Reimbursement Audits: Understanding the Trends & How to Prepare for Them Andrea Stark, Consultant/Owner, miravista,llc, Columbia, SC
Top 4 Things to Know for CE 1. Make sure your BADGE IS SCANNED each time you enter a session to record your attendance. 2. Carry your Evaluation Packet with you to EVERY session. 3. Pharmacists, Pharmacy Technicians and Nurses need to track their hours on the Statement of Continuing Education Form as they go (the 2-page triplicate form, so press firmly!). 4. FOR CE: At your last session, total the hours and sign both pages of your Statement of Continuing Education Form. Keep the PINK copy for your records and place the YELLOW and WHITE copies in your CE Envelope. Make sure an Evaluation Form is in your CE Envelope for each session you attended (extra forms are available at the registration desk if you forgot to pick one up). Write your name and unique ID number (six digit number at the bottom of your name badge) in the designated area on the outside of the envelope, seal it, and place it in the drop box located near the 4/8/2012 2 registration area.
Andrea Stark is Consultant/Owner of miravista,llc. The conflict of interest was resolved by peer review of slide content. Clinical trials and off-label/investigational uses will not be discussed during this presentation. 4/8/2012 3
Agenda Audits Impacting Home Infusion Providers The OIG s Radar for 2012 RAC, CERT, ZPIC, DME MACS Top Reasons for Denial Lessons Learned Will Your Documentation Cut the Mustard? Take a Proactive Approach Educate Referral Sources 4
Agenda Understanding Your Rights Appealing an Unfavorable Determination Putting Together Your Response Audit Proofing Your Business Conducting Internal Audits Educational Resources for Staff 5
Audits Impacting Home Infusion Providers
On The OIG s Radar for 2012 Enteral/Parental High Billing Volumes Medicare Pricing for Parenteral Nutrition Too High Compared to Others? Use of Surety Bonds to Recover Overpayments Solicitation of Physicians Under Competitive Bidding 7
On The OIG s Radar for 2012 Compliance with Assignment Rules Claims with GA, GZ, GX and GY Modifiers Services Ordered by Excluded Physicians 8
Recovery Audit Contractors 3 Types of Reviews: Automated Complex New: Semi Automated 9
Automated Reviews Software Driven Process 100% Certainty of Error No Records Requested Unlimited Number Overpayment = Payment Demand Letter 10
Complex Reviews Human Review Not 100% Certain of Error Medical Records Requested = Additional Documentation Request Letter Limited Number Max of 10% of Annual Billing Volume per 45 days Capped at 250 Records, per 45 days May Request Permission to Exceed Cap 11
Complex Reviews Respond Within 45 Days of Date on ADR Letter RACs Have 60 Days to Respond Review Results Letter Will Include: RACs Decision Regulation Violated Information on Appeal Rights 12
Complex Reviews Overpayment Determination = Payment Demand Letter Infusion NOT Currently Under Complex Review 13
RAC Regulations Limited to a 3 year Look Back Period Always post payment reviews Issues must be approved by CMS Issues must be posted to website 14
On going RAC Reviews Name Description Jurisdictions Auditing Parenteral Nutrition Additives with Premix When premix parenteral nutrition solutions are used there may not be separate billing for the carbohydrates, amino acids or additives. A Infusion Supplies (A4221) Excessive Units Infusion supply code A4221 is billed on a weekly basis. Providers are billing A4221 more than one unit per week which resultsinanoverpayment. C PEN supplies more than 1 time a day The description or the billing guidelines state parenteral/enteral nutrition codes are allowed once a day. D Infusion Pump Denied/ Accessories & Drug Codes should be denied When the infusion pump is denied, then the infusion accessories and infusion drug codes are also denied. D 15
Name Pharmacy Supply Dispensing Fee On going RAC Reviews Description Medicare pays pharmacy supply/dispensing fees for immunosuppressive, oral anti cancer, chemotherapeutic, and oral anti emetic drugs as well as drugs used as part of an anti cancer chemotherapeutic regimen when they are submitted on the same claim as the drug being billed. A claim submitted with a pharmacy supply/dispensing fee in the absence of any of the previously mentioned drugs represents an overpayment and will be denied as not medically reasonable and necessary. Jurisdictions Auditing B 16
IVIG Rescinded IVIG Audit Human Immunoglobulin G Administered by intravenous infusion Contains antibodies 17
Claims Targeted: Rescinded IVIG Audit IVIG billed with chemotherapeutic administration codes Incorrect RAC Rational: IVIG infusion therapy should be billed with therapeutic administration codes, not chemotherapeutic Audit Rescinded July 5, 2011 Source: http://infusioncenter.net/index.php/news/nica news/105 july52011 18
ZPICs Zone Program Integrity Contractors (ZPICs): Formerly Program SafeGuard Contractors (PSCs) Review Parts A D, Home Health and Medi Medi Analyze data, look for outliers Conduct pre pay and post pay audits Main Objective = Identify Fraud Payments suspended pending investigation 19
ZPICs Zone Program Integrity Contractors (ZPICS): Audits unannounced or limited notice Uses statistical sampling to estimate overpayments Payment demand letters come from your MAC Respond within 30 days of date on letter ZPICs no time limit No maximum records 20
ZPIC Zones Safegaurd Services LLC Zone 1 CA, NV, American Samoa, Guam, HI, and the Mariana Islands. Zone 7 FL, Puerto Rico and Virgin Islands AdvanceMed Corporation (Acquired by NCI, Inc.) Zone 2 AK, WA, OR, MT, ID, WY, UT, AZ, ND, SD, NB, KS, IA and MO Zone 5 AL, AK, GA, LA, MS, NC, SC, TN, VA and WV Health Integrity, LLC Zone 4 CO, NM, OK, and TX 21
ZPIC Zones TBD Currently Under Protest Zone 3 MN, WI, IL, IN, MI, OH, and KY TBD Currently Under Protest Zone 6 PA, NY, MD, Washington DC, DE, ME, MA, NJ, CT, RI, NH, and VT 22
CERT Comprehensive Error Rate Testing (CERT): Targets DME MACs more than suppliers Sample of suppliers audited Audits identify DME MAC overpayments Error rate identified High error rate = widespread DME MAC prepay reviews 23
CERT Comprehensive Error Rate Testing (CERT): Always request additional documentation The requests identify patient and records under review Requests NOT limited to LCD Documents from other CMS Manuals may be cited Respond within 75 Days of the date on the letter Respond via fax or mail 24
DME MACs Durable Medical Equipment Medicare Administrative Contractors (DME MACs): Process claims Medical Reviews (MRs) = Nurse reviewers manually process responses Medically Unlikely Edits (MUEs) = Automated Excess units of service, span dates, Etc. 25
DME MACs Jurisdictions Auditing for Enteral Nutrition: A NHIC Prepay: B9000, B9002 (Pumps) Previous quarter charge denial rate 73.9% C CIGNA Prepay: B4150, B4154 (Formula) Previous quarter charge denial rate 64% 26
Top Reasons for Denial Jurisdiction A, NHIC: Insufficient clinical documentation No medical records submitted No proof of delivery Missing patient name, date or signature Item provided not listed Missing detailed written order Incomplete Order dated after delivery 27
Top Reasons for Denial Jurisdiction A, NHIC: Incomplete or missing DIF HCPCS Code not on DIF Illegible Records & Patient Refusals Dates Signatures Medical records 28
Top Reasons for Denial Jurisdiction C, CGS: No documentation of a non functioning GI tract (anatomical impairment or a motility disorder) Severity of condition not documented for specialty formula Patient history, physical exam, lab results No evidence standard formula tried Condition not permanent (at least 3 months) No records dated within 1 year of DOS verifying continued use and need 29
Lessons Learned CGS, Jurisdiction C: Proof of delivery If shipped, DOS = shipping date In person, DOS = date delivered/picked up Nursing Home Patients Combined delivery OK, BUT Break down individual nutrients/supplies per patient Refill requests must be documented so that refill quantities are based on the individual s not facility s needs 30
CGS, Jurisdiction C: Lessons Learned Preliminary dispensing order OK for delivery Written, fax or verbal Transcribe verbal Detailed written order needed to bill Checklists do not equal medical records Do not alter DIF Form at all No company logo 31
Will Your Documentation Cut the Mustard?
Insufficient Documentation (Nutrition) Diagnosis codes ALONE Dispensing or prescription orders ALONE Supplier generated forms NOT a substitute for physician records! Stamped signatures Illegible signatures 33
Ensure You Have (Nutrition): Dispensing/verbal order Detailed written order Listing Each Item Billed Supplier signed and dated DIF (Form 10126) Clinical records supporting coverage criteria Permanent non function or disease of the structures that normally permit food to reach the small bowel, or Disease of the small bowel which impairs digestion and absorption of an oral diet. Justification for pump or special formulas Proof of delivery Contractors must be able to determine who, what and where. 34
Pumps (B900 B9002): For Pumps Physician must document conditions that justify need, such as: Gravity feeding is not satisfactory due to reflux and/or aspiration Severe diarrhea Dumping syndrome Administration rate less than 100 ml/hr Blood glucose fluctuations Circulatory overload 35
Pumps (B900 B9002): For Pumps If discontinued for two consecutive months and later resumed, a new initial DIF is required If nutrition is changed from syringe/gravity to a pump A new Initial DIF is required (for pump) A revised DIF is required (for nutrition) 36
For Specialty Nutrients Specialty Nutrients (B4149, B4153 B4157, B4161 and B4162): Covered for patients with specific diseases Requires additional documentation identifying the specific condition and need for the nutrient Auditors expect evidence of failure on standard formulas No more LCA = meet requirements or ABN 37
For Nutrients Revised DIF needed for ALL nutrients if: Number of calories per day changes Number of days per week the nutrient is administered changes Method of administration changes between syringe, gravity, or pump Route of administration changes from feeding tubes to oral tubes (if billing for a denial) 38
For E0799 Use JB modifier for subcutaneous immune globulin, and pump E0779 LCA Removed for E0781/E0791 for subcutaneous immunoglobulin (must bill E0779 only) 39
Refills and Supplies Patient must be contacted prior to delivery Contact no more than 14 days before expected depletion May deliver 10 days early (NOT routinely) Confirm supply is nearly depleted Obtain information on frequency of utilization Are you the only supplier? 40
Refills and Supplies For telephone contact, document: The patient s name The person contacted (patient or caregiver) General description of items requested Statement that refill is requested Date of contact 41
Refills and Supplies For written contact, document: The patient s name General description of items requested Statement that refill is requested Patient or caregiver s signature and date 42
Maintaining Documentation Documentation must be on file for 7 years Cut back on paper files Consider a scanning solution Maintain electronic copies Faster recall of old documents More organized Less storage space 43
Take a Proactive Approach Key in all patient information at intake Insurance information Address information ABNs Verify prescriptions/orders prior to delivery Get signed DIF on file Check for same or similar Already had a pump in the past 5 years? Real time eligibility checks for SNF or HH stays 44
Take a Proactive Approach Don t assume the system will catch all errors Make a diagnosis code & common HCPCs cheat sheet: Screen for every transmission! Use software to flag when diagnoses & HCPCs don t match Make a list of HCPCs to check for policy specific modifiers (BA, BO, KX, etc) 45
Take a Proactive Approach Obtain notes from all sources High calorie diets (exceeding 2000 calories) Physical therapy Oncologist notes Cal/kg requirements Dietitian Call 10 Days ahead to confirm refills needed Document patient response Protocol for date stamping documentation 46
Educating Referral Sources Audit physician records Are you comfortable? Long or short turn around time? Support medical necessity? Missing required pieces of information? 47
Educating Referral Sources Check your DME mac s website: Physician documentation request letters Enteral nutrition dear physician letter Include cover letters quoting LCD coverage requirements Not regulated, but be broad based Provide documentation checklist Although not considered part of medical record 48
Myth: Obtaining Documentation HIPPA prevents physicians from supplying requested documents Truth: HIPPA allows disclosure of PHI for: Treatment Payment Health care operations 49
Obtaining Documentation SSA mandates physicians comply with documentation requests Section 1842(p)(4): [i]n case of an item or service ordered by a physician or a practitioner but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner. 50
Make it Easy to Send Ask up front, while fresh Include pre addressed, pre stamped envelope Accept faxes Electronic medical records are acceptable Get the patient involved 51
Understanding Your Rights
Your Rights You have every right to appeal a denial There is NO fee to appeal a denial at any level You do NOT need a lawyer to appeal Submitting an appeal does NOT increase your audit vulnerability Success increases at higher levels 53
Your Rights You can delay recoupments from post payment audits Collection attempts must stop when an appeal is filed at levels 1 or 2 Redeterminations (level 1): Contractors must wait 41 days to collect You have 120 days to appeal from the EOB date Reconsiderations (level 2): Contractors must wait 60 days to collect You have 180 days to appeal from the EOB date 54
Details Are Critical Pay attention to dates: Anywhere from 14 120 days to respond Date = date response must be received Pay attention to requirements: Know the reason for denial Only submit what is requested Submit all documents at one time Follow submission guidelines to a T 55
Be Prepared to Submit The preliminary dispensing/verbal order Detailed written order Physician progress notes to verify medical necessity Signed DIFs Proof of delivery Requested medical records from: Physician s office, nursing home, HHA, hospital, lab, dietitian 56
