DME MAC CERT Education Task Force. Collaborating for Medicare Program Improvement

Transcription

1 DME MAC CERT Education Task Force Collaborating for Medicare Program Improvement 1

2 Agenda CMS & AdvanceMed, Corp What is CERT? How is CERT Performed? Medical Records Requests Responding to CERT Requests Documentation Benefits of CERT Corrective Actions DME MAC CERT Task Force DME MAC Most Frequent Errors CERT Appeals Recommendations/Resources

3 CERT Overview Jill Nicolaisen Technical Advisor, Division of Error Rate Measurement Centers for Medicare & Medicaid Services Dr. David Perez National Director, CERT Program AdvanceMed, Corp. 3

4 Background: Improper Payment Information Act of 2002 (IPIA) IPIA requires all federal agencies to: Assess programs for risk of making improper payments Estimate and report improper payment amounts annually, for programs at risk Take corrective actions to reduce improper payments Defines improper payment as: payments that should not have been made, or payments made in an incorrect amount (including overpayments and underpayments) payment to an ineligible recipient, payment for an ineligible service, any duplicate payment, payment for services not received, payments for an incorrect amount. 4

5 Executive Order Reducing Improper Payments Issued by the President on November 20, 2009 Aimed at further intensifying efforts to eliminate payment error, waste, fraud, and abuse in federal programs while continuing to ensure that the right people receive the right payment for the right reason at the right time. The EO adopts a comprehensive set of policies that include: Transparency and public scrutiny of significant payment errors Focus on identifying and eliminating the highest improper payments Agency accountability for reducing improper payments Coordinated federal, state, and local government action in identifying and eliminating improper payments 5

6 Executive Order Supplemental Measures Measure What is Being Reviewed Sample Size Sample Months Request Records Report Findings Power Wheelchairs 8 HCPCS codes identified ~ November 2009 through January 2010 Beginning May 2010 Initial report: Sept 2010 Subsequent reports: Semiannually Short Hospital Stays inpatient claims for 0 and 1 day length of stay ~200 April 2010 through June 2010 Beginning June 2010 Initial report: March 2011 Subsequent reports: Semiannually Chiropractic Services beneficiaries with at least one claim from the same chiro in each month for sample months all claims with DOS for the prior 12 months for 100 bene s April 2010 through June 2010 Beginning August 2010 Initial report: March 2011 Subsequent reports: Semiannually Pressurereducing Support Surfaces 9 HCPCS codes identified ~ April 2010 through June 2010 Beginning June 2010 Initial report: March 2011 Subsequent reports: Semiannually 6

7 Overview of CERT What is CERT? What does CERT do? How does CERT help physicians and other health care providers? Is there anyway I will know my claims are being reviewed by CERT? How can I help lower the claims payment error rate? 7

8 What does CERT mean and who administers CERT? Comprehensive Error Rate Testing CERT is administered by one of the Program Safeguard Contractors (PSCs) 8

9 What does CERT do? CERT - will produce: National paid claim error rate Contractor paid claim error rates Along with a Medicare Contractor s claims resolution error rate and provider compliance error rate Benefit Category paid claim error rates Provider Specific paid claim error rates MAC error rates 9

10 CERT National Error Rate Calculations The building block of the national rate is the individual error rate at the contractor/mac level. Historically, for each Part A, Part B and DME MAC contractor, an error rate is calculated based on approximately 2,000 claims per year. The error rate, and its standard error, is calculated. Sample size varied from 120, ,000 For A/B MACs - 2,000 Part B, 1800 Part A with 300 inpatient hospital claims per A/B MAC For DME MACs 2,000 Claims per DME MAC 10

11 National Error Rate Calculations Within a provider type, such as DME, the contractorspecific error rates are aggregated into a provider type (DME) for improper payment estimation. The rates are weighted by the proportion of DME Medicare payments represented by each DME MAC over the period of inference (year). The standard error is a function of weighted aggregation of the individual contractor s variances. 11

12 National Paid Claims Error Rate Part A/RHHI, Part B and DME MAC Error rates are aggregated into a CERT Error Rate. The weights are the proportion of total Medicare Part A, B and DME MAC expenditures represented by each. The standard error of the CERT Error Rate is based on a weighted aggregation of the individual component variances in the error rate computation. 12

