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Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
Seven steps to minimize the pain of healthcare audits, including RACs
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Seven steps to minimize the pain of healthcare audits, including RACs

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Healthcare audits and Enterprise Content Management (ECM): Helping organizations manage the audit process; seven steps to minimize pain

Healthcare audits and Enterprise Content Management (ECM): Helping organizations manage the audit process; seven steps to minimize pain

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  • Medicare recommends compiling a RAC Team: RAC Pre-audit Review ICD9 diagnosis accuracy procedure code accuracy MS-DRG accuracy present on admission or POA indicator accuracy CPT HCPCS procedure code assignments for outpatient accounts appropriate medical necessity for services assess appropriate patient status for observation accounts, inpatient-only procedures and one-day inpatient stays   RAC coordinator: managing medical-records requests and appeals manage the RAC audit process track all RAC audits (including medical-record requests, appeals and financial outcomes) identifying areas for process improvements or focused education in order to avoid future RAC auditsT
  • Contractor/reviewers staff the following individuals: Certified coders Physicians Nurses and/or Therapists
  • History: (Chief Complaint, Medical History, Review of Systems, History of Present Illness) Medical Decision Making: (Diagnoses, Options, Data – labs/radiology, etc., Risk of Complications, Morbidity and Mortality) Examination: (Problem – 1 body area/system, detailed and comprehensive – documentation containing multi-system exam including at least 8 of the 12 organ systems) Time: (level of service)
  • For Part B providers, the 2009 limits are: 10 medical records per 45-day period for solo practitioners; 20 medical records per 45-day period for two to five provider offices; 30 medical records per 45-day period for groups of six to 15 providers; and 50 medical records per 45-day period for groups of 16 or more providers. For Part A claims, the 2009 maximum number of records RACs may demand varies by the hospital’s NPI and will equal 10 percent of their average monthly Medicare claims. The RACs cannot request more than 200 records in a 45-day period for both inpatient and outpatient claims combined. Medicare RAC site: Provide access to an online application to track updates (improper payments) and status of MR requests Permanent RAC findings: will be listed on the RACs’ websites AHA RACTrac: ID results of previous audits, targeted codes (be proactive) Compare current organizations practices to national stats Identify trends Modify/correct internal processes
  •  
  • Additional Documentation Limits for FY 2010 for DRG Validation as of December 1, 2009 In response to feedback from the RACs, providers/suppliers and their associations, CMS has modified the additional documentation request limits for the RAC program in FY 2010. These limits will be set by each RAC (CMS) on an annual basis to establish a cap per campus on the maximum number of medical records that may be requested per 45-day period. A campus unit (defined below) may consist of one or more separate facilities/practices under a single organizational umbrella; each limit will be based on that unit’s prior calendar year Medicare claims volume. 1. Limits will be based on the servicing provider/supplier’s Tax Identification Number (TIN) and the first three positions of the ZIP code where they are physically located. Using TINs will reduce the total number of limits that would have been imposed per organization under the previous draft policy, which was based on National Provider Identifiers, while factoring in ZIP codes will promote equitability for regional or national organizations. For example: Provider A has TIN 123456789 and two physical locations in ZIP codes 12345 and 12356; the two locations would qualify as a single campus unit for additional documentation limit purposes. Provider B has TIN 123456780 and is physically located in 12345 as well as 21345. This provider would be considered as two distinct entities for additional documentation purposes, and each location would have its own additional documentation limit. Please note that the definition of a campus for RAC documentation request limits differs significantly from the definition in 42 CFR 413.65(a)(2) used to determine eligibility for provider-based billing. 2. Limits will be set at 1% of all claims submitted for the previous calendar year (2008), divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days. A provider’s limit will be applied across all claim types, including professional services. Note: FY 2010 limits are based on submitted claims, irrespective of paid/denied status and/or individual lines, although interim/final bills and RAPs/final claims shall be considered as a unit. For example: Provider C billed 156,253 claims last year. The provider’s additional documentation limit would be (156253 *.01)/8= 195.31, or 195 additional documentation requests per 45 days. Provider D billed 50,000 inpatient claims, 75,000 outpatient claims, 20,000 SNF covered stays, 20,000 home health episodes of care, 250,000 physician claims, 10,000 inpatient rehab claims and 1.000 hospice claims. The total number of claims for this provider would equal 426,000. The provider’s additional documentation limit would be (426000*.01)/8= 532.5. The provider’s additional documentation limit would be 532 additional documentation requests every 45 days, if there were no cap in place (see below). While respecting a provider’s overall limit, the RAC may exercise discretion in the exact composition of an additional documentation request. For example, the RAC may request inpatient records up to the full limit even though the provider’s inpatient business may only be a small portion of their total claim volume. 