Agenda. Key Terms. How to Effectively Manage A Medicare Audit. Welcome. The Basics. ADR Process Appeals. Record Submission Process Questions & Closing

Transcription

1 How to Effectively Manage A Medicare Audit ASCEND 2017 September 29, 2017 Washington DC Mary R. Daulong, PT, CHC, CHP 1 Agenda Welcome Tag us during this #ascendevent The Basics Key Terms, Who, What & Why ADR Process Appeals Level Summaries Record Submission Process Questions & Closing 2 Key Terms Pre-payment Review Post-payment Review Underpayment Review of claims prior to payment. Pre-payment reviews result in an initial determination. Review of claims after payment. Post-payment reviews may result in either no change to the initial determination or a revised determination, indicating an underpayment or overpayment. A payment a provider receives under the amount due for services furnished under Medicare statute and regulations. A payment a provider receives over the amount due for services furnished under Medicare statutes and regulations. Common reasons for overpayment are: Overpayment Billing for excessive or non-covered services Duplicate submission and subsequent payment of the same service or claim Payment for excluded or medically unnecessary services Payment for services that were furnished in a setting that was not appropriate to the patient s medical needs Payment to an incorrect payee 3

2 What Makes You Vulnerable? Being an outlier i.e. having billing practices that vary significantly from their peers. Posing the greatest financial risk to the Medicare trust fund. Having a high error rate as compared to their peers, nationally. 4 Some of the CMS Audit Contractors CERT Comprehensive Error Rate Testing Contractor MAC Medicare Administrative Contractor RAC Recovery Audit Program (formerly Recovery Audit Contractor) SMRC Supplemental Medical Review Contractor Zone Program Integrity Contractor & United Program Integrity Contractor ZPIC/UPIC NOTE: There are multiple CMS audit contractors. This list includes those most commonly encountered but is not all inclusive. 5 What & When Do They Audit? Pre-payment Contractor Type Medical Record Reviews n-medical Record Reviews Post-payment Automated Reviews Medical Record Review n-medical Record Review MACs CERTs RACs SMRCs ZPIC/UPICs 6

3 Medicare is Shaking It Up, a Bit CMS rewires MAC auditing by: Establishing the Provider Compliance Group (PCG). Stressing that an important role of MACs is that they must educate providers/suppliers. Launching the Targeted Probe and Education audit process to be performed by the MACs. 7 Provider Compliance Group (PCG) Targets providers with the highest claim error rates or the greatest risk to the Medicare trust fund. Selects (randomly) claims from a provider. Provides education to the provider on the incorrect claims. Conducts 3 rounds of audits before referring the provider to other program integrity contractors such as the RAC or Z/UPICs. 8 PCG Findings of n-compliance Requirements: Provider must participate in an educational program re: requirements. MACs must wait 45 or more days before reviewing the another batch. MACs must determine the provider s compliance or lack of it; if non-compliant the provider must participate in a second and third round of education. MACs must refer the provider to CMS (RAC or ZPIC) for further action if they are still not compliant after the third batch of claims and education. 9

4 Referral to the RAC by PCG CMS has reformed the RAC New Requirements: Discussion period with the provider Provider claim correction prior to RAC taking action Remember the RAC is paid on a contingency basis! 10 CMS Recovery Audit Program Contractors Region 1 Performant Recovery, Inc. Region 2 Cotiviti, LLC Region 3 Cotiviti, LLC Region 4 HMS Federal Solutions Region 5 Performant Recovery, Inc. 11 Referral to ZPIC/UPIC by PCG ZPIC s goal is to identify cases of suspected fraud, investigate them, and take action to ensure any inappropriate Medicare payments are recouped. ZPICs perform ZPICs authority Medical Review-focuses on coverage or coding determination for medical necessity; n-medical Reviews- focuses on claims for possible fraudulent billing activity; Statistical sampling to extrapolate the results of the audit. Payment suspensions, provider exclusions, overpayment recoveries and referrals to law enforcement authorities 12

