Unusual Weather We Are Having: The Medicare Audit Climate

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This presentation provides a comprehensive review and forecast of the trends in Medicare Medical Review by numerous Medicare Contractors and is appropriate for all SNF Management, nursing staff, and therapy professionals. The presentation provides insight on the tidal wave of newly exposed compliance issues at the eye of the storm, leading to remote and on-site audits in the long-term care industry. Presentation highlights the historical drought in audits and the tornado effect the current scrutiny is causing amongst the SNF providers. Learn strategies to prepare records before the impending audit storm. Avoid slip ups on the seemingly invisible black ice of Medicare non-compliance. Become aware of the most recent CMS updates impacting the RAI process and subsequently reimbursement. Create an anemometer for Managers and staff to read the winds of change and create clear visibility for accurate and compliant records.

1. Learn to summarize the multiple types of Medicare Contractor Audits and associated Compliance themes.

2. Understand the trends and triggers in Compliance Audits and Common Provider Pitfalls.

3. Learn strategies for appealing Medicare Claim Denials.

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Unusual Weather We Are Having: The Medicare Audit Climate

  1. 1. Unusual Weather We Are Having: The Medicare Audit Climate HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Carrie Mullin Director of Denial Management Elisa Bovee, MS OTR/L, Vice President of Operations
  2. 2. Housekeeping Sign In Contact Hours Certificate A Little About Me Handouts Contact Information for Questions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  3. 3. Speaker Bio (Elisa Bovee) Vice President of Operations for Harmony Healthcare International (HHI), an industry leader in Long-Term Care consulting on a national level Over 20 years of experience in the long-term care industry, practicing and providing consulting services related to therapy services and Medicare Regulations and Guidelines Manager of a diversified team of consultants who have extensive knowledge in the areas of MDS 3.0, RUG-IV, Documentation, Therapy Program development and state-specific Medicaid Case mix Appeals Coordinator for a National nursing home company Proficient in Medicare Denials Professional in Reimbursement guidelines for Medicare and Medicaid in the skilled nursing facility Former Director of Education and Training and Regional Consultant for Harmony Healthcare International Author of many articles featured in select long-term care industry trade magazines Provider of public and private education on a national level focused on a multitude of topics including Medicare regulations, and therapy solutions for case management in the SNF Provider of extensive training for MDS Coordinators, Therapy Directors and Rehabilitation Staff on MDS coding, RUG-IV Intimacy, Skilled Nursing Therapy Documentation in the SNF and Denials Management for the SNF Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. Harmony Healthcare International, Inc. 4 Speaker Bio (Carrie Mullin) Director of Denial Services for Harmony Healthcare International, Inc. and Corporate Consultant for HHI since 2008 MS OTR/L, RAC-CT Education: Masters of Science in Occupational Therapy from Spalding University in Louisville, KY Continuing Education in Contracture and Geriatric Therapeutic Exercise Courses Experience: Senior Occupational Therapist and Director of Rehabilitation Services at Episcopal Senior Life Communities in Rochester, NY Expert in Denials, Appeal letters, and prepping facilities for ALJ hearings Copyright © 2013 All Rights Reserved
  5. 5. Harmony Healthcare International, Inc. 5 Unusual Weather We Are Having: The Medicare Audit Climate Disclosure: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose: Planners: Elisa Bovee, MS, OTR/L Diane Buckley, BSN, RN, RAC-CT Beckie Dow, RN, RAC-MT Keri Hart, MS CCC, SLP, RAC-CT, Kristen Mastrangelo, OTR/L, MBA, MHA Christine Twombly, RNC, RAC-MT, LHRM Presenters: Carrie Mullin Director of Denial Management Elisa Bovee, MS OTR/L, Vice President of Operations Copyright © 2013 All Rights Reserved
  6. 6. Harmony Healthcare International, Inc. Unusual Weather We Are Having: The Medicare Audit Climate Disclosure Speakers: Carrie Mullin Director of Denial Management Elisa Bovee, MS OTR/L, Vice President of Operations The speakers have no relevant financial relationships to disclose The speakers have no relevant nonfinancial relationships to disclose Copyright © 2013 All Rights Reserved 6
  7. 7. Unusual Weather We Are Having: The Medicare Audit Climate Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 8. Objectives The learner will be able to summarize the multiple types of Medicare Contractor Audits and associated Compliance themes. The learner will be able to summarize Trends and Triggers in Compliance Audits and Common Provider Pitfalls. The learner will be able to summarize strategies for appealing Medicare Claim Denials. Harmony Healthcare International, Inc. 8Copyright © 2013 All Rights Reserved
  9. 9. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9 Unusual Weather We Are Having: The Medicare Audit Climate
  10. 10. Section I What is Skilled Care? Harmony Healthcare International, Inc. 10Copyright © 2013 All Rights Reserved
  11. 11. What is Skilled Care? Why is this material important? Which team members should be aware of the Medicare Skilled Care criteria? How often will this criteria be relevant to current beneficiaries and applicable for denied claims? Harmony Healthcare International, Inc. 11Copyright © 2013 All Rights Reserved
  12. 12. What is Skilled Care? Requires the skills of qualified technical or professional health personnel such as RN, LPN, PT, OT or SLP Must be provided directly by or under the general supervision of a licensed nurse or skilled rehab personnel to assure the safety of the resident and to achieve the medically desired result “General supervision” requires initial direction and periodic inspection of activity Ordered by a physician Services are needed and provided on a daily basis Harmony Healthcare International, Inc. 12Copyright © 2013 All Rights Reserved
  13. 13. What is Skilled Care? The need for skilled care must be justified and documented in the medical record Conditions may have prompted the initial hospitalization, but also include the conditions that arose during recovery in the SNF Harmony Healthcare International, Inc. 13Copyright © 2013 All Rights Reserved
  14. 14. Harmony Healthcare International, Inc. 14 What is Skilled Care ? Direct Skilled Nursing Services Management and Evaluation of a Care Plan Observation and Assessment Teaching and Training Skilled Rehabilitation Copyright © 2013 All Rights Reserved
  15. 15. Skilled Services Categories: Inherent Complexity Inherent Complexity – Direct skilled nursing services including: IV feeding IV meds Suctioning Tracheostomy Care Ventilator support Ulcers Harmony Healthcare International, Inc. 15Copyright © 2013 All Rights Reserved
  16. 16. Skilled Services Categories: 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 Harmony Healthcare International, Inc. 16Copyright © 2013 All Rights Reserved
