Transcript Prepayment Review’s - Florida Buccaneer AAHAM-Home

Prepayment Review’s
Managing MAC & RAC Requests
Cheryl MacKinnon, CPAM
Director, Government Insurance, CBO
Lee Memorial Health System
Agenda for Today’s Discussion
Why Prepayment reviews ?
 MAC’s
 RAC’s
 How do the CERT’s fit in?
 What is being reviewed
 Steps you can take now
 Minimize Financial Impacts
 Keeping Everyone Informed
 Latest Trends
 Resources – Finding answers

Lee Memorial Health System
Cape Coral
Hospital
Gulf Coast
Medical
Center
HealthPark
Medical Center
Lee
Memorial
Hospital
Lee
Rehabilitation
Hospital
Beds – 291
Beds – 349
Beds -368
Beds 355
Beds - 60
 Located in SW Florida
 Total 1,423 Beds
 54% Medicare
 40.7% Medicare
 13.6% Medicare HMO
 Central Business Office handles all hospital billing
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Why Prepayment Reviews?

Executive Order 13520

Lower Medicare FFS improper payment
error rate percentage by 50%

2012 Goal – 5.4%

Multi faceted approach

Intended to prevent improper payments
before they occurred
Medicare Administrative Contractor
(MAC) – First Coast Service Options
FCSO awarded funding for Part A & B review of
high dollar claims with high risk of error
 15 MS-DRG’s initially identified in 2011 plus
Cardiac MS-DRG’s
• Reviews impact both Hospital & Physician claims

•
•
•
•
•
Physician claim review – Post payment
FCSO Notification Letter is sent to Physician
FCSO Recoupment letter will follow
Separate Part B appeal
Providers with low error rates on specific DRG’s
will be exempt from prepayment review
Recovery Auditors (RAC)

Pre Payment Review Demonstration in 11 states
High One
Day Stays
High Rates
for Fraud &
Abuse
Began August 27, 2012 and ends
August 26, 2015
Focus on claims with historically
high error rates
Missouri
California
North
Carolina
Florida
Lower error rates by preventing
them before they occur
Ohio
Illinois
Pennsylvania
Louisiana
Prepayment claim volume will be
incorporated into providers current RAC
post payment claim review limits
Michigan
New York
Texas
Once claim is reviewed it can’t be
selected again for post payment review
MAC & RAC will not review the same DRG’s
CERT’s – How do they fit in..

Comprehensive Error Rate Testing Program (CERT)
 Separate
initiative but closely related to
MAC’s & RAC’s

CERT’s Provide Annual Report to Congress

Designed to monitor MAC performance
MAC’s - Monthly Performance Reports

Providers need to monitor requests closely
 Post
payment reviews
 Track
requests
 Respond
 Submit
timely
complete records
MS-DRG’s Under Review by MAC
RAC is now reviewing 069
DRG’s without an LCD/NCD
DRG’s with LCD’s
MS-DRG Prepayment
Timeline
MS-DRG 226, 227, 242, 243, 244,
245, 247, 251, 253, 264, 287, 313,
392, 458, 460, 470, 490, 552, 641
MS-DRG 153, 328, 357, 455, 473,
and 517
March 2011 to March 2013
•2 years of data
•27 DRG’s plus
one day stays on
prepayment
review
• majority on 60%
review
MS-DRG with
One day LOS
MS-DRG 312
1st RAC
Review
MSDRG 069
and 254
MS-DRG 069
Stopped By
MAC
MS-DRG 377-379 G.I. Hemmorrage
MS-DRG 637-639 Diabetes
MS-DRG 069
Now reviewed by
RAC
Steps You Can Take Today

Update Your Financial Clearance Policy to
include Medicare Coverage Criteria
“Medicare National Coverage Determination (NCD) Guidelines or
Medicare Local Coverage Determinations (LCD) Guidelines: The
requirement that a service provided to a Medicare beneficiary meets the
medical necessity criteria established by Medicare as described in either
a NCD or a LCD”

Share at Medical Executive Committee Meetings
 Educate
Physician’s on the changes
 Explain the Benefits
 Gain Support
 Provide Tools & Guidelines on LCD & NCD
Requirements
Develop A Pre-Screening Process
Implement a proactive
review process
 Pre Screen scheduled
patients
 Ensure documentation
meets Medicare medical
necessity criteria
 Add Resources and Staff
to areas responsible for
this new process
 Continually monitor and
adjust screening focus

