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935 Limitation of Recoupment Process Palmetto GBA Provider Outreach & Education 7/7/2015 1 Objective July 7, 2015 To provide a better understanding of the 935 limitation of recoupment process and how it relates to the appeal process 2 Agenda 935 Background Information Overpayment Process Demand Letter Discussion Period Rebuttal Process Demand Repayment Process How to Stop Recoupment Reporting of Recoupment on Remittance Advice CERT Information July 7, 2015 3 935 Background Information 4 Background Information Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) provides limitation on the recoupment of Medicare overpayments and the processes available to providers July 7, 2015 Amended Title XVIII of Social Security Act (SSA) 5 Background Information Section 935 required Centers for Medicare and Medicaid Services (CMS) to change: Way contractors recoup certain overpayments How it pays interest to a provider, physician or supplier whose overpayment is reversed at Administrative Law Judge (ALJ) or judicial levels of appeal July 7, 2015 6 Background Information Section 1893(f)(2)(a) protects providers, physicians and suppliers at initial stages of appeal process by limiting recoupment process while appeal underway. CMS and its contractors may not recoup overpayment until a decision on the redetermination/reconsideration is made. July 7, 2015 7 935 Did Not Change Appeal requirements or timeframes Requirement on interest accrual and assessment for each 30-day period from the date of demand letter; If overpayment is not fully paid within 30 days of demand notice OR Until the debt is fully paid off July 7, 2015 8 935 Did Not Change Existing underpayment interest requirements Existing rebuttal requirements Payments which have been suspended July 7, 2015 9 Overpayment Defined Overpayments are Medicare monies a provider has received in excess of amounts due and payable Examples Payment for excluded or medically unnecessary services Payment made as primary when Medicare should have paid as secondary July 7, 2015 10 Recoupment Defined Recoupment is the recovery by Medicare of any outstanding Medicare debt by: Reducing present or future Medicare remittance advice payments and Applying amount withheld to the indebtedness July 7, 2015 11 Overpayments That Are Subject to Limitation on Recoupment Post-pay denial of claims for benefits under Part A and Part B for which a written demand letter was issued Palmetto GBA Medical Review (MR) Zone Program Integrity Contractor (ZPIC) Comprehensive Error Rate Testing (CERT) Recovery Auditors (RAC) Office of the Inspector General (OIG) July 7, 2015 12 Overpayments That Are Subject to Limitation on Recoupment Medicare secondary payer (MSP) recovery where provider received duplicate primary payment and for which a written demand letter was issued MSP recovery based on the provider’s failure to file a proper claim with the third party plan July 7, 2015 13 Overpayments That Are Not Subject to Limitation on Recoupment All other MSP recoveries Beneficiary overpayments Overpayments arising from a cost report determination Overpayments that are appealed July 7, 2015 14 Overpayments That Are Not Subject to Limitation on Recoupment Provider initiated adjustments Accelerated/advanced payments Claim adjustments at contractors discretion Mass adjustments due to system errors Requires CMS approval July 7, 2015 15 Overpayment Process 16 Findings Letter First, providers receive a findings letter Providers are notified in writing when an overpayment subject to the limitation on recoupment has been identified Who conducts the review? July 7, 2015 Palmetto GBA Recovery Auditors CERT Contractor 17 Findings Letter Palmetto GBA conducts the review: Medicare Notice of Medical Review Findings letter is sent prior to any claim adjustments Addressed to the attention of compliance officer at correspondence address listed on provider file (Section 2C of CMS 855A form) Recovery Auditors conduct complex review: Review results letter is sent to provider July 7, 2015 18 Findings Letter CERT contractor conducts the review: Findings letter is not sent CERT adjustment identified by type of bill XXH and Palmetto GBA includes reason for denial in “Remarks” of claim adjustment July 7, 2015 19 935 Overpayment Process If adjustment results in an overpayment 935 rules apply and claim is available for limitation on recoupment protections An adjustment may result in a refund Existing underpayment policies followed July 7, 2015 20 Remittance Advice When claim is adjusted: A 935 overpayment is established and two separate claim Internal Control Numbers (ICN) are reflected