  17. 17. Skilled Services Categories: Skilled Observation and Assessment Reasonable probability or possibility for complication Potential for further acute episodes Identify and Evaluate the need for modification of treatment Evaluate initiation of additional medical procedures Skilled observation can be required until the treatment regimen is essentially stabilized Harmony Healthcare International, Inc. 17Copyright © 2013 All Rights Reserved
  18. 18. Skilled Services Categories: Skilled Observation and Assessment Fever Dehydration Septicemia Pneumonia Nutritional Risk Chemotherapy Weight loss Blood sugar control Impaired cognition Severe Mood and Behavior conditions Harmony Healthcare International, Inc. 18Copyright © 2013 All Rights Reserved
  19. 19. Skilled Services Categories: Skilled Observation and Assessment Identify and outline daily skilled nursing observations and assessments Record DAILY each itemized area listed on your outline Harmony Healthcare International, Inc. 19Copyright © 2013 All Rights Reserved
  20. 20. Skilled Services Categories: Skilled Observation and Assessment Neurological Respiratory Cardiac Circulatory Pain/Sensation Nutritional Gastrointestinal Genitourinary Musculoskeletal Skin Harmony Healthcare International, Inc. 20Copyright © 2013 All Rights Reserved
  21. 21. Skilled Services Categories: Skilled Observation and Assessment A patient with arteriosclerotic heart disease with congestive heart failure requires close observation by skilled nursing personnel for signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication Skilled observation is needed to determine when the digitalis dosage should be reviewed or whether other therapeutic measures should be considered, until the patient’s treatment regimen is essentially stabilized Harmony Healthcare International, Inc. 21Copyright © 2013 All Rights Reserved
  22. 22. Skilled Services Categories: Skilled Observation and Assessment A patient has been hospitalized following a heart attack. Following treatment but before mobilization, he is transferred to the SNF. Because it is unknown whether exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated and continued until the patient’s treatment regimen is essentially stabilized Harmony Healthcare International, Inc. 22Copyright © 2013 All Rights Reserved
  23. 23. Skilled Services Categories: Skilled Observation and Assessment A frail 85-year-old man was hospitalized for pneumonia. The infection resolved, but the patient, who had previously maintained adequate nutrition, will not eat or eats poorly. The patient is transferred to a SNF for monitoring of fluid and nutrient intake and the assessment of the need for tube feeding and assisted feeding if required. Observation and monitoring by skilled nursing personnel of the patient’s oral intake is required to prevent dehydration. Harmony Healthcare International, Inc. 23Copyright © 2013 All Rights Reserved
  24. 24. Skilled Services Categories: Skilled Observation and Assessment A patient left the acute hospital on a high dosage of Coumadin with daily clotting time studies Assessment and observation is needed until a maintenance dosage is attained and the patient/resident shows no adverse symptoms. Regulation is an integral part of this patient/resident’s coverage. Ongoing observation and assessment, notifying the physician and multiple changes in the plan of care, are also skilled in nature. Harmony Healthcare International, Inc. 24Copyright © 2013 All Rights Reserved
  25. 25. Skilled Services Categories: Skilled Observation and Assessment If a patient was admitted for skilled observation but did not develop a further acute episode or complication, the skilled observation services still are covered so long as there was reasonable probability for such a complication or further acute episode “Reasonable probability” means that a potential complication or further acute episode is a likely possibility Harmony Healthcare International, Inc. 25Copyright © 2013 All Rights Reserved
  26. 26. 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 Harmony Healthcare International, Inc. 26Copyright © 2013 All Rights Reserved
  27. 27. This area includes The sum total of unskilled services Potential for serious complications High probability of relapse Recovery and safety Meet medical needs Includes resident’s overall condition Harmony Healthcare International, Inc. 27 Skilled Services Categories: Management and Evaluation of a Care Plan Copyright © 2013 All Rights Reserved
  28. 28. Skilled Services Categories: Management and Evaluation of a Care Plan Topic Areas to include: Surgical sites Circulatory status Status of fractures Maintenance of weight-bearing status Skin Care Labs Consultant Recommendations Harmony Healthcare International, Inc. 28Copyright © 2013 All Rights Reserved
  29. 29. Skilled Services Categories: Management and Evaluation of a Care Plan Although any of the required services could be performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the nature of the patient’s condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient’s recovery and safety. The management of this plan of care requires skilled nursing personnel until the patient’s treatment regimen is essentially stabilized, even though the individual services involved are supportive in nature and not require skilled nursing personnel. Harmony Healthcare International, Inc. 29Copyright © 2013 All Rights Reserved
  30. 30. Skilled Services Categories: Management and Evaluation of a Care Plan Example: An aged patient is recovering from pneumonia, is lethargic, is disoriented, has residual chest congestion, is confined to bed as a result of his debilitated condition, and requires restraints at times To decrease the chest congestion, the physician has prescribed frequent changes in position, coughing and deep breathing. While the residual chest congestion alone would not represent a high risk factor, the patient’s immobility and confusion represent complicating factors when coupled with the chest congestion, could create high probability of a relapse. Harmony Healthcare International, Inc. 30Copyright © 2013 All Rights Reserved
  31. 31. 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 Harmony Healthcare International, Inc. 31Copyright © 2013 All Rights Reserved
  32. 32. Skilled Services Categories: Teaching and Training Colostomy care Insulin administration Prosthesis management Catheter care G-tube feedings IV access sites Braces, splints and orthotics Wound dressings and skin treatments Medication Management Orthopedic Precautions Harmony Healthcare International, Inc. 32Copyright © 2013 All Rights Reserved
  33. 33. 33 Skilled Rehabilitation Transmittal 262 On a daily basis Services rendered are reasonable and necessary MD ordered Practical matter An appropriately licensed or certified individual must provide or directly supervise the therapeutic service and coordinate the intervention with nursing services Harmony Healthcare International, Inc. Copyright © 2013 All Rights Reserved
  34. 34. 34 Skilled Rehabilitation/ MD Involvement The service must be ordered by a physician. The therapy intervention must relate directly and specifically to an active written treatment regimen established by the physician after any needed consultation with the qualified rehabilitation therapy professional and must be reasonable and necessary to the treatment of the beneficiary’s illness or injury necessary to the treatment of the beneficiary’s illness or injury Harmony Healthcare International, Inc. Copyright © 2013 All Rights Reserved
