The Medicare Review Process February 25, 2015

Transcription

1 WELCOME TO REVENUE CYCLE BASICS: The Medicare Review Process February 25, 2015 Greg Beech Senior Revenue Cycle Analyst esolutions, Inc.

2 02 Objectives Identify Five Common Sources of Claim Reviews Identify Each Review Contractor s Role Learn How to Identify Your Review Contractors Review Recent Updates to ADR Process Learn How esolutions Can Simplify Your Audit Process

3 NEXT Five Common Sources of Audits

4 Five Common Medicare Review Contractors 04 The term Review Contractor refers to: Medicare Administrative Contractors (MACs) Comprehensive Error Rate Testing (CERT) Contractors Recovery Auditors (RACs) Supplemental Medical Review Contractor (SMRC) Zone Program Integrity Contractors (ZPICs) Review Contractors shall follow all sections of the Medicare Program Integrity Manual (PIM) unless otherwise indicated as required by their applicable Statements of Work (SOW). Medicare Program Integrity Manual 1.1

5 NEXT Review Contractors and Their Role

6 Medicare Administrative Contractor (MAC) 06 Purpose To process claims submitted by physicians, hospitals, and other health care professionals and to submit payment to those providers in accordance with Medicare rules and regulations. This includes identifying and correcting underpayments and overpayments. Goal of MAC Medical Review Program To reduce payment error by preventing the initial payment of claims that do not comply with Medicare s coverage, coding, payment, and billing policies. To achieve the goal of the MR program, MACs: Identify provider noncompliance with coverage, coding, billing, and payment policies through analysis of data (profiling of providers, services, or beneficiary utilization) and evaluation of other information (complaints, enrollment and/or cost report data). Take action to prevent and/or address the identified improper payment. Place emphasis on reducing the paid claims error rate by notifying the individual billing entities (providers, suppliers, or other approved clinician) of review findings identified by Affiliated Contractors (ACs) or by the MACs and making appropriate referrals to Provider Outreach and Education (POE) and ZPIC. Medicare Program Integrity Manual 1.3.8

7 A/B MAC Jurisdictions 07 Jurisdiction Contractor States Jurisdiction 5 WPS Iowa, Kansas, Missouri, and Nebraska Jurisdiction 6 NGS Illinois, Minnesota, and Wisconsin Jurisdiction 8 WPS Indiana and Michigan Jurisdiction 10 (J) Cahaba GBA Alabama, Georgia, and Tennessee Jurisdiction 11 Palmetto GBA Jurisdiction 15 CGS Kentucky and Ohio Jurisdiction E Jurisdiction F Jurisdiction H Jurisdiction K Jurisdiction L Noridian Noridian Novitas Solutions NGS Novitas Solutions North Carolina, South Carolina, Virginia, and West Virginia American Samoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania Jurisdiction N First Coast (FCSO) Florida, Puerto Rico, and U.S. Virgin Islands

8 Home Health and Hospice Regions 08 Jurisdiction Contractor States Jurisdiction K HH+H NGS Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont Jurisdiction 15 HH+H CGS Colorado, Delaware, District of Columbia, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia and Wyoming Jurisdiction 11 HH+H Palmetto GBA Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee and Texas Jurisdiction 6 HH+H NGS Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, US Virgin Islands, Wisconsin and Washington

9 Durable Medical Equipment Jurisdictions 09 Jurisdiction Contractor States DME Jurisdiction A NHIC Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont DME Jurisdiction B NGS Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin DME Jurisdiction C CGS Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia and West Virginia DME Jurisdiction D Noridian Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington and Wyoming

