October 10, th Annual Ambulatory Surgery Center Conference Improving Profitability and Business / Legal Issues

Transcription

1 October 10, th Annual Ambulatory Surgery Center Conference Improving Profitability and Business / Legal Issues

2 How It All Started. What Should I Do Next? 2

3 Defense Plan Audit Management Recoupment Appeals 3

4 Establish Internal Accountability RAC Coordinator Clinical / Medical Director Involvement Point of Contact Form 4

5 5

6 Know What is HOT! Develop a watch list of particular errorprone areas Demonstration Project Website CMS website Q & A Section RAC@cms.hhs.gov Your RAC s Vulnerabilities 6

7 7

8 8

9 Region A: Diversified Collection Services, Inc Ebony Brandon Ebony.Brandon@cms.hhs.gov 9

10 Region B: CGI RACB (7222) Scott Wakefield Scott.Wakefield@cms.hhs.gov General address: racb@cgi.com 10

11 Region C: Connolly Consulting, Inc Amy Reese Amy.Reese@cms.hhs.gov RACinfo@connollyhealthcare.com 11

12 Region D: HealthDataInsights, Inc. Kathleen Wallace Part A: Part B and Suppliers: E mail address: racinfo@ hdi.com 12

13 Self Audits Types of Audits: Voluntary Refunds Pre Emptive Extrapolation 13

14 Voluntary Refunds Protection against fraud claims asset in proof of self audits Non protection against RAC claims Can be done pre or post RAC audit Generates less income for RAC s Offers practice / facility no RAC protection 14

15 Pre Emptive Extrapolation Protective Nature On going to be effective Specific in nature 15

16 Source: Connelly Healthcare 16

17 Objective Scope Methodology Findings Cause Corrections 17

18 Name and identification number of the provider or supplier; Name and title of reviewer; The Health Insurance Claim Number (HICN), the unique claim identifier (e.g., the claim control number), and the line item identifier; Identification of each sampling unit and it components (e.g. UB 92 or attached medical information) The amount of the original submitted charges (in column format) The amount paid; The amount that should have been paid (either over or underpaid); and The date(s) of service 18

19 Deadlines, Deadlines, Deadlines Automated Audits (Demand Letter only) 15 days Complex Audits (Record Request) 45 days to submit record 19

20 RAC Process NO Automated Review RAC makes a claim determination RAC decides whether medical records are required to make determinations YES Complex Review RAC requests medical records Provider has 45 days plus 10 calendar days mail time to submit. RAC has up to 60 days to review medical records RAC makes a claim determination RAC issues Review Results Letter to provider (does NOT communicate improper amount or appeal rights including no findings ) If no findings STOP 20 20

21 Automated Review Discussion Period RAC sends claim info to Carrier/FI/MAC Carrier/FI/MAC adjusts & issues Remittance Advice (RA) to provider. Code N432 Day 1 RAC issues Demand Letter which includes amount and appeal rights. On Day 41, Carrier/FI/MAC recoups by offset. Complex Review Discussion Period 21 21

22 1. Stamp date and time received 2. Review all records before they are released 3. Stamp number (Bates Stamp) on bottom of each page to be sent 4. Scan final packet prior to sending 5. Include cover letter that itemizes the contents 6. Send Certified Mail 22

23 Audit ID Number Patient Information Type of Audit Status of case Reason for Audit (Issue specific) Reimbursement information Date of Record Request Date Received RAC response Status of each level of appeal Next Deadline 23

24 Provider Medical Record (MR) Submission Requirements (Paper/CD/DVD) DUE DATE: 45 days from the date of the medical record request letter Paper Medical Records Include the original or copy of the medical record request letter from the RAC. If possible, highlight claims on the letter identifying the medical records attached. CD/DVD Medical Record Submission Requirements: Attention Prior to an ongoing submission of medical records via a CD/DVD, a provider will have to perform a successful test of transferring medical records with Connolly Healthcare. A successful test will be contingent on the below specifications being met: MRs Format Scanned image resolution must be 300 dpi and in black and white Image format must be in either.tiff or.pdf format One image per medical record, i.e., multiple-page image file. For example, a two hundred page medical record will be one file. The image file name must be the requested claim number. For example if the claim number is requested, the filename would be pdf or tif Copy of our medical record request letter continued. Source: Connelly Healthcare 24

25 The following metadata (excel file or tab delimited text file) must be included with the image submission Requested Claim Number Begin Date of Service End Date of Service Patient name (first and last name) Patient DOB Patient HIC Number Patent Account/Control Number Medical record number Provider Name (full name) Provider Number Provider NPI Number of pages or the file size of the image submitted for acknowledgement purposes Total number of medical records on the CD/DVD There should be one entry per image in the metadata file continued. Source: Connelly Healthcare 25