  35. 35. 35 Skilled Rehabilitation/ MD Involvement MD involvement to prevent injuries Medicare allows the professional therapist to develop a suggested plan of treatment and to begin providing services based on the plan prior to MD signature MD signature required before facility bills Medicare. MD Faxed signatures acceptable Harmony Healthcare International, Inc. Copyright © 2013 All Rights Reserved
  36. 36. 36 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 clinical practice Expectation of improvement of restorative potential in a reasonable and predictable period of time….or…. Establishment of a safe and effective maintenance program Harmony Healthcare International, Inc. Copyright © 2013 All Rights Reserved
  37. 37. 37 Basic Criteria for Rehabilitation Services Must be specifically related to the Physician’s Treatment Plan Skill of a qualified therapist must be needed Treatment plan must expect the patient to improve Services must fall within accepted standards of medical practice and be specific to the patient The services must be reasonable and necessary Harmony Healthcare International, Inc. Copyright © 2013 All Rights Reserved
  38. 38. Harmony Healthcare International Section II Improvement Standard Harmony Healthcare International, Inc. 38Copyright © 2013 All Rights Reserved
  39. 39. CMS Settlement What does this mean for the SNF? How do you proceed? What can I do tomorrow to implement change in my facility? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
  40. 40. CMS Settlement Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the "Improvement Standard" case, Jimmo v. Sebelius A proposed settlement agreement was filed in federal District Court on October 16, 2012 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 40
  41. 41. CMS Settlement The lawsuit, Jimmo v. Sebelius, was brought on behalf of a nationwide class of Medicare beneficiaries by six individual beneficiaries and seven national organizations Representing people with chronic conditions, to challenge the use of the Improvement Standard Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 41
  42. 42. CMS Settlement CMS will revise the Medicare Benefit Policy Manual and other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a beneficiary "improving" New policy provisions will state that skilled nursing and therapy services necessary to maintain a person's condition can be covered by Medicare Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
  43. 43. CMS Settlement CMS will undertake a comprehensive nationwide Educational Campaign to inform health care providers, Medicare contractors, and Medicare adjudicators they should not limit Medicare coverage to beneficiaries who have the potential for improvement Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
  44. 44. CMS Settlement Instead, providers, contractors, and adjudicators must recognize "maintenance" coverage and a beneficiary's need for skilled care that is performed or supervised by professional nurses and therapists Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44
  45. 45. CMS Settlement Providers should apply the maintenance standard and provide medically necessary nursing services or therapy services, or both, to patients who need them to maintain their function, or prevent or slow their decline Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
  46. 46. CMS Settlement Under the maintenance standard articulated in the settlement, the important issue is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will "improve" Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 46
  47. 47. CMS Settlement The CMS clarification will state: 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 (“skilled care”) are necessary for the performance of a safe and effective maintenance program Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
  48. 48. CMS Settlement The CMS clarification will state: Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48
  49. 49. CMS Settlement The settlement also establishes a process of "re-review" for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out- patient therapy services (physical therapy, occupational therapy, or speech therapy) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49
  50. 50. CMS Settlement Re-review only covers individuals who seek Medicare on their own behalf, and “specifically excludes providers or suppliers of Medicare services or a Medicaid State Agency.” The settlement agreement would specifically preclude providers, suppliers, and a Medicaid State Agency from receiving a re- review of claims on behalf of, or under assignment from, a beneficiary class member Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
  51. 51. CMS Settlement BUT - the “revised” standard should be applied to future claims and/or those that are currently in the denial or appeal process Embrace the OBRA 87 regulations which require facilities to provide services to meet “the highest practicable physical, medical and psychological well-being” of every resident Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
  52. 52. Harmony Healthcare International Section III Auditing Agencies and Contractors Harmony Healthcare International, Inc. 52Copyright © 2013 All Rights Reserved
  53. 53. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53
  54. 54. Harmony Healthcare International OIG Investigation Harmony Healthcare International, Inc. 54Copyright © 2013 All Rights Reserved
  55. 55. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55Harmony Healthcare International, Inc. 55 OIG Report: Part A OIG REPORT Questionable Billing by Skilled Nursing Facilities Medicare Part A
  56. 56. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56Harmony Healthcare International, Inc. 56 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
  57. 57. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 57 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
  58. 58. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 58 Findings From 2006 to 2008, SNFs increasingly billed for higher paying RUGs, even though beneficiary characteristics remained largely unchanged Percentage of RUGs for ultra high therapy increased from 17 to 28 percent Percentage of RUGs with high ADL scores increased from 30 percent in 2006 to 34 percent in 2008 Even though SNFs significantly increased their billing for these higher paying RUGs, beneficiaries’ ages and diagnoses at admission were largely unchanged from 2006 to 2008
  59. 59. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 59Harmony Healthcare International, Inc. 59 Findings For-profit SNFs were far more likely than nonprofit or government SNFs to bill for higher paying RUGs 32 percent of RUGs from for-profit SNFs were for ultra high therapy, compared to 18 percent from nonprofit SNFs and 13 percent from government SNFs. In addition, for- profit SNFs had a higher use of RUGs with high ADL scores than both for profit and government SNFs. For-profit SNFs also had longer lengths of stay, on average, compared to those of the other types of SNFs.
