Transcript Downloads - Montana HIMA

Not Another RAC
Presentation!
MHIMA 2011 Spring Meeting
Presented By:
Virginia Gleason, JD/MPA, CHC, CPHRM
Then and Now
• "They believe we are bounty hunters," N. Lee White, who
heads U.S operations for PRG-Shultz International, said of
California lawmakers and the California Hospital Association.
"I don't appreciate the characterization.” November 12, 2007
•
According to the Associated Press, on March 9th 2010,
President Barack Obama said he'll bring in high-tech “bounty
hunters” to help root out health care fraud using data mining
and computer programs that looks for fraudulent claims and
erroneous data.
RACs Are Here
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RAC Program implemented nationwide
Automated and Complex Audits underway
Started with focus on DRG Validation
Coding Validations are underway
Medical Necessity Reviews underway
Health Care Reform expands RACs to Medicaid
and Medicare Parts C and D
The Alphabet Soup
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Medicare Administrative Contractor (MAC)
Recovery Audit Contractor (RAC)
Medicare Secondary Payor RAC (MSP RAC)
RAC Validation Contractor
Medicaid Integrity Program Contractor (MIP, MIC)
Program Safeguard Contractor (PSC)
Zone Program Integrity Contractor (ZPIC)
Qualified Independent Contractor (QIC)
Quality Improvement Organization (QIO)
Medicaid Payment Error Rate Measurement Contractor
(PERM)
Medicare Drug Integrity Contractor (MEDIC)
Medicare Demos (DME, HHA)
What does this mean to
Providers?
They perform data mining.
"This is a new era of using data in the health care
marketplace," says Larry Vernaglia, an attorney
with Foley & Lardner LLP. "CMS has always had
access to tons of data, but now they have new
ways to slice and exploit this data both internally
and through Medicare contractors."
What is AHA RACTrac?
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Web-based survey to collect RAC experience data from
hospitals
Unit of analysis is the hospital
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Quarterly data collection
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General Medical/Surgical Hospitals including Critical Access Hospitals
LTCH
Psych
Review the RACTrac
Rehab
Automated Denials
Complex Denials
Underpayments
Appeals
Administrative burden
Survey Questions and
Definitions at
www.aha.org/rac
under RACTrac!
Collect both quarterly snapshot and cumulative
information on RAC experience to date
Results of AHA RACTrac Survey
4th Quarter, 2010
Let’s look at some data
http://www.aha.org/aha/content/2011/pdf/Q4ractracresults.pdf
The Big Picture
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79 percent of the 1850 hospitals surveyed have had RAC
activity through the fourth quarter of 2010
Of this 79 percent, nearly four out of five reported complex
RAC reviews which involve the review of medical records
and other documentation to identify improper payments
Majority (90 percent) of denials that hospitals are receiving
from RACs are for complex reviews, totaling over $78
million dollars
Hospitals are appealing only 23 percent of the denied
claims
Of the claims that have completed the appeals process, 85
percent were overturned in favor of the provider
Where does that leave us?
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RAC to accept records electronically
CMS refines guidance regarding inpatient
admissions
Increase in records request limit for certain
hospitals
CMS announces RAC Medical Records Request
Limits for Physicians
Medicaid RAC Program Update
RAC Accepting Electronic
Records?
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Announced February, 2011
Electronic Submission of Medical Documentation
(“esMD”) pilot.
http://www.cms.gov/ESMD/
Two Phases:
Phase 1 – anticipated July 2011
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RACs will send requests via paper letters
Providers will have the option to electronically submit
documentation
RAC Regions A, B and D “anticipate” participating in Phase 1
Phase 2 – Beginning 2012
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RACs will electronically send documentation requests
RAC Region C will participate by Phase 2
What Constitutes an
Inpatient?
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During the demonstration project, 85% of claims
denied were inpatient hospital claims.
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Routinely denied for lack of medical necessity to support
inpatient level of care
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“High Risk” medical necessity denials – MLN
Matters revised November, 2010
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Guidance on Hospital Inpatient Admissions – MLN
Matters January, 2011
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CMS Podcast – March 9, 2011
http://www.cms.gov/MLNProducts/MLM/itemdetail.asp?filterType=none&filterByDID=99&sortByDID=3&sortOrder=ascending&itemID=CMS1245720&intNumPerPage=10%20
Interqual vs. Milliman vs.
CMS Regulations and Manuals
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Guidance on Hospital Inpatient Admissions – MLN
Matters January, 2011
Acknowledged “commerically available screening
tools”
Supported RACs ability to use these tools
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Cited: Medicare Program Integrity Manual (CMS Pub. 100-08), Chapter 6,
Section 6.5.1
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When reviewing claims, a medical reviewer “shall
use a screening tool” as part of their review
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CMS “screening tool” is its published criteria
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Medicare Benefit Policy Manual (CMS Pub. 100-02), Chapter 1, Section 10
Contractors “may” use proprietary criteria when reviewing
medical necessity of inpatient admissions.
