RAC Audit Strategic Road Map for Leaders

1,006 views

Published on

Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of the medical review is to determine whether the services provided are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. This presentation discusses recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The presentation highlights specific denial trends associated with claims following hospitalization for a psychiatric diagnosis. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.

1. Learn to summarize goals of Medicare Medical Review.

2. Learn identify and articulate examples of the Medicare Medical Review Process.

3. Learn to identify strategies for interdisciplinary management of Medicare documentation requests and appeals.

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,006
On SlideShare
0
From Embeds
0
Number of Embeds
26
Actions
Shares
0
Downloads
17
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

RAC Audit Strategic Road Map for Leaders

  1. 1. RAC Audit Strategic Road Map for Leaders: Successfully Prevent & Appeal Denied Claims HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Elisa Bovee MS OTR/L Vice President of Operations
  2. 2. HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Elisa Bovee, MS OTR/L Vice President of Operations Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 2 RAC Audit Strategic Road Map for Leaders: Successfully Prevent & Appeal Denied Claims Hello everyone! To have the Audio experience, please Dial the number: +1 (213) 493-0004 Access code: 578-279-270 If you have any difficulties connecting, please call Elena at 1-978-899-8919 x 13
  3. 3. Agenda Defense! Audit Triggers and Tools Contractor Findings/Themes Potential Audit Triggers Medical Record Review Preparedness Audit Tools Appeal Process; Medicare Denied Claims ADR Management PREP Letter Team Process Appeal Strategies For Success Levels of Medicare Appeals A Successful ALJ Hearing Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. Objectives Learner will be able to summarize SNF Medicare qualifiers Learner will be able to discuss key elements of skilled rehabilitation documentation Learner will be able to articulate Audit Triggers Learner will be able to Summarize the ADR and appeal process Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 4
  5. 5. Documenting Medicare Skilled Coverage Requirements DEFENSE!! Copyright © 2014 All Rights Reserved 5Harmony Healthcare International, Inc.
  6. 6. Advice from Ben Franklin Copyright © 2014 All Rights Reserved “Either write something worth reading or do something worth writing.” “An ounce of prevention is worth a pound of cure.” 6Harmony Healthcare International, Inc.
  7. 7. Prevention The key to preventing denials is documentation of skilled services provided The key to documenting skilled services provided is understanding the Medicare requirements for coverage Copyright © 2014 All Rights Reserved 7Harmony Healthcare International, Inc.
  8. 8. The Importance of Documentation The key to ensuring accurate reimbursement for services provided is understanding skilled coverage requirements Copyright © 2014 All Rights Reserved 8Harmony Healthcare International, Inc.
  9. 9. Technical Requirements Technical requirements are not eligible for appeal—if the patient does not meet technical requirements, their stay will not be covered Responsibility of the facility to determine if technical eligibility requirements are met The facility should have a process for determining technical eligibility prior to or immediately upon admission Copyright © 2014 All Rights Reserved 9Harmony Healthcare International, Inc.
  10. 10. Technical Requirements Beneficiary is enrolled in Medicare Part A and has available days Beneficiary had a three-day qualifying hospital stay Skilled care must begin within 30 days after discharge from a hospital or the last covered Medicare day of a SNF stay Copyright © 2014 All Rights Reserved 10Harmony Healthcare International, Inc.
  11. 11. Technical Requirements Three-day qualifying stay does not include: Nights spent in observation status or in an ER bed Can be in different hospitals, but nights must be consecutive The day of admission, but not the day of discharge, is counted in the three days Copyright © 2014 All Rights Reserved 11Harmony Healthcare International, Inc.
  12. 12. 60 Day Wellness Maintain 60 calendar days without inpatient hospital admissions (ER visits are allowable) and without receiving any skilled services (as defined by Medicare). The litmus test for this break in the spell of illness is to determine whether the services being provided to the resident meet the criteria for a Medicare skilled level of care, if Medicare benefit days were available. Copyright © 2014 All Rights Reserved 12Harmony Healthcare International, Inc.
  13. 13. Exhausted Benefit Patients who have exhausted their Medicare benefits must be reviewed clinically to determine if they continue to meet the guidelines for a Medicare skilled level of care Business Office sends a bill to CMS communicating they have dropped in their level of care Not automatic Not based on Diagnosis Copyright © 2014 All Rights Reserved 13Harmony Healthcare International, Inc.
  14. 14. Physician Certification Physician Certification Frequency Admission 14th Day Every 30 Days (from last certification) Addresses all skilled qualifiers Rehab Nursing Copyright © 2014 All Rights Reserved 14Harmony Healthcare International, Inc.
  15. 15. Additional Certifications to Support Therapy Certification Plan of Treatment/Care Frequency of Services Plan Goals Physician Involvement Therapy Physician Orders Evaluation Treatment clarification Copyright © 2014 All Rights Reserved 15Harmony Healthcare International, Inc.
  16. 16. Clinical (Level of Care) Requirements The patient requires physician-ordered skilled nursing or rehabilitation services that relate to the hospital stay or a condition that arose while receiving post- hospital care The services are provided on a daily basis As a practical matter, the services must be delivered in the SNF The services are reasonable and necessary for treatment of the illness/injury Copyright © 2014 All Rights Reserved 16Harmony Healthcare International, Inc.
  17. 17. Medicare Manual Source Document Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance (Rev. 175, 12-06-13) Effective 1/7/14 Copyright © 2014 All Rights Reserved 17Harmony Healthcare International, Inc.
  18. 18. Medicare Coverage/Skilled Care Provided on a “daily” basis: Skilled nursing (or combination of nursing and rehabilitation) must be seven days per week Skilled restorative nursing must be at least six days per week Rehabilitation (PT, OT and/or SLP) must be at least five days per week An isolated break of “a day or two” is allowable Copyright © 2014 All Rights Reserved 18Harmony Healthcare International, Inc.
  19. 19. Chapter 8 Medicare Manual (2014) Rehabilitation Daily Single type of skilled rehabilitation every day, or by furnishing various types of skilled services on different days that collectively add up to “daily” skilled services. “Arbitrarily staggering the timing of various therapy modalities though the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a “daily basis.” To meet this requirement, the patient must actually need skilled rehabilitation services to be furnished on each of the days that the facility makes such services available “ Copyright © 2014 All Rights Reserved 19Harmony Healthcare International, Inc.
  20. 20. What is Skilled Care? Nature of service requires the skills of a licensed person (e.g. technical or professional personnel) Skilled services are provided directly by or under general supervision of a licensed nurse or therapist to assure the safety of the patient and to achieve the medically desired result Diagnosis and prognosis do not determine what is skilled care – it is the care of the patient that is the deciding factor Copyright © 2014 All Rights Reserved 20Harmony Healthcare International, Inc.
