HPCANYS 39th Annual Interdisciplinary Seminar and Meeting · 6. Provider has at least 45, up to 56, days until next level of review begins –count begins from date of billing, not

© 2019 Rachel Hold-Weiss (except government or MAC materials)

Are You Ready for the Next Wave of Audits?

HPCANYS 39th Annual

Interdisciplinary Seminar and Meeting

Albany Marriott, Albany, NY

April 3, 2019

Presented by:

Rachel Hold-Weiss

Smart In Your World


Targeted Probe and Educate

Smart In Your World 2


Targeted Probe and Educate (TPE)

Started as a pilot program

CMS chose the topics

Request for 5 records was issued to Medicare certified home health agencies

Actions that were taken at the time depended on how many denials there were of the 5 records



Targeted Probe and Educate (TPE) (Cont’d)

“Providers and suppliers who have high claim error rates or unusual billing practices, and items and services that have high national error rates and are a financial risk to Medicare”

1.Pilot expanded to all providers as of October 2017

2.Providers chosen based on data mining

3.Topics chosen by each MAC based on data analysis (or CMS)



Targeted Probe and Educate (TPE) (Cont’d)

4. Letters arrive in a pink envelope to the correspondence address noted on the CMS 855A form

5. 20-40 claims per item or service

6. Review is pre-pay (or in some limited instances post-pay)

7. Records must be received by the MAC prior to the 45th day – dates are based on date of ADRs which are generated through the usual process

8. Contractor discretion to allow for a late submission (within 120 days)

9. Non-response counts as an error



Targeted Probe and Educate – Results

1. Acceptable error rate varies based on item or service under review – known as Payment Error Rate or “PER”

2. NGS has indicated that the acceptable PER is less than 15% - to arrive at the PER: total Medicare dollars would have been paid versus dollars denied

3. Claims error rate may also be calculated and may be reported, but is not a factor in continuing review - # of claims reviewed and # of claims denied

4. Results provided within 30 days of the full receipt of the records (if paper copies are sent, may take longer)

5. If don’t meet the acceptable PER threshold, education offered; appeal rights are preserved



Targeted Probe and Educate – Results (Cont’d)

6. Provider has at least 45, up to 56, days until next level of review begins – count begins from date of billing, not DOS

7. If provider is compliant, will not be chosen for review on same topic for at least one year

8. Up to 3 rounds of TPE

9. If fail at third round, referral to CMS (RAC, UPIC, 100% pre-pay review, extrapolation, etc.)

10. PER will not change if claims are overturned on appeal



Differences from Prior Audits

If a document is missing during review of the claim that would otherwise be in the record, the reviewer will contact the provider for the missing document – opportunity for provider to send in missing information during the review

Goal is “education” and to “fix easily curable denials allowing for claim payment”

Education is offered during the review if there is a common theme that can be corrected during the review

Education is offered at each level of review that is specific to the denials of the applicable provider



How the Audits are the Same

Appeal rights remain the same at each level of denial

Educational sessions are not appeals – they do not take the place of appeals, nor do they extend the appeal time frame

If the MAC finds issues related to the topic of the denied claim, they may conduct reviews of the related matters outside of the TPE process



What is Included in an Initial TPE Letter?

MAC is responsible for TPE

Explanation of TPE process

Explanation of why provider is subject to TPE

General explanation of ADRs

Explanation of the education process



What Is Included in a TPE Results Letter?

Outlines the TPE process again

Reasons for the denial – citations to CMS regulations

Provides the PER

Release or continuation of TPE review

Education information and contact



Current Hospice TPE Reviews

Place of Service

5CPQ1/5CPQ2/5WPQ1, 5WPQ2

Review of Q5003 and Q5004 as place of residence

Round 1 completed – 61% released from further review and 38% moved to Round 2

Top three denials:

Terminal prognosis not supported (55H1L)

Initial certification not signed timely (55H1B)

Initial certification not signed by physicians (55H1U)



Current Hospice TPE Reviews (cont’d)

GIP Greater Than 7 Days

5CPG1/5WPG1/5WPG2

Round 1 completed – 56% released and 44% were moved to Round 2

Round 2 completed – 50% released and 50% moved to Round 2

Top three denials:

Documentation indicates GIP not reasonable and necessary (55H1M)

Initial certification not signed timely by physician(s) (55H1B) (8.89%)

Initial certification not signed by physician(s) (55H1U)(5.08%)




Significant increase in reimbursement

5CPN1 – Round 1 is still ongoing

For providers who completed Round 1, 50% moved to Round 2

Top three denials:


Hospice election consent not signed timely (55H1G)

NOE not received as requested (55H1Q)




Increased Average Length of Stay

Recently started, only 20% have completed Round 1, but 100% have moved to Round 2

Top three denials:


Notice of election is invalid – does not meet statutory and regulatory requirements(55H1R)

Physician certification not sent in with documentation (55H1F)



Information from NGS Regarding TPE Response NGS recommends responding to ADRs within 35-40 days of letter date.

Include all records necessary to support the services for the dates requested.

Do not include additional correspondence with documentation submissions. Unrelated correspondence should be submitted separately.

Records must be complete and legible. Be sure to include both sides of double-sided documents.

Submit documents via mail, overnight mail, NGS Connex or Fax - Make sure you track and receive confirmation.

If sending by mail, be sure to forward the requested documentation to the correct NGS post office box.

All services must include necessary signatures and credentials of professionals.

https://www.ngsmedicare.com – Medical Review – Targeted Probe and Educate Strategy and the NGS Medical Review Process (accessed February 13, 2019)Smart In Your World 16

https://www.ngsmedicare.com/


Medicaid Hospice Payments



OMIG Hospice Audits

Dates of Service prior to 8/31/2016

Hospice Audit Protocol – available at https://www.omig.ny.gov/images/stories/audit_protocols/Hospice_Protocols_3-2017_posted_copy.pdf

Recent Final Audit Reports – Dually eligible patients serviced from January 1, 2013 to December 31, 2017

OMIG looking to work with Safeguard Services (SGS), the Unified Program Integrity Contractor (UPIC) to expand UPIC audits to hospice


https://www.omig.ny.gov/images/stories/audit_protocols/Hospice_Protocols_3-2017_posted_copy.pdf


Improper Medicaid Payments

NYS Office of the State Comptroller report – Improper Medicaid Payments for Recipients in Hospice Care – Report 2017-S-76 Issued December 2018 available at:https://osc.state.ny.us/audits/allaudits/093019/sga-2019-17s76.pdf


https://osc.state.ny.us/audits/allaudits/093019/sga-2019-17s76.pdf


Improper Medicaid Payments (cont’d)

$8 Million in improper payments

$2.9 million was paid to non-hospice providers for services, such as private duty nursing, that were not allowed in combination with the daily hospice rate;

$2.4 million was paid to non-hospice providers for drugs, durable medical equipment, home care, and other services that are covered under the daily hospice rate;

$2.6 million was paid for hospice services that should have been covered by Medicare or a Medicaid managed care organization; and

$107,141 was paid for hospice services while the patient was in the hospital



Post-Payment Claim Reviews



Supplemental Medical Review Contractor (SMRC)


Noridian Healthcare Solutions, LLC (Noridian) has been chosen as the SMRC

Nationwide medical reviews of all provider types


Hospice Post-Payment Review

Project ID 01-009


Noridian is conducting post-payment reviews of GIP services for the following:

Q5004: Skilled Nursing Facility (SNF)

Q5005: Inpatient hospital

Q5006: Inpatient hospice facility

Dates of Service from January 1, 2017 through December 31, 2017


Hospice Post-Payment Review (Cont’d)


Request will come in as an ADR

Documentation must be submitted within 45 days

Extensions may be granted – written request to Noridian must be made be made prior to the 45 days

Documentation can be submitted by hard copy, fax, electronically, but specific guidelines must be followed. If submitted electronically, CD/DVD, not flash drive

Include SMRC Response Cover Sheet for each claim


Documentation that is required to be submitted1. Notice of Election (NOE) for Hospice effective for the date of service (DOS) under review.

2. Certification(s) of Terminal Illness (CTI) that cover the DOS under review.

3. Face-to-Face Encounter Attestation statements as applicable to the certification period(s) during which the GIP care was provided.

