Top Ten Tips for a Successful ALJ Hearing

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A comprehensive review of the Medicare appeal process. Appropriate for all SNF nursing staff, management, and therapy professionals. The presentation discusses the level of Medicare appeal, how facilities can thoroughly and timely manage the appeal process, and how facilities can participate in a successful ALJ hearing.

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Top Ten Tips for a Successful ALJ Hearing

  1. 1. Please note: Handouts and Recordings will be emailed following the webinar. Please allow for processing time. HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 1 Top Ten Tips for a Successful ALJ Hearing Hello everyone! To have the Audio experience, please Dial the number: 1 (626) 521-0032 Access code: 838-687-657 Audio pin will be shown after joining the training If you have any difficulties connecting, please call Mary at 1-978-887-8919 x 13
  2. 2. Top Ten Tips for a Successful ALJ Hearing HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Caroline Mullin, OTR/L, RAC-CT Claims Review Specialist
  3. 3. Harmony Healthcare International, Inc. About Caroline Claims Review Specialist 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 2014 All Rights Reserved 3
  4. 4. Objectives The Learner will be able to summarize goals of Medicare Medical Review The Learner will be able to identify and articulate examples of the Medicare Medical Review Process The Learner will be able to identify strategies for preparation and execution of an ALJ hearing Harmony Healthcare International, Inc. 4Copyright 2014 All Rights Reserved
  5. 5. Top Ten Tips for a Successful ALJ Hearing Auditing Agencies and Contractors Harmony Healthcare International, Inc. 5Copyright 2014 All Rights Reserved
  6. 6. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 6 Top Ten Tips for a Successful ALJ Hearing
  7. 7. OIG Audits How We Got Here Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 8. Wall Street Journal, November 12, 2012 Thomas Burton, November 2012 “More intensive services were done than actually performed” “Patients could not benefit from it” “Cutting fraud” Obama Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. Wall Street Journal Sample 499 claims by 245 (stays) nursing facilities 1 home reached a settlement agreement on allegations of fraudulent billing for “medically unnecessary” therapy “More therapy during the period on which bills were based” “Look-Back Period” Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 9
  10. 10. OIG Report: Claims in 2009 25% billed all claims in error 1.5 billion 26% claims not supported in the medical record 542 million in over payment “Majority” error “upcoded”* Many Ultra High * Original RUG was a higher paying RUG than the revised RUG Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 10
  11. 11. OIG Report: Claims in 2009 20.30% 2.50% 2.10% 75.10% Billing Errors Issues found with skilled-nursing facilities’ Medicare claims, based on an outside review of 2009 data Properly billed Billed for a more expensive treatment than was provided Billed for a less expensive treatment than was provided Billed for a condition not covered by Medicare Source: Department of Health and Human Services Office of Inspector General Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 11
  12. 12. Increase and expand reviews of SNF claims CMS should instruct its contractors to conduct more medical reviews of SNF claims Use its Fraud Prevention System to Identify SNFs that are Billing for Higher Paying RUGs CMS should use its Fraud Prevention System to identify and target these SNFs Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 12 OIG Recommendations
  13. 13. Monitor Compliance with the New Therapy Assessments As of October 2011, SNFs must complete a “change of therapy” assessment when the amount of therapy provided no longer reflects the RUG and an “end of therapy” assessment when therapy is discontinued for 3 days Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 13 OIG Recommendations
  14. 14. OIG Recommendations CMS should instruct its MACs and RACs to closely monitor SNFs utilization of these assessments through analyses of claims data. Such analyses will identify SNFs that are using the assessments infrequently or not at all. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 14
  15. 15. Change the Current Method for Determining How Much Therapy is Needed to Ensure Appropriate Payments CMS should instruct the MACs to provide education to all SNFs, as well as specific training to selected SNFs, to improve the accuracy of their MDS reporting Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 15 OIG Recommendations
  16. 16. Follow up on the SNFs That Billed in Error In a separate memorandum, we will refer to CMS for appropriate action for the SNFs with claims in our sample that had inaccurate RUGs or that did not meet coverage requirements Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 16 OIG Recommendations