  21. 21. “Practical Matter” Criterion “As a practical matter, considering economy and efficiency, the daily skilled services can only be provided in a skilled nursing facility” Copyright © 2014 All Rights Reserved 21Harmony Healthcare International, Inc.
  22. 22. “Practical Matter” Criterion 1. Outpatient services are not available in the area where the individual lives 2.Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective than placement in the skilled nursing facility Copyright © 2014 All Rights Reserved 22Harmony Healthcare International, Inc.
  23. 23. “Practical Matter” Criterion 3. The availability at home of a capable and willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/patient to reside there safely 4. If the use of alternative services would adversely affect the patient/patient’s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis Copyright © 2014 All Rights Reserved 23Harmony Healthcare International, Inc.
  24. 24. Basic Medicare Requirements If any one of these three factors is not supported by the documentation in the patient’s record, the SNF stay, even though it might include the delivery of daily skilled services, will not be covered. Copyright © 2014 All Rights Reserved 24Harmony Healthcare International, Inc.
  25. 25. RUG-IV Resource Utilization Groups Each MDS qualifies for multiple RUGs, and the software automatically chooses the highest reimbursement rate Rehabilitation Intensity, Diagnoses, Nursing Services, and ADLs all contribute Documentation must support all coding on the MDS 3.0 assessment Copyright © 2014 All Rights Reserved 25Harmony Healthcare International, Inc.
  26. 26. Presumption of Coverage Medicare beneficiaries who are correctly assigned to one of the upper 52 RUG-IV groups on the initial 5-Day, Medicare required assessment are automatically classified as meeting the SNF level of care definition up to and including the assessment reference date on the 5-day Medicare- required assessment Only applies when admitted from Acute Care Hospital (Not Swingbed or another SNF) Copyright © 2014 All Rights Reserved 26Harmony Healthcare International, Inc.
  27. 27. Presumption of Coverage This presumption recognizes the strong likelihood that beneficiaries assigned to one of the upper 52 RUG-IV groups during the immediate post-hospital period require a covered level of care, which would be less likely for those beneficiaries assigned to one of the lower 14 RUG-IV groups Copyright © 2014 All Rights Reserved 27Harmony Healthcare International, Inc.
  28. 28. Presumption of Coverage This administrative presumption policy does not supersede the SNF’s responsibility to ensure that its decisions relating to level of care are appropriate and timely, including a review to confirm that the services prompting the beneficiary’s assignment to one of the upper 52 RUG-IV groups Copyright © 2014 All Rights Reserved 28Harmony Healthcare International, Inc.
  29. 29. Totality While it is true that dialysis is one of the discrete indicators for assignment to a RUG within the Special Care Low category – a category to which the level of care presumption applies for a short period of time at the start of a SNF stay – it is the totality of items and services included within a given RUG, not any one specific coded service, that actually serves to justify the presumption Copyright © 2014 All Rights Reserved 29Harmony Healthcare International, Inc.
  30. 30. What is Skilled Care ? Direct Skilled Nursing Services Management and Evaluation of a Care Plan Observation and Assessment Teaching and Training Skilled Rehabilitation Copyright © 2014 All Rights Reserved 30Harmony Healthcare International, Inc.
  31. 31. What is Skilled Care? Nursing Anchors the Skill Need to remain in a SNF Medical Complexity Supports Non-Therapy RUG Increased potential Lower 14 and reviews with October 1st Changes Copyright © 2014 All Rights Reserved 31Harmony Healthcare International, Inc.
  32. 32. Skilled Services Categories: Nursing Inherent Complexity Inherent Complexity – Direct skilled nursing services including: IV feeding IV meds Suctioning Tracheostomy Care Ventilator support Ulcers Copyright © 2014 All Rights Reserved 32Harmony Healthcare International, Inc.
  33. 33. Skilled Services Categories: Nursing Inherent Complexity Inherent Complexity Tube feedings Respiratory Therapy 7 days per week Surgical wound or open lesions with treatments Unstable clinically with diabetes with injections Transfusions Chemotherapy Colostomy Care, early post op care Copyright © 2014 All Rights Reserved 33Harmony Healthcare International, Inc.
  34. 34. Observation and Assessment Skilled services when the likelihood of change in a patient’s condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures, until the patient’s condition is essentially stabilized. Reasonable potential for a future complication or acute episode sufficient to justify the need for continued skilled observation and assessment. Copyright © 2014 All Rights Reserved 34Harmony Healthcare International, Inc.
  35. 35. Observation and Assessment Example (from Chapter 8 of the Medicare Benefit Policy Manual): A patient has been hospitalized following a heart attack, and following treatment but before mobilization, is transferred to the SNF Copyright © 2014 All Rights Reserved 35Harmony Healthcare International, Inc.
  36. 36. Observation and Assessment Example (continued): Because it is unknown whether exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated, until the patient’s treatment regimen is essentially stabilized Copyright © 2014 All Rights Reserved 36Harmony Healthcare International, Inc.
  37. 37. Observation and Assessment The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the stabilization of the patient's medical condition and safety (Effective 1/2014). Copyright © 2014 All Rights Reserved 37Harmony Healthcare International, Inc.
  38. 38. Observation and Assessment KEY POINT: If a patient was admitted for skilled observation but did not develop a further acute episode or other complications, the skilled observation services still are covered so long as there was a reasonable probability for such a complication or further acute episode Copyright © 2014 All Rights Reserved 38Harmony Healthcare International, Inc.
  39. 39. Observation and Assessment Fever Dehydration Septicemia Pneumonia Nutritional Risk Chemotherapy Weight loss Blood sugar control Impaired cognition Severe Mood and Behavior conditions Copyright © 2014 All Rights Reserved 39Harmony Healthcare International, Inc.
  40. 40. Observation and Assessment Neurological Respiratory Cardiac Circulatory Pain/Sensation Nutritional Gastrointestinal Genitourinary Musculoskeletal Skin Copyright © 2014 All Rights Reserved 40Harmony Healthcare International, Inc.
  41. 41. Skilled Services Categories: Management and Evaluation of a Care Plan Based on the Physician’s orders, these services require the involvement of skilled nursing to meet the resident’s Medical needs Promote recovery Ensure medical safety Copyright © 2014 All Rights Reserved 41Harmony Healthcare International, Inc.
  42. 42. Skilled Services Categories: Teaching and Training Teaching and Training: Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen Copyright © 2014 All Rights Reserved 42Harmony Healthcare International, Inc.
  43. 43. Copyright © 2014 All Rights Reserved Skilled Rehabilitation Overview Directly related to a written plan of treatment. Requires knowledge/skills/judgment of qualified professional. Services must be considered under acceptable standards of clinical practice. Expectation of improvement of restorative potential in a reasonable and predictable amount of time…or… Establishment of a safe and effective maintenance program. 43Harmony Healthcare International, Inc.
