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.
The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing the goals of Medical Review and various Medical Review programs including Recovery Audit Contractor (RAC) and Carrier (Medicare Administrative Contractor or Fiscal Intermediary) Medical Review programs.
This presentation reviews the key points of therapy and nursing documentation to support skilled care. Carrie will share tips and strategies for both responding to a medical record request and appealing a denied claim. Recommended for Administrators, Executive Directors, CEOs, CFOs, COOs and Interdisciplinary Staff.
A comprehensive review of the Medicare appeal process. Appropriate for all SNF nursing staff, management, and therapy professionals. The presentation discusses the various levels of Provider Medicare appeal rights. The presentation further explains how facilities can thoroughly manage the appeal process and participate in a successful ALJ hearing.
The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing the goals of Medical Review and various Medical Review programs including Recovery Audit Contractor (RAC) and Carrier (Medicare Administrative Contractor or Fiscal Intermediary) Medical Review programs.
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.
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) was released in April 2014 by CMS. CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Audit Contractors (RACs). This important report details your facility-specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries).
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of the medical review is to determine whether the services provided are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. This presentation discusses recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The presentation highlights specific denial trends associated with claims following hospitalization for a psychiatric diagnosis. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
1. Learn to summarize goals of Medicare Medical Review.
2. Learn identify and articulate examples of the Medicare Medical Review Process.
3. Learn to identify strategies for interdisciplinary management of Medicare documentation requests and appeals.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. As a Skilled Nursing Facility leader, are you confident in your ability to appeal any and all denied claims that may arise in your building?
The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing the goals of Medical Review and various Medical Review programs including Recovery Audit Contractor (RAC) and Carrier (Medicare Administrative Contractor or Fiscal Intermediary) Medical Review programs.
This presentation reviews the key points of therapy and nursing documentation to support skilled care. Carrie will share tips and strategies for both responding to a medical record request and appealing a denied claim. Recommended for Administrators, Executive Directors, CEOs, CFOs, COOs and Interdisciplinary Staff.
A comprehensive review of the Medicare appeal process. Appropriate for all SNF nursing staff, management, and therapy professionals. The presentation discusses the various levels of Provider Medicare appeal rights. The presentation further explains how facilities can thoroughly manage the appeal process and participate in a successful ALJ hearing.
The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing the goals of Medical Review and various Medical Review programs including Recovery Audit Contractor (RAC) and Carrier (Medicare Administrative Contractor or Fiscal Intermediary) Medical Review programs.
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.
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) was released in April 2014 by CMS. CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Audit Contractors (RACs). This important report details your facility-specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries).
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of the medical review is to determine whether the services provided are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. This presentation discusses recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The presentation highlights specific denial trends associated with claims following hospitalization for a psychiatric diagnosis. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
1. Learn to summarize goals of Medicare Medical Review.
2. Learn identify and articulate examples of the Medicare Medical Review Process.
3. Learn to identify strategies for interdisciplinary management of Medicare documentation requests and appeals.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. As a Skilled Nursing Facility leader, are you confident in your ability to appeal any and all denied claims that may arise in your building?
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends associated with Medicare Part B Claims. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
As digitization of the healthcare industry increases, the need to safeguard electronic patient data is also becoming increasingly important. Electronic protected health information (ePHI) is not just in the electronic medical records (EMRs). It also resides in emails, in documents and images on computers, servers, printer hard drives and mobile devices like laptops, cell phones, tablets and USB memory sticks. Healthcare professionals are also using texting and online file sharing services to conveniently share confidential information. The loss of this confidential patient health information is disastrous for patients and healthcare organizations.
Can your Skilled Nursing Facility (SNF) afford to provide care to Medicare patients and not receive accurate and appropriate reimbursement? The resources utilized to respond to additional documentation requests, manage denials and the loss of revenue for care provided can have a devastating impact on your facilities budget. In addition, early identification of potential issues and prompt resolution of actual issues reduces a facilities risk of hefty fines and penalties related to non-compliance.
Skilled Nursing Facilities are required to have a compliance program effective March 2013. Compliance programs strengthen and document a SNFs efforts to prevent and reduce Medicare fraud and abuse and ensure accurate and appropriate reimbursement for quality care provided. Under SNF compliance regulations Medicare has redefined the definition of fraud. When a facility has not taken all the necessary steps to ensure all the technical and clinical qualifications are supported by your medical records to prevent improper billing, fines and penalties may be applied. The critical components of an effective compliance program include monitoring and auditing to ensure Skilled Nursing Facility provider's have a formalized and proactive approach towards detecting fraud, abuse, and waste of precious company resources.
Provisions set forth in the Affordable Care Act (ACA) require the Centers for Medicare and Medicaid Services (CMS) to broaden quality improvement activities in nursing homes. Although the mandatory implementation date for nursing homes to provide evidence of a systematic Quality Assurance and Performance Improvement (QAPI) program has been delayed, but facilities should not delay in implementing a detailed and well-documented QAPI program. This presentation moves beyond the five elements of a QAPI and begins to drill down to practical concepts for “beefing up” an existing Quality Improvement program to meet QAPI standards. Learn how to objectively assess where your facility is in the QAPI journey, and gain a deeper insight into how practical implementation of QAPI activities can be a part of the culture of excellence that is part of all successful nursing homes.
1. Learn to detail the five elements of QAPI and correlate the five elements to the twelve step action plan for QAPI implementation.
