns completed to date Initial audit of 2012 completed Statewide with no formal summary findings/reports issued How many facilities audited to date? Which collections? Several facilities have had back to back collections reviewed with same residents How many charts are audited in a day by individual reviewers? What is acceptable documentation? Are they reviewing entire chart or only explicit pieces of paper in folders as requested? What are the types, volume or significance of findings? Frequency of audits (and findings) for Facilities that have error rates? No error rates? For facilities with low CMI under 0.90? What about the draft (and some final) reports that have been issued with $ FINANCIAL PENALTIES noted 12 ZIMMET HEALTHCARESERVICESGROUP 6
What We Think We Know Facilities getting a call and letter upwards of a month Schedule not flexible after established Lists of specific residents being sent upwards of 2 weeks ahead Teams of OMIG Nurses going to facilities with more conversation with facility staff and peer reviews Inconsistency among OMIG nurses about accepted standards of practice Who documents ADLs in building (CNA vs LPN vs RN vs MDS) Review (or lack of review) of Care Plans 13 What We Think We Know If it isn't documented, it doesn t count! Allowance for facilities to submit missing information within 24-48 hours Advising facilities to prepare RUG folders as they complete MDS assessments with all supporting documentation available Handwritten findings issued during audit and given to facility as informal findings not necessarily upheld off site Audit findings being reviewed by DOH before Draft Audit Report issued 14 ZIMMET HEALTHCARESERVICESGROUP 7
OMIG Comments & Findings to Date Activities of Daily Living Most significantly, OMIG is looking for an initial nurse assessment to evaluate the level of functioning and the need for assistance Requires completed CNA documentation Flow sheets/accountability records of care provided during prior 7 days with no missing shifts ( down coding for missing information and care plans not accepted) Utilizing the rule of 3 for higher scores Looking for documentation to support utilizing 2 person assist Making clinical & critical thinking Documentation by nursing must be detailed Q shift for the 4 ADL RUG drivers Discrepancies' in CNA and Nursing ADLs must be documented with examples for over rides and changes 15 OMIG Comments & Findings to Date Specific episodic documentation about Behaviors must include frequency and type of Behavior, causal factors, staff interventions and results of interventions. Care Plan alone not enough Dementia add-on requires MD Dx in past 60 days, active Care Plan identifying specific care concerns related to Resident Dementia, Nurses notes in prior 7 days stating how the Dementia drives/affects daily care issues Hemiplegia, CP, MS and other RUG driven Dx require MD Dx in past 60 days, active Care Plan identifying specific care concerns related to Dx and Nurses notes in prior 7 days stating how the Dx drives/affects daily care issues Weights that influence BMI payments must be exactly within the prior 30 days of ARD 16 ZIMMET HEALTHCARESERVICESGROUP 8
OMIG Comments & Findings to Date Looking for specific ADL changes, Significant Change assessments and/or detailed supportive nursing documentation to initiate Rehab Therapy programs OMIG nurses mentioning significant improvements when on Rehab Therapy programs eg: PRI language OMIG nurses commenting that returns from hospital are deconditioned and weak and usually not appropriate for formal Rehab Therapy services OMIG nurses commenting that Resident showed improvement from Rehab Therapy program but prior declines and other conditions were not documented to consider Therapy services appropriate OMIG nurses commenting that Residents with severe cognitive loss not good candidates for formal Rehab Therapy services no improvement is possible OMIG nurses commenting that specific Resident on Speech & Cognitive Therapy program is too confused and would not benefit from interventions contrary to Speech Therapy note OMIG nurses commenting that Rehab Therapy programs for pain management are not reasonable because medication management and alternatives should have been given and documented first OMIG nurses stating that the Rehab Therapy programs are not appropriate despite being audited by Medicare Part B as appropriate 17 OMIG Comments & Findings to Date OMIG nurses commenting that Physician orders should not be counted as there was no mention of new problems or conditions and these orders were considered routine and/or follow up to old problems OMIG nurses stating that changes in Coumadin medications are considered similar to Insulin orders and do not count. Stating reference information was from MDS manual when it was a privately written /personal opinion newsletter 18 ZIMMET HEALTHCARESERVICESGROUP 9
Reports to Facilities Being Issued Letters with Draft Audit Report being sent now for findings of 2012 audits Findings identified during the OMIG review include adjustments to CMI score based on cases specific cases denied. Facility CMI score re-calculated and Medicaid $ dollar overpayments included in the Draft Audit Report. Facilities given 30 days to respond in writing to findings with supporting documentation submitted for additional reviews A Final Audit Report will be issued and Facility will have 60 days to request a Hearing specific to the items raised in the response to findings identified in the Draft Audit Report 19 Make Sure Facility Policies Include Strict adherence to Part B Rehab Therapy requirements including: Documented referral to Rehab that indicates area of functional decline, Nursing documentation (CNA flow sheets, nurses notes) that identifies specific ADL or other functional changes and problems, MD orders that clearly state the reasons for Rehab Therapy services, frequency and duration, Documentation of Therapy evaluation and written Plan of Care with short and long term goals, Accurate Therapy logs including days and minutes of service provided Detailed Rehab Therapy progress notes, appropriate Care Plan documentation, supportive nursing documentation 20 ZIMMET HEALTHCARESERVICESGROUP 10
Things to Remember Everything requires documentation within ARD timeframes specific to MDS manual individual item definitions and clarifications Surgical Wound care requires documentation of orders treatments and care, observation of wound areas does not count as a treatment Restorative Nursing Programs requires Nursing assessment of problem, formal program with detailed plan & instructions, care plan and signed log of days and time care program Respiratory Therapy programs include training of responsible staff, MD orders, facility P & P, treatment logs with minutes RUG drivers eg: O2, Chemo, Hemodialysis, Fever, Tubes, etc...require documentation, flow sheets and more 21 Final Thoughts This is a work in progress with much more to come NYSHFA and other Associations are meeting with the DOH specific to OMIG auditing protocols, facility findings and targeted review areas. Including requests for documentation of Frequently Asked Questions with clarifications and explicit RUG & CMI policies Facilities are responsible to have written clinical team assessment and documentation policies specific to MDS completion, Care Plan and reimbursement guidelines Under NYS Mandatory Compliance Rules & Regulations, facilities must have written compliance policies, education and training programs for employees, on going identification with self & external auditing programs, disciplinary policies, self reporting of non compliant matters and good faith participation. 22 ZIMMET HEALTHCARESERVICESGROUP 11
Resources cms.gov/mds30raimanual.htm www.nyshfa.org Compliance@omig.ny.gov MDS3@health.state.ny.us info@zhsg.com Thank You 23 ZIMMET HEALTHCARESERVICESGROUP 12