  44. 44. Copyright © 2014 All Rights Reserved Medicare Benefit Policy The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist. 44Harmony Healthcare International, Inc.
  45. 45. Harmony Healthcare International, Inc. 45 Maintenance Therapy Maintenance Therapy. The repetitive services required to maintain function sometimes involve the use of complex and sophisticated therapy procedures and consequently, the judgment and skill of a physical therapist might be required for the safe and effective rendition of such services (see §214.1.B). Must be necessary for the establishment of a safe and effective maintenance program; or, the services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program (Effective 1/2014). Copyright © 2014 All Rights Reserved 45Harmony Healthcare International, Inc.
  46. 46. Maintenance Therapy Therapy services in connection with a maintenance program are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) If all other requirements for coverage under the SNF benefit are met, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of a safe and effective maintenance program. Copyright © 2014 All Rights Reserved 46Harmony Healthcare International, Inc.
  47. 47. Jimmo v. Sebelius The Jimmo v. Sebelius lawsuit was brought on behalf of a nationwide class of Medicare beneficiaries by six individual Medicare beneficiaries and seven national organizations representing people with chronic conditions The Jimmo v. Sebelius case challenged Medicare's use of an "Improvement Standard" to make coverage determinations Copyright © 2014 All Rights Reserved 47Harmony Healthcare International, Inc.
  48. 48. Jimmo v. Sebelius On January 24, 2013, a settlement was approved by the federal district court in Vermont in the case of Jimmo v. Sebelius regarding the "Improvement Standard" Addresses the ability to terminate or deny coverage to beneficiaries who are not improving for Medicare Part A and Part B Copyright © 2014 All Rights Reserved 48Harmony Healthcare International, Inc.
  49. 49. Jimmo v. Sebelius Expands Medicare Part A and Part B coverage to include the rendering of skilled nursing and therapy services necessary to maintain a person's condition and is not dependent on whether the Medicare beneficiary will ". improve“. CMS Fact Sheet States this is simply a clarification Copyright © 2014 All Rights Reserved 49Harmony Healthcare International, Inc.
  50. 50. Jimmo v. Sebelius The judgment indicates that as long as a patient requires skills of a therapist or a nurse a patient would meet skilled coverage criteria despite not making functional gains Documentation must support the need for skilled therapy intervention Copyright © 2014 All Rights Reserved 50Harmony Healthcare International, Inc.
  51. 51. Skills of a Therapist or a Nurse Must require, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist or a nurse that qualified personnel, trained caretakers or the patient cannot provide independently Copyright © 2014 All Rights Reserved 51Harmony Healthcare International, Inc.
  52. 52. Skilled Nursing Documentation What To Consider Including Patient is at high risk for … Skilled assessment of … Daily skilled monitoring of … Potential for recurrence of … Potential for the following complications… There is a likelihood of change related to… The medical regimen is not essentially stabilized as evidenced by… Copyright © 2014 All Rights Reserved 52Harmony Healthcare International, Inc.
  53. 53. Skilled Nursing Documentation What To Consider Including Patient continues to require daily skilled rehab for … Observation and assessment for potential complications related to … Potential for medical complications related to the diagnosis of … Plan of care is being monitored to promote recovery and ensure medical safety related to … The patient requires daily skilled management and evaluation of the plan of care related to … Copyright © 2014 All Rights Reserved 53Harmony Healthcare International, Inc.
  54. 54. Skilled Nursing Documentation What To Consider Including Skilled neurological assessment resulted in… Daily skilled monitoring for signs and symptoms of exacerbation of _____ secondary to _______ Patient is high risk for ______ secondary to _______ Medications adjusted to _____________, ongoing skilled assessment of regimen to promote recovery and ensure medical safety Patient continues to require daily skilled nursing as his treatment regimen is not essentially stabilized and there is a potential for recurrence of ________ Copyright © 2014 All Rights Reserved 54Harmony Healthcare International, Inc.
  55. 55. Non-Supportive Nursing Documentation Plateau in progress Voiced no complaints Patient requires custodial care Patient requires intermittent care Patient is unable to follow directions Patient requires intermittent services Patient has poor rehabilitation potential Patients medical treatment is essentially stabilized Refuses to participate in therapy (instead give the reason the patient is unable) Condition stable Slept well/family into visit Copyright © 2014 All Rights Reserved 55Harmony Healthcare International, Inc.
  56. 56. UB-04 Pulling It All Together Harmony Healthcare International, Inc. 56Copyright © 2014 All Rights Reserved
  57. 57. UB-04 Diagnosis Does it all work together? Physician Certifications MDS Diagnoses (Section I) Skilled Nursing Documentation Therapy ICD-9 Coding Skilled Therapy Documentation UB-04 Copyright © 2014 All Rights Reserved 57Harmony Healthcare International, Inc.
  58. 58. UB-04 Submitted by the SNF to the MAC Multipurpose form used for all Medicare providers Not all fields pertain to the SNF Copyright © 2014 All Rights Reserved 58Harmony Healthcare International, Inc.
  59. 59. FL 66 – 69 FL 66 – 68 ICD-9 Codes Principle Diagnosis goes in FL 67, secondary codes to follow Sequentially ordered by importance (top 5) FL 69 = Admission Diagnosis ICD-9 Copyright © 2014 All Rights Reserved 59Harmony Healthcare International, Inc.
  60. 60. Code Order Codes should be ordered according to most skilled to least skilled need. The top 5 codes are the most vital to have ordered appropriately. ICD-9 coding is one way auditors select records to review. Copyright © 2014 All Rights Reserved 60Harmony Healthcare International, Inc.
  61. 61. Principle Diagnosis Governed by the condition chiefly responsible for the admission to the SNF and that is primarily responsible for the need for skilled services. This may or may not be the same as the Admission Diagnosis. Copyright © 2014 All Rights Reserved 61Harmony Healthcare International, Inc.
  62. 62. Principle Diagnosis It is not acceptable to use acute care conditions as the Principle Diagnosis. For example, the facility would not want to use CVA (435.9), they would use the Late effects of cerebrovascular disease codes that start with 438.xx. Copyright © 2014 All Rights Reserved 62Harmony Healthcare International, Inc.
  63. 63. Principle Diagnosis When the reason for skilled care is Rehabilitation Services, codes from the V57.xx category are appropriate. The condition therapy is treating should be listed as an additional diagnosis. Parkinson’s Disease (332.x) Lack of coordination (781.3) Abnormality of gait (781.2) Copyright © 2014 All Rights Reserved 63Harmony Healthcare International, Inc.