  60. 60. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 60Harmony Healthcare International, Inc. 60 Findings A number of SNFs had questionable billing in 2008 Some SNFs billed much more frequently for higher paying RUGs than other SNFs. Some SNFs also had unusually long average lengths of stay compared to those of other SNFs They identified 348 SNFs that were in the top 1 percent for the use of ultra high therapy, RUGs with high ADL scores, or long average lengths of stay
  61. 61. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61Harmony Healthcare International, Inc. 61 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
  62. 62. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62Harmony Healthcare International, Inc. 62 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
  63. 63. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63Harmony Healthcare International, Inc. 63 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.
  64. 64. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 64 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
  65. 65. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65Harmony Healthcare International, Inc. 65 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
  66. 66. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66Harmony Healthcare International, Inc. 66 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
  67. 67. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67Harmony Healthcare International, Inc. 67 Background In recent years, the Office of Inspector General (OIG) has identified a number of problems with SNF billing for Medicare Part A payments Notably, an OIG report found that 26 percent of claims submitted by SNFs in fiscal year (FY) 2002 were not supported by the medical record, representing $542 million in potential overpayments* *Source: OIG, A Review of Nursing Facility Resource Utilization Groups, OE1-02- 02-00830, February 2006.
  68. 68. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 68Harmony Healthcare International, Inc. 68 Background Additionally, OIG audits of five SNFs found that 20 to 94 percent of sampled claims from 2002 through 2004 were medically unnecessary, were submitted at an inappropriate payment rate, or were insufficiently documented* OIG estimated that overpayments to these SNFs totaled nearly $2.5 million *Source: OIG, Review of Rehabilitation Services at Gulf Health Care, Texas City, TX, A-06-03-00078, July 2007; Review of Rehabilitation Services at Skilled Nursing Facilities – Avante at Leesburg, A-06-06-00107, May 2007; Review of Skilled Services at Heartland Health Care Center of Bedford, TX, A-06-07-00045, April 2008; Review of Skilled Services at Four Seasons Nursing Center of Durant, OK, A-06-07-00046, May 2008; and Review of Skilled Services at Regent Care Center of Laredo, TX, A-06-06-00047, August 2006.
  69. 69. Harmony Healthcare International, Inc. 69Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 69 Background Further, the Medicare Payment Advisory Commission (MedPAC) has raised concerns about SNFs’ improperly billing for therapy to obtain additional Medicare payments Specifically, MedPAC noted that the current system “encourages SNFs to furnish therapy, even when it is of little or no benefit”* *Source: MedPAC, Report to Congress: Promoting Greater Efficiency in Medicare, June 2007, ch. 8, p. 192. Accessed at http://www.medpac.gov/chapters/Jun07_Ch08.pdf on May 29, 2009.
  70. 70. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 70Harmony Healthcare International, Inc. 70 Background In addition, staff at the Centers for Medicare & Medicaid Services (CMS) noted that some facilities, to increase payments, may be inappropriately overstating a beneficiary’s need for assistance with certain activities of daily living (ADL) Staff also noted that certain SNFs might be keeping beneficiaries in Part A stays longer than necessary
  71. 71. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71Harmony Healthcare International, Inc. 71 Background This study is the first of a three- part series that focuses on Medicaid Part A payments to SNFs The other two studies will be based on medical record reviews Source: OIG, Medicare Part A Payments to Skilled Nursing Facilities, OEI-02-09-00200, and Medicare Requirements for Quality of Care in Skilled Nursing Facilities, OEI-02-09-00201, forthcoming.
  72. 72. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 72Harmony Healthcare International, Inc. 72 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.
  73. 73. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 73Harmony Healthcare International, Inc. 73 Identification of SNFs With Questionable Billing They determined whether these SNFs had beneficiary populations that indicated a need for a particularly high use of higher paying RUGs or for longer lengths of stay
  74. 74. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 74Harmony Healthcare International, Inc. 74 Limitations This study assesses SNF billing based on an analysis of Medicare Part A claims. It does not, however, determine whether the claims were appropriate. A companion study, based on a medical review, will address this question and determine whether Part A SNF claims met Medicare coverage requirements.
  75. 75. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 75Harmony Healthcare International, Inc. 75 Findings Billing for ultra high therapy increased substantially from 2006 to 2008. In 2006, 17 percent of all RUGs were for ultra high therapy. In 2008, this share increased to 28 percent. Over the same period, SNFs’ use of the other levels of therapy – very high, high, medium and low – decreased or stayed about the same. For example, SNFs’ use of high therapy decreased from 16 percent in 2006 to 11 percent in 2008. Similarly, the percentage of RUGs in the nontherapy categories decreased from 16 percent in 2006 to 12 percent in 2008.
