Audits and Current Therapy Trends

Kimberly Saylor, OTR/LVP of Business Development

Concept Rehab, Inc.937-776-3581

Objectives for Today:

• Understanding of types of audits being conducted in LTC

• Understand the appeal process of audits on therapy services

• Discuss the current trends of therapy in LTC/SNF setting

• Explore the business-side of therapy

Audits…Audits…Everywhere

Types of Audits:• MAC Audits

• RAC Audits

• MMR (Manual Medical Review)

• Medicaid Audits

• Managed Care Audits

• ZPIC

What is a MAC ?

• MAC = Medicare Administrative Contractors

• Regional Contracts with CMS

• MACs are responsible for:• Reviewing, Revising, and Issuing updated Local Coverage

Determination (LCD) guidance covering the services in their area

• Ohio is in Jurisdiction 15

• CIGNA (CGS) is our MAC for Medicare Part A and Part B

• CIGNA website:• http://www.cgsmedicare.com/

MAC• Medical Review (MR) program goal: to reduce payment error

by preventing the initial payment of claims that do not comply with Medicare’s coverage, coding, payment, and billing policies.– Identify noncompliance through analysis of data

– Take action to prevent improper payment with goal of reducing the paid claims error rate.

MAC• Medical Review Process

ADR • Focused Reviews (Probe)

• Ex: 2009 Focused Review OT/PT (97110)

• Random Reviews

Potential Outcome of ADR• Full, Partial or Denied Payment

What is a RAC?• RAC = Recovery Audit Contractor

• Subcontractor that is hired by CMS to detect, correct, and prevent future improper payments • CGI Federal RAC for Region B which includes Ohio

• RAC is paid on a contingency fee basis. This means they are paid only if they find reason to deny a claim.

• The fee is % of amount of improper payment. • RACs became permanent in 2010.

RAC

• Primary task is to ID improper PAST Medicare payments

• 3 year look back period

• Must get CMS ok to conduct widespread review or referred to as “issues”

RAC AUDITS

3 Types of RAC Review:• Automated Review:

• Overpayment data based solely on data billed (no medical record reviewed.). Audit focused on billing and coding patterns compared to peers and other providers.

• Semi-Automated Review:• Claims are reviewed using data and possibly a reviewer to

look at the medical record, if requested.

• Complex Review:• RAC demands medical records to determine if there was

over payment.

RAC 2005-2007 What Did They Find?

• RAC demonstration project of 2005-2007 recovered over $1.3 billion mostly

due to:

• 45% Medically unnecessary

• 35% Incorrect coding

• 10% Insufficient documentation

• Officially started August 27, 2012

• Will conduct Pre-payment reviews on claims that historically have high rates of improper payments

• Ohio to be reviewed d/t high claims volumes of short stay hospital visits

New RAC Prepayment Reviews:

Zone Program Integrity Contractors• ZPICs handle Medicare Program integrity functions for CMS

• They work with the Medicare Administrative Contractor (MAC) to handle fraud and abuse within their jurisdiction

• They refer cases of potential fraud to the Dept. of Health and Human Services (HHS) and Office of Inspector General (OIG)

• ZPICs have the power to suspend claims/ payment for up to 1 year and there is no appeal recourse at this time

ZPIC• Scrutinize providers across settings; i.e. hospital with hospital

based SNF/HH etc.

• Don’t have a limit on the time they spend looking at the provider in question

• No ZPIC audit is random. A ZPIC audit is either the subject of a fraud investigation, or process to review information to determine if a fraud investigation should be opened.

• ZPIC for Ohio Cahaba Safeguard Administrators, LLC

Part B Manual Review Process (MMR)• Specific to Part B Therapy Services - Effective October 1, 2012

and was in place temporarily for 3 months

• Current cap is $1900. Threshold of $3700 for OT and $3700 for PT/ST combined for Medicare Part B

• American Taxpayer Relief Act of 2012 extended Part B OP manual medical review (MMR) requirements thru Dec 31, 2013

• MMR – completed on every claim at and after the services exceed $3,700.

