All emergency All emergency transports are transports are

medically necessary, medically necessary, right?right?

and other Myths about Compliance and and other Myths about Compliance and DocumentationDocumentation

Medical Necessity

• Recent Federal Fraud CasesRecent Federal Fraud Cases– False Claims includes submission of claim for

services that did not meet the medical necessity requirements.

– Providers must assure the medical necessity requirements are met prior to submitting a claim seeking reimbursement for the service.

Medical Necessity

• EmergencyEmergency– 911 Call or Equivalent– Immediate Response– In Response to an Accident, Illness, Injury

• CMS Medicare Condition CodesCMS Medicare Condition Codes

Medical Necessity

• Contractor Review Findings: Contractor Review Findings: – Narrative Field is still vitally important– Beware of Field’s Default Values– All Patient Care Reports must stand alone.– Be Cautious of Contradictory Information.

Narratives

Narratives

Narratives

Emergency Condition Codes

• Assessments – Document Decision MakingAssessments – Document Decision Making– Ex: Possible CVA - what lead you to that decision?

• Be DescriptiveBe Descriptive– Patient’s actual quotes sometimes better describes the

chief complaints

• Ask QuestionsAsk Questions– OPQRST – Onset, Provocation, Quality, Region, Severity,

Time

Documentation Reminders

• Emergency Claims - Emergency Claims - Medicare Condition Codes (examples)Medicare Condition Codes (examples)

– Abdominal PainAbdominal Pain• With associated Nausea, vomiting, mass, distention, With associated Nausea, vomiting, mass, distention,

rigidity, tenderness on exam, guardingrigidity, tenderness on exam, guarding

– Abnormal Skin SignsAbnormal Skin Signs• Diaphoresis, cyanosis, delayed cap refill, poor turgor, Diaphoresis, cyanosis, delayed cap refill, poor turgor,

mottledmottled

– Allergic ReactionAllergic Reaction– Rapid progression of symptoms, prior hx of anaphylaxis,

wheezing, difficulty swallowing, hives, itching, rash, local swelling, redness, erythema

Documentation Reminders

• Medicare Condition CodesMedicare Condition Codes• Chest PainChest Pain– Dull, severe, crushing, substernal, epigastric,

associated pain, ie. Jaw, left arm, neck, back, with nausea vomiting, palpitations, diaphoresis

• Cardiac other than Chest PainCardiac other than Chest Pain– Persistent nausea and vomiting, weakness, hiccups, pleuritic Persistent nausea and vomiting, weakness, hiccups, pleuritic

pain, feeling of impending doom, palpitations, skipped beatspain, feeling of impending doom, palpitations, skipped beats

• Abnormal Cardiac Rhythm Abnormal Cardiac Rhythm

Documentation Reminders

• Medicare Condition CodesMedicare Condition Codes• Neurologic DistressNeurologic Distress

– Facial Drooping, aphasia, difficulty swallowing, tingling extremities, stupor, delirium, confusion, hallucinations, paralysis, vertigo, unsteady gait/balance, slurred speech

• Pain, SeverePain, Severe– Acute onset, unable to ambulate or sit due to pain, severity

scale (7-10 indicates severe), receiving pharmacological interventions

• AlcoholAlcohol– Unable to care for self, unable to ambulate, pharmacological

intervention, decreased LOC potentially compromising airway

Documentation Reminders

• Medicare Condition CodesMedicare Condition Codes• Abnormal Vital SignsAbnormal Vital Signs• Blood Glucose (<80 or >250)Blood Glucose (<80 or >250)• Altered Level of Consciousness (GCS <15)Altered Level of Consciousness (GCS <15)• Convulsions, SeizuresConvulsions, Seizures

– Seizing, immediate post-seizure, postictal

• Suspected Fracture/ImmobilizationSuspected Fracture/Immobilization

Interfacility Transports

• Medical NecessityMedical Necessity• Reason for TransferReason for Transfer– Medical or Patient Convenience

• Nearest Appropriate FacilityNearest Appropriate Facility• Type of ResponseType of Response

Examples

Patient Protection and Affordable Patient Protection and Affordable Care Act (PPACA)Care Act (PPACA)

• Fraud and Abuse ProvisionsFraud and Abuse Provisions• Provider Enrollment ProcessProvider Enrollment Process• Revalidation Process (every 3 years)Revalidation Process (every 3 years)• Site VisitSite Visit• $523 Fee$523 Fee

• Prepayment ReviewsPrepayment Reviews• Patient Care Report (PCR) must be submitted prior to Patient Care Report (PCR) must be submitted prior to

paymentpayment• Delayed PaymentsDelayed Payments

Patient Protection and Affordable Patient Protection and Affordable Care Act (PPACA)Care Act (PPACA)

• Fraud and Abuse ProvisionsFraud and Abuse Provisions• Post-payment ReviewsPost-payment Reviews• ““Vulnerabilities” in MedicareVulnerabilities” in Medicare• Statistical ComparisonsStatistical Comparisons• ExtrapolationsExtrapolations

• Medicare Contractor OversightMedicare Contractor Oversight• Corrective Action Process for Vulnerabilities Corrective Action Process for Vulnerabilities • Mandatory Compliance PlanMandatory Compliance Plan