26 MRs Submission Images are to be sent via CD or DVD in a tamper-proof package CD or DVD should follow the following naming convention for easy communication, tracking, and reconciling purposes: <Provider ID>_<sent date in MM-DD-YYYY format>_<number of images> For security purposes it is strongly suggested that all images sent should be encrypted and password protected. If medical images are encrypted through Winzip, a separate to the MR address located at should be sent to Connolly with the password needed to unzip the files referencing: <Provider ID>_<sent date in MM-DD-YYYY format>_<number of images> If medical images are encrypted using PGP, public and private keys to decrypted image files must be established prior to shipment Source: Connelly Healthcare 26

27 Timing current or future payment CODE N432 Alternate Plan Installments Settlements 27

28 Recoupment stopped if valid and timely request for redetermination received within 30 days from date of demand letter. If valid and timely request for redetermination received more than 30 days from date of demand letter, recoupment will be stopped from that point, but any previously recouped funds may not be refunded. 28

29 Benefits vs. Cost Availability of Resources Quality of Medical Records 29

30 1. Did RAC follow the rules? * Records, letters 2. Challenge statistical analysis. 3. Were audit deadlines honored by RAC? 30

31 Rebuttal Five Levels of Appeal First Level Redetermination Second Level Reconsideration Third Level Administrative Law Judge Fourth Level Medicare Appeals Council / Departmental Appeals Board Fifth Level United States District Court 31

32 Request for the RAC to re evaluate their initial determination Must be filed within 15 calendar days of the date on the Demand Letter Does not stop the recoupment process Does not stay the timeframe for filing an appeal 32

33 Organization of staff Education of staff Multi disciplinary approach 33

34 Cathy Montgomery President Phone: office Cell:

35 Demand Letter Date RAC Point of Contact Provider Name Address 1 Address 2 City, State Zip Re: Provider Name # Letter ID: XXXXXX Issue: (Issue Name) Dear Medicare Provider, The Centers for Medicare & Medicaid Services (CMS) has retained (name of RAC) to carry out the Recovery Audit Contracting (RAC) program in the State of. The RAC program is mandated by Congress aimed at identifying Medicare improper payments. This letter is to notify you that Medicare has made an overpayment to you for the amount of $. A brief description of the claims associated with this overpayment can be found on the "Overpayment Report" page. In order to correct this overpayment, please refund $ by xx/xx/xxxx. This overpayment was identified through data analysis. Data analysis showed an aberrant billing pattern inconsistent with (insert LCD or policy in violation). (The policy in violation) states. Data analysis showed that the claims paid by Medicare. (The above lines are the rationale for the improper payment and the detailed explanation.) The results of our data analysis justified reopening your claim under 1869(b) (1) (G) of the Social Security Act and 42 CFR (a) (1). These results also serve as good cause to reopen the claim, if required by 42 CFR (b) (2). Please make the check payable to Medicare and send it with a copy of this letter to the following address: Accounting Dept P.O. Box 9999 City, State Zip If your local claims processing contractor offers an immediate offset option contact (name of contractor). 1

36 NOTE: If the overpayment is for services that are not medically reasonable and necessary per Medicare standards, and you collected the amount of the overpayment from the beneficiary, the beneficiary has the right to request payment from Medicare. Any such indemnification will be recovered from you. Key Timeframes As you review the overpayment, below is some important information and key timeframes (15, 30, 40 and 120 days) to consider: 15 Days: 30 Days: Rebuttal Process: Under our existing regulations 42 CFR , providers, physicians and suppliers have 15 days from the date of this demand letter to submit a rebuttal statement. The rebuttal process provides the debtor the opportunity to submit a statement and accompanying evidence indicating why recoupment should not be initiated. The outcome of the rebuttal process could change how or if CMS will recoup. If you have reason to believe the withhold should not occur on x/x/xxxx you must notify the claim processing contractor before. CMS will review your documentation. The claim processing contractor will advise you of its decision in writing within 15 days of your request. However, the rebuttal statement is not an appeal of the overpayment determination, and it will not delay/cease recoupment activities. 40 Days Repayment Plans: Please contact us immediately if you are unable to refund the entire amount at this time so that we may determine if you are eligible for a repayment plan. Any CMS approved repayment plan would run from the date of this letter. Recoupment by offset (which starts on day 41) can be averted by submitting a check with your repayment plan application. Interest Assessment Begins on the 31 st Day: Under Medicare law, 42 CFR , a refund is required within 30 days from the date of this letter or interest will be assessed. Interest began to accrue as of the date of this demand letter and will continue to accrue at a rate of %. Beginning on the 31 st day interest will be assessed for each full 30-day period payment is not made on time. If the entire amount is refunded before day 30 no interest will be assessed on the overpayment. Example: An overpayment is identified for $ and a demand letter is sent on 03/01/09. The physician does not remit payment on the overpayment until 04/15/09 (45 days after the date of the initial demand letter). Therefore, on 04/01/09 interest accrues on the $ for one full 30-day period. Information for those in Bankruptcy: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare financial obligations will be resolved in accordance with the applicable bankruptcy process. Please contact us immediately to notify us about the bankruptcy so that we may coordinate with CMS and the Department of Justice to assure your situation is handled appropriately. Please supply the name and district under which the bankruptcy is filed if possible. 2