  76. 76. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 76Harmony Healthcare International, Inc. 76 Findings Changes in SNF Billing From 2006 to 2008 25% 17% 16% 26% <1% 16% 28% 25% 11% 24% <1% 12% 0% 5% 10% 15% 20% 25% 30% Ultra High Therapy Very High Therapy High Therapy M edium Therapy Low Therapy Nontherapy PercentageofRUGs 2006 2008
  77. 77. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 77Harmony Healthcare International, Inc. 77 Findings Overall, payments increased by $4.3 billion, or 18 percent from 2006 to 2008. As shown in the below table, payments to SNFs for ultra high therapy rose from $5.7 billion in 2006 to $10.7 billion in 2008, an increase of nearly 90 percent. Changes in Medicare Payments From 2006 to 2008 RUGs Total Medicare Payments 2006 Total Medicare Payments 2008 Difference in Payments Ultra high therapy RUGs $5.7 billion $10.7 billion $5.04 billion Other therapy RUGs $15.6 billion $15.3 billion -$0.25 billion Nontherapy RUGs $2.5 billion $2.0 billion $-0.46 billion Total* $23.8 billion $28.1 billion $4.32 billion *Medicare payments in 2008 do not sum to total because of rounding. Source: OIG analysis of Part A SNF claims, 2010.
  78. 78. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 78Harmony Healthcare International, Inc. 78 Findings The shift to ultra high therapy RUGs was also associated with an increased use of grace periods. SNFs’ use of grace periods increased substantially, from 51 percent in 2006 to 61 percent in 2008 for 5 day assessments.
  79. 79. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 79Harmony Healthcare International, Inc. 79 Findings Billing for high levels of assistance with daily activities also increased from 2006 to 2008 In 2006, 30 percent of RUGs had high ADL scores, compared to 34 percent of RUGs in 2008
  80. 80. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 80Harmony Healthcare International, Inc. 80 Findings The shift toward higher paying RUGs did not appear to be the result of changes in beneficiary characteristics Beneficiaries’ ages and diagnoses at admission were largely unchanged from 2006 to 2008 The average age of beneficiaries changed minimally, from 79.9 to 79.8 years of age, and the distribution of beneficiaries’ ages also did not change significantly during this time Additionally, the top 20 admitting diagnoses of beneficiaries were identical and accounted for over half of all admissions in both years
  81. 81. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 81Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 81 Findings Billing for Ultra High Intensity RUGs With High ADL Scores, by Type of SNF Ownership, 2008 32% 13% 18% 0% 10% 20% 30% 40% For-Profit SNFs Nonprofit SNFs Government SNFs PercentageofRUGsforUltraHighTherapy 35% 31%31% 0% 10% 20% 30% 40% For-Profit SNFs Nonprofit SNFs Government SNFs PercentageofRUGsWithHighADLScores Source: OIG analysis of Part A SNF claims, 2010.
  82. 82. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 82Harmony Healthcare International, Inc. 82 Findings Billing by For-Profit SNFs, 2008 Independently Owned SNFs (n = 3,678) SNFs Owned by Small Chains (n = 4,579) SNFs Owned by Large Chains (n = 2,048) Percentage of RUGs for ultra high therapy 28% 29% 43% Percentage of RUGs with high ADL scores 33% 34% 38% Average length of stay 28 days 29 days 31 days Source: OIG analysis of Part A SNF claims, 2010.
  83. 83. Harmony Healthcare International, Inc. 83Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 83 OIG Report: Part B OIG REPORT Questionable Billing for Medicare Outpatient Therapy Services Medicare Part B
  84. 84. Harmony Healthcare International, Inc. 84Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 84 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
  85. 85. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 85Harmony Healthcare International, Inc. 85 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
  86. 86. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 86Harmony Healthcare International, Inc. 86 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
  87. 87. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 87Harmony Healthcare International, Inc. 87 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
  88. 88. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 88Harmony Healthcare International, Inc. 88 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
  89. 89. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 89Harmony Healthcare International, Inc. 89 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
  90. 90. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 90Harmony Healthcare International, Inc. 90 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
  91. 91. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 91Harmony Healthcare International, Inc. 91 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.
  92. 92. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 92Harmony Healthcare International, Inc. 92 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.
  93. 93. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 93Harmony Healthcare International, Inc. 93 Counties With Highest Utilization
  94. 94. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 94Harmony Healthcare International, Inc. 94 Findings Medicare Outpatient Therapy Services in Miami-Dade County Compared to National Levels, 2009 Outpatient Therapy Utilization Miami-Dade County Average National Average* Ratio of Miami-Dade County Average to National Average Medicare payments per beneficiary $3,459 $1,078 3:1 Number of services per beneficiary 158 49 3:1 Medicare payments per provider serving beneficiaries in a county $83,867 $10,131 8:1 Number of services per provider serving beneficiaries in a county 3,828 458 8:1 *Beneficiaries who received services in more than one county and providers that served beneficiaries in more than one county during 2009 are included in multiple counties in the national averages. In 2009, 4,531,609 beneficiaries received outpatient therapy from 81,170 providers. Less than 1 percent of these beneficiaries lived in more than one county. Providers served outpatient therapy beneficiaries in an average of six counties. Note: All figures have been rounded to nearest whole number. Source: OIG analysis of 2009 Medicare outpatient therapy claims, 2010.