  17. 17. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 17 Top Ten Tips for a Successful ALJ Hearing Recovery Audit Contractors 17
  18. 18. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 18 Recovery Audit Contractors The Recovery Auditors Program Mission The Recovery Auditor detect and correct past improper payments so that CMS can implement actions that will prevent future improper payments: Providers can avoid submitting claims that do not comply with Medicare rules CMS can lower its error rate Taxpayers and future Medicare beneficiaries are protected 18
  19. 19. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 19 Recovery Audit Contractors If you bill fee-for-service programs, your claims will be subject to review by the Recovery Auditors Target areas are posted on the RACs’ websites 19
  20. 20. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 20 Recovery Audit Contractors The Recovery Audit Review Process: Recovery Auditors review claims on a post-payment basis Recovery Auditors use the same Medicare policies as Carriers, FIs and MACs: NCDs, LCDs and the CMS Manuals Three types of review: Automated (no medical record needed) Semi-Automated (claims review using data and potential human review of a medical record or other documentation) Complex (medical record required) Recovery Audits look back three years from the date the claim was paid Recovery Auditors are required to employ a staff consisting of nurses, therapists, certified coders and a physician CMD 20
  21. 21. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 21 Recovery Audit Contractors The appeal process for Recovery Audit denials is the same as the appeal process for Carrier/FI/MAC denials “Discussion Period” by phone in the first 15 days of denial If you disagree with the Recovery Auditor’s determination: File within 30 days to avoid recoupment Up to 120 days to appeal Interest will still accrue during the appeal process 21
  22. 22. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 22 Top Ten Tips for a Successful ALJ Hearing ZPIC Audit
  23. 23. Frequency of Medical 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 2014 All Rights Reserved Harmony Healthcare International, Inc. 23
  24. 24. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 24 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
  25. 25. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 25 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
  26. 26. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 26 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
  27. 27. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 27 ZPIC Audits ZPIC targets are often selected based on Unusual trends or changes in utilization over time Specific schemes noted by CMS that inappropriately maximize generated reimbursement Referrals from law enforcement and other sources for possible fraud and abuse High volume or high cost services that appear like they are being over utilized
  28. 28. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 28 ZPIC Audit Targets Providers with patients having unusually long lengths of service or high-case mix levels HHAs with patients having extended numbers of visits Hospice providers with high, length-of-stay patients A SNF with a large volume of high “RUG” level claims Disgruntled employee who threatened you as a “whistleblower” Operators in areas identified as high risk for fraud (Miami-Dade and Broward Counties)
  29. 29. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 29 ZPIC Audits ZPICs are specifically allowed to Place you on pre-payment review The pre-payment review flag remains until a determination is issued on the audit, which can take a long time Place you on billing suspension Withhold payments
  30. 30. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 30 ZPIC Audits; What auditors demand at an unscheduled visit Require proof that you are operating at the identified practice locations Interview your staff Required documentation that you meet conditions of participation Submit a request for records, including: Business records Medical records Members of law enforcement can accompany ZPIC auditors
  31. 31. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 31 ZPIC Audits; How to Prepare? Create or review your Compliance Plan Have an outside party conduct an annual coding accuracy review Perform data analysis to determine areas of exposure Review documentation procedures Train staff on how to respond to questions from ZPIC auditors
  32. 32. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 32 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?
  33. 33. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 3333 On-site Medical Record Review Audits Sample MDS staff interview questions: 1. Who decides the ARD? 2. Do they provide group and concurrent treatments?