4. Documentation to support the GIP stay for pain control and/or symptom management indicating the interventions performed could not be feasibly provided in any other setting for the DOS under review. This may include, but is not limited to, the following:

a. Hospice Plan of Care (POC) covering the GIP stay supporting the change in LOC including dates, reason for GIP, interventions, beneficiary’s response and collaboration between the hospice and hospital teams.

b. Clinical documentation to include, but not limited to, admission history and physical, progress notes, consultation notes, nursing assessments, treatment records, wound care documentation, medication administration records and discharge summary.

c. Hospice team documentation to include, but not limited to, visits, assessments and discharge planning for the DOS under review.



Documentation that is required to be submitted (Cont’d)

5. Copies of any written notices provided to the patient. For example, Advance Beneficiary Notice (ABN) of Noncoverage)

6. Valid clinician signatures.

a. Signature Attestations and Signature Logs should be submitted when Physician or Clinician signatures are illegible.



Noridian Completed the Review – Now What?


Once the review is completed, a results letter will be sent by Noridian

The results letter will note the claim(s) reviewed and the specific review findings associated with such claim(s)

If a provider disagrees with Noridian’s findings, the provider can request a Discussion & Education (D&E) session for eligible projects

A provider can also elect to submit missing documentation

Both the D&E and notification of intent to submit missing documentation must be submitted within 14 days of the notification of results


Noridian Completed the Review – Now What? (cont’d)


The notification of submission of additional information must include:Provider/Supplier nameNational Provider Identifier (NPI)Provider/Supplier representative namePhone numberFax numberNumber of claims submitted within request

The specific claims information for each claim must include:Project sample IDBeneficiary’s nameBeneficiary’s date of birthClaim numberDate(s) of service


Noridian Completed the Review – Now What? (cont’d)


If a provider agrees with Noridian’s findings, the amount owed will be sent to the MAC for collection in accordance with the usual overpayment recovery process

If a provider submits additional documentation, when Noridian finalizes the review of the missing documentation, the MAC will proceed with collection of the overpayment in accordance with the usual overpayment recovery process

Appeal rights are not available with Noridian but are available in connection with the MAC overpayment recovery process


APPEALS

District Court

Medicare Appeals Council

Administrative Law Judge

Reconsideration – Qualified Independent Contractor

Redetermination - MAC



Appeals Process for a Redetermination

Provider has 120 days from the date the denied claim was processed on the remittance to appeal

No set amount in controversy

Can be an appeal of the entire denied claim or partially denied claim

Can be done electronically or via paper

Reviewed by MAC

MAC has 60 days to issue a redetermination decision

If denied, how to apply for reconsideration



Appeals Process for a Reconsideration

Provider has 180 days from the date the date the redetermination was denied to appeal

No amount in controversy


Reviewed by Qualified Independent Contractor (“QIC”) – C2C Innovative Solutions, Inc. is the Part A East QIChttp://www.c2cinc.com/QIC-PART-A-EAST

QIC has 60 days to issue a reconsideration decision

How to apply for ALJ hearing



Appeals Process for an ALJ Hearing

Provider has 60 days from the date the reconsideration was denied to appeal

$160 amount in controversy (adjusted)


Reviewed by ALJ Office of Medicare haring and Appeals (OMHA)

ALJ has 90 days to issue a reconsideration decision - Average processing time 1st quarter Fiscal Year 2019 is 1302.9 days

How to submit appeal to the Medicare Appeals Council



Appeals Process for the Medicare Appeals Council

Have 60 days from the date of the ALJ decision to appeal

Record for review is limited to prior record

Appeal to Federal District Court



Appeals Process for Federal District Court

Have 60 days from the date of the MAC decision to file a complaint

Record for review is limited to prior record

$1,630 amount in controversy (adjusted)

No time frame for decision



Questions?

ContactRachel Hold-WeissArent Fox [email protected]


mailto:[email protected]


AFDOCS #17,537,785


Documents

HPCANYS 39th Annual Interdisciplinary Seminar and Meeting · 6. Provider has at least 45, up to 56, days until next level of review begins –count begins from date of billing, not