13 National Paid Claims Error Rate CERT sample is drawn for all claims submitted over a 12 month period (fiscal year) CERT uses a submitted claim as the sampling unit Sample is based on random sample using a skip interval.\ Random start changes monthly

14 CERT Implementation Schedule Phase System Implementation Date Official Sampling Month I. DME VMS 8/14/ /2000 II. Part B VMS 10/31/2000 1/2001 III. Part B EDS/MCS 4/1/2001 7/2001 IV. Part A APASS/FISS 1/1/2002 4/1/2002 V. Miscellaneous HPBSS/Verizon Staggered from 4/1/2002 8/1/2002 VI. Inpatient claims DRG and LTC FISS October 1, /1/2008

15 CUF SCTF SCRF PAF DME Documentation Monthly Reports Semi-Annual and Annual Reports Aug 2000 VMS Part B Oct 2000 EDS/ MCS Part B April 2001 CERT Operations Center (CMS) AdvanceMed Part A APASS/FISS January 2002 CERT SAMPLED CLAIMS DATABASE CUF Claims Universe File SCTF Sampled Claims Transaction File SCRF Sampled Claims Resolution File CHRF Claims History Replica File PAF Provider Address File 15

16 CERT Time Frame Beginning with Claims sampled on or after Aggressive Call 1 days Aggressive Call 15 days Aggressive Call 50 days Timeframe (Days) DAILY Sample Request for Collection Claims daily Transaction File Return of Claims Replica, Provider Address and Claims Resolution Files Initial Request Letter Second Request (1 st Reminder 30 days) Third Request (2 nd Reminder 45 days) Fourth Request (3 nd Reminder 60 days) 3 calls and 75 days to respond 16

17 How does CERT help physicians and other health care providers? A pre-pay sample but post-pay review Providers will not be subject to random pre-pay reviews For the improper payment error rate Under-coded claims or improperly denied claims are as important as improperly paid claims

18 Other CERT Benefits Contractor Provider Outreach and Education teams are responsible for CERT education. Claims Payment Error Rate WILL IMPROVE Pay the claim right the first time Clear and Consistent Standards for Medical Review CMS wants contractors applying the same review standards

19 Is there any way I will know my claims are being reviewed by CERT? 19

20 Documentation Myths Because of HIPAA, I cannot respond to this request without authorization from the beneficiary. 20 D

21 HIPAA "The Health Insurance Portability and Accountability Act (HIPAA)Privacy Rule permits disclosure of personal health information to carry out treatment, payment or health care operations. When Medicare beneficiaries enroll in the program, they are informed of Medicare's use of their personal health information to carry out health care operations. AdvanceMed performs health care operations as a business associate of CMS with respect to the HIPAA Privacy Rule. Providing the requested documentation does not violate the minimum necessary provision of the HIPAA Privacy Rule and does not require beneficiary authorization." 21 D

22 HIPAA- CMS Business Associates 22

23 Documentation Myths Information requested by CERT should go to CMS Central Office Information requested by CERT should go to the local Medicare Contractor or MAC DME supplier generated information is enough to support medical necessity

24 CERT Operation Center Address CERT Documentation Contractor CERT Documentation Office Attn CID #: Junction Drive, Suite 9 Annapolis Junction, MD D

25 Submitting Documentation to the CERT Contractor Instructions for Submitting Requested Medical Records/Documentation The preferred method for receipt of medical records/documentation is via FAX to: (240)

26 C 26

27 C 27

28 Medical Record/Claim Attachment Pull-List 28 C

29 CERT Record Request Bar-code Sheet 29 C

30 CERT Documentation Requests Documentation Request facts: Letters now viewable at: CERT makes additional requests for support of an order or medical necessity of a service. CERT may request additional documentation via phone or letter Ultimately no response results as documentation error We would like our no response rate to be zero

31 Program Integrity Manual 5.7 Documentation in the Patient s Medical Record For any DMEPOS item to be covered by Medicare, the patient s medical record must contain sufficient documentation of the patient s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient s diagnosis and other pertinent information including, but not limited to, duration of the patient s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. If an item requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient s record. However, neither a physician s order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient s medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable).

32 CERT Documentation Keys Submitted diagnosis may be insufficient Even if diagnosis is a covered diagnosis in LCD/NCD Order Forms or Prescription Orders are insufficient Medical record must support medical necessity Medical Record must support ALL requirements of NCDs or LCDs Our LCDs can be found at:

33 Excerpt from November 2009 Medicare FFS Improper Payment Rpt

34 Excerpt from November 2009 Medicare FFS Improper Payment Rpt

35 Excerpt from November 2009 Medicare FFS Improper Payment Rpt - Corrective Actions CMS is revising Medicare FFS manuals to clarify requirements for reviewing documentation to promote uniform interpretation of our policies across all medical reviews performed by Medicare contractors. CMS is revising Medicare FFS manuals to address the errors related to signature requirements. CMS is currently devising a process whereby providers can attest to their signature if it is illegible or missing in a medical record under review. CMS also plans to conduct provider education related to signature requirements. CMS is developing comparative billing reports to help Medicare contractors and providers analyze administrative claims data.

36 Excerpt from November 2009 Medicare FFS Improper Payment Rpt - Corrective Actions (cont.)

37 Medicare FFS Improper Payments

38 November 2009 Report Improper Payments

39 Medicare FFS Improper Payments

40 Medicare FFS Improper Payments

41 MAC Medical Review CERT versus Traditional PI Balancing Priorities 41

42 Major Issues Affecting all Claim Types Medical records versus attestations Physician order must be present Physician authentication Billed service covered by a NCD or LCD must meet all aspects of coverage Linking a billed service to a covered ICD-9 code does not guarantee payment on post payment review Medical records from the ordering physicians are critical to support medical necessity for all DME items.

43 DME MAC CERT Education Task Force Task Force representatives (in speaker order): Max Garner, POE, CIGNA, DME MAC C Jody Whitten, POE, Noridian, DME MAC D Denise Winsock, POE, NHIC, Corp, DME MAC A Charity Bright, POE, NGS, DME MAC B Amy Capece, PCSP Manager, NHIC, Corp. DME MAC A

44 DME MAC CERT Education Task Force Max Garner Provider Outreach and Education CIGNA Government Services Jurisdiction C

45 Purpose The DME MAC CERT Education Task Force is a collaboration of all four DME MAC contractors. Our primary purpose is to centralize education specific to the CERT program and to present a single educational voice and message to suppliers throughout the United States. Our goal is to improve knowledge and performance related to the Comprehensive Error Rate Testing program on a national level.

46 Purpose Collaboration of all DME MAC contractors First multi-contractor educational effort on CERT Introduced to all Medicare contractors in October, 2009 at MedTrade Atlanta Conducted national Ask-the-Contractor conference call in January, 2010

47 DME MAC Most Frequent Errors Oxygen Diabetic Supplies Power Mobility Devices/Wheelchairs Nebulizers & Drugs Enteral Nutrition Positive Airway Pressure (PAP) Devices & Supplies

48 Oxygen Oxygen No physician medical records submitted for review No physician documentation to support Long-term/continued use of oxygen for current service date Beneficiary is using, needing, or benefiting from oxygen usage Evaluation of the patient occurred prior to the initial prescription or recertification Saturation test level is not supported by physician medical records Physician order errors Either not received, were invalid, or no legible physician identifier 48

49 Oxygen Oxygen Intake Required Documentation: Verbal Order, if applicable Written Order Proof of delivery Certificate of Medical Necessity (CMN) Initial Revised Recertification Recommended Documentation: Copy of qualifying arterial blood gas or pulse oximetry report Medical records supporting Medicare coverage criteria is met 49

50 Diabetic Supplies/PMDs & Wheelchairs Jody Whitten Education Representative Noridian Administrative Services Jurisdiction D 50

51 Diabetic Supplies Physician order is incomplete or missing No beneficiary test log or other justification for test frequency No medical documentation to support reason the patient is testing above policy limits No physician medical records to support the diagnosis No documentation to show testing is as prescribed or beneficiary is not testing as prescribed (i.e. conflicting documentation) No legible physician identifier 51