37 Recoupments: After 40 days Medicare will begin withholding. NOTE: The withholding of Medicare payments will apply to current and future claims until the full overpayment amount and any applicable interest has been recouped or an acceptable extended repayment request is received. How to Stop Recoupment: Even if the overpayment and any assessed interest have not been paid in full you can stop Medicare from recouping any payments if you act quickly and decidedly. Medicare will permit providers, physicians and suppliers to stop recoupment at several points. The first occurs if Medicare receives a valid and timely request for a redetermination within 30 days from the date of this letter. If the appeal is filed later than 30 days, we will also stop recoupment at whatever point that an appeal is received but Medicare may not refund any recoupment already taken. Medicare will again stop recoupment if, following an unfavorable or partially favorable redetermination decision, you decide to act quickly and file a valid request for reconsideration with the Qualified Independent Contractor (QIC). The address and details on how to file a request for reconsideration will be included in the redetermination decision letter. What are the timeframes to stop recoupment: First Opportunity: To avoid the recoupment, the appeal request must be filed within 30 days of this letter. We request that you clearly indicate on your appeal request that this is an overpayment appeal and you are requesting a redetermination. Send your appeal request to: Contractor Name Address City, State and Postal ZIP Code Second Opportunity: If the redetermination decision is 1) unfavorable Medicare can begin to recoup no earlier than the 61st day from the date of the Medicare redetermination notice (Medicare Appeal Decision Letter), or, 2) if the decision is partially favorable, we can begin to recoup no earlier than the 61st day from the date of the Medicare revised overpayment Notice/Revised Demand Letter or, 3) if the appeal request was received and validated after the 60th day Medicare will stop recoupment. The address and details on how to file a request for reconsideration will be included in the redetermination decision letter. What Happens following a reconsideration by a Qualified Independent Contractor. Following decision or dismissal by the QIC, if the debt has not been paid in full, Medicare will begin or resume recoupment whether or not you appeal to any further level. NOTE: Even when recoupment is stopped, interest continues to accrue. 120 Days 3

38 Appeals Must be Filed WITHIN 120 Days: If you disagree with the overpayment decision, you may file an appeal. You have the option to appeal all of the claims from the overpayment letter or only part of the claims in the overpayment letter. An appeal is a review performed by people independent of those who have reviewed your claim so far. There are multiple levels of appeals. The first level of appeal is called a "redetermination." A redetermination must be filed within 120 days of the date you receive this letter (presume five days following date of this letter). However, if you wish to avoid recoupment from occurring and assessment of interest of this overpayment you need to file your request for redetermination within 30 days from the date of this letter as described above. Filing An Appeal: A request for a redetermination along with a copy of this letter should be mailed to: Appeal Dept P.O. Box 9999 City, State Zip NOTE: Interest continues to accrue throughout the appeals process. Thank you for your cooperation and prompt attention to this overpayment. If you have any questions regarding this letter or would like to discuss the overpayment identification, please direct your inquiry to the below associate at (phone number). Sincerely, Auditor Name Ext: xxxx Enclosure 4

39 Overpayment Report Accounts Receivable Number: Accounts Receivable Date: 6/23/2009 Date of Service From Date of Service To RAC Updated Allowed Amount Improper Payment Amount Beneficiary Name/ HIC Claim Number *HCPCS Code* Medicare Allowed Smith, John A 1/6/2008 1/8/ $1, $ $ Doe, Jane A 4/7/2008 4/7/ $ $ $ Rodriquez, Jesus A 6/6/2008 6/6/ $ $0.00 $ * We would use whatever code field is involved. For example, for inpatient DRG claims the field would be DRG Code instead of HCPCS* 5