The Decision Seems Easy…
Patient
Presents
Admit as
Inpatient
Treat as
Outpatient
But It’s Much More Complicated
Office
Follow-up
Admit as
Inpatient
Treat as
Outpatient
Outpatient
Procedure
Observation Diagnostic
Testing
Specialty
Clinic
Follow-up
SNF
Follow-up
Patient Status Options
Admit as
Inpatient
Patient
Outpatient
Observation
Presents
Outpatient
Procedure and/or
Followup
Medicare’s Definition of
Inpatient
Medicare benefit policy manual chapter 1 sec. 10
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An inpatient is a person who has been admitted to a hospital for
bed occupancy for purposes of receiving inpatient hospital services.
Generally, a patient is considered an inpatient if formally admitted
as inpatient with the expectation that he or she will remain at least
overnight and occupy a bed even though it later develops that the
patient can be discharged or transferred to another hospital and
not actually use a hospital bed overnight.”
“However, the decision to admit a patient is a complex medical
judgment which can be made only after the physician has
considered a number of factors, including the patient's medical
history and current medical needs, the types of facilities available
to inpatients and to outpatients, the hospital's by-laws and
admissions policies, and the relative appropriateness of treatment
in each setting. Factors to be considered when making the decision
to admit include such things as:
– The severity of the signs and symptoms exhibited by the patient;
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– The medical predictability of something adverse
happening to the patient…”
Medicare’s Definition of
Inpatient
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Admitted to a hospital
Bed occupancy for purposes of receiving inpatient hospital services.
Formally admitted as inpatient
Expectation that he or she will remain at least overnight … even
though it later develops that the patient can be discharged or
transferred to another hospital and not actually use a hospital bed
overnight
Admit decision is a “complex medical judgment”
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patient's medical history
current medical needs
the types of facilities available to inpatients and to outpatients
hospital's by-laws and admissions policies
Key Factors:
– The severity of the signs and symptoms exhibited by the patient;
– The medical predictability of something adverse
happening to the patient…”
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Transmittal 47
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Interpretive Guidelines for Hospitals
June 5, 2009
www.cms.hhs.gov/transmittals/downloads/R47SOMA.pdf
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“All entries in the medical record must be complete.
Defined by: sufficient info to identify the pt; support the
dx/condition; justify the care, treatment, and services;
document the course and results of care, treatment and
services and promote continuity of care among providers.
“All entries must be dated, timed and authenticated, in
written or electronic format, by the person responsible for
providing or evaluating the service provided.”
“All entries must be legible. Orders, progress notes, nursing notes,
or other entries …..
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More Transmittal 47
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Timing establishes when an order
was given, when an activity
happened or when an activity is to
take place. Timing and dating
establishes a baseline for future
actions or assessments and
establishes a timeline of events. (71
FR 68687)
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Increased Record Limit
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CMS increase in records request limit for certain
hospitals
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Hospitals with more than $100 Million in annual
Medicare reimbursement
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500 records allowed per 45-day period
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AHA estimates this will impact 87 hospitals
Physicians Are a Target
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CMS announces RAC Medical Records Request
Limits for Physicians
February 14, 2011
Based on number of physician / non-physician
practitioners reported under the Tax ID Number
CMS reserves the “right” to exceed the caps
Group / Office Size
Max Number of Records Every 45 Days
50 or more
50 records
25 – 49
40 records
6 – 24
25 records
Less than 5
10 records
Medicaid RACs
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Section 6411 of the Patient Protection and Affordable Care
Act (“Affordable Care Act”) requires each State to establish a
Medicaid RAC program similar to the existing Medicare RAC
program
New implementation deadline will be announced in the
publication of the Final Rule anticipated “later” in 2011.
“Out of consideration for State operational issues and to ensure States
comply with the provisions of the Final Rule, we have determined that
States will not be required to implement their RAC programs by the
proposed implementation date of April 1, 2011.”
http://www.cms.gov/MedicaidIntegrityProgram/Downloads/6411racdelay.pdf
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CMS Medicaid RAC Website
http://www.cms.gov/medicaidracs/
More CMS Communications
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Medicare Quarterly Provider Compliance
Newsletter
 “Help” providers understand audit findings of Medicare
contractors
 MAC, RAC, PSCs, ZPICs etc
Newsletter describes problems, the issues
that may occur and steps CMS has taken.
 Important resource
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http://www.cms.gov/MLNProducts/downloads/MedQtrlyComp_Newsletter
_ICN905712.pdf
February 2011
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February 2011 Newsletter Highlights
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Coding of tracheostomy procedures
Coding of “new patients”
Coding of chemotherapy administration and non-chemotherapy injections
and infusions
Coding of excisional debridement
E/M billing during a global surgery period
DME provided to hospice beneficiaries
Billing of Budensonide
Funding Healthcare Reform
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The Reform of Healthcare
 To be funded through “fraud, waste and
abuse” detection and recovery
 What does Medicare’s audit strategies have to
do with “fraud, waste and abuse”?
 Wasteful spending = paying for care that is
not supported by the documentation in the
record and in compliance with Medicare
laws, rules and regulations.
Questions and Answers
Contact Information:
Virginia Gleason, JD/MPA, CHC, LPN
Senior Consultant
Quorum Health Resources
[email protected]