  95. 95. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 95Harmony Healthcare International, Inc. 95 Findings Questionable Outpatient Therapy Billing in Miami-Dade County Compared to National Levels, 2009 Characteristic Miami-Dade County National Ratio of Miami-Date County to National Average number of outpatient therapy services per beneficiary that providers indicated would exceed an annual cap 60 14 4:1 Percentage of outpatient therapy beneficiaries whose providers indicated that an annual cap would be exceeded on the beneficiaries’ first date of service in 2009 20% 5% 4:1 Average Medicare payment per beneficiary who received outpatient therapy from multiple providers $5,664 $1,670 3:1 Percentage of outpatient therapy beneficiaries whose providers were paid for services provided throughout the year 10% 3% 3:1 Percentage of outpatient therapy beneficiaries whose providers were paid for services that exceeded an annual cap 63% 22% 3:1 Percentage of outpatient therapy beneficiaries whose providers were paid for more than 8 hours of outpatient therapy provided in a single day 0.3% 0.7% <1:1 Note: All figures have been rounded to nearest whole number. Source: OIG analysis of 2009 Medicare outpatient therapy claims, 2010.
  96. 96. Findings As a result of the OIG investigations CMS launched multiple Medical Review Initiatives Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96
  97. 97. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 97
  98. 98. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 98Harmony Healthcare International, Inc. 98 Harmony Healthcare International What is PEPPER?
  99. 99. PEPPER Program for Evaluating Payment Patterns Electronic Report Harmony Healthcare International
  100. 100. PEPPER CMS has announced that they have mailed all SNFs a “Program for Evaluating Payment Patterns Electronic Report” (PEPPER). This report details Medicare claims data in certain targeted areas and compare your facility to other SNFs nationally. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 100
  101. 101. PEPPER This report will the SNFs detailed Medicare claims data in certain targeted areas and compare he SNF to other SNFs nationally. Skilled Nursing Facilities (SNFs) should have received via mail on or about August 30, 2013 Envelope with red print on the outside containing your facility specific PEPPER Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 101
  102. 102. Where is My PEPPER Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 102
  103. 103. Where is My Pepper? From TMF Health Quality Institute These reports are only distributed to Skilled Nursing Facilities via traditional mail delivery. Many facilities did not identify the document mailed as important and may have even discarded the report as junk mail. PEPPERResources.org from the PEPPER HELP Desk (http://pepperresources.org/HelpContactUs.aspx). Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 103
  104. 104. PEPPER PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper payments Allows providers to see how their facility compares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdiction. PEPPER data is also shared with both Medicare Audit Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs). Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 104
  105. 105. PEPPER Targeted areas were derived from two recent Office of Inspector General (OIG) Reports: “Inappropriate Payments to skilled Nursing Facilities Cost Medicare than a Billion Dollars in 2009” (November 2012) “Questionable Billing by Skilled Nursing Facilities” (December 2010). Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 105
  106. 106. Claims Data The SNF PEPPER provides SNFs with their jurisdiction, state and national percentile values for each target area with reportable data for the most recent three fiscal years FY 2012 (October 1 2011 through September 30th )is displayed on the first table When the target (numerator) count is less than 11 for a target area for a time period, statistics are not displayed Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 106
  107. 107. Compare Target Report Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 107 Skilled Nursing Facility PEPPER Compare Targets Report, Four Quarters Ending Q4 FY 2012 Target Description Target Count Percent SNF National %ile SNF State %ile SNF Jursidict. %ile Therapy High ADL Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to RUX, RVX, RHX, RMX, RUC, RVC, RHC, RMC, RLB, to days billed w ithin episodes of care ending in the report period for all therapy RUGs 2,730 51.6% 85.3 83.1 82.7 Nontherapy High ADL Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to SSC, CC2, CC1, BB2, BB1, PE2, PE1, IB2, IB1 in RUG III; HE2, HE1, LE2, LE1, CE2, CE1, BB2, BB1, PE2, PE1 in RUG IV, to days billed w ithin episodes of care ending in the report period for all nontherapy RUGs 528 26.7% 58.3 40.0 46.1 Change of Therapy Assessment Proportion of assessments w ith AI second digit equal to D w ithin episodes of care ending in the report period, to all assessments w ithin episodes of care ending in the report period 60 6.9% 21.8 40.0 34.0 Ultrahigh Therapy RUGs Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to RUX, RUL, RUC, RUB, RUA, to days billed w ithin episodes of care ending in the report period for all therapy RUGs 3,097 58.5% 64.6 69.3 71.4 Therapy RUGs Proportion of days billed w ithin episodes of care ending in the report period for therapy RUGs, to days billed w ithin episodes of care ending in the report period for all therapy and nontherapy RUGs 5,292 72.8% 8.8 15.0 13.7 90+ Day Episodes of Care Proportion of episodes of care ending in the report period at the SNF w ith a length of stay of 90+ days, to all episodes of care ending in the report period at the SNF 19 9.0% 25.9 32.9 36.9 Harmony Healthcare International (HHI) The Compare Targets Report displays statistics for target areas that have reportable data (11+ target numerator count) in the most recent time period. Percentiles indicate how a Skilled Nursing Facility's (SNFs) target area percent compares to the target area percents for all SNFs in the respective comparison group. For example, if a SNF's national percentile (see below) is 80.0, 80% of the SNFs in the nation have a lower percent value than that SNF. The SNF's state percentile (if displayed) and the Medicare Administrative Contractor (MAC) jurisdiction percentile values should be interpreted in the same manner. Percentiles at or above the 80th percentile for any target areas, or at or below the 20th percentile for areas at risk for undercoding, indicate that the SNF may be at a higher risk for improper Medicare payments. The greater (or smaller, for areas at risk for undercoding) the percentile value, in particular the national and/or jurisdiction percentile, the greater consideration should be given to that target area. Target Areas