  34. 34. Harmony Healthcare International Top 10 Tips for a Successful ALJ Hearing Harmony Healthcare International, Inc. 34Copyright 2014 All Rights Reserved
  35. 35. Harmony Healthcare International Tip #1: Know your Medicare guidelines Harmony Healthcare International, Inc. 35Copyright 2014 All Rights Reserved
  36. 36. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 36 Top Ten Tips for a Successful ALJ Hearing Medicare Medical Review Claim Determinations 36
  37. 37. Technical Denial Reasons Response to Additional Documentation Request (ADR) did contain documentation requested Documentation not received within requested time frame Physician Certification not signed or missing Therapy Billing logs do not support billing Part A – MDS Assessment Part B - 8 Minute Rule Illegible documentation Hospital documentation was not submitted Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 37
  38. 38. Clinical Denial Reasons Documentation did not support medical necessity Documentation does not support daily skilled intervention by a qualified therapist Documentation in the medical records must support continued progress Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 38
  39. 39. Denial Reasons Services provided were likely clinically appropriate but the documentation provided to reviewers did not support: Technical requirements Medical necessity The skills of a therapist were required Functional outcome Need to receive an inpatient level of care Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 39
  40. 40. Denial Reasons Reasonable and Necessary The amount, frequency and duration of services were not reasonable, given the patient’s current status ST documentation demonstrates that the therapist worked long enough with the beneficiary to develop a restorative program Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 40
  41. 41. Denial Reasons Skills of a Therapist ST minutes were reduced based on clinical judgment because documentation did not support the billed minutes were reasonable and necessary. The beneficiary could not participate in self feeding during this period and required the speech therapist to assist with 100% of the feeding. Documentation did not support medical necessity and need for continued skilled therapy. Patient needs assistance and supervision. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 41
  42. 42. Denial Reasons Deconditioning Skills of a therapist are not required to maintain function or improve strength and endurance Services related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation), do not constitute physical therapy services for Medicare purposes Practicing of previously taught exercises does not require the skills of a therapist Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 42
  43. 43. 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 Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 43
  44. 44. 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 Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 44
  45. 45. Denial Reasons Prior Level of Function The therapist ignored the patient’s prior level of function and set unrealistic goals Prior level of function was illegible. Prior level of function was blank. Patient's functional level had not changed when compared to his prior level of functioning documented in the medical record Weekly nursing progress notes demonstrate that the beneficiary required the same amount of assistance (extensive assistance) prior to and after the hospital stay Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 45
  46. 46. Denial Reasons Rehab Potential The medical record did not support that the condition of the patient would improve materially in a reasonable and generally predictable period of time Poor Rehab potential Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 46
  47. 47. Denial Reasons Goals Goals are not functional (i.e., patient will perform 10 repetitions of upper extremity exercises with the yellow theraband) Duplication of services between disciplines Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 47
  48. 48. Denial Reasons Lack of Functional Progress Gains were not significant and there was no indication of carryover of the functional task Lack of documentation relating to the patient having the potential to show significant progress No significant improvement with functional ability The outcome of therapy treatment was not documented Failure to document a complete treatment plan as outlined in Documentation Required section Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 48
  49. 49. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. Skilled Interventions Medicare will support continued services when the patient is not making progress if there is documentation that multiple skilled interventions have been trialed It is appropriate to give each trial an adequate amount of time to determine if the patient will progress 49
  50. 50. 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 Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 50
  51. 51. Denial Reasons Cognitive Therapy The record documented a diagnosis of Alzheimer’s disease. SLP documentation does not support further significant practical improvement could be expected. Medical justification for ST services is not established Speech treatment cognition for dementia Poor progress with cognition Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 51
  52. 52. 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 Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 52
  53. 53. 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 Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 53