3. Two caps will exist in FY 2010: Through March 2010, the cap will remain at 200 additional documentation requests per 45 days for all providers/suppliers. However, from April through September 2010, providers/suppliers who bill in excess of 100,000 claims to Medicare (per TIN, across all claims processing contractors) will have a cap of 300 additional documentation requests per campus unit, per 45 days. 4. In addition, in FY 2010 CMS will allow the RACs to request permission to exceed the cap. Permission to exceed the cap cannot be requested in the first six (6) months of the fiscal year. The expanded cap will not be automatic; the RACs must request approval from CMS on a case-by-case basis and affected providers will be notified prior to receiving additional requests. Questions concerning this update can be directed to RAC@cms.hhs.gov
  • Rollout of the program to specific states at certain times, as evidenced by the map. Region A: Diversified Collection Services Inc. in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York;  Region B: CGI Technologies and Solutions Inc in Michigan, Indiana and Minnesota; Region C: Connolly Consulting Associates Inc. in South Carolina, Florida, Colorado and New Mexico; and Region D: HealthDataInsights Inc. in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona. Additional Documentation Limits for FY 2010 for DRG Validation (as of December 1, 2009)… - CMS has modified the MR request limits for the RAC program in FY 2010. Limits will be established on an annual basis Per campus on the maximum number of MR that may be requested per 45-day period. A campus unit (defined below) may consist of one or more separate facilities/practices under a single organizational umbrella; each limit will be based on that unit’s prior calendar year Medicare claims volume. 1. Limits will be based on the servicing provider/supplier’s Tax Identification Number (TIN) and the first three positions of the ZIP code where they are physically located. Using TINs will reduce the total number of limits that would have been imposed per organization under the previous draft policy, which was based on National Provider Identifiers, while factoring in ZIP codes will promote equitability for regional or national organizations. For example: Provider A has TIN 123456789 and two physical locations in ZIP codes 12345 and 12356; the two locations would qualify as a single campus unit for additional documentation limit purposes. Provider B has TIN 123456780 and is physically located in 12345 as well as 21345. This provider would be considered as two distinct entities for additional documentation purposes, and each location would have its own additional documentation limit. Please note that the definition of a campus for RAC documentation request limits differs significantly from the definition in 42 CFR 413.65(a)(2) used to determine eligibility for provider-based billing. 2. Limits will be set at 1% of all claims submitted for the previous calendar year (2008), divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days. A provider’s limit will be applied across all claim types, including professional services. Note: FY 2010 limits are based on submitted claims, irrespective of paid/denied status and/or individual lines, although interim/final bills and RAPs/final claims shall be considered as a unit. For example: Provider C billed 156,253 claims last year. The provider’s additional documentation limit would be (156253 *.01)/8= 195.31, or 195 additional documentation requests per 45 days. Provider D billed 50,000 inpatient claims, 75,000 outpatient claims, 20,000 SNF covered stays, 20,000 home health episodes of care, 250,000 physician claims, 10,000 inpatient rehab claims and 1.000 hospice claims. The total number of claims for this provider would equal 426,000. The provider’s additional documentation limit would be (426000*.01)/8= 532.5. The provider’s additional documentation limit would be 532 additional documentation requests every 45 days, if there were no cap in place (see below). While respecting a provider’s overall limit, the RAC may exercise discretion in the exact composition of an additional documentation request. For example, the RAC may request inpatient records up to the full limit even though the provider’s inpatient business may only be a small portion of their total claim volume. 3. Two caps will exist in FY 2010: Through March 2010, the cap will remain at 200 additional documentation requests per 45 days for all providers/suppliers. However, from April through September 2010, providers/suppliers who bill in excess of 100,000 claims to Medicare (per TIN, across all claims processing contractors) will have a cap of 300 additional documentation requests per campus unit, per 45 days. 4. In addition, in FY 2010 CMS will allow the RACs to request permission to exceed the cap. Permission to exceed the cap cannot be requested in the first six (6) months of the fiscal year. The expanded cap will not be automatic; the RACs must request approval from CMS on a case-by-case basis and affected providers will be notified prior to receiving additional requests. Questions concerning this update can be directed to RAC@cms.hhs.gov