  108. 108. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 108 Skilled Nursing Facility PEPPER Compare Targets Report, Four Quarters Ending Q4 FY 2012 Target Description Target Count Percent SNF National %ile SNF State %ile SNF Jursidict. %ile Therapy High ADL Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to RUX, RVX, RHX, RMX, RUC, RVC, RHC, RMC, RLB, to days billed w ithin episodes of care ending in the report period for all therapy RUGs 2,730 51.6% 85.3 83.1 82.7 Nontherapy High ADL Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to SSC, CC2, CC1, BB2, BB1, PE2, PE1, IB2, IB1 in RUG III; HE2, HE1, LE2, LE1, CE2, CE1, BB2, BB1, PE2, PE1 in RUG IV, to days billed w ithin episodes of care ending in the report period for all nontherapy RUGs 528 26.7% 58.3 40.0 46.1 Change of Therapy Assessment Proportion of assessments w ith AI second digit equal to D w ithin episodes of care ending in the report period, to all assessments w ithin episodes of care ending in the report period 60 6.9% 21.8 40.0 34.0 Ultrahigh Therapy RUGs Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to RUX, RUL, RUC, RUB, RUA, to days billed w ithin episodes of care ending in the report period for all therapy RUGs 3,097 58.5% 64.6 69.3 71.4 Therapy RUGs Proportion of days billed w ithin episodes of care ending in the report period for therapy RUGs, to days billed w ithin episodes of care ending in the report period for all therapy and nontherapy RUGs 5,292 72.8% 8.8 15.0 13.7 90+ Day Episodes of Care Proportion of episodes of care ending in the report period at the SNF w ith a length of stay of 90+ days, to all episodes of care ending in the report period at the SNF 19 9.0% 25.9 32.9 36.9 Harmony Healthcare International (HHI) The Compare Targets Report displays statistics for target areas that have reportable data (11+ target numerator count) in the most recent time period. Percentiles indicate how a Skilled Nursing Facility's (SNFs) target area percent compares to the target area percents for all SNFs in the respective comparison group. For example, if a SNF's national percentile (see below) is 80.0, 80% of the SNFs in the nation have a lower percent value than that SNF. The SNF's state percentile (if displayed) and the Medicare Administrative Contractor (MAC) jurisdiction percentile values should be interpreted in the same manner. Percentiles at or above the 80th percentile for any target areas, or at or below the 20th percentile for areas at risk for undercoding, indicate that the SNF may be at a higher risk for improper Medicare payments. The greater (or smaller, for areas at risk for undercoding) the percentile value, in particular the national and/or jurisdiction percentile, the greater consideration should be given to that target area. Target Count and Percent
  109. 109. Percentiles Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 109 Skilled Nursing Facility PEPPER Compare Targets Report, Four Quarters Ending Q4 FY 2012 Target Description Target Count Percent SNF National %ile SNF State %ile SNF Jursidict. %ile Therapy High ADL Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to RUX, RVX, RHX, RMX, RUC, RVC, RHC, RMC, RLB, to days billed w ithin episodes of care ending in the report period for all therapy RUGs 2,730 51.6% 85.3 83.1 82.7 Nontherapy High ADL Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to SSC, CC2, CC1, BB2, BB1, PE2, PE1, IB2, IB1 in RUG III; HE2, HE1, LE2, LE1, CE2, CE1, BB2, BB1, PE2, PE1 in RUG IV, to days billed w ithin episodes of care ending in the report period for all nontherapy RUGs 528 26.7% 58.3 40.0 46.1 Change of Therapy Assessment Proportion of assessments w ith AI second digit equal to D w ithin episodes of care ending in the report period, to all assessments w ithin episodes of care ending in the report period 60 6.9% 21.8 40.0 34.0 Ultrahigh Therapy RUGs Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to RUX, RUL, RUC, RUB, RUA, to days billed w ithin episodes of care ending in the report period for all therapy RUGs 3,097 58.5% 64.6 69.3 71.4 Therapy RUGs Proportion of days billed w ithin episodes of care ending in the report period for therapy RUGs, to days billed w ithin episodes of care ending in the report period for all therapy and nontherapy RUGs 5,292 72.8% 8.8 15.0 13.7 90+ Day Episodes of Care Proportion of episodes of care ending in the report period at the SNF w ith a length of stay of 90+ days, to all episodes of care ending in the report period at the SNF 19 9.0% 25.9 32.9 36.9 Harmony Healthcare International (HHI) The Compare Targets Report displays statistics for target areas that have reportable data (11+ target numerator count) in the most recent time period. Percentiles indicate how a Skilled Nursing Facility's (SNFs) target area percent compares to the target area percents for all SNFs in the respective comparison group. For example, if a SNF's national percentile (see below) is 80.0, 80% of the SNFs in the nation have a lower percent value than that SNF. The SNF's state percentile (if displayed) and the Medicare Administrative Contractor (MAC) jurisdiction percentile values should be interpreted in the same manner. Percentiles at or above the 80th percentile for any target areas, or at or below the 20th percentile for areas at risk for undercoding, indicate that the SNF may be at a higher risk for improper Medicare payments. The greater (or smaller, for areas at risk for undercoding) the percentile value, in particular the national and/or jurisdiction percentile, the greater consideration should be given to that target area.
