PRESENTED BY:

Aaron Sorensen, MBA, CPO, LPO

O and P Billing Solutions, Inc.

Appeal Hierarchy Audits ◦Types ◦Agencies

Good practices Additional thoughts and Concerns

Great resource for CMS forms http://www.cgsmedicare.com/

jc/forms/index.html ◦ CMS Signature Requirements ◦ Corrective Action Plan ◦ Electronic Funds Transfer

(EFT) Authorization Agreement

◦ Medicare Secondary Payer (MSP) Questionnaire

◦ Offset Request Form ◦ Physician Documentation

Request Letter ◦ Prior Authorization Request

Coversheet

◦ PWK Fax/Mail Cover Sheet ◦ Reconsideration Request

Form ◦ Redetermination Request

Form Redetermination Checklist

NEW! Separator Sheet

NEW! Separator Sheet Instructions

Redetermination Completion Guide

◦ Reopening Request Form Reopenings Checklist

Reopening Request Form Completion Guide

Overpayment Recovery Request Form

◦ Suggested Intake Form ◦ Voluntary Overpayment Refund

Resource for variety of “Dear Physician” letters

http://www.cgsmedicare.com/jc/mr/Doc_Req.html ◦ Dear Physician – General

Documentation ◦ Dear Physician – PECOS ◦ Dear Physician – Power

Wheelchairs and Power Operated Vehicles

◦ Dear Physician – Therapeutic Shoes for Diabetics

◦ Dear Physician – Artificial Limbs

◦ Dear Physician – Completion of Certificates of Medical Necessity (CMNs)

◦ Dear Physician – Documentation of Continued Medical Necessity

Website explaining the levels and type of appeals

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/index.html

Important to research and understand each level specifically.

Different rules at different levels

Level 1: Redetermination https://www.cms.gov/Medi

care/Appeals-and-Grievances/OrgMedFFSAppeals/RedeterminationbyaMedicareContractor.html

A Redetermination is a completely new, critical re-examination of a disputed claim or charge.

A minimum monetary threshold is not required to request a redetermination.

Include any supporting documentation to the redetermination request

You should not request a Redetermination if you have identified a minor error or omission when you first filed your claim.

In that case, you should request a "Reopening".

List of re-opening examples ◦ http://www.cgsmedicare.

com/jc/claims/reopenings.html

Level 2: Reconsideration by a Qualified Independent Contractor

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ReconsiderationbyaQualifiedIndependentContractor.html

A written reconsideration request must be filed with a QIC within 180 days of receipt of the redetermination.

If the QIC cannot complete its decision in the applicable timeframe, it will inform the appellant of their right to escalate the case to an Administrative Law Judge.

Original Medicare (Fee-For-Service) Qualified Independent Contractors

◦ The following is a list of the QICs and the jurisdictions that they serve:

◦ Part A East Jurisdiction: Maximus, Inc.

◦ Part A West Jurisdiction: Maximus, Inc.

◦ Part B North Jurisdiction: C2C Solutions, Inc.

◦ Part B South Jurisdiction: Q2 Administrators, LLC

◦ DME Jurisdiction: C2C Solutions, Inc. Entire Country, All regions

Reconsideration form: ◦ https://www.cms.gov/Medicare/App

eals-and-Grievances/OrgMedFFSAppeals/Downloads/CMS20033.pdf

If the form is not used, the written request must contain all of the following information: ◦ Beneficiary's name ◦ Beneficiary's Medicare health

insurance claim (HIC) number ◦ Specific service(s) and item(s)

for which the reconsideration is requested, and the specific date(s) of service

◦ Name and signature of the party or representative of the party

◦ Name of the contractor that made the redetermination

The request should clearly explain why you disagree with the redetermination.

A copy of the MRN (Medicare redetermination notice) and any other useful documentation should be sent with the reconsideration request to the appropriate QIC.

Evidence not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless you show good cause for not submitting the evidence.

The QIC will send its decision to all parties within 60 days of receipt of the request for reconsideration

Level 3: Administrative Law Judge Hearing ◦ a party to the reconsideration

may request an ALJ hearing within 60 days of receipt of the reconsideration decision.

◦ Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration.

◦ Request a hearing by an ALJ, the $ amount remaining must meet threshold requirement. This amount is recalculated each year 2012 the amount must be at least

$130.

2013, the amount in must be at least $140.

ALJ request form

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20034AB.pdf

ALJ hearings are generally held by video-teleconference (VTC) or by telephone.

◦ An in-person hearing may be requested

◦ Must demonstrate good cause for an in-person hearing, the ALJ will determine if an in-person hearing is warranted on a case-by-case basis

Appellants may also ask the ALJ to make a decision without a hearing (on-the-record).

ALJ generally issues a decision within 90 days of receipt of the hearing request.

This timeframe may be extended for a variety of reasons including, but not limited to:

◦ The case being escalated from the reconsideration level

◦ The submission of additional evidence not included with the hearing request

◦ The request for an in-person hearing

◦ The appellant's failure to send a notice of the hearing request to other parties

◦ The initiation of discovery if CMS is a party

If the ALJ cannot issue a decision in the applicable timeframe, the ALJ will notify the appellant of their right to escalate the case to the Medicare Appeals Council.