  54. 54. Documentation to Support Identified Risk Areas Identify potential denial risk areas What might the reviewer have not seen in the documentation provided to lead the reviewer to deny services? What additional documentation may be included to further support skilled rehabilitation and nursing services provided? Consultations/ED Visits Care Plan Physician Progress Notes Social Services/Dietary Notes Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 54
  55. 55. What is Skilled Care? Anchoring the Skill Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 55
  56. 56. Copyright 2014 All Rights Reserved Medicare Requirements The patient requires Skilled Nursing Services or Skilled Rehabilitation Services (i.e., services that must be performed by or under the supervision of professional or technical personnel) (See §214.1 – 214.3) Harmony Healthcare International, Inc. 56
  57. 57. Medicare Eligibility Treated for a condition which was treated during a qualified stay…or… which arose while in a SNF for a treatment of condition for which the beneficiary previously was treated in a hospital For Example: Fractured hip develops pneumonia secondary to immobility Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 57
  58. 58. Copyright 2014 All Rights Reserved Medicare Requirements The patient requires these skilled services on a daily basis (see §214.5) Daily Nursing Notes Treatment Sheets Harmony Healthcare International, Inc. 58
  59. 59. 59 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 © 2014 All Rights Reserved
  60. 60. Harmony Healthcare International Medicare Benefit Policy Manual Chapter 8 Revisions December 2013 Harmony Healthcare International, Inc. 60Copyright 2014 All Rights Reserved
  61. 61. Why Update the Policy Manual? CMS Settlement CMS revised the Medicare Benefit Policy Manual (December 2013) and will revise other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a beneficiary "improving" New policy provisions state that skilled nursing and therapy services necessary to maintain a person's condition can be covered by Medicare Harmony Healthcare International, Inc. 61Copyright 2014 All Rights Reserved
  62. 62. Medicare Benefit Policy Manual Update “Coverage for such skilled therapy services does not turn on the presence or absence of a beneficiary’s potential for improvement from therapy services, but rather on the beneficiary’s need for skilled care. Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) These skilled services may be necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” - December 2013 Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 62
  63. 63. Medicare Benefit Policy Manual Update (continued) Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) These skilled services may be necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition” - December 2013 Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 63
  64. 64. Medicare Benefit Policy Manual Update “The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that The condition of the patient will improve materially in a reasonable and generally predictable period of time; or, The services must be necessary for the establishment of a safe and effective maintenance program; or, The services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program” – December 2013Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 64
  65. 65. RAI User’s Manual Update RAI User’s Manual September 2013: Therapy services can include the actual performance of a maintenance program in those instances where the skills of a qualified therapist are needed to accomplish this safely and effectively However, when the performance of a maintenance program does not require the skills of a therapist because it could be accomplished safely and effectively by the patient or with the assistance of non-therapists (including unskilled caregivers), such services are not considered therapy services in this context Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 65
  66. 66. Harmony Healthcare International Tip #2: Ensure your medical record has supportive documentation Harmony Healthcare International, Inc. 66Copyright 2014 All Rights Reserved
  67. 67. Harmony Healthcare International, Inc. 67 What is Skilled Care ? Direct Skilled Nursing Services Management and Evaluation of a Care Plan Observation and Assessment Teaching and Training Skilled Rehabilitation Copyright 2014 All Rights Reserved
  68. 68. Skills of a Therapist or a Nurse Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 68 Services must require the expertise, knowledge, clinical judgment, decision making and abilities of a therapist or a nurse that qualified personnel, trained caretakers or the patient cannot provide independently
  69. 69. Skills of a Therapist or a Nurse Documentation must support: Description of skilled treatment Changes made to the plan of care due to assessment of the patient’s needs Medical complexity Why the clinical and critical thinking of a therapist or a nurse are required Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 69
  70. 70. Harmony Healthcare International Tip #3: The best defense is a good offense Harmony Healthcare International, Inc. 70Copyright 2014 All Rights Reserved
  71. 71. How Does Your Team Measure Up? Take the Harmony Healthcare International (HHI) Denied Claims Appeals Process Proficiency Exam http://info.harmony-healthcare.com/medicare- denied-claims-guide Harmony Healthcare International, Inc. 71Copyright 2014 All Rights Reserved
  72. 72. How Does Your Team Measure Up? 1. To what degree does your facility have a monthly Triple Check system in place? a. The team meets every month to review UB-04s, MDS assessments, and Therapy Billing Logs b. The team tries to meet each month, but sometimes it’s hard to get the team together c. The Billing Department double checks everything d. There is no a Triple Check system in place Harmony Healthcare International, Inc. 72Copyright 2014 All Rights Reserved