on remittance advice First claim ICN is a reversal of the originally paid claim Contains a negative net reimbursement July 7, 2015 21 Remittance Advice Second ICN is the 935 adjustment claim and contains remark code N469 Code communicates that claim adjustment is for 935 limitation of recoupment and signals to provider the overpayment was not collected July 7, 2015 CERT and Recovery Auditors line-level adjustments also contain remark code N432 Recovery Auditors claim-level adjustments only contain remark code N469 22 Remittance Advice Results of original claim reversal and 935 claim can be an overpayment amount for full amount of claim or a partial amount On same RA the resulting overpayment amount is then added back to RA total net reimbursement in Adjust to Balance field This results in overpayment recoupment being eliminated July 7, 2015 23 Remittance Advice To see the Adjustment to Balance field on the Electronic Remittance Advice (ERA) Provider would choose to see summary portion If provider’s automated posting system does not account for this type of activity; It would then post as if it was collected July 7, 2015 24 Demand Letters 25 Demand Letter Recovery Process Demand letters from Recovery Auditors are issued by Palmetto GBA Change made to avoid delays in demand letter issuance Change Request (CR) 7436, effective January 1, 2012 MLN Matters article MM7436 http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads//MM7436.pdf July 7, 2015 26 Demand Letter Recovery Process Recovery Auditors find improper payment made to provider Submits claim adjustments to Palmetto GBA Answers audit specific questions relating to demand letter Rational for identifying potential improper payment July 7, 2015 27 Demand Letter Recovery Process Palmetto GBA establishes accounts receivable and issues automated demand letter for overpayment identified Same process used to recover any other overpayment Letter includes name and contact info of initiating RA Palmetto GBA fields administrative concerns such as timeframes for payment recovery and appeals process July 7, 2015 28 How to Identify RA Demand Letter RA related demand letters identified by the letter number printed at the top right hand corner of each page of the demand notice R-xxxxxxx Second paragraph of first page of the demand notice will also indicate – “This finding was a result of a Recovery Audit Program review” RA Demand letter envelopes will be stamped – “RECOVERY AUDIT DEMAND” July 7, 2015 29 Demand Letter When a claim is adjusted it triggers: Demand letter automatically generated by Health Integrated General Ledger Accounting System (HIGLAS) Mailed by Palmetto GBA to physical address on the provider file Demand letter date and remittance advice date are not the same date Dates are within a few days of each other July 7, 2015 30 Demand Letter Demand letter explains why overpayment occurred, amount and that provider may: July 7, 2015 Submit rebuttal statement within 15 days to any proposed recoupment Stop recoupment by submission of a valid appeal request within 30 days from date of demand letter 31 Demand Letter Recoupment will begin on 41st day from the date of the demand letter if one of the following is not date stamped in Palmetto GBA’s mailroom by the 30th day from the date of the demand letter: July 7, 2015 Payment is not received in full Request for an extended repayment schedule Valid request for a contractor redetermination 32 Demand Letter Appeals filed later than 30 days July 7, 2015 Will stop recoupment at whatever point an appeal is received and validated Medicare may not refund any recoupment already taken 33 Interest Assessment Interest begins to accrue on 31st day from date of demand letter Simple interest charged on unpaid balance of overpayment beginning on 31st day July 7, 2015 34 Interest Assessment Interest is calculated in 30-day periods Assessed for each full 30-day period that payment is not made on time If payment is received 31 days from final determination date, then one 30-day period of interest is charged Current rate of interest charged Payments applied first to accrued interest then to principal July 7, 2015 35 Automatic Offset Request Providers may request to automatically offset any identified claims overpayments Benefit of automatic offset is: Recoupment begins immediately and reduces or eliminates the amount of interest assessed July 7, 2015 36 Automatic Offset Request If recoupment of overpayment is satisfied within 30 days, no interest is charged If sufficient funds for recoupment are not available and overpayment does not collect in full within 30 days of demand letter Interest will be assessed on the