10 Medicare Administrative Contractor (MAC) 10 MAC, CERT, and RAC Cooperation The MACs primarily use error rates produced by the CERT program and vulnerabilities identified through the Recovery Audit program to identify where to target their improper payment prevention efforts. The MACs analyze their internal data to determine which corrective actions would be best to prevent the CERT-identified and Recovery Auditor-identified vulnerabilities in the future. The CMS has determined that most improper payments in the Medicare FFS program occur because a provider did not comply with Medicare s coverage, coding, or billing rules. The cornerstone of the MACs efforts to prevent improper payments is each contractor s Error Rate Reduction Plan (ERRP), which includes initiatives to help providers comply with the rules. These initiatives usually fall into one of three categories: Provider education targeted to items or services with the highest improper payments. Pre-payment and post-payment claim review targeted to those services with the highest improper payments. In addition, in order to encourage providers to submit claims correctly, MACs can perform extrapolation reviews as needed. New or revised local coverage determinations, articles or coding instructions to assist providers in understanding how to correctly submit claims and under what circumstances the services will be considered reasonable and necessary. Medicare Program Integrity Manual B

11 Comprehensive Error Rate Testing (CERT) 11 Purpose To establish error rates and estimates of improper payments. CERT is compliant with the Improper Payments Information Act (IPIA) of 2002 as amended by the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of Goal To calculate the paid claims error rate for Medicare claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs). The Centers for Medicare and Medicaid Services receives in excess of 2 billion claims per year. CERT randomly selects a statistical sample of these claims for review to determine whether the claims were paid properly. The CERT Program uses two contractors to accomplish this work: the CERT Review Contractor and the CERT Documentation Contractor. The CERT Review Contractor is responsible for reviewing the selected claims and associated medical record documentation. The CERT Documentation Contractor is responsible for requesting and receiving the medical record documentation from providers. The CERT Documentation Contractor (Livanta LLC) is a national review contractor. Medicare Program Integrity Manual A, CERT Provider Website

12 Comprehensive Error Rate Testing (CERT) 12 w or

13 Recovery Auditors (RACs) 13 Purpose To correct past improper payments through post-payment claim review. Recovery Auditors are responsible for reviewing claims where improper payments have been made or where there is a high probability that improper payments were made. Goal To identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries and to identify underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states. w Medicare Program Integrity Manual 1.3.2, C, CMS.gov

14 Recovery Auditors (RACs) 14 Jurisdiction Contractor States Region A Performant Recovery CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI and VT. Region B CGI Federal, Inc IL, IN, KY, MI, MN, OH and WI Region C Connolly, Inc. AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico and U.S. Virgin Islands Region D HealthDataInsights, Inc (HDI) AK, AZ, CA, HI, ID, IA, KS, MO, MT, ND, NE, NV, OR, SD, UT, WA, WY, Guam, American Samoa and Northern Marianas

15 Supplemental Medical Review Contractor (SMRC) Purpose To perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. The centralized medical review (MR) resource performs large volume MR nationally and allows for a timely and consistent execution of MR review, activities and decisions. The focus of the reviews may include but are not limited to issues identified by CMS internal data analysis, the CERT program, professional organizations and other Federal agencies, such as the OIG/GAO and comparative billing reports. Goal of SMRC Medical Review Program To reduce payment error by preventing the initial payment of claims that do not comply with Medicare s coverage, coding, payment, and billing policies. To achieve the goal of the MR program, SMRC: Identifies provider noncompliance with coverage, coding, billing, and payment policies through the research and analysis of data related to assigned task (profiling of providers, services, or beneficiary utilization). Performs medical review as directed by CMS. Performs extrapolation as directed by CMS. Notifies the individual billing entities (providers, suppliers, or other approved clinician) of review findings and makes appropriate recommendations for POE and ZPIC referrals. 15 Medicare Program Integrity Manual D, 1.3.8