  64. 64. Rehabilitation Diagnosis Medical diagnosis supports deficits identified on evaluation being treated Reported on the UB-04. What is the process between therapy and billing? Ensure chronic codes that are not related are not used Dementia UTI Only a Therapist can Determine Not always the “first code” in Discharge Summary or Face sheet May need to request Physician Clarification (e.g. Dysphagia) Copyright © 2014 All Rights Reserved 64Harmony Healthcare International, Inc.
  65. 65. Rehabilitation Diagnosis Indicate the Medical DX that has resulted in the therapy disorder. Relate to the current plan of care for therapy. Represent the most intensive services (over 50% of the revenue code billed) Relevant to the problem to be treated E.g. O.A. with treatment diagnosis of “pain in the joint” or “difficulty walking” Copyright © 2014 All Rights Reserved 65Harmony Healthcare International, Inc.
  66. 66. Sometimes have to dig! Psychiatric hospitalizations can be difficult to code. Remember Principle and Admission don’t have to be the same diagnosis. Recent RAC audits for psych diagnosis reveal a number of additional diagnoses treated during hospitalizations: Pneumonia, Dysphagia, Pressure Ulcers, Cardiac Episodes, Hypotension, Dehydration, Malnutrition, UTI, MRSA, and Extrapyramidal Disease. Copyright © 2014 All Rights Reserved 66Harmony Healthcare International, Inc.
  67. 67. Key Point! The ICD-9 Coding needs to tell the story of the skilled services in the SNF. Needs to tell the story behind the RUG score and make sense with the RUG billed. DO include the necessary ICD-9 codes to support skill and DO NOT to include unrelated codes (e.g. Chronic Codes). Beware! A code for Personality Disorder with an RUC – High Risk to get reviewed! Copyright © 2014 All Rights Reserved 67Harmony Healthcare International, Inc.
  68. 68. Audit Triggers and Tools Harmony Healthcare International, Inc. 68Copyright © 2014 All Rights Reserved
  69. 69. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 69
  70. 70. Harmony Healthcare International OIG Investigation Harmony Healthcare International, Inc. 70Copyright © 2014 All Rights Reserved
  71. 71. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 71Harmony Healthcare International, Inc. 71 OIG Report: Part A OIG REPORT Questionable Billing by Skilled Nursing Facilities Medicare Part A
  72. 72. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 72Harmony Healthcare International, Inc. 72 Background An OIG report found that 26 percent of claims submitted by SNFs were not supported by the medical record, representing over $500 million in potential overpayments
  73. 73. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 73Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 73 Background This study based on an analysis of Medicare Part A claims from 2006 and 2008 and on data from the Online Survey, Certification and Reporting system
  74. 74. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 74Harmony Healthcare International, Inc. 74 Recommendations 1. Monitor overall payments to SNFs and adjust rates, if necessary Adjust RUG rates annually, if necessary, to ensure that the changes do not significantly increase overall payments
  75. 75. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 75Harmony Healthcare International, Inc. 75 Recommendations 2. Change the current method for determining how much therapy is needed to ensure appropriate payments CMS should consider requiring each SNF to use the beneficiary’s hospital diagnosis and other information from the hospital stay to better predict the beneficiary’s therapy needs In addition, CMS should consider requiring that therapists with no financial relationship to the SNF determine the amount of therapy needed throughout a beneficiary’s stay
  76. 76. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 76Harmony Healthcare International, Inc. 76 Recommendations 3. Strengthen monitoring of SNFs that are billing for higher paying RUGs CMS should instruct it’s contractors to monitor SNFs’ use of higher paying RUGs using the indicators discussed in this report. CMS should develop thresholds for the indicators and instruct its contractors to conduct additional reviews of SNFs that exceed them. If SNFs from a particular chain frequently exceed the thresholds, then additional reviews should be conducted of the other SNFs in that chain.
  77. 77. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 77Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 77 Agency Comments and Office of Inspector General Response CMS concurred with three of the four recommendations 1. Agree: CMS concurred and stated that it would assess the impact of the recent changes on overall SNF payments as data became available and would expect to recalibrate RUG rates in future years, as appropriate 2. Not Agree: CMS noted several concerns with relying on information from the beneficiary’s hospital stay to determine the beneficiary’s therapy needs during a SNF stay
  78. 78. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 78Harmony Healthcare International, Inc. 78 Agency Comments and Office of Inspector General Response 3. Agree: CMS concurred and stated that it would determine whether additional safeguards shall be put in place by the Medicare contractors to target their efforts 4. Agree: CMS concurred and stated that it would forward the list of SNFs with questionable billing to the appropriate contractors
  79. 79. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 79Harmony Healthcare International, Inc. 79 Objectives To determine the extent to which billing by skilled nursing facilities (SNF) changed from 2006 to 2008 To determine the extent to which billing varied by type of SNF ownership in 2008 To identify SNFs with questionable billing in 2008
  80. 80. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 80Harmony Healthcare International, Inc. 80 Identification of SNFs With Questionable Billing Analysis based on the 12,286 SNFs that had at least 50 Part A stays in 2008* For each SNF, they determined: The percentage of RUGs for ultra high therapy, The percentage of RUGs with high ADL scores and The average length of stay They considered a SNF to have questionable billing if it was in the top 1 percent for any of the three measures *We established a minimum of 50 Part A stays per SNF to ensure the reliability of the measures. For SNFs with fewer Part A stays, changes in the characteristics of a small number of Part A stays could have a large effect on the measures, making the measures loss reliable.