2. Learn to articulate the steps to evaluating their facilities progress in QAPI efforts.
3. Understand Performance Improvement Projects (PIPs).
4. Learn the five steps of Root Cause Analysis (RCA) and learn how to apply the RCA process to adverse events in their facility routinely.
In February 2013, the Office of Inspector General (OIG) released a report entitled Skilled Nursing Facilities Often Fail to Meet Care Planning Requirements, in which they found that 26% of facilities fail to meet care planning requirements. Is your facility meeting federal guidelines for care planning? This presentation discusses the important link between the MDS 3.0, the Care Area Assessments (CAAs) and the care plan. Learn the essential components of a resident-centered care plan, how to develop a care plan that supports the clinical care that is provided to the patient, and how to proactively maintain a care plan that will meet annual survey requirements. The presentation discusses strategies for completing the CAAs more effectively, and how the CAA process can be used to create a more resident-specific care plan. Learn to develop a resident centered known as ( I careplan) through a workshop discussing different elements of the careplan, from profile, interim, and diagnosis.
1. Gain an understanding of the purpose of a Care Plan.
2. Learn to define the purpose of the discharge Care Plan and Summary.
3. Learn to to articulate the link between the MDS 3.0 assessment, the nursing Care Plan, the discharge Care Plan, and accurate RUG-IV classification.
4. Understand the the correlation between the MDS 3.0 assessment, the Care Area Assessments (CAAs), and the Care Plan.
Survey preparation is a never ending process and with the new QIS survey process in transition, it represents a new paradigm shift. This presentation will provide insight into key elements, tips and strategies that providers should use as part of their quality assurance survey preparation efforts. Learn from this multi-level licensed nursing home administrator with expertise in regulatory compliance sharing his lessons learned through the years.
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) was released in April 2014 by CMS. Join Keri Hart, MS, CCC-SLP, CHHRP-QT, RAC-CT, in this in-depth interpretation of the elements of the PEPPER. Keri will detail how to interpret your PEPPER and discuss the practical application of this critical information to your Skilled Nursing Facility’s practice. Follow along with your own PEPPER report to develop an action plan to ensure compliance with Medicare regulatory requirements and ensure accurate reimbursement for clinically appropriate care provided.
CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Audit Contractors (RACs). This important report details your facility-specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries).
Improve participation and functional outcomes through creativity out of the gym. Functionally based treatment will ensure patients receive medically necessary physical therapy, occupational therapy and speech services. The presentation reviews practical application to Medicare requirements.
1. Learn to identify creative treatment strategies.
2. Learn to define Medicare coverage and Medicare documentation.
3. Learn to identify the clinical benefits of Functional Based Therapies.
“Documentation not supportive of the RUG-IV classification billed…” is cited as the reason for multiple post-payment medical record review denials. Accurate and concise documentation to support the RUG-IV classification billed is a critical element in gaining accurate reimbursement, and supporting that reimbursement level during a medical review. This presentation covers the technical and clinical requirements for Medicare coverage, and requirements of skilled nursing documentation. The presentation identifies areas of the MDS 3.0 that are vulnerable to error and critical to accurate RUG-IV classification and identify strategies for better supporting these areas in medical record documentation. The correlation between the MDS 3.0 assessment and publicly reported information for the Quality Measures and 5 Star Quality Reporting are discussed.
1. Learn to describe the technical and clinical requirements for Medicare coverage.
2. Understand the goal of supportive skilled nursing documentation.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn to identify sections of the MDS 3.0 assessment that are vulnerable to error and articulate strategies to support these areas in medical record documentation.
5. Learn to identify the correlation between medical record documentation, the MDS 3.0, and publicly reported information for the Quality Measures and 5 Star Quality Rating.
Preventing falls in the SNF environment can be a challenge. Learn how to become a fall CSI and inspire your interdisciplinary team to meet the challenge of Falls Reduction. Improve patient care and survey outcomes.
1. Learn to detail the Benefit of Root Cause analysis.
2. Gain an understanding of the Fall Investigation process.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn how to verbalize the benefit of interdisciplinary involvement and follow-up for Fall Events.
Coding of activities of daily living (ADLs) on the MDS is complex and often misunderstood by those engaged in completing the assessment. In addition to affecting care, public information and survey, this area of the MDS has a tremendous financial impact. This presentation defines late loss ADLs and provide insights aimed at helping facility staff document resident status accurately. Calculating the ADL score for the RUG-IV system is reviewed and implications of inappropriate coding will be demonstrated.
Under the scrutiny of review, rehabilitation and nursing documentation must support skilled coverage criteria. This presentation covers skilled coverage criteria and documentation by rehabilitation professionals and nursing to support clinically appropriate levels of care.
1. Learn to define skilled coverage criteria.
2. Learn to define key elements of documentation.
3. Learn examples of rehabilitation and nursing documentation to support Medicare coverage criteria.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends with examples of denial statements. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
On July 31, 2014, the Centers for Medicare and Medicaid Services (CMS) issued the Final Rule under the Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities to be implemented on October 1, 2014. This seminar will discuss the impact of Fiscal Year 2015 Medicare payment rate increases for Skilled Nursing Facilities (SNFs) and will review the most recent Office of Management and Budget (OMB) statistical area delineations affecting the SNF PPS Wage Index. Learn about the revision to the existing COT OMRA policy. Additionally attendees will be apprised of updates to Chapter 8, Section 30 of the Medicare Benefit Policy Manual (Pub. 100-02) which directs providers on coverage decisions for reasonable and necessary treatment of patient’s illness or injury.