16 16 Supplemental Medical Review Contractor (SMRC) w

17 Zone Program Integrity Contractors (ZPICs) 17 Purpose To identify cases of suspected fraud and take appropriate corrective actions. Current ZPIC contracts analyze all claim types including Part A, Home Health, Hospice, Part B, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and perform Medicare and Medicaid Data Matching. Goal To identify cases of suspected fraud, develop them thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped. There are seven ZPIC zones and the ZPICs for these zones are tasked with performing program integrity for Medicare Parts A, B, C, Durable Medical Equipment (DME), Home Health and Hospice (HH+H), and the Medicare-Medicaid data match program (Medi-Medi). Medicare Program Integrity Manual 1.7.A, 1.7.B

18 ZPIC Jurisdictions 18 Zone Contractor States Zone 1 Zone 2 Zone 3 Safeguard Services AdvanceMed Cahaba California, Nevada, American Samoa, Guam, Hawaii, the Northern Mariana Islands, Palau, Marshall Islands, and the Federated States of Micronesia Alaska, Washington, Oregon, Montana, Idaho, Wyoming, Utah, Arizona, North Dakota, South Dakota, Nebraska, Kansas, Iowa and Missouri Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, and Kentucky Zone 4 Health Integrity, LLC Colorado, New Mexico, Oklahoma, and Texas Zone 5 Zone 6 AdvanceMed TBD Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia and West Virginia Pennsylvania, New York, Maryland, Washington D.C., Delaware, Maine, Massachusetts, New Jersey, Connecticut, Rhode Island, New Hampshire, and Vermont Zone 7 Safeguard Services Florida, Puerto Rico and Virgin Islands

19 NEXT Identifying Your Review Contractors

20 CMS Review Contractor Directory Interactive Map 20 w

21 NEXT Recent Updates

22 22 Time-Frames for Submission (Effective: ) Pre-payment Review Time Frames When requesting documentation for pre-payment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46. Post-payment Review Time Frames When requesting documentation for post-payment review, the MAC, CERT and RAC shall notify providers that the requested documents are to be submitted within 45 calendar days of the request. ZPICs shall notify providers that requested documents are to be submitted within 30 calendar days of the request. Because there are no statutory provisions requiring that post-payment review of the documentation be completed within a certain timeframe, MACs, CERT, and ZPICs have the discretion to grant extensions to providers who need more time to comply with the request. The number of submission extensions and the number of days for each extension is solely within the discretion of the MACs, CERT and ZPICs. RACs shall follow the time requirements outlined in their SOW. MLN Matters Number: MM8583

23 New CMS Post-payment ADR Letter Format 23 Medicare Program Integrity Manual

24 NEXT How to Simplify Your Audit Process

25 Audit Solutions 25 esolutions has audit solutions for all organizations. NexusMD NexusMD Convenient website portal for esmd submission. Secure solution that s cost-effective for all providers. Maven Maven Comprehensive ADR tracking and appeals management workflow tool. Network Integration Network Integration (esmd) Fully integrate with existing systems. Ideal for large organizations. w esolutions, Inc.

26 What is esmd? 26 Electronic Submission of Medical Documentation (esmd) provides a quick and easy way to respond to additional documentation requests (ADRs) by CMS Review Contractors such as the RACs, MACs, DME MACs, ZPICs, SMRC, CERT, and PERM. In addition to ADRs, esmd also allows you to submit Level 1 appeals (Redetermination), RAC Discussion Requests, Advanced Determination of Medicare Coverage (ADMC) Requests, and Power Mobility Device Prior Authorization Requests (PMD PAs). Secure, HIPAA Compliant Submission Accepts Portable Document Format (PDF) Simple and Efficient $ Audits already cost you money. Stop spending more than you need to.

27 27 esmd Benefits Taking advantage of esmd can help providers save money and increase efficiency Quicker Turnaround Providers have reported the payment turnaround when using esmd is 6 days, as opposed to the paper process which is approximately 3 weeks. Delivery Confirmation esmd provides electronic confirmation tracking when records are delivered and received by a Review Contractor. Reduced Costs esmd helps to reduce the amount of labor required to fulfill these requests by no longer having to mail records, feed a fax machine, or burn CDs.

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