  81. 81. Harmony Healthcare International, Inc. 81Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 81 OIG Report: Part B OIG REPORT Questionable Billing for Medicare Outpatient Therapy Services Medicare Part B Copyright © 2014 All Rights Reserved
  82. 82. Harmony Healthcare International, Inc. 82Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 82 Background Medicare expenditures for outpatient therapy increased 133 percent between 2000 and 2009, from $2.1 billion to $4.9 billion, while the number of Medicare beneficiaries receiving outpatient therapy increased only 26 percent from 3.6 million to 4.5 million Copyright © 2014 All Rights Reserved
  83. 83. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 83Harmony Healthcare International, Inc. 83 Background Medicare limits (i.e., caps) its annual per beneficiary outpatient therapy expenditures Providers may exceed a beneficiary’s cap if the services are medically necessary and are supported by medical record documentation If services are expected to exceed an annual cap, providers must indicate this when submitting the claim to Medicare
  84. 84. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 84Harmony Healthcare International, Inc. 84 Background Identified 20 counties that had in 2009: The highest average Medicare payment per beneficiary and More than $1 million in total Medicare payments for outpatient therapy (i.e., high utilization counties) Analyzed Miami-Dade County, Florida, separately because it had the highest average Medicare payments per beneficiary among the high utilization counties and the highest total Medicare payments for outpatient therapy in 2009
  85. 85. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 85Harmony Healthcare International, Inc. 85 Background Six questionable billing characteristics that may indicate fraud: (1) Services for which providers indicated that an annual cap would be exceeded (2) Beneficiaries whose providers indicated that an annual therapy cap would be exceeded on the beneficiaries first date of service (3) Payments for beneficiaries who received outpatient therapy from multiple providers
  86. 86. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 86Harmony Healthcare International, Inc. 86 Background (4) Payments for therapy services provided throughout the year (5) Payments for services that exceeded an annual cap (6) Providers who were paid for more than 8 hours of outpatient therapy provided in a single day
  87. 87. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 87Harmony Healthcare International, Inc. 87 Findings Medicare per-beneficiary spending on outpatient therapy services in Miami-Dade County was three times the national average in 2009 Medicare paid an average of $3,459 per Miami- Dade beneficiary for outpatient therapy, compared to an average of $1,078 nationally Each therapy beneficiary in Miami-Dade County received an average of 158 services during 2009, while the national average was 49 services per beneficiary
  88. 88. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 88Harmony Healthcare International, Inc. 88 Recommendations Target outpatient therapy claims in high utilization areas for further review Target outpatient therapy claims with questionable billing characteristics for further review Review geographic areas and providers with questionable billing and take appropriate action based on results Revise the current therapy cap exception process
  89. 89. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 89Harmony Healthcare International, Inc. 89 Background Outpatient therapy is designed to improve, restore, and/or compensate for loss of functioning following illness or injury Medicare beneficiaries are eligible to receive outpatient therapy under Medicare Part B. Medicare covers three types of outpatient therapy.
  90. 90. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 90Harmony Healthcare International, Inc. 90 Background Physical Therapy (PT): Diagnosis and treatment of impairments, functional limitations, disabilities, or changes in physical function and health status* Occupational Therapy (OT): Treatment to improve or restore functions that have been impaired (or permanently lost or reduced) because of illness or injury, to improve the individual’s ability to perform tasks required for independent functioning**; and Speech Therapy (SLP): Diagnosis and treatment of speech and language disorders, that result in communication disabilities or swallowing disorders*** *CMS, Medicare Benefits Policy Manual, Pub. No. 100-02, ch. 15, § 230.1. **Ibid., § 230.2. ***Ibid., § 230.3.
  91. 91. Findings As a result of the OIG investigations CMS launched multiple Medical Review Initiatives Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 91
  92. 92. Common Auditors Significant increase in frequency of Medical Review Office of Inspector General (OIG) Reports Department of Justice (DOJ) Review Zone Program Integrity Contractor (ZPIC) Recovery Audit Contractor (RAC) Budget cuts Expect to be Reviewed Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 92
  93. 93. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 93Harmony Healthcare International, Inc. 93 Harmony Healthcare International Recovery Audit Contractors
  94. 94. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 94Harmony Healthcare International, Inc. 94 Recovery Audit Contractors The Recovery Auditors Program Mission The Recovery Auditor detect and correct past improper payments so that CMS can implement actions that will prevent future improper payments: Providers can avoid submitting claims that do not comply with Medicare rules CMS can lower its error rate Taxpayers and future Medicare beneficiaries are protected.
  95. 95. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 95Harmony Healthcare International, Inc. 95 Recovery Audit Contractors If you bill fee-for-service programs, your claims will be subject to review by the Recovery Auditors.
  96. 96. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 96Harmony Healthcare International, Inc. 96 Recovery Audit Contractors The Recovery Audit Review Process: Recovery Auditors review claims on a post-payment basis Recovery Auditors use the same Medicare policies as Carriers, FIs and MACs: NCDs, LCDs and the CMS Manuals Three types of review: Automated (no medical record needed) Semi-Automated (claims review using data and potential human review of a medical record or other documentation) Complex (medical record required) Recovery Audits look back three years from the date the claim was paid Recovery Auditors are required to employ a staff consisting of nurses, therapists, certified coders and a physician CMD
  97. 97. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 97Harmony Healthcare International, Inc. 97 Recovery Audit Contractors The appeal process for Recovery Audit denials is the same as the appeal process for Carrier/FI/MAC denials Do not confuse the “Recovery Audit Programs’ Discussion Period” with the Appeals process If you disagree with the Recovery Auditor’s determination: Do not stop with sending a discussion letter File an appeal before the 120th day after the Demand letter.
  98. 98. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 98Harmony Healthcare International, Inc. 98 Recovery Audit Contractors Recovery Auditors will offer an opportunity for the provider to discuss the improper payment determination with the Recovery Auditors (this is outside the normal appeal process)
  99. 99. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 99Harmony Healthcare International, Inc. 99 Harmony Healthcare International Appeal Determinations
  100. 100. Technical Denial Reasons Response to Additional Documentation Request (ADR) did contain documentation requested Documentation not received within requested time frame Physician Certification not signed or missing Therapy Billing logs do not support billing Part A – MDS Assessment Part B - 8 Minute Rule Illegible documentation Hospital documentation was not submitted Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 100
  101. 101. Clinical Denial Reasons Documentation did not support medical necessity Documentation does not support daily skilled intervention by a qualified therapist Documentation in the medical records must support continued progress Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 101
  102. 102. Denial Reasons Services provided were likely clinically appropriate but the documentation provided to reviewers did not support: Technical requirements Medical necessity The skills of a therapist were required Functional outcome Need to receive an inpatient level of care Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 102
  103. 103. Denial Reasons Reasonable and Necessary The amount, frequency and duration of services were not reasonable, given the patient’s current status ST documentation demonstrates that the therapist worked long enough with the beneficiary to develop a restorative program Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 103