This presentation discusses the key elements of a Corporate Compliance program allowing an organization to self-monitor operations on an ongoing basis to ensure compliance with supportive documentation to adhere to applicable laws and the organization’s own policies and procedures.
Appropriate for CEOs, CFOs, Administrators, Nursing Management, Direct Care Nurses in a SNF, MDS Coordinators and Business Office Managers.
The management of the Minimum Data Set (MDS) 3.0 assessment schedule is complex and time consuming. Combining scheduled MDS assessments with unscheduled Prospective Payment System (PPS) Other Medicare Required Assessments (OMRAs) correctly will lead to accurate reimbursement and can ease the MDS workflow burden on the entire team, and save the facility costly mistakes due to noncompliance. Practitioners need to know what to do if the MDS schedule is not followed correctly, and how to regain compliance with the schedule as quickly as possible. This presentation reviews the scheduled and unscheduled PPS assessment requirements and describe how to select and set Assessment Reference Dates (ARDs) strategically and accurately. The presentation also discusses implications of not following the assessment schedule correctly, and how to regain compliance once an error in assessment scheduling is discovered. The Correction Process of existing MDS assessments, including modification, inactivation, and manual correction request will be discussed. This all-important information will help the MDS coordinator to maintain and regain federal compliance with the PPS assessment schedule.
1. Learn to outline the scheduled PPS assessment schedule and unscheduled PPS assessment requirements and explain the correct Assessment Reference Date selection for each assessment type.
2. Learn to state the correct application of default or provider liable days for an early, late, or missed scheduled or unscheduled assessment.
3. Learn to identify the appropriate use of the Start of Therapy OMRA, End of Therapy OMRA, End of Therapy-Resumption OMRA, and Change of Therapy OMRA.
4. Learn the eight criteria for a Medicare Short-Stay assessment.
5. Learn to identify the difference between a MDS modification and a MDS inactivation and recognize when to choose modification or inactivation.
Keep your MMQ and MDS Coordinators up to speed to prepare for Case Mix. Learn MDS 3.0 coding strategies and how to optimize case mix reimbursement. Learn the documentation requirements to support the RUG level achieved.
1. Learn to identify requirements for scheduling OBRA MDS Assessments for Case Mix.
2. Learn to identify Rehabilitation Case Management strategies for Clinically Appropriate placement in RUG-III and RUG-IV Classification categories.
3. Learn to identify Nursing RUG-III and RUG-IV Qualifiers.
4. Learn to identify ADL Documentation strategies.
This New York Medicaid Nursing Facility Case Mix Seminar discusses the necessary documentation needed to support the assigned Medicaid RUG to ensure accurate reimbursement for care provided. New York OMIG Auditors are focused on auditing "high risk" Medicaid Case Mix MDSs for Nursing Facilities with a change in CMI by more than five percent for 2012.
1. Learn to identify the specific components of NY RUG-III 53 categories.
2. Learn to identify high risk NY RUG-III 53 categories.
3. Learn to identify documentation requirements to support the RUG components.
4. Learn to identify strategies for organization of the Medical Record in preparation for OMIG Audits.
Dream of a Lex Entrepreneur: project to create a market niche law firmJC Verdades dos Santos
This powerpoint is based in my idea to create a specialized market niche law firm, using new management techniques. It is an ongoing project, my own venture and dream!
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends associated with Medicare Part B Claims. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
As digitization of the healthcare industry increases, the need to safeguard electronic patient data is also becoming increasingly important. Electronic protected health information (ePHI) is not just in the electronic medical records (EMRs). It also resides in emails, in documents and images on computers, servers, printer hard drives and mobile devices like laptops, cell phones, tablets and USB memory sticks. Healthcare professionals are also using texting and online file sharing services to conveniently share confidential information. The loss of this confidential patient health information is disastrous for patients and healthcare organizations.
Can your Skilled Nursing Facility (SNF) afford to provide care to Medicare patients and not receive accurate and appropriate reimbursement? The resources utilized to respond to additional documentation requests, manage denials and the loss of revenue for care provided can have a devastating impact on your facilities budget. In addition, early identification of potential issues and prompt resolution of actual issues reduces a facilities risk of hefty fines and penalties related to non-compliance.
Skilled Nursing Facilities are required to have a compliance program effective March 2013. Compliance programs strengthen and document a SNFs efforts to prevent and reduce Medicare fraud and abuse and ensure accurate and appropriate reimbursement for quality care provided. Under SNF compliance regulations Medicare has redefined the definition of fraud. When a facility has not taken all the necessary steps to ensure all the technical and clinical qualifications are supported by your medical records to prevent improper billing, fines and penalties may be applied. The critical components of an effective compliance program include monitoring and auditing to ensure Skilled Nursing Facility provider's have a formalized and proactive approach towards detecting fraud, abuse, and waste of precious company resources.
Provisions set forth in the Affordable Care Act (ACA) require the Centers for Medicare and Medicaid Services (CMS) to broaden quality improvement activities in nursing homes. Although the mandatory implementation date for nursing homes to provide evidence of a systematic Quality Assurance and Performance Improvement (QAPI) program has been delayed, but facilities should not delay in implementing a detailed and well-documented QAPI program. This presentation moves beyond the five elements of a QAPI and begins to drill down to practical concepts for “beefing up” an existing Quality Improvement program to meet QAPI standards. Learn how to objectively assess where your facility is in the QAPI journey, and gain a deeper insight into how practical implementation of QAPI activities can be a part of the culture of excellence that is part of all successful nursing homes.