outstanding principal balance July 7, 2015 37 NO Second Demand Letters Sent Reminder - second demand letter is no longer sent Ceased as of August 1, 2011 Providers will only receive a first demand letter Providers may receive an Intent to Refer letter, if appropriate July 7, 2015 38 Discussion Period 39 Discussion Period Recovery Auditors discussion period July 7, 2015 Allows provider to receive an explanation of the overpayment decision Provides additional information indicating why recoupment should not be initiated 40 Discussion Period Discussion period must be initiated with the Recovery Auditor within 15 days Timeframe for discussion is day 1-40 Note: RA will close the discussion period if the provider files an appeal with Palmetto GBA Recovery Auditor makes decision within 40 days of: Demand letter for automated reviews Review results letter for complex reviews July 7, 2015 41 Discussion Period Recovery Auditor sends letter to provider detailing the outcome of discussion period Recovery Auditor may reverse decision after review of additional documentation Provider returns money for original demand Palmetto GBA readjusts claim for repayment July 7, 2015 42 Rebuttal Process 43 Rebuttal Process Allows provider the opportunity to provide a statement and evidence indicating why overpayment action will cause a financial hardship and should not take place Rebuttal is not intended to review supporting medical documentation or disagreement with overpayment decision July 7, 2015 44 Rebuttal Process Providers may submit a rebuttal statement to Palmetto GBA within 15 days from the date of the demand letter The rebuttal statement explains or provides evidence regarding why recoupment should not be initiated. The rebuttal process is not considered an appeal July 7, 2015 45 Rebuttal Process Rebuttal statement does not stop the recoupment process July 7, 2015 The process is a means by which the provider can submit documentation to show why recoupment should not be put into effect Disagreement with the overpayment assessment or overpayment rationale should be submitted as a redetermination/appeal Palmetto GBA will review and consider whether to proceed or discontinue with the recoupment 46 July 7, 2015 47 Demand Repayment Process 48 Repayment Options Effective July 1, 2012, a new, standard immediate offset process was implemented. This new process allows you to request an immediate offset each time you receive a demand letter. Additional information regarding the offset process can be located on the Palmetto GBA/j11a Web site at: Immediate Offset Requests J11 Part A Immediate Offsets Form (PDF, 98 KB) July 7, 2015 49 Part A Immediate Offset Requests A job aid outlining the Part A Immediate Offset Requests can be located on the Palmettogba.com/j11a Web site. Click on Learning and Education, and then click job aid In addition, there are other job aids regarding financial issues located at the site as well. July 7, 2015 50 Provider Requested Offset Process Request for immediate offset notification received within 20 days of date of the demand letter allows sufficient time for processing and avoiding interest Interest will not accrue on the debt if it can be recovered prior to the 31st day July 7, 2015 51 Provider Requested Offset Process You must notify Palmetto GBA via fax that you would like an immediate offset Fax received prior to 12:00 PM Open debt placed into immediate offset same day Fax received after 12:00 PM Open debt placed into immediate offset on next business day July 7, 2015 52 Provider Requested Offset Process Fax must be on company letterhead and include: Name, telephone and Medicare provider number NPI or PTAN Invoice and claim number from claims detail page If there are multiple claims, provide each invoice and claim number listed on attachment Authorized signature on fax to indicate request is for immediate offset Individual is at discretion of the provider July 7, 2015 53 Change Request (CR) 7688 CR 7688 - Immediate Recoupment for Fee for Service Claims Overpayments Effective: July 1, 2012 Implementation: July 2, 2012 Related MLN Matters Article MM 7688 at: http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM7688.pdf July 7, 2015 54 CR 7688 – Key Points Two options for immediate recoupment 1. One-time request on specific overpayment and all future overpayments 2. Request on specific overpayment addressed in demand letter July 7, 2015 55 CR 7688 – Key Points Request must be received in writing no later than sixteen (16) days from date of the demand letter Providers waive rights to 935 interest Providers can terminate immediate recoupment process at anytime - must be in writing! July 7, 2015 