  73. 73. How Does Your Team Measure Up? 2. ICD-9 codes on the UB-04 are determined using which of the following methods? a. The ICD-9 coding is updated monthly as the patient’s skilled nursing and therapy needs change b. The ICD-9 coding is determined shortly after the patient is admitted based on nursing and therapy needs c. The ICD-9 coding is discussed by the team prior to end of month billing to ensure codes reflect the reason for hospitalization and skilled nursing needs d. ICD-9 codes on the UB-04 are not a priority and likely do not reflect the patient’s skilled needs Harmony Healthcare International, Inc. 73Copyright 2014 All Rights Reserved
  74. 74. How Does Your Team Measure Up? 3. Which item best represents how therapy evaluations support a decline in function? a. Therapy evaluations document a clear prior level of function and a significant decline from the patient’s highest practicable level of function b. Therapy evaluations document a clear prior level of function, but not all functional areas are tested on evaluation c. Therapists are not always able to obtain a prior level of function or not all functional areas are tested on evaluation d. Evaluations lack the details required to support a decline in function Harmony Healthcare International, Inc. 74Copyright 2014 All Rights Reserved
  75. 75. How Does Your Team Measure Up? 4. Accuracy on the Physician Certification Forms to reflect the skilled care provided by the Nursing and Therapy departments is achieved through which process below? a. Skilled qualifiers notated on the Certification forms are discussed as an interdisciplinary team and reflect the details of both nursing and therapy skilled services b. Skilled qualifiers are pulled from the hospital discharge summary; therapy disciplines are also listed if the patient is evaluated per physician orders c. Physician ordered therapies are listed on the form; the skilled nursing needs are only included if therapy is not involved d. Physician Certification Forms are not in use Harmony Healthcare International, Inc. 75Copyright 2014 All Rights Reserved
  76. 76. ADR/Help Letter Checklist Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 76 HELP LETTER REVIEW CHECK LIST Period Skilled Nursing Chart Review: From: __________________ To: _________________ Medicare Admission Date: ___________ Diagnosis: ________________________________ MDS Reference Dates Review 5 day 14 day 30 day 60 day 90 day SOT/EOT OMRA ARD Billing Dates RUG/HIPPS COT COT COT COT COT COT ARD Billing Dates RUG/HIPPS ICD-9 Codes ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
  77. 77. Harmony Healthcare International Tip #4: You have to play to win! Harmony Healthcare International, Inc. 77Copyright 2014 All Rights Reserved
  78. 78. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 78Harmony Healthcare International, Inc. 78 Top Ten Tips for a Successful ALJ Hearing What To Do When You Get An ADR
  79. 79. Help Letters and Appeals In order to effectively manage a Medicare Help Letter or denied claim, the facility must work as a team to gather pertinent information Assign a team leader to oversee the preparation of the ADR/appeal package All members of the team should review the medical record to ensure completeness Harmony Healthcare International, Inc. 79Copyright 2014 All Rights Reserved
  80. 80. Help Letters and Appeals The following team members are beneficial in this process: MDS Coordinator Director of Nursing Unit Managers (consider) Restorative Nursing program Manager Director of Therapy Any therapy professionals involved in the patient’s care Social Services Dietary Additional team members who participated in care Harmony Healthcare International, Inc. 80Copyright 2014 All Rights Reserved
  81. 81. Help Letters and Appeals 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. 81Copyright 2014 All Rights Reserved
  82. 82. Help Letters and Appeals 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. 82Copyright 2014 All Rights Reserved
  83. 83. Top Ten Tips for a Successful ALJ Hearing Appealing Medicare Denied Claims Harmony Healthcare International, Inc. 83Copyright 2014 All Rights Reserved
  84. 84. 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. 84Copyright 2014 All Rights Reserved
  85. 85. 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. 85Copyright 2014 All Rights Reserved
  86. 86. 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. 86Copyright 2014 All Rights Reserved
  87. 87. 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. 87Copyright 2014 All Rights Reserved
  88. 88. Appeal Process 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. 88Copyright 2014 All Rights Reserved
  89. 89. 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. 89Copyright 2014 All Rights Reserved
  90. 90. Harmony Healthcare International Tip #5: Do it right the first time Harmony Healthcare International, Inc. 90Copyright 2014 All Rights Reserved
  91. 91. Appeal Rights Medicare offers five levels in the Part A and Part B Appeals Process: 1. Redetermination by a MAC 2. Reconsideration by a QIC 3. Hearing by an Administrative Law Judge (ALJ) 4. Review by the Medicare Appeals Council, within the Department Appeals Board 5. Judicial review in U.S. District Court Harmony Healthcare International, Inc. 91Copyright 2014 All Rights Reserved
  92. 92. Appeal Rights Right to Appeal All appeal requests must be made in writing Harmony Healthcare International, Inc. 92Copyright 2014 All Rights Reserved