  104. 104. Denial Reasons Skills of A Therapist ST minutes were reduced based on clinical judgment because documentation did not support the billed minutes were reasonable and necessary. The beneficiary could not participate in self feeding during this period and required the speech therapist to assist with 100% of the feeding. Documentation did not support medical necessity and need for continued skilled therapy. Patient needs assistance and supervision. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 104
  105. 105. Denial Reasons Deconditioning Skills of a therapist are not required to maintain function or improve strength and endurance Services related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation), do not constitute physical therapy services for Medicare purposes Practicing of previously taught exercises does not require the skills of a therapist Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 105
  106. 106. Denial Reasons Restorative Level of Care Skilled therapy was provided when non-skilled maintenance services would have been more appropriate Restorative level of care provided Documentation supports that restorative nursing could have helped the beneficiary progress versus skilled rehabilitation services 106Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  107. 107. Denial Reasons Custodial Level of Care Skilled rehabilitation and nursing services were custodial in nature and could have been met with restorative nursing, family member, or nursing provision of intermittent skilled rehabilitation and nursing services and that needs were custodial in nature and could have been met with restorative nursing, family member, or nursing assistant 107Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  108. 108. Denial Reasons Prior Level of Function The therapist ignored the patient’s prior level of function and set unrealistic goals Prior level of function was illegible. Prior level of function was blank. Patient's functional level had not changed when compared to his prior level of functioning documented in the medical record Weekly nursing progress notes demonstrate that the beneficiary required the same amount of assistance (extensive assistance) prior to and after the hospital stay Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 108
  109. 109. Denial Reasons Rehab Potential The medical record did not support that the condition of the patient would improve materially in a reasonable and generally predictable period of time Poor Rehab potential Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 109
  110. 110. Denial Reasons Goals Goals are not functional (i.e., patient will perform 10 repetitions of upper extremity exercises with the yellow theraband) Duplication of services between disciplines Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 110
  111. 111. Denial Reasons Lack of Functional Progress Gains were not significant and there was no indication of carryover of the functional task Lack of documentation relating to the patient having the potential to show significant progress No significant improvement with functional ability The outcome of therapy treatment was not documented Failure to document a complete treatment plan as outlined in Documentation Required section Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 111
  112. 112. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 112 Skilled Interventions Medicare will support continued services when the patient is not making progress if there is documentation that multiple skilled interventions have been trialed It is appropriate to give each trial an adequate amount of time to determine if the patient will progress
  113. 113. Denial Reasons Modalities Electrical Stimulation used to treat motor function disorders, such as multiple sclerosis, is considered investigational and therefore, non-covered Electrical Stimulation used in the treatment of facial nerve paralysis, commonly known as Bell’s Palsy, is considered investigational and therefore, non-covered Diathermy and Ultrasound heat treatments for the treatment of asthma, bronchitis, or any other pulmonary condition are considered not reasonable and necessary, and therefore, non- covered 113Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  114. 114. Denial Reasons Cognitive Therapy The record documented a diagnosis of Alzheimer’s disease. SLP documentation does not support further significant practical improvement could be expected. Medical justification for ST services is not established Speech treatment cognition for dementia Poor progress with cognition Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 114
  115. 115. Denial Reasons Inpatient Level of Care Documentation did not support the need for inpatient level of care No daily skilled care requiring a stay in the SNF Supervised level of care 115Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  116. 116. Denial Reasons Medical Record Conflicts Nursing notes mostly dependent ADLs/functional tasks throughout the SNF stay. Nursing note indicated there was no improvement and fluctuation of progress with self-care tasks. MDS assessments indicate that the beneficiary's ability to perform functional tasks/ADLs did not improve from the 5-day to the 90-day assessment 116Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  117. 117. Documentation to Support Identified Risk Areas Identify potential denial risk areas What might the reviewer have not seen in the documentation provided to lead the reviewer to deny services? What additional documentation may be included to further support skilled Rehabilitation and Nursing services provided? Consultations/ED Visits Care Plan Physician Progress Notes Social Services/Dietary Notes Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 117
  118. 118. Appeal Process Harmony Healthcare International, Inc. 118Copyright © 2014 All Rights Reserved
  119. 119. Appeal Rights Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 119
  120. 120. Appeal Rights Right to Appeal: If the Beneficiaries is the only one with the right to appeal given specific situations, provider must obtain transfer from beneficiary Beneficiaries may transfer appeal rights to providers who provide the items or services and do not otherwise have appeal rights Form CMS-20031 must be completed and signed by the beneficiary and supplier to transfer the beneficiary’s appeal rights Harmony Healthcare International, Inc. 120Copyright © 2014 All Rights Reserved
  121. 121. Appeal Rights Right to Appeal All appeal requests must be made in writing Harmony Healthcare International, Inc. 121Copyright © 2014 All Rights Reserved
  122. 122. Appeal Rights Medicare offers five levels in the Part A and Part B Appeals Process: 1. Redetermination by a MAC 2. Reconsideration by a QIC 3. Hearing by an Administrative Law Judge (ALJ) 4. Review by the Medicare Appeals Council, within the Department Appeals Board 5. Judicial review in U.S. District Court Harmony Healthcare International, Inc. 122Copyright © 2014 All Rights Reserved
  123. 123. Appeal Rights Redetermination A review of the claim by the MAC utilizing personnel who are different from the personnel who made the initial determination The appellant (individual filing the appeal) has 120 days from the date of receipt of initial denial to file an appeal A minimum monetary threshold is not required to request a redetermination Harmony Healthcare International, Inc. 123Copyright © 2014 All Rights Reserved
  124. 124. Appeal Rights Reconsideration If the facility is dissatisfied with result of redetermination, they may request a reconsideration A Qualified Independent Contractor (QIC) will conduct the reconsideration The reconsideration process is an independent review of medical necessity by a panel of physicians or other health care professionals A minimum monetary threshold is not required to request a reconsideration Harmony Healthcare International, Inc. 124Copyright © 2014 All Rights Reserved
  125. 125. Appeal Rights ALJ Hearing If at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration The facility must also send a notice of the ALJ hearing request to the QIC and verify this on the hearing request form or in the written request Harmony Healthcare International, Inc. 125Copyright © 2014 All Rights Reserved
  126. 126. Harmony Healthcare International The Appeal Harmony Healthcare International, Inc. 126Copyright © 2014 All Rights Reserved
  127. 127. The Appeal Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 127 Assign a team leader to oversee the preparation of the denial package Work as a team to gather pertinent information for the Medicare Appeal Review the medical record to ensure completeness