MEDICAL NECESSITY REVIEW FORM
(This form is only for review purposes, and to assist with H/P dictation. It will not be part of the medical record.)
Patient Name: ______________________________
Patient DOB: ______________________________
Procedure: IMPLANTABLE CARDIAC DEFIBRILLATOR
All answers “YES” to any of the following 7 questions, your patient DOES NOT meet required criteria for
surgery
1.
Patient is unable to give informed consent
2.
Irreversible brain damage from preexisting cerebral disease
3.
CABG within past 3 months Date:__________
PTCA within past 3 months Date: __________
Acute MI within past 40 days Date: ___________
4.
Symptoms/findings making patient a candidate for coronary revascularization
5.
Any disease, other than cardiac disease, with likely survival <1 year
6.
Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm
NYHA class IV heart failure unless all current CMS coverage requirements for cardiac resynchronization therapy
(CRT) are met (see below)
***STOP!! If you marked YES above, your patient does NOT meet criteria***
*LVEF Data (at least one method is required for all criteria points below where a value is denoted)
Most recent LVEF DATE: ____________________
LVEF %: ______________________
How was LVEF measured:
Angiography
Radionuclide Scan
Echocardiogram
Date of EP Study: (if applicable)_______________
7.
If the above are negative AND you answer “YES” to any of the following 8 questions, your patient MEETS
required criteria for ICD implant surgery.
1.
2.
3.
Documented episode of cardiac arrest due to VF, not due to a transient or reversible cause
Documented familial or inherited conditions with a high risk of life threatening VT, such as long QT syndrome or
hypertrophic cardiomyopathy.
Documented sustained ventricular tachyarrythmia, either spontaneous or induced by an EPS, not associated with an
acute MI and not due to a transient or reversible cause
4.
IDCM, prior documented MI, NYHA Class II or III heart failure, and LVEF < 35%* (Class must be documented)
5.
Documented prior MI with LVEF ≤30% * OR
Documented prior MI with LVEF < 35%*, CAD with inducible sustained VT or VF at EPS and EPS > 4 weeks post MI
6.
Meets all current CMS coverage for a CRT device AND NYHA Class IV heart failure
7.
Documented prior MI with LVEF ≤ 35%*, IDCM and NYHA Class II or III heart failure (Class must be documented)
8.
NIDCM > 3 months, NYHA Class II and III heart failure and LCEF < 35%* (Class must be documented)
NOTE: Provider must be able to justify the medical necessity of devices other than single lead devices in the medical record
Please fax completed form to Prepayment Review 239-343-2597; or call 343-2479
Other Areas to Consider
Medical Records
 Keep coders informed of MS-DRG’s being
reviewed.
 Review Medical Records for completeness
before submitting to MAC’s, RAC’s & CERT’s
 Case Management
 Well documented cases that support Medical
Necessity – a must!
Build strong CM and Utilization Review
Processes
 Prompt communication on status changes

Financial Impacts
Our Goal is to Minimize Them
Joint Project
Management
Work ADR’s
Daily
Track & Trend
DRG’s Closely
• Implement Department Accountability Standards
• Scheduling – Identifying & Reviewing All Cases
• HIM – Responding Timely to Records Requests
• Case Management – Submitting Timely Appeals
• First Job of the Day
• Request Medical Records Immediately
• Submit Complete Medical Records
• Meet All Deadlines
• Know Your Top DRG’s
• Highest Volume
• Highest Dollars at Risk
• Areas of Concern
LMHS – Top 10 MS-DRG’s Based on
Highest Dollars at Risk
813
9%
641
1%
227
1%
0%
Lee Memorial 470 – 460 - 255
247
0%
Gulf Coast Medical Center 287- 313- 392
813
227
247
255
460
470
641
0%
392
18%
255
29%
247
227 287
255
813
641
0%
0% 5%
2%
313
8%
813 227
0% 8%
470
41%
Cape Coral Hospital 470- 460 -313
Healthpark Medical Center 641-247-227
392
6%
247
21%
641
55%
470
40%
313
23%
470
460
0%
1%
255
0%
287
6%
313
392 6%
3%
460
38%
460
14%
287
59%
287
1%
313
3%
392
2%
MS-DRG’s Selected
227
247
255
287
313
392
460
470
641
813
LMHS – Where is the money?
Prepayment Requests in Process
Records Being Reviewed by MAC
Communication
Keeping Everyone Informed
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Communication- Medical Staff
Provide Regular Updates
on MS-DRG’s Under
Review
 Share the Success when
an MS-DRG is removed
from prepayment review
 Notify the physician
when a hospital claim
has been selected for
review
 Work with physician &
office staff to address
any documentation
deficiencies to prevent
future denials

Communication – Team Approach
Scheduling
Physician’s
Finance
HIM & Coding
Case Management
Business Office
VP Revenue Cycle
Latest Trends
 Therapy
Claims Exceeding $3,700
Cap now on Prepayment Review
 ALJ’s
Remanding Cases to QIC
CMS Ruling 1455-NR Announced
Effective March 13, 2013
CMS Proposed Rule 1455-P
http://ofr.gov/(X(1)S(03a1ssnfvj5r1newt2xvuj
3e))/OFRUpload/OFRData/2013-06159_PI.pdf
Resources

Medicare Fee-for-Service 2011 Improper Payments Report
http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/CERT/Downloads/2011-Medicare-FFS-Improper-Payment-Report-.pdf

Guidance on Hospital Inpatient Decisions
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/se1037.pdf

FCSO ADR Calculator
http://medicare.fcso.com/claim_submission_guidelines/232239.asp

FCSO Appeals Calculator
http://medicare.fcso.com/Appeals/164098.asp

FCSO MS-DRG Information
http://medicare.fcso.com/Inpatient_DRG/

CMS Prepayment Review Demonstration

Questions for CMS regarding RAC Prepayment – [email protected]

CMS“Chapter 3 – Verifying Potential Errors and Taking Corrective
Actions.” ProgramIntegrityManual. https://www.cms.gov/RegulationsandGuidance/Guid
ance/Manuals/downloads/pim83c03.pdf.
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/RecoveryAudit-Program/RecoveryAuditPrepaymentReview.html#
Questions?
Thank You
[email protected]
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