  • • Copies are reimbursable at $0.12/pg Items to submit at 1stLevel of Appeal Appeal letter printed on hospital letterhead with case review and medical justification information RAC notice of denial Remittance advice for the recoupment (also called date “harmed”) Complete copy of the medical record Some facilities submit records with pages numbered for reference purposes and portions highlighted to demonstrate medical necessity, where applicable   • Items to Submit at 2nd Level of Appeal Form Letter from redetermination denial Initial appeal letter Any additional information supporting the claim and responding to the justification given by the FI for upholding the redetermination level denial • 3 rd 4 th and 5 th Levels of Appeal require personal appearances
  • Transcript

    • 1. Helping organizations manage the audit process Healthcare Audits and Enterprise Content Management (ECM) 7 steps to minimize pain
    • 2. So many audits so little time…
      • Medicare
      • QIO (Quality Improvement Organization)
      • CERT (Comprehensive Error Rate Test)
      • RAC (Recovery Audit Contractor)
      • ZPIC (Zone Program Integrity Contractors)
      • MAC (Medicare Administrative Contractors)
      • PSC (Program Safeguard Contractor)
      • Medicaid
      • MIP (Medicaid Integrity Program)
      • PERM (Payment Error Rate Measure)
      • MFCU (Medicaid Fraud Control Unit)
      • OIG (Office of Inspector General Audits)
      • Ancillary Audits
      • Permedion (Independent Medical Review Organization)
    • 3. 1 st Step to Minimize Pain… Form Audit Team
        • Audit Coordinator / Team Leader / Project Manager
          • Outside consultant or Internal Auditor
        • Patient Financial Services/Revenue Management
        • HIM / MR
        • QA / Compliance
        • Coding Specialist
        • Admin / Management
        • Medical Staff
        • Case Management
        • Clerical staff
    • 4. 2 nd Step to Minimize Pain… Response strategy
      • Over 11 agencies may audit an individual organization
        • If audited by a ZPIC, OIG or FBI – need an attorney ASAP
          • FBI – no prior notification – they will come knocking on your door
      • Internal Audits/Review
        • Identify if you are in compliance with audit guidelines/rules
        • Review processes (coding, etc.) – be proactive
        • Identify corrective actions to implement for compliance
          • Know where previous improper payments have been found
          • Know if you are submitting claims with improper payments
        • Learn from past experiences
      • Attend Coding courses
    • 5. 3 rd Step to Minimize Pain… Establish Response Process to Auditors
      • Implement procedures to promptly respond to audits and medical record requests
        • Who will be in charge of each stage of the process?
        • Generate practice letters, verify response times
        • Identify staff responsible for medical record requests
      • Initiate responses within the identified timeframes/deadlines
        • Claim $ could be lost
        • Lose appeal rights
        • Potential fines / loss of reimbursement
      • Keep track of denied claims and correct identified previous errors
    • 6.
      • Contractors / reviewers typically staff specialists to identify errors
        • Certified coders
        • Nurses and/or Therapists
        • Physician(s)
      • RAC specific info
        • CMS – New Issue Review Board provides greater oversight
        • RAC Validation Contractor
          • Provides annual accuracy scores for each RAC
          • If a RAC loses at any level of appeal, the RAC must return the contingency fee
      4 th Step to Minimize Pain… Ensure Claim / Process Accuracy
    • 7.
      • Adhere to the auditor’s medical record submission requirements
      • Prepare to respond to the auditor’s additional documentation requests
      • Limit the number of additional documentation requests
      • Most auditors will accept paper medical records
        • Some will accept medical records via CD/DVD
      • Send medical records in a tamper-proof package
        • Strongly suggest that all medical records be sent via trackable carriers
      5 th Step to Minimize Pain… Medical Record Submission
    • 8.
      • History
      • Presenting Problem
      • Medical Decision Making
      • Examination
      • Counseling
      • Coordination of Care
      • Time
      Do cumentation needed…
    • 9. 6 th Step to Minimize Pain… Review websites
      • Review CMS and ancillary audit websites
        • Ensure compliance with requirements and avoid submitting incorrect claims
        • Look to see what improper payments have been found in OIG and CERT reports
          • OIG reports: www.oig.hhs.gov/reports.asp
          • CERT reports: www.cms.hhs.gov/cert
      • RAC Specific information
        • CMS / Medicare RAC site
        • AHA RACTrac
    • 10. 7 th Step to Minimize Pain… Identify the Appeal Process
      • Identify guidelines for appeals
        • Internal or external resources
          • Agree upon criteria for the following:
            • When to appeal
            • How to initiate appeal
            • Identify trends for future claims generation
        • Appeals can cost organizations $ by hiring legal representation and can take years for a determination
          • Is it worth the cost to an organization to appeal?
    • 11. RAC Program Update Awareness
      • OnBase RAC = RACTrac Compatible Vendor
      • New issues will be reviewed by the CMS and a RAC Validation Contractor - updates on websites
      • Permanent program is expected to be more aggressive
      • RACs will be required to pay back contingency fees when an adverse determination is overturned upon appeal
      • Maximum look back period is 3 years - October 1, 2007
      • A Medicaid RAC Audit program is on the horizon…
    • 12. Schedule… Implementation nationwide January 1, 2010
    • 13.  