5 This is t Junk Mail! 13 CERT Contractor The CERT contractor program measures improper payment to the Medicare FFS program; it produces an annual error rate report. It: Selects (randomly) Medicare FFS claims of providers Reviews the claims and documentation provided for compliance with Medicare s coverage, coding and billing rules Assigns the Proper Payment Category Refers non-compliant findings to the MAC for appropriate payment adjustment 14 CERT tification Timelines Documentation request and receipt schedule: Letter 1 or fax 1 Day 0 Day 30 Letter 2 or fax 2 Letter 3 or fax 3 Day 60 Send Letter 4 Day 45 Score claim as an error code 99 on the Claims Status website Day 76 15

6 Supplemental Medical Review Contractor The SMRC is Strategic Health Solutions and it was tasked by CMS to review claims on a post-payment basis based on: Providers with a high percentage of patients exceeding the $3,700 threshold as compared to peers Units/hour of service provided in a day 16 Types of Medicare Contractor Audits 1. Medical Records Review (formerly complex review ) 2. Automated Review 3. n-medical Record Review NEW! 17 Medical Records Reviews Involve Requesting Receiving Reviewing Medical documentation associated with a claim. If the purpose is to determine medical necessity the review must be performed by a medical professional who uses clinical review judgment to evaluate the documentation. 18

7 Clinical Review Judgment - 2 Steps 1. The synthesis of all submitted medical record information to generate a clinical picture of the patient and, 2. The comparison of the clinical picture to the review criteria to see if relevant policies1 have been met. Clinical review judgment cannot be carried out if there is missing or inadequate documentation i.e. if it isn t present it can t be favorably judged. 1 Policies include laws, regulations, CMS rulings, manual instructions, MAC policy articles attached to a LCD or listed in the Medicare Coverage Database, national and local coverage determinations. 19 Reviewer Credentials MACs, CERT, ZIPC/UPICs must use licensed nurses (RNs & LPNs) or physicians unless it is delegated to other licensed health care professionals whose scope of practice includes specialties like SLP, PT, etc. RACs and SMRCs shall ensure that the credentials of their reviewers are consistent with the requirements in their respective Statements of Work. Certified coders must be used by RACs for coding determinations, but CERTs and MACs have the discretion to chose whether to use certified coders or not. 20 Automated Reviews Decisions are made when: There is no response to an ADR There is a clear policy that specifies when services will always be considered non-covered, incorrectly coded, or improperly billed Payment decisions are made at the system level using available electronic information no manual intervention i.e. no review of documentation required. 21

8 n-medical Record Review Occurs when a claim determination is made based on the information on the claim. There is no clinical review of medical documentation because: Denials of related claims and/or There was no receipt of documentation in response to an ADR 22 CMS Top Three Therapy Audits Performed Therapy Threshold Audits Post-payment Claims Audit Targeted audits Comprehensive Error Rate Testing- (CERT) Post-payment Claims Audits Random selection of dates of service Automated Reviews by the Medicare Administrative Contractor (MAC) Pre or Post-payment Claims Audits Based on aberrant billing behavior. 23 Reminders! If you engage a consultant to assist or carry out the ADR or appeals be certain to obtain a signed Business Associate Agreement before any Protected Health Information (PHI) is exchanged. Don t send your response (charts) to CMS Additional Documentation Request (ADR) with PHI in it via unless it is encrypted. If you fax PHI please make certain it is transmitted to a stand alone fax not an internet based fax line. 24

9 ADR PROCESS 25 Mail Sorting is Paramount! Assign a responsible person to sort your mail and faxes Instruct the mail sorter to prioritize all mail from payers Require that all ADR s/audit notices be brought immediately to your attention. Open mail & determine if it is an Additional Documentation Request (ADR) or notice of an audit. Save the envelope! 26 Do It Right the First Time If you receive a request for records or an audit notice: Read and read re-read the request and the directions and stay involved in the process Meet and/or beat submission deadlines Use the correct form, if noted in instructions Provide ALL support documentation from the beginning of care through the DOS requested 27