  128. 128. The Appeal It is important to read the ADR or denial letter thoroughly as the letters will assist the facility in gathering the appropriate information Review the list of items provided in the decision statement to include in the medical record Consider additional info not listed that will support the services provided Harmony Healthcare International, Inc. 128Copyright © 2014 All Rights Reserved
  129. 129. Monitor the Appeal Internal tracking system to monitor When ADR or denial was received When package was sent out Final results of the review Harmony Healthcare International, Inc. 129Copyright © 2014 All Rights Reserved
  130. 130. Additional Development Requests Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 130
  131. 131. Additional Development Requests Medicare Contractors send providers additional development request (ADR) letters requesting additional documentation The ADR letters will be mailed and /or the claim in question will be in status location S B6001 that identifies claims in FISS that are in an ADR status/location Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 131
  132. 132. Additional Development Requests Do not submit replacement/duplicate claims for the ones pending in medical review The submission of replacement/duplicate claims will result in claim denial, rejection or recoupment This will p r o l o n g the medical review process Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 132
  133. 133. Additional Development Requests When the claim is finalized, the claim will have paid in full or part, or denied If you disagree with the decision, you can request a redetermination/1st level of appeal within 120 days of the determination (date on the remittance advice) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 133
  134. 134. Additional Development Requests After the 45th day, if the documentation needed to make a medical determination is not received, the claim may be denied as records not received timely and these claim denials are issued with Remittance Advice Code N102/56900 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 134
  135. 135. Additional Development Requests CMS guidelines allow contractors the time frame of 60 days to complete the review from the date on which the last of the requested medical records is received Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 135
  136. 136. Harmony Healthcare International ADR Response And Appeal Packages Harmony Healthcare International, Inc. 136Copyright © 2014 All Rights Reserved
  137. 137. The Appeal In order to effectively manage a Medicare denial, the facility must work as a team to gather pertinent information Assign a team leader to oversee the preparation of the denial package All members of the team should review the medical record to ensure completeness Harmony Healthcare International, Inc. 137Copyright © 2014 All Rights Reserved
  138. 138. The Appeal The following team members are beneficial in this process: MDS Coordinator Director of Nursing Unit Managers (consider) Restorative Nursing program Manager Director of Therapy Any therapy professionals involved in the patient’s care Social Services Dietary Additional team members who participated in care Harmony Healthcare International, Inc. 138Copyright © 2014 All Rights Reserved
  139. 139. The Appeal It is important to read the ADR or denial letter thoroughly as the letters will assist the facility in gathering the appropriate information Review the list of items listed in the ADR/decision statement to include in the medical record Consider additional info not listed that will support the services provided Harmony Healthcare International, Inc. 139Copyright © 2014 All Rights Reserved
  140. 140. ADR/Help Letter Checklist Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 140 HELP LETTER REVIEW CHECK LIST Period Skilled Nursing Chart Review: From: __________________ To: _________________ Medicare Admission Date: ___________ Diagnosis: ________________________________ MDS Reference Dates Review 5 day 14 day 30 day 60 day 90 day SOT/EOT OMRA ARD Billing Dates RUG/HIPPS COT COT COT COT COT COT ARD Billing Dates RUG/HIPPS ICD-9 Codes ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
  141. 141. The Appeal Package List of items typically requested: Initial MDS and any MDS that corresponds to the billed dates of service and look back All physician documentation for dates of service in question Physician’s orders MD certifications MD progress notes History and Physical Harmony Healthcare International, Inc. 141Copyright © 2014 All Rights Reserved
  142. 142. The Appeal Package Important to know the consequences if the facility does not submit all necessary paperwork Facility needs to review the packet carefully to avoid a technical denial based on missing information including signatures Harmony Healthcare International, Inc. 142Copyright © 2014 All Rights Reserved
  143. 143. The Appeal Package Each team member should review the package as a whole The team leader should have a final look prior to submitting the appeal PREP Letter Proper Reimbursement Explanation Paper Always keep a copy of the packet sent to the reviewing agency Harmony Healthcare International, Inc. 143Copyright © 2014 All Rights Reserved
  144. 144. Appeals Process PREP Include a statement of position letter with the medical record documentation to the reviewing agency explaining the services provided to the patient Harmony Healthcare International, Inc. 144Copyright © 2014 All Rights Reserved
  145. 145. Monitor the Appeal Harmony Healthcare International, Inc. 145Copyright © 2014 All Rights Reserved
  146. 146. Monitor the Appeal Internal tracking system to monitor When ADR or denial was received When package was sent out Final results of the review Harmony Healthcare International, Inc. 146Copyright © 2014 All Rights Reserved
  147. 147. Harmony Healthcare International Redetermination and Reconsideration Harmony Healthcare International, Inc. 147Copyright © 2014 All Rights Reserved
  148. 148. Redetermination and Reconsideration If a claim is initially denied, there is action the facility can take The first stage is the Redetermination The next step is a Reconsideration Harmony Healthcare International, Inc. 148Copyright © 2014 All Rights Reserved
  149. 149. Redetermination An examination of a claim by a review agency who is different from the agency who made the initial determination The facility has 120 days from the date of receipt of the initial claim determination to file an appeal A minimum monetary threshold is not required to request a determination Harmony Healthcare International, Inc. 149Copyright © 2014 All Rights Reserved
  150. 150. Redetermination Request for redetermination may be filled on Form CMS-20027 available at http://www.cms.hhs.gov/CMSForms/C MSForms/list.asp#TopOfPage Harmony Healthcare International, Inc. 150Copyright © 2014 All Rights Reserved
  151. 151. Redetermination Requests not made on Form CMS-20027 must include: Beneficiary name Medicare Health Insurance Claim (HIC) number Specific service and/or items(s) for which a redetermination is being requested. Specific date(s) of service Harmony Healthcare International, Inc. 151Copyright © 2014 All Rights Reserved
  152. 152. Redetermination Requests not made on Form CMS-20027 must include Name and signature of the party or the representative of the party (Usually the administrator of the building) The name and address of the facility Harmony Healthcare International, Inc. 152Copyright © 2014 All Rights Reserved
  153. 153. Redetermination Include an appeal letter that outlines the argument for coverage Brief explanation of the hospitalization (if one occurred) Past medical history Status of patient on admission List of the skilled nursing services provided to the patient Harmony Healthcare International, Inc. 153Copyright © 2014 All Rights Reserved
  154. 154. Redetermination Appeal Letter An explanation of skilled therapy services provided to the patient Medicare guidelines used in the skilled care decision making process, if applicable Harmony Healthcare International, Inc. 154Copyright © 2014 All Rights Reserved
  155. 155. Redetermination Any additional supporting documentation not submitted during the Help letter phase from the medical record should be submitted along with the redetermination request Highlight Add sticky tabs The redetermination request should be sent to the contractor that issued the initial determination Harmony Healthcare International, Inc. 155Copyright © 2014 All Rights Reserved
  156. 156. Redetermination Contractors will generally issue a decision within 60 days of receipt of redetermination request in the form of : A letter A Medicare Redetermination Notice (MRN) Revised remittance advice Harmony Healthcare International, Inc. 156Copyright © 2014 All Rights Reserved