52 PMDs/Wheelchairs No physician documentation of mobility limitations to support medical need for the equipment No physician documentation justifying the power option is needed over a manual wheelchair No physician face-to-face visit documented Patient is ambulatory and does not qualify for wheelchair/pmd 52

53 Nebulizers & Drugs/Enteral Nutrition/PAP & Supplies Denise Winsock Provider Outreach and Education NHIC, Corp. Jurisdiction A 53

54 Nebulizers & Drugs No documentation to show beneficiary uses the nebulizer (is compliant with the physician orders) Missing or insufficient clinical documentation from treating physician to support: Management of airway issues, Covered diagnosis, Initial medical necessity and continued medical need, and Types of medications, and/or frequency No valid physician order Order signed after the claim submission

55 Enteral Nutrition No clinical records from ordering/treating physician were submitted for review to support: Medical need for enteral nutrition Continued need based on current date of service No DME Information Form (DIF) submitted for review (Note: DIF is required for enteral supplies) No physician order for the pump and/or supply kits

56 Positive Airway Pressure (PAP & Supplies No evidence that beneficiary is compliant with physician order No sleep study documentation No clinical documentation of continued medical need or use No clinical records of medical management of the patient No physician order or invalid order (such as not signed)

57 CERT Appeals Charity Bright Provider Outreach and Education NGS Jurisdiction B

58 CERT Appeals Suppliers are entitled to an appeal of a CERT determination Regular Medicare appeals guidelines apply Appeals Documentation Resources Local Coverage Determinations (LCD) National Coverage Determinations (NCD) CMS Internet Only Manuals (IOM) DME MAC Supplier Manuals 58

59 CERT Appeals Appeal Level Time Limit for Filing Where to file an Appeal Monetary Threshold to be met Redeterminations 120 days from the receipt of the notice of initial claim determination DME MAC with Jurisdiction None Reconsideration 180 days from date of receipt of the redetermination notice RiverTrust Solutions 1 Cameron Hill Circle, Suite 0011 Chattanooga, TN None Administrative Law Judge (ALJ) 60 days from the receipt of the reconsideration notice HHS Office of Medicare Hearings and Appeals (OMHA) field office On or after January 1, 2009, at least $120 remains in controversy On or after January 1, 2010, at least $130 remains in controversy Departmental Appeals Board (DAB) Review 60 days from the receipt of the ALJ hearing decision/dismissal DAB or ALJ hearing office None Federal Court review 60 days from the date of receipt of DAB decision or declination of review by DAB United States District Court On or after January 1, 2009, at least $1,220 remains in controversy On or after January 1, 2010, at least $1,260 remains in controversy 59

60 Recommendations/Resources Amy Capece Provider Customer Service Program Manager NHIC, Corp. Jurisdiction A 60

61 Recommendations For positive CERT results, Take Action! Obtain all related medical records up front Suggested Intake Form Ensure the records are complete, legible, are signed, and contain both sides of each page Always respond to the 1 st CERT request letter Ensure all medical records are accessible for a minimum of 7 years Update your contact information at: For assistance in updating your contact information, call the CERT Documentation Contractor at: (301) (or) toll free When you call the CERT Documentation Contractor to confirm an information update/change, please be ready to provide your DME MAC Jurisdiction Contractor number 61

62 Resources Jurisdiction A: NHIC, Corp. CERT Coordinator: Alina Jimenez at or Jurisdiction B: NGS CERT Coordinator: Dawn Hermes at or 62

63 Resources Jurisdiction C: CIGNA Government Services CERT Coordinator: Brenda Normandia at , Jurisdiction D: Noridian Administrative Services CERT Coordinator: Lynda Hanson at *Important Note: CERT Coordinators can only assist with information about sampled claims by the CERT Contractor and submission of documentation to the CERT Contractor process. 63

64 References CERT Contractor Customer Service: or PDAC: (Disaster Attestation) Website references: Internet Only Manual (IOM) 100-8, Ch. 4 section 26.1 Program Integrity Manual (PIM) 100-8, Ch. 5 section 5.7 CMS CERT: Reports: 64

65 Questions 65