10 Doing It Right the First Time (cont.) Put the documents in an orderly and legible form per the letter directives Make a copy of everything submitted for yourself Send documents via a traceable vendor Engage a reliable consultant if you are unsure of why, how, when, etc. te: Handouts will be available at the end of the presentation 28 Don t Be a -Show If a Medicare contractor or other payer requests records you must provide them within the specified timeframe. The consequence of not doing so is that they can consider the payment an error or an overpayment and will solicit payment from you or initiate a recoupment from subsequent payments due! 29 APPEALS 30

11 Prepare for an Appeal Unless well versed in completing appeals a consultant should be utilized to shore up support documents, meet deadlines and to facilitate a strong appeal. 31 Medicare s Five Levels of Appeal 1st 2nd 3rd 4th 5th Redetermination by a Medicare Administrative Contractor (MAC). Reconsideration by a Qualified Independent Contractor (QIC). Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals (OMHA). Review by the Medicare Appeals Council (MAC). Judicial Review in Federal District Court. 32 CMS Demand Letter First Level of Appeal s Demand Letter is issued by the Medicare Administrative Contractor and explains that: Medicare made an overpayment Interest begins to accrue if you do not repay the overpayment in full within 30 days Options to request immediate recoupment or an Extended Repayment Schedule (ERS) Rebuttal/appeal rights 33

12 If You Choose to Pay: Payment Options Immediate Payment Follow the directions in the demand letter to submit payment. Request Immediate Recoupment Request Standard Recoupment Recoupment occurs when Medicare recovers overpayment by withholding interim payments. Follow the instructions to approve immediate recoupment. You do not need to do anything to request standard recoupment. Request an ERS Follow the instructions in the demand letter and request an Extended Repayment Schedule (ERS) from your MAC. 34 Defensive Actions Rebuttal You can submit a rebuttal to your MAC within 15 calendar days from the date of a demand letter. In your rebuttal statement, explain or provide evidence about why the MAC should not initiate recoupment. While the rebuttal process is not considered an appeal and does not stop recoupment activities, MACs promptly evaluate this information. Appeal If you disagree with an overpayment decision, you can file an appeal with your MAC to conduct an independent review of the decision. A redetermination is the first level of appeals in which a qualified employee of the MAC conducts an independent review of the decision. Following an unfavorable or partially favorable redetermination decision, you can request a second-level appeal or reconsideration by a Qualified Independent Contractor (QIC). 35 Appeal Level Summary Appeal Level Appeal Submission Date Deadline Prevent Recoupment Filing Date Redetermination Level days from receipt of Demand Letter By 30th day from Demand Letter date (5 days) Reconsideration Level days from the receipt of Redetermination Decision Administrative Law Judge Hearing-Level 3 60 days from the receipt of the Redetermination Decision ne Immediately after am unfavorable Reconsideration Decision Letter s receipt Medicare Appeals Council Level 4 60 days from the receipt of the ALJ Decision ne Continues from Level 2 decision Federal Court Review Level 5 60 days from the receipt of the MAC Decision ne Continues from Level 2 decision Recoupment Initiation Timeframe On 41st day from the Demand Letter date (5 days) By the 60th day from the By the 30th day from the Redetermination Decision Redetermination Decision Letter Letter date (5 days) date (5 days) 36

13 Appeal Forms CMS Appeal Forms: ml Redetermination: CMS Reconsideration: CMS ALJ Hearing Request: CMS Multiple Beneficiaries: OMHA 100 Appointment of Rep: CMS 1696 Waiver of Hearing: OMHA 104 Filing of New Evidence: OMHA The Redetermination A redetermination is the first level of appeal for Medicare providers and/or beneficiaries. A redetermination request should be made when the provider or beneficiary is unsatisfied with the initial claims determination or a contractor s initial audit. 38 The Redetermination (cont.) A redetermination must be filed within 120 days of the initial determination and the contractor must complete the request within 60 days. To stop recoupment the appeal must be filed within 30 days. If the denial/decision is reversed and the claim is paid, payment will be sent/deposited with a Remittance Advice tice (RAN) remark; if the claim is partially paid that too will appear on the RAN but, in addition, it will include instruction for the next level of appeal. If payment is not made or the decision is not reversed, the provider will receive a letter outlining the action taken and instructions for the next appeal level. 39

