case management/ur denials and appeals. agenda denials management – rac, mac, zpic, etc....
TRANSCRIPT
Case Management/URDenials and Appeals
Agenda
• Denials Management – RAC, MAC, ZPIC, etc.
• Preventing RAC Denials
• Successful Appeals Strategy
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Denials Management
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Total Corrections (Millions)
October 2009 – September 2010 FY 2010 $92.3
October 2010 – September 2011 FY 2011 $939.33
October 2011 – September 2012 FY 2012 $2,400.7
October 2012 – September 2013 FY 2013 $3,834.8
October 2013 – September 2014 FY 2014 $2,404.6
Total National Program $9,671.7
CMS RAC Stats
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Underpayments Collected (Millions)
Underpayments Returned(Millions)
Total Quarter Collections(Millions)
FY To Date Collections(Millions)
Region C: Connolly $92.34 $9.33 $17.71 $394.01
Region C: Connolly Stats
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RAC Update
• Two mid-night delay in enforcement was lifted 3/31/15
• Probe & Educate ended 3/31/15• CMS has re-contracted with existing recovery
auditors 3/31/15• MACs will no longer be limited to chart pull limits
when reviewing claims for patient status 3/31/15
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New Rules – Be Careful
• Moratorium ended 3/31/15.• Patient status reviews began 4/1/15• 10/1/13 through 3/31/15 are excluded from review
for patient status• They are NOT excluded from review for medical
necessity, NCD/LCD, documentation, and other approved issues
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New Rules – Be Careful
• Gaming the System– Comprehensive Error Rate Testing (CERT)– First-Look Analysis for Hospital Outlier Monitoring
(FATHOM)– Program for Evaluating Payment Patterns Electronic Report
(PEPPER)
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FATHOM
• FATHOM: First-Look Analysis Tool for Hospital Outlier Monitoring is a Microsoft Access application that allows CMS to provide each State with hospital-specific Medicare claims data statistics, which identify areas having high payment errors. These target area statistics serve as relative indicators of payment errors. FATHOM reports include: short-term acute care inpatient prospective payment system (IPPS) hospitals (ST FATHOM), long-term acute-care IPPS hospitals (LT FATHOM), CAHs, IRFs and IPF. FATHOMs contain administrative data extracted from the Standard Data Processing System data warehouse for three previous fiscal years (FYs) and the current FY to date (cumulative). 9
Review of Two Midnight rule “CMS-1599 F”
• NOT JUST FOR MEDICARE ADMISSIONS• Inpatient Admission Order– Signed/authenticated prior to discharge
• Physician Certification – Separately signed no longer required
• Medical Necessity• Expectation of a Two-midnight Stay
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Review of Two Midnight rule “CMS-1599 F”
• Exclusions– Patient’s Procedure in on the Inpatient Only List from CMS– Patient left AMA(Against Medical Advice)– Patient expired– Patient newly elected Hospice– Patient transferred to another acute care hospital– Patient unexpectedly improved
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Two Midnight rule “CMS-1599 F”
• While CMS is saying to just have physician sign inpatient orders for 2 midnights, you still need to ensure medical necessity.
• You must ensure that you have sufficient documentation.
• You must have a consistent and 100% compliant method to get the CMS approved inpatient order, whether in CPOE or on paper.
• You should audit to minimize your risk of future denials.
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Two Midnight rule Denial Results MAC
• Most Current Data Results– 27% Denial Rate• Denial Reasons–37% missing, unsigned, invalid order–63% failed to document 2 midnight
expectation• PROBE Results– 30-60% based on sample size of 10
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2-Midnight Rule
• What is your facility’s PLAN?• Written procedures for – Case Managers– Physicians– Patient Access (Registration) Reps– PFS Medicare Billers
• Consider CM – Physician “team” for inpatient documentation!
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2-Midnight Rule
• Consider pre-bill edit to hold Medicare inpatient claims that are one-day stays.
• Case Manager or Nurse Auditor Review prior to billing
• Take specific deficiencies in documentation and LOS back to physician for review (ideally, back to CM – Phys team)
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Preventing RAC Denials
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Not Just for Acute Care Providers
• Denials are affecting all organizations along the continuum of care– Hospice – Home Health – DME – Inpatient Rehab – LTAC
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Best Practices
• Centralized Function• Multi-Disciplinary Team Consisting of:– RN/Case Managers– Physician Advisors– Coders– Billers– Revenue Integrity– Clerical
• Systematic Methodology to approach appeal process
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Best Practices - Continued
• Flow charted process• Role Clarity• State of the Art Software System– Easy to use– Has powerful reporting capabilities– Alerts to ensure deadlines are met– Dollars at risk vs. dollars lost
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Best Practices - Continued
• Focus should be on determining the root cause and putting preventative measures in place
• Requires support at highest level and process changes in many facets of the organization
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Change Physician Behavior
• Physicians are scientists • Provide hard facts and data• Evidenced based Medicine• Physicians do not like to be outliers• Leave emotion and finances out of discussions
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Denials Management
• Are you monitoring your metrics?• Who is responsible?• Have you flowcharted the processes?• Have you assigned responsibility?• How do you track deadlines?• Who determines if a denial is worth the appeal cost?– How is that determined?
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Denials Management
• Do you use an external company? Is the cost worth it? Are you paying a contingency or flat fee?
• How do you track denials so you can determine root causes and implement improvement processes?
• MedPerformance has a system to help you.
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iMAD
Denial Management Program
iMAD = interactive MedPerformance Appeals and Denials
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iMAD - Main Menu
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iMAD – Patient Information
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iMAD – Due Dates
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iMAD – Standard Reports
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Successful Appeals Strategy
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The Appeal Process
• Appeal process– Intentionally complex and deceptive process….– Hard deadlines– Labor intensive– Allow recoupment or risk interest
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Successful Appeals Strategy
• Must have tool to track denials and deadlines• Need guidance from Executives• If a medical necessity denial – paint a clear picture of
patient• Include only abnormal data• Include what is being done that can only be done in
an acute care facility
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Rebecca Corzine TarrOwner
MedPerformance LLC
(813) 786-8974
Questions/Comments?
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