56 Extended Repayment Plan (ERP) If a provider needs longer than 30 days to repay the full amount of the overpayment, the provider may request an Extended Repayment Plan (ERP) Initial demand letter includes list of detailed explanation and a check list to request an ERP Providers need to include a copy of their check for the first payment calculated under their proposed extended repayment plan with their ERP request July 7, 2015 57 Extended Repayment Plan (ERP) Include copy of demand letter with the request The ERP should be mailed to: Palmetto GBA, LLC ERP Consultant (AG-340) 2300 Springdale Drive Bldg. One Camden, SC 29020 July 7, 2015 58 How to Stop Recoupment 59 Recoupment Process Timeframe After the First Demand Letter July 7, 2015 60 Stopping Recoupment Once Demand Letter is Received Recoupment will stop upon receipt of a valid and timely request for a redetermination within 30 days from the date of the demand letter Following an unfavorable or partially favorable redetermination decision if provider files a valid request for a reconsideration with the Qualified Independent Contractor (QIC) July 7, 2015 Timeliness of the appeal request is important Interest continues to accrue during the appeal process 61 First Level Appeal - Redetermination Upon receipt of valid request for redetermination of overpayment Palmetto GBA will: Cease or not initiate recoupment, if not yet started Retain amounts recouped (if already recouped) and apply it to interest and then to principal Continue to collect other debts; but not withhold or place in suspense any monies related to this debt while in appeal status Interest continues to accrue on the debt July 7, 2015 62 First Level of Appeal - Redetermination Palmetto GBA is providing a Redetermination: 1st Level Appeal form for providers to use. While not required, this form may make submitting your redeterminations easier. The form includes all of the required elements for making a valid request, and it will ensure that your request is directed to the proper area once received in our office. Reminder: Please submit redetermination requests separately and avoid stapling multiple redetermination requests together. July 7, 2015 63 First Level of Appeal - Redetermination You can download the form and type your information directly onto it. Note that after you complete the form, it still needs to be printed, signed and mailed to us. To access this form, please go to Forms Web page at www.PalmettoGBA.com/j11a/forms. July 7, 2015 64 First Level of Appeal - Redetermination Reminder: If the appeal is due to a 935 Recoupment or Recovery Auditors request: Crucial for timely processing Attach the 935 or Recovery Auditor letter directly following the form July 7, 2015 65 First Level of Appeal - Redetermination Reminder: Reason for Redetermination section Provide a detailed explanation of why you are requesting the redetermination and why you believe the initial determination is inappropriate Don’t forget to sign the form! July 7, 2015 66 First Level of Appeal - Redetermination Attach: A copy of the overpayment demand letter Please attach this form completed in its entirety. Please complete one form per beneficiary July 7, 2015 67 First Level of Appeal - Redetermination You must include documentation to support an appeal. Examples include: Medical Records for dates of service appealed Physician's orders, office records and progress notes Certification or re-certifications for dates of service Treatment plan or plan of care Required assessment records July 7, 2015 68 Redetermination Outcome A redetermination has three possible outcomes: Full Reversal Partial Reversal Full Affirmation July 7, 2015 69 Redetermination - Full Reversal Palmetto GBA may: Need to adjust overpayment and amount of interest charged Apply funds to other debts provider might owe July 7, 2015 70 Question on Favorable Appeal Decision Why is there no interest paid to provider when the appeal is favorable? When a provider appeals a denied Recovery Auditor claim, interest withheld previously for that claim will be paid back at a later date Listed on remittance advice under either ‘Refunds’ section or ‘935 add pay’ section July 7, 2015 71 Redetermination - Partial Reversal Recalculates correct amounts of both underpayment and overpayment Makes appropriate payments to you if due If necessary, issues a revised demand letter for newly calculated amount July 7, 2015 72 Partial Reversal Letter Recoupment no earlier than the 61st day from the date of revised overpayment determination To stop recoupment under the provisions of Section 935 of MMA of 2003, provider must request a valid reconsideration within 60 days of