  110. 110. A Closer Look at Target Areas Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 110
  111. 111. HHI Analysis Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 111
  112. 112. HHI Comparative Data Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 112
  113. 113. HHI Comparative Data Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 113
  114. 114. HHI State and Jurisdiction Data Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 114
  115. 115. PEPPER Skilled Nursing Facilities (SNFs) received via mail on or about August 30, 2013 Envelope with red print on the outside containing your facility specific PEPPER Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 115
  116. 116. PEPPER PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper payments Allows providers to see how their facility compares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdiction. PEPPER data is also shared with both Medicare Audit Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs). Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 116
  117. 117. PEPPER Targeted areas were derived from two recent Office of Inspector General (OIG) Reports: “Inappropriate Payments to skilled Nursing Facilities Cost Medicare than a Billion Dollars in 2009” (November 2012) “Questionable Billing by Skilled Nursing Facilities” (December 2010). Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 117
  118. 118. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 118Harmony Healthcare International, Inc. 118 Harmony Healthcare International ZPIC Audit
  119. 119. Frequency of Medical of Review 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 119
  120. 120. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 120Harmony Healthcare International, Inc. 120 Insulate, Insulate, Insulate!! Zone Program Integrity Contractor (ZPIC) CMS launched another major initiative to target providers other than the hospital setting as the RAC auditors have been focusing on hospital audits Southeast, south central, midwest, northeast and west coast regions of the U.S. are seeing the most ZPIC audits at this time
  121. 121. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 121Harmony Healthcare International, Inc. 121 Zone Program Integrity Contractor (ZPIC) ZPICs SafeGuard Services AdvanceMed Health Integrity Integriguard Surprise on-site visits Targeted data analysis Random audits 100% pre-payment holds
  122. 122. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 122Harmony Healthcare International, Inc. 122 On-site Medical Record Review Audits AdvanceMed Request for 160-170 Medical Records 14 Days to Submit Requesting ONLY Therapy Documentation Therapy Staffing levels were requested AdvanceMed interviews with Staff
  123. 123. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 123Harmony Healthcare International, Inc. 123 On-site Medical Record Review Audits Rehab and MDS Questions Sample therapy staff interview questions: 1. Do you feel pressure to meet your RUG levels? 2. Who has the say on discharge from therapy?
  124. 124. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 124Harmony Healthcare International, Inc. 124 On-site Medical Record Review Audits Sample MDS staff interview questions: 1. Who decides the ARD? 2. Do they provide group and concurrent treatments?
  125. 125. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 125Harmony Healthcare International, Inc. 125 Harmony Healthcare International Appeal Determinations
  126. 126. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 126
  127. 127. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 127
  128. 128. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 128
  129. 129. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 129
  130. 130. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 130
  131. 131. 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 131Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  132. 132. 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 132Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  133. 133. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 133
  134. 134. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 134
  135. 135. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 135
  136. 136. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 136
  137. 137. 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 137Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  138. 138. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 138
  139. 139. 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 139Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  140. 140. 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 140Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  141. 141. Denial Reasons Services provided were likely clinically appropriate but the documentation 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 141
  142. 142. Harmony Healthcare International Section IV Appealing Medicare Denied Claims Harmony Healthcare International, Inc. 142Copyright © 2013 All Rights Reserved
  143. 143. Proactive Management of the Appeal Process Raise Facility Awareness Function as a TEAM Communication Organization Harmony Healthcare International, Inc. 143Copyright © 2013 All Rights Reserved
  144. 144. Appeal Process Common practice to receive communications from Medicare review agencies requesting proof of skilled services Understand the process to manage the inquiry in a timely and detailed manner in order to minimize lost Revenue Harmony Healthcare International, Inc. 144Copyright © 2013 All Rights Reserved
  145. 145. CMS Overview Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) included provision aimed at improving the Medicare fee-for-service appeals process Part of the provisions mandate that all second-level appeals (for both Part A and Part B), also known as reconsiderations, be conducted by Qualified Independent Contractors (QICs) Harmony Healthcare International, Inc. 145Copyright © 2013 All Rights Reserved
  146. 146. CMS Overview Centers for Medicare & Medicaid Services (CMS) contracts with Medicare Administrative Contractors (MACs) to assist with local claims processing and the first level appeals adjudication function Harmony Healthcare International, Inc. 146Copyright © 2013 All Rights Reserved
  147. 147. Medical Review Many times the process starts with an Additional Development Request (ADR) These can be triggered by items specific to the patient, such as: RUG score ICD-9 code billed Wide spread probe Harmony Healthcare International, Inc. 147Copyright © 2013 All Rights Reserved
  148. 148. Probe Reviews Under probe reviews, contractors may examine 20-40 claims per provider for provider-specific problems Contractors also conduct widespread probe reviews (involving approx. 100 claims) when a larger problem, such as a spike in billing for a specific procedure, is identified Harmony Healthcare International, Inc. 148Copyright © 2013 All Rights Reserved
  149. 149. Medical Review It is not uncommon for an ADR to result in the denial of part or all of a claim Once an initial claim determination is made providers have the right to appeal Harmony Healthcare International, Inc. 149Copyright © 2013 All Rights Reserved
  150. 150. Harmony Healthcare International Section V The Appeal Harmony Healthcare International, Inc. 150Copyright © 2013 All Rights Reserved
  151. 151. The Appeal Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 151 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
  152. 152. 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. 152Copyright © 2013 All Rights Reserved
  153. 153. 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. 153Copyright © 2013 All Rights Reserved
  154. 154. 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. 154Copyright © 2013 All Rights Reserved
  155. 155. Keys to Success Provide clinically appropriate care Document Medical necessity Deficits Outcomes Meet technical requirements Review entire medical record Respond to ADRs timely Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 155
  156. 156. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 Cmullin@harmony-healthcare.com Ebovee@Harmony-Healthcare.com Harmony Healthcare International, Inc. 156Copyright © 2013 All Rights Reserved
  157. 157. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 157 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 Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc.

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