1. Learn to detail the five elements of QAPI and correlate the five elements to the twelve step action plan for QAPI implementation.
2. Learn to articulate the steps to evaluating their facilities progress in QAPI efforts.
3. Understand Performance Improvement Projects (PIPs).
4. Learn the five steps of Root Cause Analysis (RCA) and learn how to apply the RCA process to adverse events in their facility routinely.
In February 2013, the Office of Inspector General (OIG) released a report entitled Skilled Nursing Facilities Often Fail to Meet Care Planning Requirements, in which they found that 26% of facilities fail to meet care planning requirements. Is your facility meeting federal guidelines for care planning? This presentation discusses the important link between the MDS 3.0, the Care Area Assessments (CAAs) and the care plan. Learn the essential components of a resident-centered care plan, how to develop a care plan that supports the clinical care that is provided to the patient, and how to proactively maintain a care plan that will meet annual survey requirements. The presentation discusses strategies for completing the CAAs more effectively, and how the CAA process can be used to create a more resident-specific care plan. Learn to develop a resident centered known as ( I careplan) through a workshop discussing different elements of the careplan, from profile, interim, and diagnosis.
1. Gain an understanding of the purpose of a Care Plan.
2. Learn to define the purpose of the discharge Care Plan and Summary.
3. Learn to to articulate the link between the MDS 3.0 assessment, the nursing Care Plan, the discharge Care Plan, and accurate RUG-IV classification.
4. Understand the the correlation between the MDS 3.0 assessment, the Care Area Assessments (CAAs), and the Care Plan.
Survey preparation is a never ending process and with the new QIS survey process in transition, it represents a new paradigm shift. This presentation will provide insight into key elements, tips and strategies that providers should use as part of their quality assurance survey preparation efforts. Learn from this multi-level licensed nursing home administrator with expertise in regulatory compliance sharing his lessons learned through the years.
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) was released in April 2014 by CMS. Join Keri Hart, MS, CCC-SLP, CHHRP-QT, RAC-CT, in this in-depth interpretation of the elements of the PEPPER. Keri will detail how to interpret your PEPPER and discuss the practical application of this critical information to your Skilled Nursing Facility’s practice. Follow along with your own PEPPER report to develop an action plan to ensure compliance with Medicare regulatory requirements and ensure accurate reimbursement for clinically appropriate care provided.
CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Audit Contractors (RACs). This important report details your facility-specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries).
Improve participation and functional outcomes through creativity out of the gym. Functionally based treatment will ensure patients receive medically necessary physical therapy, occupational therapy and speech services. The presentation reviews practical application to Medicare requirements.
1. Learn to identify creative treatment strategies.
2. Learn to define Medicare coverage and Medicare documentation.
3. Learn to identify the clinical benefits of Functional Based Therapies.
“Documentation not supportive of the RUG-IV classification billed…” is cited as the reason for multiple post-payment medical record review denials. Accurate and concise documentation to support the RUG-IV classification billed is a critical element in gaining accurate reimbursement, and supporting that reimbursement level during a medical review. This presentation covers the technical and clinical requirements for Medicare coverage, and requirements of skilled nursing documentation. The presentation identifies areas of the MDS 3.0 that are vulnerable to error and critical to accurate RUG-IV classification and identify strategies for better supporting these areas in medical record documentation. The correlation between the MDS 3.0 assessment and publicly reported information for the Quality Measures and 5 Star Quality Reporting are discussed.
1. Learn to describe the technical and clinical requirements for Medicare coverage.
2. Understand the goal of supportive skilled nursing documentation.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn to identify sections of the MDS 3.0 assessment that are vulnerable to error and articulate strategies to support these areas in medical record documentation.
5. Learn to identify the correlation between medical record documentation, the MDS 3.0, and publicly reported information for the Quality Measures and 5 Star Quality Rating.
Preventing falls in the SNF environment can be a challenge. Learn how to become a fall CSI and inspire your interdisciplinary team to meet the challenge of Falls Reduction. Improve patient care and survey outcomes.
1. Learn to detail the Benefit of Root Cause analysis.
2. Gain an understanding of the Fall Investigation process.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn how to verbalize the benefit of interdisciplinary involvement and follow-up for Fall Events.
Coding of activities of daily living (ADLs) on the MDS is complex and often misunderstood by those engaged in completing the assessment. In addition to affecting care, public information and survey, this area of the MDS has a tremendous financial impact. This presentation defines late loss ADLs and provide insights aimed at helping facility staff document resident status accurately. Calculating the ADL score for the RUG-IV system is reviewed and implications of inappropriate coding will be demonstrated.
Under the scrutiny of review, rehabilitation and nursing documentation must support skilled coverage criteria. This presentation covers skilled coverage criteria and documentation by rehabilitation professionals and nursing to support clinically appropriate levels of care.
1. Learn to define skilled coverage criteria.
2. Learn to define key elements of documentation.
3. Learn examples of rehabilitation and nursing documentation to support Medicare coverage criteria.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends with examples of denial statements. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
On July 31, 2014, the Centers for Medicare and Medicaid Services (CMS) issued the Final Rule under the Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities to be implemented on October 1, 2014. This seminar will discuss the impact of Fiscal Year 2015 Medicare payment rate increases for Skilled Nursing Facilities (SNFs) and will review the most recent Office of Management and Budget (OMB) statistical area delineations affecting the SNF PPS Wage Index. Learn about the revision to the existing COT OMRA policy. Additionally attendees will be apprised of updates to Chapter 8, Section 30 of the Medicare Benefit Policy Manual (Pub. 100-02) which directs providers on coverage decisions for reasonable and necessary treatment of patient’s illness or injury.
This presentation discusses the key elements of a Corporate Compliance program allowing an organization to self-monitor operations on an ongoing basis to ensure compliance with supportive documentation to adhere to applicable laws and the organization’s own policies and procedures.
Appropriate for CEOs, CFOs, Administrators, Nursing Management, Direct Care Nurses in a SNF, MDS Coordinators and Business Office Managers.
The management of the Minimum Data Set (MDS) 3.0 assessment schedule is complex and time consuming. Combining scheduled MDS assessments with unscheduled Prospective Payment System (PPS) Other Medicare Required Assessments (OMRAs) correctly will lead to accurate reimbursement and can ease the MDS workflow burden on the entire team, and save the facility costly mistakes due to noncompliance. Practitioners need to know what to do if the MDS schedule is not followed correctly, and how to regain compliance with the schedule as quickly as possible. This presentation reviews the scheduled and unscheduled PPS assessment requirements and describe how to select and set Assessment Reference Dates (ARDs) strategically and accurately. The presentation also discusses implications of not following the assessment schedule correctly, and how to regain compliance once an error in assessment scheduling is discovered. The Correction Process of existing MDS assessments, including modification, inactivation, and manual correction request will be discussed. This all-important information will help the MDS coordinator to maintain and regain federal compliance with the PPS assessment schedule.
1. Learn to outline the scheduled PPS assessment schedule and unscheduled PPS assessment requirements and explain the correct Assessment Reference Date selection for each assessment type.
2. Learn to state the correct application of default or provider liable days for an early, late, or missed scheduled or unscheduled assessment.
3. Learn to identify the appropriate use of the Start of Therapy OMRA, End of Therapy OMRA, End of Therapy-Resumption OMRA, and Change of Therapy OMRA.
4. Learn the eight criteria for a Medicare Short-Stay assessment.
5. Learn to identify the difference between a MDS modification and a MDS inactivation and recognize when to choose modification or inactivation.
Keep your MMQ and MDS Coordinators up to speed to prepare for Case Mix. Learn MDS 3.0 coding strategies and how to optimize case mix reimbursement. Learn the documentation requirements to support the RUG level achieved.
1. Learn to identify requirements for scheduling OBRA MDS Assessments for Case Mix.
2. Learn to identify Rehabilitation Case Management strategies for Clinically Appropriate placement in RUG-III and RUG-IV Classification categories.
3. Learn to identify Nursing RUG-III and RUG-IV Qualifiers.
4. Learn to identify ADL Documentation strategies.
This New York Medicaid Nursing Facility Case Mix Seminar discusses the necessary documentation needed to support the assigned Medicaid RUG to ensure accurate reimbursement for care provided. New York OMIG Auditors are focused on auditing "high risk" Medicaid Case Mix MDSs for Nursing Facilities with a change in CMI by more than five percent for 2012.
1. Learn to identify the specific components of NY RUG-III 53 categories.
2. Learn to identify high risk NY RUG-III 53 categories.
3. Learn to identify documentation requirements to support the RUG components.
4. Learn to identify strategies for organization of the Medical Record in preparation for OMIG Audits.
Dream of a Lex Entrepreneur: project to create a market niche law firmJC Verdades dos Santos
This powerpoint is based in my idea to create a specialized market niche law firm, using new management techniques. It is an ongoing project, my own venture and dream!
Rencontres eAtlas FAO, Cotonou 2011 / Atelier 4 : TIC, Gouvernement, démocratie locale, citoyenneté…Communication d'Ousmane AG DALLA, Chef du Département des Études, de la Planification, de la Coordination des projets Agence de Développement du Nord-Mali. Doctorant en SIG et gestion durables des territoires. Université Jean Monnet St-Étienne (France) et Université de Bamako (Mali).
A/Professor Cecile King, Immunology Division, Garvan Institute of Medical Research. http://www.garvan.org.au/news-events/leaders-in-science-and-society
software medico o científico
trata de los electrodomésticos creado para tratar todo tipo de salud en los hospitales para que sea mas rápida la atención.
Somos una empresa con experiencia en la integracion y desarrollo de soluciones tecnológicas encaminadas a la excelencia y optimización de procesos y gestiones empresariales. Nuestras soluciones se desarrollan acorde a a las necesidades identificadas en nuestros procesos de Consultoría Quality.
Somos la solución adecuada no sólo para empresas de un sector específico. Nuestra experiencia y talento humano nos da la posibilidad de desenvolvernos con éxito en diferentes sectores. Por esto Quality es la solución adecuada para:
-Compañías con necesidades de información sistematizada.
-Compañías con altos volúmenes de información.
-Compañías de procesos complejos que demandan en ocasiones caer en reprocesos de una misma gestión.
-Compañías que requieran integración de información generada desde diferentes fuentes o áreas dentro una misma compañía.
-Compañías que requieran informacion confiable y en linea, de manera oportuna.
-Compañías con altas exigencias en calidad y servicio al cliente.
Hidden Risk Area: Grievances- Are you Prepared for a Survey?PYA, P.C.