14 The Reconsideration Request A reconsideration request is the second level in the administrative appeals process. A Reconsideration request is processed by a Qualified Independent Contractor (QIC). Maximus and C2C Innovative Solutions are QICs. A reconsideration is requested if the provider is dissatisfied with the redetermination decision. A reconsideration must be requested within 180 days of receipt of the redetermination decision, per the date on the letter, and the QIC must complete the request within 60 days of receipt. To stop recoupment the appeal must be filed within 60 days. 40 Reconsideration Request (cont.) QIC reconsiderations must offer: 1. A panel of health professionals review o If the denial was based on medical necessity, the QIC must have a panel of physicians or other health care professionals with the appropriate clinical expertise to review a claim 2. Detailed information in the decision letter o The QIC must include a detailed explanation of the decision, including any pertinent facts and applicable regulations and, in the case of a medical necessity denial, an explanation of the medical and scientific reason for the decision. 41 Reconsideration Request (cont.) 3. Must comply with National Coverage Determinations (NCDs), CMS rulings, statutes and regulations. 4. Have some latitude in determining medical necessity as QICs are not bound by Local Coverage Determinations (LCDs) produced by Medicare contractors. 5. Must provide sound instructions to the provider for proper ALJ steps to take if dissatisfied with the decision at the reconsideration level. 42

15 Administrative Law Judge ALJ hearing: Is the third level of administrative appeal Has a monetary threshold of no less than $160 (2017) Must be requested on a CMS A/B form Must be requested within 60 days of the date of the QIC decision as noted on the decision letter Filing an appeal at this level does not halt recoupment. 43 Medicare Appeals Council The Medicare Appeals Council: Is the fourth level of administrative appeal Is part of the DAB of the U.S. Department of Health and Human Services Must be requested within 60 days of the receipt of the ALJ decision/dismissal as noted on the letter Has 90 days to accept or reject the case referred; (currently ALJ has a 2 year backlog) Filing an appeal at this level does not halt recoupment. 44 Federal Court Review Federal court review or judicial review: Is the fifth level of appeal Has a monetary threshold of $1560 (2017) Must be filed within 60 days of the MAC/DAB decision per the decision letter date Must name the Secretary of Health and Human Services as the defendant and must be filed in the same district in which the beneficiary resides 45

16 Extended Repayment System (ERS) Guidelines CMS will approve an ERS if the total amount of all outstanding overpayments is 10% or greater than the total Medicare payments made for the previous calendar year. The longest time period an ERS can last, if approved, is 60 months from the date of the initial demand letter. The interest rate associated with an ERS is statutorily set at percent. Payments recouped during ERS processing will not be refunded to the provider. CMS does not have to approve the amount or the duration of the extended payment. Interest rates begin to accrue on unpaid balances within 30 days of demand letter receipt but are halted with an ERS. 46 INSTRUCTIONS FOR SUBMITTING PAPER PATIENT RECORDS TO A PAYER Instructions: Record Submissions Perform a self audit on each chart requested, the following items should be present, complete and legible: Signed (therapist and certifying physician or non-physician practitioner) & dated Plan of Care covering each date of service being reviewed Do not send a chart without a signed Plan of Care! Progress Reports (PR) covering all dates of service requested (there is no MD signature required for PRs). Signed & dated initial evaluation (does not need to be separate from the Plan of Care). Treatment Encounter tes (daily notes) for each date of service requested If your notes are compliant you can submit all of them from the initial evaluation through the requested date(s) of service. 48

17 Instructions: Record Submissions (cont.) Discharge Report, if applicable. Referral, if rendered (not a Medicare requirement). Signature list for treating therapist(s) on the dates of service requested, if not legible. Home Programs, if applicable. Copy of the remittance advice notice or the claim form covering the dates of service rendered. 49 Instructions: Record Submissions (cont.) Request for Records or Audit tice letter (all pages including completed attachments): Completed Point of Contact Form (if requested); List of beneficiaries being audited-highlighting the patient s name associated with the chart. Signature Attestation Form for the certifying individual if not legible (see copy of form). Abbreviation list, if applicable. Standardized test list with brief test description and associated scale or norms. 50 Instructions: Record Submissions (cont.) Make two (2) clean, legible and one sided copies of every item on the detailed list. 1 copy for the payer 1 copy for the clinic (Do not file the clinic copy in the patient s chart). Organize i.e. order the documents as stipulated in the letter. Number each page of documents to be submitted (always in the same location i.e. lower right corner). 51

