zpic rac mac audits proactive vs reactive 5-13 nadona ......proactive vs. reactive approach lisa...

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©Pathway Health 2013

ZPIC, RAC and MAC Audits

Proactive vs. Reactive Approach

Lisa Thomson

Vice President of Strategic Initiatives

Pathway Health Services, Inc.

1©Pathway Health 2013

After attending this presentation, the attendees will be able to :

1. Understand the different types of audits related to reimbursement: ZPIC, RAC, and MAC

2. Determine proactive approaches for positive positioning to audits

3. Identify leadership monitoring protocols for ongoing compliance and quality outcomes

Objectives

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Current Healthcare Landscape


• Leadership Tactics for this changing Environment

– Education and Knowledge

– Internal Review

– Data Agenda

– Preparedness and Protection

– Performance Improvement


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Knowledge and Education



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Healthcare Landscape

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Why External Government Audits?

• Improper payments

– Payments for services that were not medically necessary

– Payments for services that were incorrectly coded

– Providers failed to submit documentation to support the services provides OR failed to submit enough documentation to support the claim

– Other errors – (i.e. submitted twice/paid twice)


Government Reaction

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• Fraud Prevention System (FPS)

– In place for over 2 years

– Outcome – $3 for every $1 spent

– Generated leads for additional 536 new ZPICs

• FPS collaboration with law enforcement

• OIG involvement and issuance of SNF based Reports

– Overpayment

– Reviewers found SNFs incorrect coding to higher RUGs in 20% of claims


Government Reaction

Office of the Inspector General (OIG)

• Questionable billing by SNFs.

• Conduct a full review of SNF billing by end of FY 2011 and implement plan.

• Increased diligence on therapy utilization.

• Increased auditing of supporting documentation.

• NEW – HHS 2014 Budget!

– CMS and OIG (a new kind of Marriage)!



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Medicare Fraud http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf

• “In general, fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person’s own benefit or for the benefit of some other party. In other words, fraud includes the obtaining of something of value through misrepresentation or concealment of material facts.”

• Examples of Medicare fraud may include:

– Knowingly billing for services that were not furnished and/or supplies not provided, including billing Medicare for appointments that the patient failed to keep; and

– Knowingly altering claims forms and/or receipts to receive a higher payment amount.

Medicare and Medicaid Fraud and Abuse


Medicare Abusehttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf

• “Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced”.

• Examples of Medicare abuse may include:

– Misusing codes on a claim,

– Charging excessively for services or supplies, and

– Billing for services that were not medically necessary.

– Both fraud and abuse can expose providers to criminal and civil liability.


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Medicare Fraud and Abuse Laws

False Claims Act (FCA)

• The FCA (31 United States Code [U.S.C.] Sections 3729-3733) protects

the Government from being overcharged or sold substandard goods or services. The FCA imposes civil liability on any person who knowingly submits, or causes to be submitted, a false or fraudulent claim to the

Federal Government. The “knowing” standard includes acting in deliberate ignorance or reckless disregard of the truth related to the claim. https://oig.hhs.gov/fraud

Anti-Kickback Statute

• The Anti-Kickback Statute (42 U.S.C. Section 1320a-7b(b)) makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services

reimbursable by a Federal health care program. https://oig.hhs.gov/compliance/safe-harbor-regulations

Fraud and Abuse Laws


Medicare Fraud and Abuse Laws

Civil Monetary Penalties (CMPs)

Under 42 U.S.C. Section 1320a-7a, CMPs may be imposed for a variety of

conduct, and different amounts of penalties and assessments may be authorized based on the type of violation at issue. Penalties range from up to $10,000 to $50,000 per violation. CMPs can also include an assessment of up to 3 times the

amount claimed for each item or service, or up to 3 times the amount of remuneration offered, paid, solicited, or received. Examples of CMP violations include:

• Presenting a claim that the person knows or should know is for an item or service that was not provided as claimed or is false and fraudulent,

• Presenting a claim that the person knows or should know is for an item or service for which payment may not be made, and

• Violating the Anti-Kickback Statute.

Fraud and Abuse Laws

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Centers for Medicare & Medicaid Services (CMS)

Government agencies partner to fight fraud and abuse, uphold the Medicare Program’s integrity, save and recoup taxpayer funds, and maintain health care costs and quality of care.

CMS partners with the following entities and law enforcement agencies, among others, to prevent and detect fraud and abuse:

• Program Safeguard Contractors

• (PSCs)/Zone Program Integrity Contractors (ZPICs);

• Medicare Drug Integrity Contractors (MEDICs);

• State and Federal law enforcement agencies, such as the

• OIG, Federal Bureau of Investigation (FBI), Department of Justice (DOJ), and State Medicaid Fraud Control Units (MFCUs);

CMS Fraud and Abuse Partners


Centers for Medicare & Medicaid Services (CMS)

Partners (continued):

• Medicare beneficiaries and caregivers;

• Senior Medicare Patrol (SMP) program;

• Physicians, suppliers, and other providers;

• Medicare Carriers, Fiscal Intermediaries (FIs), and Medicare Administrative Contractors (MACs) who pay claims and enroll providers and suppliers;

• Accreditation Organizations (AOs);

• Recovery Audit Program Recovery Auditors; and

• Comprehensive Error Rate Testing (CERT) Contractors.


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RAC Recovery Audit Contractors

– Medicare RACs

– Medicaid RACs

ZPIC Zone Program Integrity Contractors

– PSC – Program Safeguard Contractor

MIC Medicaid Integrity Contractors

MAC Medicare Administrative Contractor

– FI – Fiscal Intermediary (now MAC)

HEAT Health Care Fraud Prevention and Enforcement Action Team (HEAT) 19

Acronyms



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Focus on Overpayment as well as Fraud and Abuse

From: Hooper, Lundy & Bookman, PC


Let’s Take a Closer Look!

Types of Audits

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MAC

RAC

ZPIC


• Medicare Administrative Contractor –MAC

– Primary Role

• Primary contact for provider enrollment

• Part A and Part B FFS billing claims in a geographic region

• Replaced FIs

– Focus

• Medicare payment accuracy

• Recoveries and process 1st level of appeals

• Additional Development Request (ADR)

• Reviews facility and professional claims related to a beneficiary

Types of Audits

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– Scope

• Process claims

• Review claims, data, history, comparisons

• Audit claims

• Re Determination Requests

• Educate

• Provide Leads to next level of Audit Partners!

– Penalties

• Claim denials

• Referral to other audit partner

Types of Audits



– Appeals Process

• 1st - Re determination by MAC

• 2nd - Reconsideration by Qualified Independent Contractor (QIC)

• 3rd – Hearing by Administrative Law Judge

• 4th – Review by Medicare Appeals Court

• 5th – Judicial Review in Federal Court

Types of Audits

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• Recovery Audit Contractor – RAC

– Primary Role

• “Independent collection agency”

• Started in demonstration project, now permanent

• 1 primary contractor for each of 4 regions

• Improper Payment Identification and collection

• % for both overpayments and underpayments they correct

– Focus

• Medicare and Medicaid overpayments and underpayments

• Detect and correct past improper payments so MAC can recover overpayments and implement further actions

Types of Audits



– Scope

• Apply statutes, regulations, CMS coverage/billing to make determinations

• 2 types

– Automated claims history review (no medical record review)

– Complex review (medical record review)

• Pre and /or Post Payment

• Look back – up to 3 years after the date the claim was filed

Types of Audits

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– Penalties

• Medicare

– No penalties if provider agrees with RAC determination and pays back monies

– If miss deadline in appeals process, CMS can automatically recoup alleged overpayment – 31st day after receipt of initial demand letter

• Medicaid

– No penalties if provider agrees with RAC determination and pays back monies

– States have flexibility to decide penalty process

Types of Audits



– Appeals

• Medicare

– Mirrors the five level MAC appeals process

• Medicaid

– States have the flexibility to decide the structure of the appeals process

Types of Audits

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• Zone Program Integrity Contractor (ZPIC)

– Primary Role

• Fraud detection, prevention and correction

• Contracted payment, non contingent (no performance %)

• ZPICs combine Program Safeguard Contractors (PSCs) and Medicare drug integrity contractors (MEDICs)

• ZPICs oversee all Medicare claims in their

zone

• 7 ZPIC Zones

Types of Audits


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– Focus

• Medicare fraud, waste and abuse

• Identify fraud within service area – review past and pending claims by investigation and audit

• Compare billings with similar providers

• NEVER random audit - if you are chosen

there is a reason – potential fraud

• ZPIC initial request is indication of scope

of investigation!

Types of Audits



– Scope

• Investigate

• Audit claims

• Authorized to initiate administrative sanctions

– Payment suspensions

– Determine overpayments returned

– Refer for exclusion form government

health care programs

– Support and refer to LAW ENFORCEMENT

Types of Audits

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– Audit initiated by:

• Complaints

– OIG hotline, whistleblower, fraud alerts, direct to ZPIC

– Referral from MAC, RAC, beneficiary

• Data analysis

• LOS out of norm

• ZIPCs may

– Use a statistician

– Review small number of records to determine

fraud

– Conduct interviews – staff, beneficiaries, etc.

Types of Audits



– Scope

• No specific look back periods

• Refer finding of fraud to law enforcement for civil, criminal, CMP, other administrative sanction

• Involve OIG and US Attorney offices

– Penalties

• Recoupment

• Civil and criminal action/sanctions

– Appeals

• Mirror 5 level Medicare appeal process

Types of Audits

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Proactive vs. Reactive

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Internal Review ©Pathway Health 2013

• Minimize Risk!

1. Review internal processes

• Admission screening and assessment

• Nursing and Rehabilitation integration

– Medicare Meeting observation

– Medical Record Documentation

– Therapy logs

• Assess Staff knowledge and competency

– MDS Coordinator

– MDS succession planning

– IDT knowledge of RAI

Internal Review

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• Minimize Risk!


• Claims error process

– MDS Coordinator process

– Business office

– Rehabilitation

• Adherence to RAI Manual

– Assessment Reference Date process

– OBRA scheduling

– ADL Tracking – accuracy

Internal Review


• Minimize Risk!