PYA Consulting Manager Susan Thomas co-presented with Sheila Limmroth of DCH Health System on “Hidden Risk Area: Patient Grievances–Are You Prepared for a Survey?” Their presentation focused on the following objectives:
-Define CMS expectations for a patient grievance process and how to use the guidance as a compliance work plan auditing tool.
-Discuss what state auditors review when they come onsite to assess your patient grievance process.
-Consider the role of compliance in the patient grievance process.
Harness Your Clinical and Financial Data with an Enterprise Health Informat...Perficient, Inc.
The importance of Enterprise Health Information Exchange (EHIE) as a key way to empower your physicians and patients and demonstrate meaningful use of electronic health records:
- Present the business case for EHIE as an important architecture that matters to progressive health systems
- Take a look at some of the market-leading EHIE architectures and products
- Provide real exam...ples of organizations that are using EHIE to improve their operations
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) is due for release April 2014. CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs). This important report details your specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries). PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper payments, according to the federal government, and allows providers to see how their facility compares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdiction.
Medical groups and individual practices in Georgia that struggle managing denials or write off denied claims as bad debts can now handle denial with the help of these strategies.
This presentation includes a detailed review of changes and updates discussed to the MDS 3.0 item set effective October 1, 2013. The presentation provides an overview of the most recent MDS 3.0 User’s Manual updates and reviews key elements for MDS coding, which will impact reimbursement based on the Federal Regulations in the FY 2014 Final Rule.
Compliance and Legal Risks in Laborist, Surgicalist, and Hospitalist Arrangem...MD Ranger, Inc.
Have you structured your hospital-based physician contracts to address all aspects of compliance?
Hospitalist agreements involve unique compliance and financial issues, particularly when global payments and advanced practice providers are involved. Risks include indirect compensation, billing and other compliance issues. This presentation will discuss compliance risks and provide guidance on how to structure compliant contracts and business arrangements.
US Healthcare Delivery SystemsQuality Outcome MeasuresDonna .docxdickonsondorris
US Healthcare Delivery Systems
Quality Outcome Measures
Donna Wilson, RN MPH MSJ CPHQ
Director, Quality Improvement/Patient Safety
Mount Sinai Beth Israel
History Pre- 1913
The godmother of quality was Florence Nightingale. She was a wealthy woman who went to work in the nurse corp during the Crimean war. She studied illness – the dysentery that the soldiers were getting.
She was the first one credited with thinking about washing hands, how close the beds were to one another and sharing needles.
2
EMERGENCE OF Continue
Quality Improvement in Health Care
1913 - American College of Surgeons (ACS)- started to measure what we are doing and what difference it makes.
1918 - Hospital Standardization Program
1951 - Joint Commission on Accreditation of
Hospitals Organizations (JCAHO)-certifies 99% of hospitals
1963 – Corporate Liability introduced to Hospitals 1st lawsuit
1986 - Corporatization of medicine (HMO’s started, PPO’s)
1988 - Harvard Health Care Demo Project
Need for objective information on physician performance
Data on cost/ outcomes of medical care used by CMS
3
3
1913
First step toward improving quality care in American hospital. Developed minimal essential standards of care for hospital. Became the Hospital’s Standardization Program (HSP).
1951
HSP became JCAH - assumed responsibility for accreditation
Shift focus from structure to process
Increasing demand for availability of data on quality outcomes, and cost
1963
Hospital can be held accountable for failing to establish system of safe practices as defined by the industry.
EMERGENCE OF CQI IN HEALTH CARE
1990 - Introduction of TQM/CQI principles to hospital management by industry people
1999:Institute of Medicine (IOM) Report said that over 100,000 patients died from medical errors
Started Patient Safety
Transparency in Healthcare
Creation of Institute for Healthcare Quality (IHI)
2000 - CMS Core Measures
2006 – Pay for Performance
2009 – Present on Admission & Readmissions
4
4
70’s-80’s
Organization demanded data on cost, use patterns and practice patterns because such information was crucial in managing care in these systems. Essential to evaluating costs and quality of care.
TQM
Growing focus on using scientific methods. TQM was introduced to hospitals to change the way certain hospitals approached quality.
Physician Performance
For appointment and reappointment process
Cost and Out come
Medicare Prospective Payment System - Center for Medicare and Medicaid (CMS)
Continuous Quality Improvement
This term started in 1990s and started to look at quality on a continuum
We would say “ this is the problem” then we would collect data to see where we were weak and then come up with a solution
Then we would measure it ( the outcome) to see if what I put in place actually helped.
If it worked we move onto a different problem. If not, we tried a new solution
5
5
CQI came from Japan’s car industry
Toyota wo ...
Cypress Benefit Administrators is a full service Third Party Administration (TPA) company. We specialize in helping companies outsource Flexible Spending Accounts (Section 125), HRA, HSA, and COBRA. Additionally, we provide expertise in self-funded medical plan administration.
The RAC's are coming: Is your medical practice prepared?sstgelais
Important notice to Medical providers/ Hospitals: starting in 2010, CMS (Medicare) has hired four RAC (Recovery Audit Contractors) to pursue claim billing violations. Their mission is to collect as many $$$ in overpayments as possible nationwide. They\\’re heavily incentivize (17% of what they collect). This presentation provides an overview of the RAC program as well as our baseline audit service to help protect you against the impending RACs
Health Insurance & Prior authorization Requirements: Its Impact and Recommend...mosmedicalreview
Insurers use prior-authorization to ensure medical necessity. Medical peer review can be initiated when a prior authorization request or a claim is denied.