  93. 93. The Appeal Package List of items typically requested: Initial MDS and any MDS that corresponds to the billed dates of service and look back All physician documentation for dates of service in question Physician’s orders MD certifications MD progress notes History and Physical Harmony Healthcare International, Inc. 93Copyright 2014 All Rights Reserved
  94. 94. The Appeal Package Items to include Include all information in the medical record from the look back period MD re-certifications for skilled stay for billed dates: If certification is signed by a NP, be aware that there may be a request for the facility to submit an attestation letter verifying no direct or indirect employment relationship with the SNF Harmony Healthcare International, Inc. 94Copyright 2014 All Rights Reserved
  95. 95. The Appeal Package Items to include Pre admission data Hospital Records that validate a qualifying stay Daily Nurses notes MDSC notes Case Manager notes Care Plan MAR and TAR Harmony Healthcare International, Inc. 95Copyright 2014 All Rights Reserved
  96. 96. The Appeal Package Items to include Documentation of all therapies provided Evidence of MD supervision Evaluations Progress notes and Therapy billing logs Any other documentation that relates to the condition for which services were rendered that skilled the patient for Medicare Part A services in the Skilled Nursing Facility Harmony Healthcare International, Inc. 96Copyright 2014 All Rights Reserved
  97. 97. The Appeal Package Items to include Diagnostic testing and lab work Documentation of adjustment to HIPPS codes resulting from MDS corrections Signature log for all staff members documenting in the medical record during the dates in question, including printed name, credentials and handwritten signatures Harmony Healthcare International, Inc. 97Copyright 2014 All Rights Reserved
  98. 98. The Appeal Package Each team member should review the package as a whole The team leader should have a final look prior to submitting the appeal PREP Letter Proper Reimbursement Explanation Paper Always keep a copy of the packet sent to the reviewing agency Harmony Healthcare International, Inc. 98Copyright 2014 All Rights Reserved
  99. 99. Appeal Rights Redetermination A review of the claim by the MAC utilizing personnel who are different from the personnel who made the initial determination The appellant (individual filing the appeal) has 120 days from the date of receipt of initial denial to file an appeal A minimum monetary threshold is not required to request a redetermination Harmony Healthcare International, Inc. 99Copyright 2014 All Rights Reserved
  100. 100. Appeal Rights Reconsideration If the facility is dissatisfied with result of redetermination, they may request a reconsideration A Qualified Independent Contractor (QIC) will conduct the reconsideration The reconsideration process is an independent review of medical necessity by a panel of physicians or other health care professionals A minimum monetary threshold is not required to request a reconsideration Harmony Healthcare International, Inc. 100Copyright 2014 All Rights Reserved
  101. 101. Appeal Rights ALJ Hearing If at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration The facility must also send a notice of the ALJ hearing request to the QIC and verify this on the hearing request form or in the written request Harmony Healthcare International, Inc. 101Copyright 2014 All Rights Reserved
  102. 102. ALJ Overview After the redetermination and reconsideration process, if at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration Combine claims to reach $130 if necessary The facility must send a notice of the ALJ hearing request to the QIC on the hearing request form or in the written request Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 102
  103. 103. ALJ Overview A letter to request the ALJ hearing should simply highlight the most pertinent reasons justifying payment Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 103
  104. 104. Harmony Healthcare International Tip #6: Submit supportive decisions Harmony Healthcare International, Inc. 104Copyright 2014 All Rights Reserved
  105. 105. ALJ Overview Submit a statement of justification Submit the medical record Submit any favorable decisions from the QIC that support skilling the patient in review Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 105
  106. 106. ALJ Overview ALJ hearings are generally held by video-teleconference (VTC) or by telephone If the facility prefers not to have a VTC or telephone hearing, they may ask for an in-person hearing, but they must demonstrate the necessity for an in- person hearing Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 106
  107. 107. ALJ Overview The ALJ will determine whether an in-person hearing is warranted on a case-by-case basis Facilities may also ask the ALJ to make a decision without a hearing (on-the-record) CMS or its contractors may participate in an ALJ hearing, but they must provide notice to the ALJ and all parties of the hearing Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 107
  108. 108. ALJ Overview ALJ will generally issue a decision within 90 days of receipt of the hearing request The timeframe may be extended for a variety of reasons including, but not limited to: The case being escalated from the reconsideration level The submission of additional evidence not included with the hearing request The request for an in-person hearing The facility’s failure to send notice of the hearing request to other parties and The initiation of discovery if CMS is a party Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 108
  109. 109. ALJ Overview If the ALJ does not issue a decision within the applicable timeframe, you may ask the ALJ to escalate the case to the Appeals Council level Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 109
  110. 110. ALJ Office of Medicare Hearings and Appeals (OHMA) Administrative law judge hearings will not be assigned to a judge for at least two years OMHA stopped assigning new hearing requests from providers as of July 15, 2013 The weekly influx of hearing requests surged from an average of 1,250 in January 2012 to more than 15,000 in December 2013 Medicare Appellant Forum to provide updates to OMHA appellants on the status of OMHA operations http://www.hhs.gov/omha/omha_medicare_appellant_foru m.html Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 110
  111. 111. ALJ Hearing Preparation Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 111
  112. 112. Harmony Healthcare International Tip #7: Work as a team Harmony Healthcare International, Inc. 112Copyright 2014 All Rights Reserved
  113. 113. ALJ Hearing Preparation Appeal Process Discuss and study CMS Guidelines Discuss type of ALJ hearing (video, phone, in person) to anticipate the format Goals of the Hearing Inform the Judge of skilled services Get the claim paid Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 113
  114. 114. ALJ Hearing Preparation Team Preparation Medical record review Outline of speaking points Select a point person for the hearing Team input Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 114
  115. 115. ALJ Hearing Preparation The following team members are beneficial in this process: MDS Coordinator Director of Nursing Unit Managers (consider) Restorative Nursing program Manager Director of Therapy Any therapy professionals involved in the patient’s care Social Services Dietary Additional team members who participated in care Harmony Healthcare International, Inc. 115Copyright 2014 All Rights Reserved
  116. 116. ALJ Hearing Hearing Process Prepare the facility designated hearing room for video or phone hearings Judge’s assistant will initiate the phone contact (test phone lines and speakers) Introductions Statement by facility Offer to fax any pertinent documents discussed during the hearing Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 116
  117. 117. Harmony Healthcare International Tip #8: Be organized Harmony Healthcare International, Inc. 117Copyright 2014 All Rights Reserved
  118. 118. ALJ Hearing Organize documentation Keep pertinent notes or forms at your finger tips Number the pages for reference Have the staff that worked with patient on the call Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 118
  119. 119. Harmony Healthcare International Tip #9: Be concise and use plain language Harmony Healthcare International, Inc. 119Copyright 2014 All Rights Reserved
  120. 120. ALJ Hearing Speak respectfully, clearly, slowly Provide a concise summary Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 120
  121. 121. ALJ Hearing Be prepared to answer questions prepared by the Judge Why did the patient require skilled therapy when they were hospitalized for a UTI? Where does the medical record state that continued therapy services were necessary after the initial date in question? Explain why skilled care continued although the notes indicate the patient did not have an exacerbation of medical condition? Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 121
  122. 122. ALJ Hearing Be prepared to answer questions asked by the Judge When did the patient get discharged from therapy services? Why do the daily nursing notes state the patient was ambulating ad lib, yet physical therapy continued to provide skilled treatment? Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 122
  123. 123. ALJ Success 37% favorable, 4% partially favorable 30% unfavorable 1% remanded 27% dismissed Favorable decisions will result in securing payment for services, plus interest accrued Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 123
  124. 124. Harmony Healthcare International Tip #10: Practice makes perfect Harmony Healthcare International, Inc. 124Copyright 2014 All Rights Reserved
  125. 125. Keys to Success 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.Copyright 2014 All Rights Reserved 125
  126. 126. Keys to Success Raise Facility Awareness Function as a TEAM Communication Organization Harmony Healthcare International, Inc. 126Copyright 2014 All Rights Reserved
  127. 127. Keys to Success Provide clinically appropriate care Document Medical necessity Deficits Outcomes Meet technical requirements Review entire medical record Respond to ADRs timely Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 127
  128. 128. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 cmullin@Harmony-Healthcare.com Harmony Healthcare International, Inc. 128Copyright 2014 All Rights Reserved
  129. 129. Harmony Healthcare International (HHI) For attending this seminar, you are eligible for one of the following: Free PEPPER Analysis Free RUGS Analysis Assess your facility against key indicators and national norms. Contact us at: RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc. 129Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved
  130. 130. Upcoming Seminars & Webinars Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. A Hands on Approach on How to Respond to ADR’s & Appeals in the SNF August 4, 2014: 8:30am-3:30pm Harmony University, Topsfield, MA Speaker: Carrie Mullin, OTR/L, RAC-CT, Claims Review Specialist 130 Online Registration Coming Soon! http://www.harmony-healthcare.com/education- training/schedule/ Visit our website for webinars, seminars & workshops!
  131. 131. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 131 Register online http://info.harmony-healthcare.com/harmony2014 or by phone (978) 887-8919 ext. 13 Register Online
  132. 132. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 132

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