• Medical necessity

– Ensure records accurately reflect care and services

– Consistent with clinical conditions

– MDS documentation per RAI and clinical documentation

– Accurate ADL’s!!!!

Internal Review

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• Minimize Risk!

2. Self Audit High Risk Areas

• Accuracy of claims

– “high” RUGs

– Sudden changes in billing

– Spikes in billing

– Compromised identities (provider/beneficiary)

– High error rates

– RUG changes or discrepancies

– Overpayments/underpayments

Internal Review


• Minimize Risk!

2. Self Audit High Risk Areas (random audits)

• Medical necessity

– Ensure records accurately reflect care and services

– Consistent with clinical conditions

– MDS documentation per RAI and clinical documentation

– Accurate ADL’s!!!!

Internal Review

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• Minimize Risk!

2. Self Audit High Risk Areas

• Physician orders support MDS sections

– Therapy

– Ancillaries

– Specialty services

• Rehabilitation Documentation

– Nursing and Rehabilitation

3. Triple Check Process

4. Update Policies and Procedures

5. Train staff

Internal Review


Internal Review

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6. Develop quality strategy for improvement

– Goals based off of internal review

• Prioritize

• Impact

– Systems and tools needed to change processes

– Resources applied or needed

– Time frames

– Approval/Agreement

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Data Agenda


Data Agenda

“We are transforming Medicare from a passive payer, to an active

purchaser of value” – Tom Valuck Assistant CMS Administrator

Quality Care + Data = Reimbursement


Data Agenda

Organizational Data: The New Path to Value and Reimbursement!

1. Determine Quality Profile: Assess Organization Data

2. Review Internal Processes: Data Collection, Review and Response

3. Establish an Information Agenda for Planning

Your data is key to positive outcomes!


• Organization Data used by Auditors

– MDS

– RUGs distribution

– Therapy Utilization

– Quality Measures

– Claims submissions

– Patterns of errors

– Spike in reimbursement

– Readmission/Discharge data

– Survey Results!

Data Agenda

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Preparedness and Protection




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1. Establish an Audit Response Team

• Compliance Officer/Lead

• Documentation Manager

• Administrator

• Director of Nursing

• Rehabilitation Director

• Business Office

• MDS Coordinator(s)

• Admission/Discharge

• Clinical, financial, legal expertise

– Determine Roles and Responsibilities

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2. Monitor MAC and Government trends

www.oig.hhs.gov/reports/html

www.cms.hhs.gov/rac

www.cms.hhs.gove/zpic

www.cms.hhs/gov/cert

www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-items/CMS019033.html



3. Audit Response Process

• Establish Timeframes and Response Reaction

• Track ALL Deadlines

• Prepare for large volume of requests

• Keep Complete record

– What requested

– Who sent

– When sent

– How sent

• Copies of all records and correspondence

• Communication point person

• Legal Counsel


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3. Corporate Compliance culture

• Established corporate compliance plan

– Updated and reviewed per requirements

– Staff trained

» Orientation

» Annually

» As needed based upon monitoring activities

– Code of Conduct

– Adherance to Medicare and Medicaid requirements

– RAI manual/MDS assessments/ARD, etc

– Documentation – medical necessity



3. Corporate Compliance culture

• External audits – good faith for compliance!

– Contract outside organization to conduct external review of MDS/RAI process

» Admission to discharge

» Record accurately reflects care, services, coding and billing

» Staff knowledge and adherence to requirements

» Identification of opportunities for improvement

– On going training and professional growth


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Performance Improvement ©Pathway Health 2013

Performance Improvement

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• Minimize Risk of Recoupments

– Proactive steps to ensure highest level of claim accuracy

– Leadership Monitoring

• Medical Necessity

• Admission/Discharge processes

• MDS Coding and Documentation

• Pre-bill screening process

• Denials and Appeals management



• Minimize Risk of Recoupments

– Leadership Monitoring

• Track denied claims

• Review data – leadership review “big picture”

• Look for patterns, trends

– Monitor Corporate Compliance processes and outcomes

– Focus on current/significant payment recoveries emerging from revenue audits


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OIG and fraud, https://oig.hhs.gov/fraud

OIG e-mail updates, https://oig.hhs.gov/contact-us

CMS, http://www.cms.gov

CMS Fraud Prevention Toolkit, which contains information for providers and information providers can give to beneficiaries, http://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/FraudPreventionToolkit.html

HEAT, http://www.stopmedicarefraud.gov/aboutfraud/heattaskforce

CMS Electronic Mailing Lists, http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MailingLists_FactSheet.pdf

Provider compliance educational materials, http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html

OIG Advisory Opinions, https://oig.hhs.gov/compliance/advisoryopinions



• Leadership Tactics for this changing Environment

– Education and Knowledge

– Internal Review

– Data Agenda

– Preparedness and Protection

– Performance Improvement


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Lisa Thomson Vice President of Strategic Initiatives

Pathway Health Services877-777-5463

[email protected]

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Thank you for your participation!

zpic rac mac audits proactive vs reactive 5-13 nadona ......proactive vs. reactive approach lisa...

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