An Overview of Kaiser Permanente - Integration and Information Systems in Hea...Empreender Saúde
Apresentação da Kaiser Permanente para o Brazilian Healthcare Trek: Mission Silicon Valley.
What is Kaiser Permanente?
Kaiser Permanente is committed to helping shape the future of health
care. We are recognized as the largest integrated delivery system in the
U.S. and one of the leading health care providers and not-for-profit
health plans.
Our strategy is to excel in providing high-quality, affordable health care
through our integrated delivery system, our investment in technology,
and our vision of supporting Total Health.
Our Mission and Vision
Mission: to provide high-quality, affordable
health care services and to improve the
health of our members and the communities
we serve.
Vision: To be a leader in Total Health by
making lives better.
7 regions serving 8 states and the District of
Columbia
More than 9.3 million members
More than 17,000 physicians and 174,000
employees (including 48,000 nurses)
38 hospitals (co-located with medical
offices)
608 medical offices and other outpatient
facilities
70 years of providing care (opened in 1945)
Developed in conjunction with the Regional Extension Center for Washington DC (eHealthDC). An archived version of the Financing your EHR System Webinar will be available soon for viewing.
In February 2013, the Office of Inspector General (OIG) released a report entitled Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Planning Requirements, in which they found that 26% of facilities fail to meet care planning and discharge planning requirements. Is your facility meeting federal guidelines for care planning?
Download the ABC’s of Care Planning presented by Beckie Dow, RN, RAC-MT for an overview of Care Planning in the Skilled Nursing Facility. Beckie discusses the important link between the MDS 3.0, the Care Area Assessments (CAAs) and the Care Plan.
Learn the essential components of a resident-centered care plan and how to develop a care plan that supports the clinical care that is provided to the patient. Beckie also discusses strategies for completing the CAAs more effectively and using the CAA process to create a more resident-specific care plan.
Learn How To:
1. Define the purpose of a Care Plan.
2. Define the purpose of the Discharge Care Plan and Summary.
3. Identify the correlation between the MDS 3.0 Assessment, the Care Area Assessments (CAAs), accurate RUG-IV Classification, and the Care Plan.
4. List three components of a Resident-centered Care Plan.
This presentation provides a comprehensive pro-active review of program development for long-term care patients in the SNF. The course outlines suggestions for how rehabilitation team members can strengthen the Medicare Part B programming in the nursing facility. An overview of the Medicare Part B Guidelines, Part B Caps, Functional Limitation G-Codes, and Manual Reviews is also provided. The presentation also discusses Medicare Part B documentation, goal writing and reasons for denied claims.
1. Gain an understanding of Proactive Medicare Part B Program Development and how to strengthen the program components.
2. Gain a better understanding of Medicare Part B documentation components, goal writing and potential risk for receiving denied claims.
3. Gain an understanding of Medicare Part B Guidelines, Medicare Part B Caps, Functional Limitation G-Codes and Medical Reviews.
The presentation details the value of standardized therapy assessment as it relates to patient care treatment planning and evidencing Medicare audits. Standardized assessments can help evidence your patients’ progress. In addition, standardized assessment can better define deficits and assist in treatment planning.
1. Learn to identify the Benefits of utilizing Standardized assessments
2. Learn to summarize appropriate use of standardized therapy assessments
3. Learn the reasons standardized assessments can be used to evidence progress and support Medicare Part G-codes
One of the major goals in MDS 3.0 is to give residents and families a more active voice in the care delivered. Interviewing processes are provided in the MDS 3.0 RAI user’s manual to help caregivers obtain quality, accurate information from patients with focused scripted interview questions. This presentation discusses techniques for interviewing that will assist with achieving more accurate data for physical therapy care and MDS coding. The presentation reviews key sections of the MDS that are coded based on direct patient interviews.
1. Learn to identify the MDS Sections which are coded based on scripted resident interview.
2. Learn to describe three specific techniques that can be used to achieve accurate interview results.
3. Gain an understanding of key RUG reimbursement and quality measure impacts of the resident interviews.
4. Learn to summarize strategies for utilization of resident interview data to drive quality of care and improve quality of life in the SNF.
The MDS 3.0 has an impact on every aspect of care in a LTC or SNF. Reimbursement, Quality Measures, Five Star rating, Care Planning, and resident-centered care all begin with an accurate, standardized, and reproducible assessment.
Download the MDS 3.0: A Guide To Coding Accuracy by Beckie Dow, RN, RAC-MT for an overview of MDS 3.0. Beckie reviews the MDS 3.0 sections most vulnerable to error, while highlighting strategies for increased accuracy. Beckie also provides the MDS scheduling clinical qualifiers for each of the 66 RUG-IV categories and examples of potential financial losses due to inaccurate coding.
Learn How To:
1. Identify three MDS 3.0 Sections vulnerable to error.
2. Identify strategies for accurate reimbursement through the MDS 3.0 process.
3. Articulate three recent MDS 3.0 Coding instruction updates.
Managing the medical complexities of patients with cognitive and behaviors requires an interdisciplinary approach to care. The presentation details strategies and hands-on examples of management techniques for practical application in the SNF setting to ensure patients receive medically necessary Rehabilitation and Nursing Service.