  157. 157. Reconsideration If the request for redetermination results in a denial, a reconsideration can be requested A QIC will conduct the reconsideration request The QIC reconsideration process allows for an independent review of medical necessity by a panel of physicians or other health-care professions A minimum monetary threshold is not required to request a reconsideration Harmony Healthcare International, Inc. 157Copyright © 2014 All Rights Reserved
  158. 158. Reconsideration A written reconsideration request must be filed within 180 days of receipt of the redetermination Instructions are provided on the Medicare Redetermination Notice (MRN) A Request for reconsideration may be made on Form CMS-20033. This form will be mailed with the MRN Harmony Healthcare International, Inc. 158Copyright © 2014 All Rights Reserved
  159. 159. Reconsideration If Form 20033 is not used, request must contain: Beneficiary name Medicare Health Insurance Claim (HIC) number Specific service(s) and/or item(s) for which the reconsideration is requested Specific date(s) of service Harmony Healthcare International, Inc. 159Copyright © 2014 All Rights Reserved
  160. 160. Reconsideration Documents to include Name and signature of the party or the representative of the party (usually the administrator of the building) Name of the contractor that made the determination Name and address of the facility Harmony Healthcare International, Inc. 160Copyright © 2014 All Rights Reserved
  161. 161. Reconsideration Include a letter outlining the argument for payment The request should clearly explain why the facility disagrees with the redetermination A copy of the MRN, and any other supportive documentation, should be sent with the reconsideration request to the QIC identified in the MRN Harmony Healthcare International, Inc. 161Copyright © 2014 All Rights Reserved
  162. 162. Reconsideration Reconsiderations are conducted on-the- record; and in most cases, the QIC will send its decision to all parties within 60 days of receipt of the request for reconsideration The decision will contain detailed info on further appeal rights if the decision is not fully favorable Harmony Healthcare International, Inc. 162Copyright © 2014 All Rights Reserved
  163. 163. Reconsideration If the QIC cannot complete its decision in the applicable timeframe, it will inform the appellant of their right to escalate the case to an ALJ Harmony Healthcare International, Inc. 163Copyright © 2014 All Rights Reserved
  164. 164. A Successful ALJ Hearing Harmony Healthcare International, Inc. 164Copyright © 2014 All Rights Reserved
  165. 165. ALJ Overview After the redetermination and reconsideration process, if at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration The facility must send a notice of the ALJ hearing request to the QIC on the hearing request form or in the written request Harmony Healthcare International, Inc. 165Copyright © 2014 All Rights Reserved
  166. 166. ALJ Overview A letter to request the ALJ hearing should simply highlight the most pertinent reasons justifying payment Harmony Healthcare International, Inc. 166Copyright © 2014 All Rights Reserved
  167. 167. ALJ Overview ALJ hearings are generally held by video-teleconference (VTC) or by telephone If the facility prefers not to have a VTC or telephone hearing, they may ask for an in-person hearing, but they must demonstrate the necessity for an in- person hearing Harmony Healthcare International, Inc. 167Copyright © 2014 All Rights Reserved
  168. 168. ALJ Overview The ALJ will determine whether an in- person hearing is warranted on a case-by- case basis Facilities may also ask the ALJ to make a decision without a hearing (on-the- record). CMS or its contractors may participate in an ALJ hearing, but they must provide notice to the ALJ and all parties of the hearing Harmony Healthcare International, Inc. 168Copyright © 2014 All Rights Reserved
  169. 169. ALJ Overview ALJ will generally issue a decision within 90 days of receipt of the hearing request The timeframe may be extended for a variety of reasons including, but not limited to: The case being escalated from the reconsideration level The submission of additional evidence not included with the hearing request The request for an in-person hearing The facility’s failure to send notice of the hearing request to other parties and The initiation of discovery if CMS is a party Harmony Healthcare International, Inc. 169Copyright © 2014 All Rights Reserved
  170. 170. ALJ Overview If the ALJ does not issue a decision within the applicable timeframe, you may ask the ALJ to escalate the case to the Appeals Council level Harmony Healthcare International, Inc. 170Copyright © 2014 All Rights Reserved
  171. 171. ALJ Hearing Preparation Harmony Healthcare International, Inc. 171Copyright © 2014 All Rights Reserved
  172. 172. ALJ Office of Medicare Hearings and Appeals (OHMA) Administrative law judge hearings will not be assigned to a judge for at least two years OMHA stopped assigning new hearing requests from providers as of July 15, 2013 The weekly influx of hearing requests surged from an average of 1,250 in January 2012 to more than 15,000 in December 2013 Medicare Appellant Forum to provide updates to OMHA appellants on the status of OMHA operations http://www.hhs.gov/omha/omha_medicare_appellant_for um.html Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 172
  173. 173. ALJ Hearing Preparation Appeal Process Discuss and study CMS Guidelines Discuss type of ALJ hearing (video, phone, in person) to anticipate the format Goals of the Hearing Inform the Judge of skilled services Get the claim paid Harmony Healthcare International, Inc. 173Copyright © 2014 All Rights Reserved
  174. 174. ALJ Hearing Preparation Team Preparation Medical record review Outline of speaking points Select a point person for the hearing Team input Harmony Healthcare International, Inc. 174Copyright © 2014 All Rights Reserved
  175. 175. ALJ Hearing Hearing Process Prepare the facility designated hearing room for video or phone hearings Judge’s assistant will initiate the phone contact (test phone lines and speakers) Introductions Statement by facility Offer to fax any pertinent documents discussed during the hearing Harmony Healthcare International, Inc. 175Copyright © 2014 All Rights Reserved
  176. 176. ALJ Hearing Organize documentation Keep pertinent notes or forms at your finger tips Number the pages for reference Have the staff that worked with patient on the call Speak respectfully, clearly, slowly Provide a concise summary Harmony Healthcare International, Inc. 176Copyright © 2014 All Rights Reserved
  177. 177. ALJ Hearing Be prepared to answer questions prepared by the Judge Why did the patient require skilled therapy when they were hospitalized for a UTI? Where does the medical record state that continued therapy services were necessary after the initial date in question? Explain why skilled care continued although the notes indicate the patient did not have an exacerbation of medical condition? Harmony Healthcare International, Inc. 177Copyright © 2014 All Rights Reserved
  178. 178. ALJ Hearing Be prepared to answer questions asked by the Judge When did the patient get discharged from therapy services? Why do the daily nursing notes state the patient was ambulating ad lib, yet physical therapy continued to provide skilled treatment? Harmony Healthcare International, Inc. 178Copyright © 2014 All Rights Reserved
  179. 179. Conclusion Educate, Discuss and Prepare Don’t Wait for Medicare Medical Review Communicate to all Staff Medicare Skilled Care Criteria Refine Interdisciplinary Management of Medicare Appeals Establish and Maintain Peer Review and External Review of Records to Assure Insulation of Claims Harmony Healthcare International, Inc. 179Copyright © 2014 All Rights Reserved
  180. 180. Keys to Success Provide clinically appropriate care Document Medical necessity Deficits Outcomes Meet technical requirements Review entire medical record Respond to ADRs timely Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 180
  181. 181. Upcoming webinars… Top 5 Ways to Prevent Falls January 28, 2014 1:00 p.m. – 2:00 p.m. Medicare Skilled Nursing Documentation February 20, 2014 1:00 p.m. – 2:00 p.m. Medicare Rehabilitation Documentation February 25, 2014 1:00 p.m. – 2:00 p.m. Rehabilitation in a SNF Setting: Skilled Medicare Coverage Criteria March 20, 10:00 a.m. – 11:00 a.m. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 181
  182. 182. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 www.Harmony-Healthcare.com ebovee@Harmony-Healthcare.com Harmony Healthcare International, Inc. 182182Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc.
  183. 183. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Assess your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc. 183Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc.
  184. 184. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 184

×