18 Instructions: Record Submissions (cont.) Create a Table of Contents Coversheet for the chart packet noting the total number of pages submitted in the packet. Use binder clips or rubber bands to secure the documents in each packet, do not staple any documents. Use colored paper to separate each chart packet in the shipping box. 52 Instructions: Record Submissions (cont.) Ship the charts in a secure box via a reliable vendor with a tracking capability, indicating: Return receipt requested; Signature for delivery requested; te: Federal Express & UPS do not ship to P.O Boxes; send to the stipulated address obtain a physical address if necessary. Monitor the shipping status regularly. Monitor your mail and fax machine for correspondence from the auditor. 53 Resources/References: 1. Fraud & Abuse Statutes & Compliance Measures Based on: a. b. OIG s Compliance Guidances for Physicians and Small Group Practices The Department of Health & Human Services Centers for Medicare and Medicaid 2. Medicare Medical Necessity Audit Based on: Medicare s Conditions of Coverage: Medicare Benefits Manual, Chapter 15 Section Coding and Billing Audit Based on Medicare Conditions of Coverage a. b. c. d. Medicare Claims Processing Manual, Chapter 5 Section; & Chapter 30 Medicare s Billing Edits: NCCI, ABN, KX & other Coding Modifiers Medicare s Billing Therapy Service Medicare s Fee-for-Service Payment Policies 4. Medicare Contractor Audits Based on Medicare s Program Integrity Manual, Chapters, 10, 12, 13, 14 & Exclusion Program & Authorities Based 42 CFR Parts 1000, 1001, 1002 and RIN 0991 AA87 Health Care Programs: Fraud and Abuse; Revised OIG Exclusion Authorities Resulting From Public Law

19 QUESTIONS? I will gladly entertain questions that are specific to this presentation. Please your questions to Mary Daulong at daulongm@bcmscomp.com Kindly include the name of the presentation in the subject line. 55 Contact or Connect with us Mary Daulong, PT, CHC, CHP daulongm@bcmscomp.com Champion Forest Drive, Suite 240 Spring, TX Follow Us! BCMSCOMP.com Facebook.com/BCMScomp Twitter.com/BCMScomp 57

20 Presenter s Biography Mary Daulong has a very diverse practice background which includes private practice ownership, corporate managed services and hospital based practice exceeding four decades. Her consulting company was established in 1985 and has been, for the past seventeen years, 100% dedicated to working with healthcare professionals in the areas of federal and state compliance, practice and business office operations, payment and coverage policy including billing, coding and documentation. Her company also provides Compliance Policies and Procedures Manuals specific to physical therapy and provider enrollment and credentialing services. Mary has been certified in Health Care Compliance since 2002 and is a member of the Healthcare Compliance Association; she is also certified as a HIPAA Professional by the HIPAA Academy. She has been an active member of the APTA for over forty years during which she served on and/or chaired multiple committees at the national and component level. Mary was the chair of the Texas Physical Therapy Association s Payment Policy Committee for ten years and held chairmanships for the TPTA of Governmental Affairs, Quality Assurance and minating Committees. She was appointed to the Texas Board of Physical Therapy Examiners and served on its Executive Council for PT and OT and Investigations Committee. Mary is a member of the vitas Solution s Provider Outreach Education Advisory Group. Mary has presented hundreds of courses related to compliance both on a federal and state level often being the featured speaker at National, Chapter and Section Annual Conferences. 58 Disclaimer These educational materials are current as of September 15, They have been prepared as tools to assist in teaching healthcare providers; they are not intended to create any rights, privileges, or benefits. Although every reasonable effort has been made to assure the accuracy of the information within these materials, the ultimate responsibility for complying with the Federal fraud and abuse laws lies with the provider of services. Please note: These educational materials are summaries that explain certain aspects of the Federal fraud and abuse laws, but are not legal documents. The official information is contained in the relevant laws and regulations 59