date of notice July 7, 2015 Opportunity to rebut proposed recoupment 73 Full Affirmation (Unfavorable) Upholds overpayment determination Recoupment will begin no earlier than 61st calendar day from redetermination notice July 7, 2015 74 Timeframe for Medicare Recoupment Process After Redetermination Timeframe Palmetto GBA Provider Day 60 - following revised Date Reconsideration notice of overpayment Request is stamped in following redetermination mailroom, or payment received from revised overpayment notice Must pay overpayment or must have submitted 2nd level of appeal Day 61-75 Recoupment could begin on the 61st day Appeals or pays Day 76 Recoupment begins or resumes Can still appeal. Recoupment stops on date of appeal receipt July 7, 2015 75 Second Level Appeal - Reconsideration Valid reconsideration request received by Qualified Independent Contractor (QIC) July 7, 2015 Cease recoupment or not initiate recoupment if it has not yet begun Retain any amounts recouped Continue to collect debts not related to this debt while in appeal status Interest continues to accrue on the debt 76 Second Level Appeal - Reconsideration Reconsiderations have three possible outcomes: Full Reversal Partial Reversal Full Affirmation July 7, 2015 77 Full Reversal Reconsideration Palmetto GBA may need to adjust overpayment and amount of interest charged May apply funds to other debts that the provider might owe July 7, 2015 78 Partial Reversal Reconsideration Reduces the overpayment Contractor effectuates decision Issues a revised demand letter for revised overpayment amount or make appropriate payments due to underpayment amount If necessary July 7, 2015 79 Partial Reversal Reconsideration Revised Demand Letter will state: Revised overpayment amount Palmetto GBA can begin to recoup on 30th day from date of notice Reminder of opportunity to make payment arrangements or rebut proposed recoupment July 7, 2015 80 Affirmation (Unfavorable) Reconsideration Recoupment may resume on the 30th calendar day after date of notice of the reconsideration Gives provider time to make payment or request a repayment plan July 7, 2015 81 Third Level Appeal – Administrative Law Judge (ALJ) Palmetto GBA will continue to recoup until debt is satisfied in full Medicare overpayment redetermination reversed Medicare refunds both principal and interest collected Pays 935 interest on recouped funds July 7, 2015 82 Third Level Appeal – Administrative Law Judge (ALJ) Payable only when reversal occurs at ALJ level or subsequent levels of administrative appeal Payment is only applicable to overpayments recovered and only on principal amount recouped July 7, 2015 83 Third Level Appeal – Administrative Law Judge (ALJ) Simple interest Will not pay interest on interest Monies recouped and applied to interest would be refunded Not included in amount recouped for purposes of calculating interest due Interest calculated in full 30-day periods using interest rate in effect on ALJ decision date July 7, 2015 84 Appeal Reminders for 935 Normal timeframes to file an appeal apply, however to stop or cease recoupment: File 1st level appeal within 30 days of the date of the overpayment demand letter File 2nd level appeal within 60 days of the date of the redetermination decision For appeals filed outside of these timeframes, recoupment will cease if it has been started Recouped funds will not be returned to the provider July 7, 2015 85 Appeal Reminders for 935 Rebuttal statements do not qualify as appeals Provider must specifically file an appeal for limitation on recoupment to apply Interest continues to accrue when recoupment is ceased. July 7, 2015 86 Reporting Of Recoupment On Remittance Advice (RA) 87 Recoupment Reminder Providers will see the adjustment on the Remittance Advice (RA) when the demand letter is generated But money will not be recouped at that time July 7, 2015 88 Claim Page on Remittance Advice July 7, 2015 89 Identifying Recovery Auditor Overpayment Remark codes N469 and N432 will be present on remit for a Recovery Auditor (RA) overpayment adjustment N469- Claim/service subject to 935 process N432- Adjustment based on Recovery Audit List of remittance advice remark codes http://www.wpc-edi.com/codes July 7, 2015 90 Overpayment Amount is Not Recouped on the Remit Showing Claim Adjustment July 7, 2015 91 Overpayment Amount is Not Recouped on the Remit Showing Claim Adjustment Instructs how to report recoupment when there is a difference between when an overpayment is identified and Palmetto GBA actually recoups the overpayment Same reporting protocol for all recoupments in addition to 935 Recovery Auditor recoupment July 7, 2015 92 Change Request (CR) 6870 Reporting of Recoupment on Remittance Advice (RA) Two step process Step 1: Reversal and Correction to report the new payment and negate the original payment Actual recoupment of money does not happen here Reason code N469 Step 2: Report the actual recoupment July 7, 2015 93 Step 1 Claim Level How this appears on electronic remit, depends on the formats used by vendor Original payment is taken back & new payment is established Provider Level Provider Level Adjustment Code (PLB) 03-1 shows PLB reason code FB (Forward Balance) PLB03-2 shows the detail July 7, 2015 1-2: CS (claims stats) 3-19: Adjustment DCN# (document control number) 20:30: HIC# (health insurance claim number) PLB04 shows adjustment amount to offset the net adjustment amount shown at claim level If claim level net adjustment amount is positive, PLB amount would be negative and vice versa Example- FB CS (DCN)(HIC): Amount 94 Step 2 How this appears on electronic remit, depends on the formats used by vendor Claim Level No additional information at this step Provider Level Provider Level Adjustment Code (PLB) 03-1 shows PLB reason code WO (Overpayment Recovery) PLB03-2 shows the detail: 1-2: CS (claim stats) 3-19: Adjustment DCN# 20:30: HIC# PLB04 shows the actual amount being recouped Example - WO CS (DCN)(HIC): Amount July 7, 2015 95 Electronic Report Summary of Provider Level Adjustments July 7, 2015 96 Electronic Report Summary of Provider Level Adjustments July 7, 2015 97 Provider-Level Adjustment Reason Codes Complete listing of provider-level adjustment reason codes can be found in the Centers for Medicare and Medicaid Services (CMS) guide titled: “Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers” http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads//RA_Guide_Full_0322-06.pdf July 7, 2015 98 Provider Summary Page Claims Accounts Receivable will be a total of all take backs on a remit Withhold will be the 935 amount including interest July 7, 2015 99 Provider Summary Page July 7, 2015 100 Provider Summary Page Reporting of Recoupment for Overpayment on Remittance Advice (RA) with Patient Control Number Effective January 1, 2012, Implemented April 2, 2012 Instructs shared systems to replace Health Insurance Claim (HIC) number sent on Electronic Remittance Advice (ERA) with Patient Control Number, received on original claim http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads//R993 OTN.pdf July 7, 2015 101 Change Request (CR) 7499 Use of Patient Control Number rather than the Health Insurance Claim (HIC): Enhance provider ability to automate payment posting Reduce need for additional communication (via telephone calls, etc.) that would subsequently reduce the costs for providers as well as Medicare Patient Control Number appear in positions 20-39 of PLB 03-2 July 7, 2015 102 CR 7268 - 935 Limitation on Recoupment Duplicate payment after favorable appeal decision for HIGLAS Users Effective October 1, 2011 Change eliminates duplicate payments due to non-recouped debts that are overturned on appeal and another payment made to provider causing double payment July 7, 2015 103 CR 7268 - 935 Limitation on Recoupment Changed way claims are processed due to overturns Palmetto GBA re-adjusts originally denied claim to reverse a denial to show services are payable The FISS suppresses subsequent adjustment Remit reflects PBL code J11 CR 7268 http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads//R892O TN.pdf July 7, 2015 104 Reconciling Refund Amounts to Patient Accounts Effective July 30, 2012, when a refund is issued to a provider, Palmetto GBA sends out a new standard refund notification letter. This letter will contain the following information: Refund Amount (Principal and Interest) Patient Information (Beneficiary Name & Dates of Service) Remittance Advice (RA) Date on which refund was included Refund Reason (e.g., “Appeal – Favorable Decision,” “RAC – Partially Favorable Decision,” “Reopening – Dismissed Decision”) AR/Overpayment Number July 7, 2015 105 Reconciling Refund Amounts to Patient Accounts Within five to seven business days of the remittance advice date, the standard refund notification letter will be sent to the provider It is our hope that this additional information will assist providers in reconciling payment activity to patient account activity and reduce the need to call the Provider Contact Center (PCC) to assist with reconciling refund amounts. July 7, 2015 106 Reconciling Refund Amounts to Patient Accounts In addition to the standard refund notification letter, Palmetto GBA is in the process of updating our Interactive Voice Response (IVR) system to allow Part A providers to look