Current MMR Framework• CMS Finalized 2013 Process

• No more prior authorization process

• April 1, 2013 begins RAC • OH is among the 11 states

in ‘Pre-Pay’ MMR demonstration RAC

• 39 states in ‘Post-Pay’ MMR RAC

Current MMR Process• MAC issues ADR once $3700 threshold is met

• Provider has 30 days from the date of ADR to submit documentation

• RAC to conduct MMR within 10 business days

• RAC notifies MAC of the decision

• RAC issues detailed review results letter to provider

ARE WE HAVING FUN YET?

Medicaid Integrity Contractors• Established in 2005 as part of the Medicaid Integrity Program

• Three Types of MICs: • Audit: Conduct post payment audits and identify over payments

which states will collect and work with provider appeals.

• Review: Analyze Medicaid claims to identify high risk areas and potential vulnerabilities.

• Education: Use findings from Audit and Review MIC to identify and provide areas of needed education and training to prevent Medicaid fraud, waste and abuse.

Humana Audits for Skilled Care• Specifics:

– to ensure accuracy of RUG scores billed– Post-Payment: going back 2 years– Providers have 14 – 30 days to respond to request

• Primary Issues:– Are therapy minutes submitted on MDS supported?– Are ADL scores supported in documentation?– Is there evidence of need for COT OMRA?

• Outcome Letter:– RUG validated – RUG not validated Results in re-rugging and request for

overpayment to be PAID back

Humana Audits for Skilled HMO• Issues:

– Therapy minutes submitted on MDS supported?– Are ADL scores supported in document?– Evidence of need for COT OMRA?

• Outcome Letter:– RUG validated – RUG not validated Results in re-rugging and request for

overpayment to be PAID back

Audits will continue until no more issues can be found!

Understanding the Appeal Process

How to Prepare for an Audit?

• Have facility specific procedure outlined for gathering records• Identify key personnel

• Billing, Medical Records, Nursing, Therapy

• Outline individual responsibilities

• Establish timeframes

• Work from checklists to assure completeness

Submitting Information for an Audit• Timing is important!

• Audits are very time sensitive - Know your deadlines

• Always send packets using certified mail, Fed Ex, or UPS• Tracking receipt a must!• Some contractors accept fax or CD/DVD in TIFF

• Submit ‘other’ records that help support medical necessity of therapy services• Social services’ notes that support PLOF• Nurses’/Restorative notes that support reason for referral or decline• Physician notes/H&P that support decline

What do I do if all or portions of my claim are denied?

• Know your appeal rights

• Uniform Process for Medicare Denied Claims• MAC and RAC have same appeal process• 5 Levels in Appeal Process

First Level of Appeal: Redetermination

• Records examined by the MAC – different department than one who reviewed ADR.

• You have 120 days from the date of the initial determination to file a redetermination.

• Must be requested in writing.

• Include additional supporting documentation to make your case.

• Appeal letter to summarize rebuttal.

Second Level of Appeal: Reconsideration

• Reconsideration by a Qualified Independent Contractor (QIC)

• Must be filed within 180 days of date of redetermination decision letter.

• Appeal letter and important to send all supporting documentation at this level.– May not be granted permission to submit further documentation

beyond this level of appeal.

• QIC will make decision in 60 days.

• Website Link to check status of Level 2 Appeal:https://www.q2a.com

Third Level of Appeal: Administrative Law Judge Hearing

• Administrative Law Judge (ALJ) Hearing

• Request this hearing within 60 days of the date of the reconsideration decision letter.– Must receive permission by Judge to submit any additional

documentation at this level– Must have ‘good cause’

• Must be a claim of at least $140.00.

• Hearing held by phone or video-telephone.

• Decision issued within 90 days

NOTE: ALJs are currently delayed due to the volume of requests being received

Third Level of Appeal: Administrative Law Judge Hearing

Fourth Level of Appeal: Medicare Appeals Council

• If dissatisfied with ALJ decision a request may be made to the Medicare Appeals Council.

• Must be requested within 60 days of the date of the ALJ decision letter.

• Appeal submitted in writing.

• Generally a decision is issued by the Council within 90 days of the request for review.