OIG Work Plan 2013OIG Work Plan 2013

• Medicare Strike Force TeamsMedicare Strike Force Teams• Federal and State CollaborationsFederal and State Collaborations• OIG, Attorney General, Medicare and Medicaid Fraud OIG, Attorney General, Medicare and Medicaid Fraud

Investigators, DOJInvestigators, DOJ• $492 Million – including $49.2 Million in Ambulance$492 Million – including $49.2 Million in Ambulance

• Ambulance ReviewAmbulance Review• Medical NecessityMedical Necessity• Level of CareLevel of Care• ALS Assessments, Specialty Care TransportsALS Assessments, Specialty Care Transports

GAO Cost StudyGAO Cost Study

• Government Accountability Office (GAO) Cost StudyGovernment Accountability Office (GAO) Cost Study• Based on 2010 DataBased on 2010 Data• Median payments = 1% lower than Medicare PaymentMedian payments = 1% lower than Medicare Payment• Wide Variance - $224 - $2,204 Wide Variance - $224 - $2,204 • Rapid increase of 59% in non-emergency transfers Rapid increase of 59% in non-emergency transfers

between nursing homes and dialysis facilitiesbetween nursing homes and dialysis facilities• Rapid entry of for-profit suppliersRapid entry of for-profit suppliers• Uncompensated Care – 5% - 14%Uncompensated Care – 5% - 14%

USA TodayUSA Today

• $4.1 Billion Record Recovery in 2011$4.1 Billion Record Recovery in 2011• $7.20 Recovery for every $1.00 spent – 2009 – 2011$7.20 Recovery for every $1.00 spent – 2009 – 2011• $5.10 Recovery – 1997-2008 $5.10 Recovery – 1997-2008 • $300 Million HHS Budget for Anti Fraud Teams$300 Million HHS Budget for Anti Fraud Teams• Health Care Fraud Prevention and Enforcement Action Teams Health Care Fraud Prevention and Enforcement Action Teams

(HEAT)(HEAT)• 175 Prison Sentences – average 47 month sentence175 Prison Sentences – average 47 month sentence

MEDPACMEDPAC

• Recommendations:Recommendations:• Allow current add-on payments to expire on 12/31/2012Allow current add-on payments to expire on 12/31/2012• Restructure Non-Emergency Payment StructureRestructure Non-Emergency Payment Structure• Lower Rates for Non-Emergency TransportsLower Rates for Non-Emergency Transports• Emergency Transports would remain the sameEmergency Transports would remain the same• Develop Medical Necessity Guidelines for NE TransportsDevelop Medical Necessity Guidelines for NE Transports• Lower Fee Structure for Dialysis TransportsLower Fee Structure for Dialysis Transports

Whose Looking at You?Whose Looking at You?

• Prepayment Audits Prepayment Audits • Postpayment AuditsPostpayment Audits• Medicare Administrative Contractors (MAC)Medicare Administrative Contractors (MAC)• Recovery Audit Contractors (RAC)Recovery Audit Contractors (RAC)• Program Safeguard Contractors (PSC)Program Safeguard Contractors (PSC)• Zone Program Integrity Contractors (ZPIC)Zone Program Integrity Contractors (ZPIC)• Comprehensive Error Rate Testing (CERT)Comprehensive Error Rate Testing (CERT)• Statistical Reporting/High Risk VulnerabilitiesStatistical Reporting/High Risk Vulnerabilities

Providers Reaction

• GAO Study of CMS AuditorsGAO Study of CMS Auditors– Defective, redundant, administrative burdens– Goal:

• Coherent Strategic Plan• Consistent Standards • Active Coordination

– Review:• Audit Criteria• Methodologies• Clear and Consistent Process• Not Duplicative

What are they Looking For?

• Patient SignaturesPatient Signatures– Patient Signature– Authorized Representative Signature– Crew/Facility Signature– Lifetime?

• Physician Certification StatementsPhysician Certification Statements– Detailed Medical Condition– Signed with Appropriate Credentials– Legible Signature– Supported by Patient Care Report (PCR)

What are they looking for?

• Medical NecessityMedical Necessity– Condition Codes – Supported by Patient Care Report (PCR)

• ALS AssessmentALS Assessment– Dispatch Protocols– Medical Necessity

• Emergency vs. Non-EmergencyEmergency vs. Non-Emergency– Immediate Dispatch

Appeals

• American Hospital Association (AHA)American Hospital Association (AHA)– 75% Appeal Rate– 48% of all Appeals are overturned

• Appeal ProcessAppeal Process– Redetermination– Reconsideration– Administrative Law Judge– Appeals Council Review– District Court

Compliance Plan

• Internal Monitoring and AuditingInternal Monitoring and Auditing• Written Policies and ProceduresWritten Policies and Procedures• Designated Compliance OfficerDesignated Compliance Officer• Training and Education ProgramsTraining and Education Programs• Appropriate Response to Offenses and Corrective Appropriate Response to Offenses and Corrective

ActionAction• Open Lines of CommunicationOpen Lines of Communication• Disciplinary Standards and EnforcementDisciplinary Standards and Enforcement

Questions???Questions???