Level 4: Review by the Medicare Appeals Council

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Downloads/DABform.pdf

No requirements regarding the amount of money in controversy.

Request must be submitted in writing within 60 days of receipt of the ALJ’s decision, and must specify the issues and findings that are being contested.

http://www.hhs.gov/dab/

Level 5: Judicial Review in Federal District Court

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Review-Federal-District-Court.html

There is a $ threshold: ◦ 2012 claims $1,350

◦ 2013 claims $1,400.

The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's

decision.

What Is Medical Review? One of the top priorities of the

Centers for Medicare & Medicaid Services (CMS) is addressing improper payments in the Medicare fee-for-service program. CMS contracts with three types of contractors to achieve the goal of reducing improper payments. These contractors are: ◦ Comprehensive Error Rate Testing

(CERT) contractors; ◦ Medicare Administrative Contractors

(MACs); and ◦ Recovery Audit Contractors (RACs) ◦ CMS also strives to protect the

program from potential fraud by contracting with Zone Program Integrity Contractors (ZPICs) to identify and stop potential fraud.

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

measure improper payments in the Medicare Fee-for-Service (FFS) program

selects random sample of approximately 40,000 claims submitted to Part A/B and Durable Medical Equipment MACs (DMACs) during each reporting period.

DMEPOS 2012 stats ◦ $9.7 billion paid ◦ Improper paid $6.4 billion ◦ Improper rate 66%

Based on this why would they stop/slow down?

It is important to note that the improper payment rate is not a “fraud rate,” but a measurement of payments that did not meet Medicare requirements. ◦ The CERT program cannot

label a claim fraudulent.

Claim is reviewed by independent medical review contractor to determine if they were paid properly under Medicare coverage, coding, and billing rules.

If these criteria are not met or the provider fails to submit medical records to support the claim billed, the claim is counted as either a total or partial improper payment and the improper payment may be recouped

Each Recovery Auditor is responsible for identifying overpayments and underpayments in approximately ¼ of the country.

The Recovery Audit Program jurisdictions match the DME MAC jurisdictions.

Details/Rules for RAC

◦ http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/The-Recovery-Audit-Program-and-Medicare-Slides-051313.pdf

The Recovery Auditor in each region is as follows:

◦ A: Performant Recovery

◦ B: CGI Federal, Inc.

◦ C: Connolly, Inc.

◦ D: HealthDataInsights, Inc.

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/RAC-Contact-Information-AbbrState-Apr2013.pdf

Primary purpose is to review payments to identify fraud

This makes ZPIC audits more serious than most ◦ These audit targets are selected

based on sample data analysis. ◦ A ZPIC audit may be performed as

the result of other audits, and after a ZPIC audit, a MAC or RAC may be referred.

◦ There are three primary reasons for conducting a ZPIC audit: a) analysis of rates (high rates of

utilization of ultra-high resource utilization groups, or RUGs)

b) whistleblower complaints, and/or

c) results of other audits.

ZPICs also wield power of referral to another governmental agency and/or referral to another audit entity.

ZPIC audits can have devastating results including: ◦ payment recoupment ◦ referral for criminal prosecution ◦ decertification from programs ◦ professional board referral for non-

compliance of practice acts

VGM resource ◦ http://www.google.com/url?sa=t&rct

=j&q=&esrc=s&frm=1&source=web&cd=7&sqi=2&ved=0CF0QFjAG&url=http%3A%2F%2Fwww.vgm.com%2FFiles%2Fmanual%2FGovtRel%2FZONE_PROGRAM_INTEGRITY_CONTRACTORS_hme_rehab.doc&ei=QJiNUoSnE4_PkQfc4ICQCQ&usg=AFQjCNGDvR355rB7mROtV4dbLiORL5k7_Q&bvm=bv.56988011,d.dmg

Think every claim as going to be audited!

Document, document, document

Review ALL supporting documentation

Create a checklist (internal)

Receive CMS e-mail blasts

◦ Check you local region website

◦ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html?redirect=/MLNMattersArticles/

Know your LCD Policies

Attend CMS sponsored meetings

Attend O and P meetings; local, state, regional, national

Check RAC websites ◦ Must post results of

audits ◦ Must inform the

direction they are going

Timing is everything ◦ DO NOT let time lapse ◦ Submit something,

starts a new clock! ◦ Buy more time if

needed to procure paperwork

Take pictures Keep invoices organized Take video Have patient write

testimonial Get attestations Have signature

cards/forms for referrals and other professionals

Know resources to tap ◦ Freedom website ◦ http://www.freedom-

innovations.com/prosthetist/

Aaron Sorensen, CPO, LPO, President OPBS asorensen@rhs-tn.com

Ph. 877-907-4180

Rob Cripe, VP Global Marketing rcripe@freedom-innovations.com Ph. 949-544-7916

Freedom Innovations thanks you for your continued support and hopes this series of webinars helps you navigate the tumultuous environment of serving MEDICARE PATIENTS.

Please provide feedback to your Freedom sales representative of future topics to cover and if you find these webinars helpful.