up and retrieve the FISS claim number associated with the Accounts Receivable (AR)/Overpayment Number supplied on the standard refund notification letter. If you have questions regarding the new standard refund letter, please call the J11 Part A PCC at (866) 830-3455. July 7, 2015 107 References CMS Publication 100-06, Medicare Financial Management Manual, Chapter 3 – Overpayments, section 200 – http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads//fin106c03.pdf Appeals Process Flowchart http://www.cms.gov/OrgMedFFSAppeals/Downloads/App ealsprocessflowchartAB.pdf Medicare Appeals Process brochure http://www.cms.gov/MLNProducts/downloads/MedicareA ppealsprocess.pdf July 7, 2015 108 References MLN Matters Articles: MM 6183 – http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/downloads//MM6183.pdf MM 7436 http://www.cms.gov/MLNMattersArticles/downloads/M M7436.pdf MM6870 – http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/downloads//MM6870.pdf July 7, 2015 109 References CMS Recovery Audit Contractor Web site http://www.cms.gov/RAC Change Requests: July 7, 2015 CR 7268 - http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads//R892OTN.p df CR 7499 - http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads//R993OTN.p df 110 Comprehensive Error Rate Testing (CERT) Overview 111 CERT What is it? A program developed by Centers for Medicare and Medicaid Services (CMS) to randomly audit claims monthly to determine if they processed correctly. Contractors then use this information to determine the cause of errors and work to resolve them. July 7, 2015 112 CERT Why does it matter? To protect the Medicare trust fund and determine error rates nationally and regionally. The error rate assists CMS so it is important for Palmetto GBA to educate our customers about proper billing techniques. July 7, 2015 113 CERT Who is involved? You, the hospital provider. A request for medical records alerts you that one of your claims has been selected as part of the monthly random sample. July 7, 2015 114 CERT July 7, 2015 How does it work? A letter will be sent to your office requesting the medical documentation. You need to comply in a timely manner with the request. No response or sending in only part of the requested documentation will result in a CERT denial and a refund of monies previously paid. 115 Common CERT Errors Based on data analysis, the majority of the errors are for insufficient documentation related to the following: Lack of documentation to support inpatient stay or continued inpatient stay; Medical Record Documentation and/or physician signature was missing or was not legible; July 7, 2015 116 Common CERT Errors Medical record did not contain a valid physician’s order, documented order intent or clinical indication for the service, e.g., laboratory testing, medications, inpatient admission; Medical record lacked sufficient documentation to support the medical necessity of the procedure/service performed July 7, 2015 117 Common CERT Errors The medical necessity errors consisted mainly of: Inpatient stays that were determined to not be medically reasonable and necessary based on the submitted documentation. The medical record documentation that was submitted did not substantiate the beneficiary’s need for an inpatient stay, but rather justified that the beneficiary’s condition could have been treated on an outpatient/observation basis. July 7, 2015 118 Common CERT Errors Documentation lacked a valid certification for physical therapy/occupational therapy services. Lack of documentation (hospital inpatient discharge summary) to support 3 day qualifying stay prior to Skilled Nursing Facility (SNF) admission. July 7, 2015 119 Common CERT Errors Related services that were required as a result of the primary service were denied because the medical necessity of the primary service was not justified such as pathology services. July 7, 2015 120 Important CERT Reminders July 7, 2015 Records should clearly indicate they have been 'electronically signed by' and include a date/time. We strongly suggest adding verbiage to this effect for clarification and establishing a protocol to ensure valid signatures are affixed to every order, record or report within a reasonable time frame (i.e., customarily 48-72 hours after the encounter) but certainly before the claim is submitted to Medicare for payment consideration. 121 Important CERT Reminders Important Elements to Remember July 7, 2015 Be sure a handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation 122 If you have questions pertaining to the information in the presentation, please call the Provider Contact Center (PCC) at 866-8303455 123