1. Learn to identify underlying deficits leading to Behaviors.
2. Learn to define interdisciplinary assessment techniques.
3. Learn Management Strategies.
Keep your MDS Coordinators and nursing staff up to speed in understanding the significance of accurate coding in section M and the required corresponding documentation. This presentation enables healthcare providers to provide quality healthcare through an understanding of wound coding in relationship to skin presentation for Section M on the MDS assessment.
1. Gain an understanding of the RAI User’s Manual intent of Section M.
2. Gain an understanding of the documentation required to support Coding in Section M.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn to identify the significance of care planning and utilizing an interdisciplinary approach.
The Centers for Medicare and Medicaid Services (CMS) recently released S&C Memo 13-35-NH, which discusses the use of psychopharmacological medications and behavioral management in America’s Nursing Homes. The management of behavioral or psychological symptoms of dementia (BPSD) is a challenge in Nursing Homes. In this presentation viewers will learn valuable behavioral management techniques that can be utilized to decrease patient dependency on psychopharmacological medication. Important government initiatives, including The Partnership to Improve Dementia Care in Nursing Homes are discussed. The presentation also discusses the recent updates to interpretive guidelines of F309 (Quality of Care) and F329 (Unnecessary Drugs), and details the Seven Dementia Care Principles provided by CMS to assist nursing homes to manage behavioral or psychological symptoms of BPSD.
1. Learn the content of S&C Memo 13-35-NH and the implications of this memo on daily resident care
2. Learn to articulate the intent and impact of F309 and F329 on resident health and well-being, and identify strategies to maintain compliance with the regulatory intent of these regulations
3. Learn about the seven Dementia Care Principles provided by CMS to assist nursing homes to manage behavioral or psychological symptoms of BPSD
4. Identify the seven Dementia Care Principles provided by CMS to assist nursing homes to manage behavioral or psychological symptoms of BPSD
Readmissions are a heightened focus under the Affordable Care Act. Initiatives are in place to reduce hospital admission through improving transition in care. During this course the speaker will discuss CMS quality initiatives, care transition, projects and barriers. This presentation reviews the key elements to tackling Avoidable Readmissions.
1. Learn to summarize the CMS quality initiative for healthcare reform related to hospital readmissions
2. Learn to identify underlying causes and barriers related to readmissions
3. Learn to state current CMS research projects and pilot programs
4. Learn to identify hospital and SNF strategies for collaboration
Managing the medical complexities of patients with cognitive and behaviors requires an interdisciplinary approach to care. The presentation details strategies and hands-on examples of management techniques for practical application in the SNF setting to ensure patients receive medically necessary Rehabilitation and Nursing Service.
More from Harmony Healthcare International (HHI) (10)
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
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. 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. 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. 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. Top Ten Tips for a Successful ALJ Hearing
Auditing Agencies and
Contractors
Harmony Healthcare International, Inc. 5Copyright 2014 All Rights Reserved
6. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 6
Top Ten Tips for a Successful ALJ Hearing
7. OIG Audits
How We Got Here
Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 7
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. 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. 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. 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. 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. 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. 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. 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. 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. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 17
Top Ten Tips for a Successful ALJ Hearing
Recovery Audit Contractors
17
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. 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. 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. 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. Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 22
Top Ten Tips for a Successful ALJ Hearing
ZPIC Audit
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Harmony Healthcare International
Top 10 Tips for a Successful
ALJ Hearing
Harmony Healthcare International, Inc. 34Copyright 2014 All Rights Reserved
35. Harmony Healthcare International
Tip #1: Know your Medicare
guidelines
Harmony Healthcare International, Inc. 35Copyright 2014 All Rights Reserved
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. What is Skilled Care?
Anchoring the Skill
Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 55
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. 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. 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
60. Harmony Healthcare International
Medicare Benefit Policy Manual
Chapter 8 Revisions
December 2013
Harmony Healthcare International, Inc. 60Copyright 2014 All Rights Reserved
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. 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. 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. 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. 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. Harmony Healthcare International
Tip #2: Ensure your medical
record has supportive
documentation
Harmony Healthcare International, Inc. 66Copyright 2014 All Rights Reserved
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. 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. 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. Harmony Healthcare International
Tip #3: The best defense is a
good offense
Harmony Healthcare International, Inc. 70Copyright 2014 All Rights Reserved
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. 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. 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. 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. 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. 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
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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. 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. 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. 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. 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. Top Ten Tips for a Successful ALJ Hearing
Appealing Medicare
Denied Claims
Harmony Healthcare International, Inc. 83Copyright 2014 All Rights Reserved
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. 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. 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. 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. 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. Monitor the Appeal
Internal tracking system to monitor
When ADR or denial was received
When package was sent out
Final results of the review
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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. Appeal Rights
Right to Appeal
All appeal requests must be
made in writing
Harmony Healthcare International, Inc. 92Copyright 2014 All Rights Reserved
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Harmony Healthcare International
Tip #6: Submit supportive
decisions
Harmony Healthcare International, Inc. 104Copyright 2014 All Rights Reserved
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. 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. 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. 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. 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. 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
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. 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. 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. 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
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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
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119. Harmony Healthcare International
Tip #9: Be concise and use
plain language
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120. ALJ Hearing
Speak respectfully, clearly, slowly
Provide a concise summary
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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. 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. 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
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
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126. Keys to Success
Raise Facility Awareness
Function as a TEAM
Communication
Organization
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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
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
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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!
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Register online
http://info.harmony-healthcare.com/harmony2014
or by phone (978) 887-8919 ext. 13
Register Online
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