The Moving Target of Successful Long Term Care Therapy Reimbursement: Audits, Denials, and Appeals Becky Finni, DHS, OTR/L Kim Karr, BS, OTR/L Senior Appeal Specialists for RehabCare OBJECTIVES Understand how current therapy regulations and upcoming changes impact reimbursement in the long term care setting, and leave with strategies to proactively identify and address triggers for technical and documentation-related therapy denials. Understand the basic medical review and denials/appeals process for therapy payment under Medicare and other payers, including successful preparation for and management of multiple types of medical review audits. 2 Who is typically auditing and why? Centers for Medicare & Medicaid Services (CMS) Medicare Advantage, HMOs, PPOs, and Private Insurers Office of Inspector General via Independent Review Organizations (IROs) 3 1
Types of Audits Automated (non-complex denials) No ADR - related to technical billing errors that cause the need for appeal and audit of record 56900-no records received from requested audit or received late Complex reviews ADR generated (medical necessity under review) Pre-payment [currently submitted claim] Post-payment [previously paid claim] Compliance (e.g. internal, IRO, Livanta) 4 Complex Review Activity in 2018 Supplemental Medical Review Contractor (SMRC) TPE (Targeted Probe and Educate)by Medicare Administrative Contractors (MACs) Zone Program Integrity Contractors (ZPICs) RUGS validation 5 Impact of negative review findings Pre-pay denials hold up reimbursement for services already rendered Post-pay denials require costly paybacks to Medicare Lengthy appeals process (2-4 years) to achieve resolution Therapist or Facility hesitancy in providing services to similar clients due to perceived lack of support for services of that type 6 2
REDUCING RISK FOR DENIALS NOW Routinely review charts and identify potential risks Ensure that documentation supports medical necessity Ensure all key technical components are present to meet reimbursement and regulatory requirements Respond timely and accurately to audit requests 7 Guidelines for Chart Review Documentation compliance review is not just for when a claim is selected for audit Regular review enables early identification of concerns and ensures documentation is audit ready 8 Chart Review Must Haves Consistent review process Combined review of technical and medical necessity components Reviewers must clearly understand practice acts and Medicare policy 9 3
10 Technical Components - Therapy All areas of documentation forms are complete Therapy orders (on or before eval date) Plans of Care/Updated Plans of Care are signed by physician/npp within 30 days Therapy supervisory ( 10 th visit ) notes by registered therapists timely and complete 11 Technical Components - Therapy Diagnosis codes match treatment areas (and LCD requirements) Prior levels of function present and related to goal areas Documentation supports specific codes billed (e.g. modalities, cotreatment, group, etc.) 12 4
Technical Components - Nursing Part A/skilled stay: Nursing record supports continued need for skilled daily nursing involvement beyond routine custodial care; need daily record of ADL performance for MDS scoring Part B/outpatient: Nursing record identifies concern and/or change in status with reason for referral to therapy 13 Technical Components - Billing Therapy treatment diagnosis ICD-10 codes listed on the UB04/claim Therapy diagnosis codes meet LCD requirements for MAC billed All therapy modifiers (-KX, -59, etc.) appropriately appended for services billed RUGs reported on MDS match minutes reported by therapy 14 Medical Necessity - Therapy Prior level of function vs. current level supports change Current impairments identified Length of stay, frequency, treatment time per visit appear appropriate Daily/progress notes reflect activities that require the unique and complex skills of therapy personnel Goals modified as appropriate 15 5
Medical Necessity - Nursing Nursing daily documentation supports therapy report of deficits/progress and does not conflict Nursing documentation captures more than routine services (for part A residents), keeping in mind this does not have to be a separately skilled service under a special nursing RUG 16 Additional Documentation Requests (ADRs) Medical records request for specific claim Received online or via hard copy letter in the mail Time sensitive response required Requires an interdisciplinary approach (nursing, therapy, medical records) Different requirements for documentation Part A vs. Part B 17 Successful Response to an ADR Requires: Timely identification of requests Sending the complete record Content review by a clinician prior to ADR submission Legible? Straight edges? Single sided copies only No highlighting Timely follow-up on audit results 18 6
Documentation Needed at ADR Records should include admission through discharge Records should include evaluation through therapy discharge 19 Common Reasons ADRs Become Denials Missing, Incomplete, or Insufficient Information No response or late response to ADR Missing technical components valid certification, hospital records, signature logs Duplication of services Excessive services Documentation did not support medical necessity 20 Determining ADR Outcomes Pre-pay ADR Change in status in FISS/DDE (paid, partially paid, fully denied) Post-pay ADR Findings letter will indicate review results Important! Claim is not yet denied - DO NOT SUBMIT APPEAL AT THIS POINT If results indicate overpayment occurred, payer will send a demand letter Demand letter is the actual denial, and takeback will also be visible in FISS/DDE once demand letter is issued 21 7
Level My audit turned into a denial what now? Medicare Appeal Process Must timely file appeals at each level to qualify Redetermination Provider Time to Respond 120 days* Expedited in 30 days Contractor Time to Respond 60 days Reconsideration 180 days* Expedited in 60 days 60 days ALJ 60 days 90 days** Current backlog of 22 48 months I need to submit my 1 st level appeal what now? 1 st Level Who gets the appeal? Redetermination MAC who denied the claim Timely filing timeframe 120 days (Expedite 30 days) What to file: Redetermination request form Appt. of Representative form (if you are not a direct employee of the appealing provider) Billing records showing the denial Medical records to support the services provided 23 My 1 st level appeal got denied what now? 2 nd Level Who gets the appeal? Timely filing timeframe Reconsideration Qualified Independent Contractor (QIC) Maximus West or C2C Solutions (East) 180 days (Expedite 60 days) What to file: Reconsideration request form Appt. of Representative form (if you are not a direct employee of the appealing provider) Unfavorable redetermination decision letter from the MAC Any additional medical records needed to support services 24 8
My 2 nd level appeal got denied what now? 3 rd Level Who gets the appeal? Administrative Office of Medicare Law Judge Hearings and (ALJ) Appeals (OMHA) Timely filing timeframe 60 days; Filing minimum of $160 in denied charges What to file: ALJ request form Appt. of Representative form (if you are not a direct employee of the appealing provider) Unfavorable reconsideration decision letter from the QIC Letter to beneficiary informing them of the appeal request ALJ waiver of hearing form (if needed) 25 The judge ruled unfavorably what now? 4 th Level Who gets the appeal? Timely filing timeframe Medicare Appeals Departmental Appeals Board 60 days Council What to file: MAC/DAB review request form Appt. of Representative form (if you are not a direct employee of the appealing provider) Unfavorable ALJ decision letter 5 th Level Who gets the appeal? Timely filing timeframe Judicial Review U.S. District Court 60 days; Filing minimum of $1560 in denied charges What to file: Request for Judicial Review (website) Appt. of Representative form (if you are not a direct employee of the appealing provider) Unfavorable Appeals Council decision letter 26 Changes on the Horizon Patient-Driven Payment Model (PDPM) for Part A reimbursement Noridian identified as new SMRC 27 9
Thank you for attending! Questions? Comments? Becky Finni: becky.finni@rehabcare.com Kim Karr: kimberly.karr@rehabcare.com TPE information: https://www.cms.gov/research-statistics- Data-and-Systems/Monitoring- Programs/Medicare-FFS-Compliance- Programs/Medical-Review/Targeted- Probe-and-EducateTPE.html Appeal Request forms can be found at: https://www.cms.gov/medicare/cms- Forms/CMS-Forms/CMS-Forms-List.html PDPM Model information: https://www.cms.gov/medicare/medicare- Fee-for-Service- Payment/SNFPPS/therapyresearch.html 28 10