Levels of Appeal Redetermination Reconsideration Administrative Law Judge Departmental Appeals Board Judicial Review 57
Levels of Appeal Redeterminations (1st level) 120 days from the date on the EOB Medicare has 60 days to respond Reconsiderations (2nd level) 180 days from the date on the EOB Qualified Independent Contractor (QIC) Medicare has 60 days to respond 58
Levels of Appeal Administrative Law Judge (ALJ) (3rd Level) Appeal within 60 days of Level 2 decision $130 minimum Video or telephone hearing (in person on a caseby case basis) Generally held within 90 days 59
Levels of Appeal Departmental appeals board (DAB) (4th level) Appeal within 60 days of Level 3 decision No minimum amount Appeals generally processed within 90 days File with local Social Security office or address in ALJ Decision Letter 60
Levels of Appeal Judicial Review/US District Court (5th Level) Appeal within 60 days of Level 4 Decision $1350 minimum Follow instructions in DAB Decision Letter 61
Putting Together Your Response Gather documents to support your claim Claim forms, EOBs, progress notes DIFs, delivery tickets, hospital records Physician evaluations, communication logs, etc. Keep copies for your records Verify receipt 62
Putting Together Your Response Be organized! Number all pages (X of Y) Include a summary paragraph (what and why?) Include a table of contents (where?) Underline relevant information Prescreen your documentation Is it relevant? 63
Audit Proofing Your Business
Conduct Internal Audits Query claims in batch mode monthly or quarterly Review patient files to catch errors internally Pull patients from specific product categories with various EOB dates Standardize the forms you use: Be consistent Use checks and balances Appoint a Compliance Officer Have work independently reviewed 65
Review: Review and Verify Client charts, billing records, EOBs Product coding, chart notes, LCDs Verify: Patient information Eligibility AOB Signatures and dates 66
Verify: Review and Verify Dispensing/verbal order Descriptions, alterations, signatures and dates Detailed written order Quantity, options/accessories, frequency of replacement, LON etc. Billing accuracy Modifiers, HCPCS, quantity, ICD 9 = match Medical documentation, DIF, ABN = on file 67
Verify: Review and Verify Delivery documentation Patient signatures and dates Who signed? Relationship on file Delivery service (FedEx ) DOS = date shipped Quantities, charges, descriptions = match SNF = identified for specific patient, records account for supply utilization 68
Educational Resources for Staff DME MAC Tools: Documentation checklists Capped rental calculator Enteral units of service calculator Redetermination request calculator Reconsideration request calculator Physician education letters Modifier finder tools and usage tables Appeals time limit calculators Timely filing calculators Supply refill and contact calculators DME FAQs Ask the Contractor teleconferences Free, product specific webinars 69
Educational Resources for Staff RSS Feeds E mail Feeds MiraVista News Blog HME News, Homecare Mag, HME Business AAHomecare Blog Sign up for List Serves NHIA Listserv CMS List Serves DME MAC List Serves Join LinkedIn Groups Durable Medical Equipment Group HME Industry Network Group Medicaid and Medicare Network Group Medical Billing and Coding Forum 70
Educational Resources for Staff This site will allow you to look up HCPCS product classifications, fee schedules and modifiers. Click on the DMECS tab (DME Coding System) Select Search for codes or fees Bookmark this site to your favorites: http://www.dmepdac.com/dmecsapp/do/search In many cases, a manufacturer s product has to be specifically approved by PDAC prior to being covered by Medicare 71
Educational Resources for Staff Join an Association NHIA tools and resources specific to the home infusion industry www.nhia.org Your state association will help you fight local and national battles and give you access to Medicaid agencies and local payers to name a few benefits. Find your association here: http://www.hmenews.com/index.php?p=resources&resid=17 American Association for Homecare http://www.aahomecare.org Member Services Organizations Hold workshops and webinars Coordinate discounted purchasing Provide support to the business as a whole Offer contracting services to get you in network with more payers 72
Educational Resources for Staff DME Pricing Data Analysis and Coding (PDAC) www.dmepdac.com CMS Quarterly HCPCS Updates https://www.cms.gov/hcpcsreleasecodesets/02_hcpcs_quarterly_update.asp Annual HCPS Updates https://www.cms.gov/hcpcsreleasecodesets/anhcpcs/list.asp Look for the 2012 Alpha Numeric HCPCS File. These are great resources that will allow you to maintain a current in house database that your staff may verify coding against 73
Educational Resources for Staff MLN Matters Articles (Search by Dates and Keywords): https://www.cms.gov/mlnmattersarticles/2011mman/list.asp LCDs and Policy Articles Bookmark Your DME MACs LCD website (My favorite: https://www.noridianmedicare.com/dme/coverage/lcd.html) Check for Revised LCDs: http://www.cms.gov/medicare coverage database/ Select the Indexes tab and look for LCDs by contractor (i.e. NGS DME MAC) Here you can see Active, Future and Draft LCDs. To see all recently revised LCDs, sort by Last Updated. 74
Learning Assessment Questions & Answers Please refer to the NHIA Annual Conference & Exposition 2012 On Site Program for a brief post test. andrea@miravistallc.com 803.462.9959 x 240 4/8/2012 75
Disclaimer These materials and links to other sources are provided for informational purposes only and are not intended to be and should not be construed as legal advice. MiraVISTA does not guarantee or warrant that the materials are without error or present a complete explanation of all aspects of coverage or billing. Laws and procedures change frequently and are subject to differing interpretations. Content and information is subject to change without notice. 76