    • 14. Audit Limit Freq. MR Request Response MR Reimburse Discussion Period Collect $ Appeal Rights Mult. Audits RAC 200 inpt 45 days 45 days $0.12/page 15 days 41 st day 5 levels No MAC Unknown Unknown Unknown Unknown Unknown Unknown 2 levels Unknown PERM Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown ZPIC Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown CERT None Any 30 days Unknown Unknown State Regulated 2 levels Yes PSC Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown OIG Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown QIC Unknown Unknown MIC/MIP None State Regulated State Regulated None State Provider MIC State CMS State Regulated State Regulated Yes MFCU Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Permedion None Any 30 days N/A State Regulated State Regulated 2 levels Yes Audit Limit Freq. MR Request Response MR Reimburse Discussion Period Collect $ Appeal Rights Mult. Audits RAC 200 inpt 45 days 45 days $0.12/page 15 days 41 st day 5 levels No MAC Unknown Unknown Unknown Unknown Unknown Unknown 2 levels Unknown PERM Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown ZPIC Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown CERT None Any 30 days None Unknown State Regulated 2 levels Yes PSC Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown MIC/MIP None State Regulated State Regulated None State Provider MIC State CMS State Regulated State Regulated Yes MFCU Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Permedion None Any 30 days N/A State Regulated State Regulated 2 levels Yes
    • 15. OnBase RAC Solution
      • Designed to manage the provider’s appeal process to the RAC auditor and the denial of medical claims
        • Task Management
          • Track responsible employee assigned to each task
        • Configurable Parameters
        • Upload Claim History
        • Tracking functionality
          • Shipping information
          • Expected completion dates / appeal timelines
          • Medical record request costs
          • Interest due on recovered funds
          • Communication with RAC personnel
      • Dashboard Views:
        • Administration/Management
        • Financial
        • Risk Analysis
        • Process Improvement
    • 16. References
      • CMS releases details on 2009 permanent Recovery Audit Contractors (RACs) program. Retrieved Jan. 21, 2009. http://www.mgma.com/policy/default.aspx?id=23052
      • Frequently Asked Questions. (Jan. 25, 2008). Retrieved Jan. 21, 2009, from http://www.aha.org/aha/content/2008/pdf/080125-racfaq.pdf
      • Healthcare Compliance Quarterly Insights: Surviving RAC. Retrieved Jan, 22, 2008. http://www.hfma.org/forums/healthcare/Healthcare_Compliance_Tips_RAC_Audit.htm
      • Center for Medicare & Medicaid Services (CMS) Recovery Auditor Contractor (RAC) Program, AAHAM Position. Retrieved 12/1/2008. http://www.txaaham.org/files/AAHAM%20Position%20Paper%202008.pdf
      • Pennsylvania Physicians Facing CERT Audits . http://www.pamedsoc.org/CERT
      • How to Survive a Medicare Audit. (May, 16, 2009). Retrieved October 13, 2009 from http://www.aace.com/advocacy/socio/HowtoSurviveaMedicareAudit.pdf
      • Legal Note: Medicaid Integrity Contractors. (August 17, 2009). Retrieved October 13, 2009 from http://www.arkhospitals.org/Legal%20Note%20Archive.pdf/08-17-09%20Legal%20Note.pdf
      • Medicaid Integrity Program Provider Audit Fact Sheet (November 2008). Retrieved October 13, 2009 from http://www.aparx.org/members/documents/MIPprovauditfactsheet-Nov2008.pdf
      • Potential NCD Topics (July 30, 2008). Retrieved November, 2, 2009 from http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?id=19
    • 17.
      • CMS RAC Review Phase-in Strategy (6/24/09). Retrieved November 2, 2009. http://www.cms.hhs.gov/RAC/Downloads/CMS%20RAC%20review%20strategy.pdf
      • Medicare-Medicaid Data Match Program . Retrieved November 3, 2009.
      • nampi.org/members/2007presentations/MediMedi.pps
      • Hospital Payment Monitoring Program (HPMP) Compliance Workbook (January 2006). Retrieved November 4, 2009. http://www.hpmpresources.org/Portals/1/Tools/HPMPCompWkbk_03-2008.pdf
      • “ Data mining programs” intensify scrutiny of Medicare claim.   National Psychologist, Vol. 17, No. 5, p. 9.. Retrieved November 5, 2009. http://www.centerforhealthyaging.com/Medicare_Audits_NP.htm
      • Medicaid Integrity Program A to Z. Retrieved November 6, 2009. www.wsha.org/files/119/MIP_A_to_Z_for_Providers_Aug%2009.pdf
      • Recovery Audit Contractors (RACs) and Medicare, The Who, What , When, How and Why?. Retrieved November 19, 2009. http://www.cms.hhs.gov/RAC/Downloads/Recovery%20Audit%20Contractor%20(RAC)%20Program%20Slide%20Presentation.pdf
      •  
      References continued…
    • 18. time to make a difference.

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