Fifth Level of Appeal: Federal District Court

• If dissatisfied with Council decision may submit final appeal to Judicial review in Federal District Court

• Current threshold is $1,400.

• Must request this review within 60 days of the date of the Council’s decision letter.

Humana Appeal Process3 Levels to Humana Appeal Process

Level 1: • 30 days to contact Humana and notify you are appealing• 120 days to submit appeal. • Appeal reviewed by original reviewing organization

Level 2: • 120 days to submit appeal• Appeal reviewed by 3rd party vendor

Level 3: • 120 calendar days to submit appeal. • Depends on type of audit and expertise required. • A physician will review all medical necessity cases. • Appeals reviewed by Humana:

• Internal Clinical Physician Review Team • Internal Coding Team

Keys to Successful Appeals• Individualize appeal letters at each level

• SAMPLE templates can assist with this process

• Focus on specific rebuttals• Decision letters as you advance in appeal process

provide more details of reasons for UNFAVORABLE decisions

• Familiarize self with LCDs and CMS Manual information• Copy and paste regulations from these resources in your appeal letters

• Don’t trigger an audit!!

Keys to Successful Claims DOCUMENTATION of Medical Necessity

• Supportive Medical and Treatment Diagnosis

• Details of specific reason for referral – helpful if supported elsewhere

• Detailed Prior Level of Function to justify decline

• Discipline specific, objective, functional goals

• Objective evidence that treatment is effective and progressive• Routine updates to the Plan of Care

• Appropriate frequency and duration of therapy relating to diagnosis

• ADL scores are consistent with RUG category

• Avoid technical denials• Physician signatures, certifications, co-signatures, dates etc.

• Treatment requires skills of therapist• Hint: why are restorative services not an option

Skilled Terminology HintsNon-Skilled Buzz-Words

Ambulation Chronic Endurance Fitness Observing Performed Practiced Refused Repetitious Uncooperative Color of theraband

Skilled Buzz-Words Acute exacerbation Analyzing/analysis Assessed/re-assessment Developing Establishing Evaluating effectiveness of Individualized Inhibition or Facilitation Modifying Remediation Minimum, moderate,

maximum resistance

Therapy Updates and Current Trends

Recent Therapy Updates• MPPR increased to 50% April 2013

• G Codes implemented 7/1/13

• Therapy Cap expires 12/31/13

• MDS RUG changes 10/1/13– Medium and Low Criteria– Co-Treatment Changes

Therapy-Specific Optimization• RUG Distribution

– ADL End Splits

• Part B Services– Case Mix

• Managed Care Management

• Technology

• Outcomes

• ACO Positioning

Therapy Service Extenders

• Out-patient

• Wellness and Education• Home Care

• In-house and Other Strategic Alliances

• Physician Collaborations

• Clinical Specialties

• Person-Centered Care Initiatives

• CCRC-Specific Models

THANK YOU

ReferencesCahaba: http://www.cahabasafeguard.com/

CERT: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/index.html?redirect=/cert

CGI: https://racb.cgi.com/default.aspx

CIGNA (CGS): http://www.cgsmedicare.com/

KePro: https://www.ohiokepro.com/

Medicare Appeals Process:http://www.cms.gov/Medicare/Appeals-and-Grievances/ OrgMedFFSAppeals/index.html?redirect=/orgmedffsappeals/

Medicare Benefit Policy Manual Chapter 15, Section 220:http://www.cms.gov/Regulations-and-Guidance/ Guidance/ Manuals/ Downloads/ bp102c15.pdf

ReferencesMMR FAQ Document: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/ Downloads/ FAQ_OutpatientTherapy_04172013.pdf

MMPR Medlearn Matters Article (9/28/12): http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/MM8036.pdf

MMPR Medlearn Matters Article (7/6/2013): http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7050.pdf

Therapy CAP Fact Sheet:http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/rev01172013TherapyCapFactSheet_v2.pdf

Resource LinksAOTA Medicare Resources: http://www.aota.org/Advocacy-PolicyFederal-Reg-Affairs/Pay/Medicare.aspx

CGS Contact Information: http://www.cgsmedicare.com/parta/help/contact_info.html

Join the CGS ListServ to receive updates from CIGNA by email: http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp