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Reimbursement Audits: Understanding the Trends & How to Prepare for Them
Andrea Stark, Consultant/Owner, miraVISTA,LLC, Columbia, SC
Top 4 Things to Know for CE
1. Make sure your BADGE IS SCANNED each time you enter a session to
record your attendance.
2. Carry your Evaluation Packet with you to EVERY session.
3. Pharmacists, Pharmacy Technicians and Nurses need to track their hours
on the Statement of Continuing Education Form as they go (the 2-page
triplicate form, so press firmly!).
4. FOR CE: At your last session, total the hours and sign both pages of your
Statement of Continuing Education Form.
 Keep the PINK copy for your records and place the YELLOW and
WHITE copies in your CE Envelope.
 Make sure an Evaluation Form is in your CE Envelope for each session
you attended (extra forms are available at the registration desk if you
forgot to pick one up).
 Write your name and unique ID number (six digit number at the bottom
of your name badge) in the designated area on the outside of the
envelope, seal it, and place it in the drop box located near the
4/8/2012
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registration area.
• Andrea Stark is Consultant/Owner of
miraVISTA,LLC. The conflict of interest
was resolved by peer review of slide
content.
• Clinical trials and off-label/investigational
uses will not be discussed during this
presentation.
4/8/2012
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Agenda
• Audits Impacting Home Infusion Providers
– The OIG’s Radar for 2012
– RAC, CERT, ZPIC, DME‐MACS
– Top Reasons for Denial
– Lessons Learned
• Will Your Documentation Cut the Mustard?
– Take a Proactive Approach
– Educate Referral Sources
4
Agenda
• Understanding Your Rights
• Appealing an Unfavorable Determination
• Putting Together Your Response
• Audit Proofing Your Business
• Conducting Internal Audits
• Educational Resources for Staff
5
Audits Impacting Home Infusion Providers
On The OIG’s Radar for 2012
• Enteral/Parental High Billing Volumes
• Medicare Pricing for Parenteral Nutrition
– Too High Compared to Others?
• Use of Surety Bonds to Recover Overpayments
• Solicitation of Physicians Under Competitive Bidding
7
On The OIG’s Radar for 2012
• Compliance with Assignment Rules
• Claims with GA, GZ, GX and GY Modifiers
• Services Ordered by Excluded Physicians
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Recovery Audit Contractors
• 3 Types of Reviews:
– Automated
– Complex
– New: Semi‐Automated
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Automated Reviews
•
•
•
•
•
Software Driven Process
100% Certainty of Error
No Records Requested
Unlimited Number
Overpayment = Payment Demand Letter
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Complex Reviews
• Human Review
• Not 100% Certain of Error
• Medical Records Requested = Additional Documentation Request Letter
• Limited Number
• Max of 10% of Annual Billing Volume per 45‐days
• Capped at 250 Records, per 45‐days
• May Request Permission to Exceed Cap
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Complex Reviews
• Respond Within 45‐Days of Date on ADR Letter
• RACs Have 60 Days to Respond
• Review Results Letter Will Include:
– RACs Decision
– Regulation Violated
– Information on Appeal Rights
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Complex Reviews
• Overpayment Determination = Payment Demand Letter
• Infusion NOT Currently Under Complex Review
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RAC Regulations
•
•
•
•
Limited to a 3‐year Look Back Period
Always post‐payment reviews
Issues must be approved by CMS
Issues must be posted to website
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On‐going RAC Reviews
Name
Description
Jurisdictions
Auditing
When premix parenteral nutrition
solutions are used there may not be
separate billing for the carbohydrates,
amino acids or additives.
A
Infusion supply code A4221 is billed on a
Infusion Supplies (A4221) weekly basis. Providers are billing A4221
more than one unit per week which
– Excessive Units
results in an overpayment.
C
The description or the billing guidelines
PEN supplies more than 1 state parenteral/enteral nutrition codes
time a day are allowed once a day.
D
When the infusion pump is denied, then
Infusion Pump Denied/ Accessories & Drug Codes the infusion accessories and infusion
drug codes are also denied.
should be denied D
Parenteral Nutrition Additives with Premix
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On‐going RAC Reviews
Name
Pharmacy Supply Dispensing Fee
Description
Medicare
pays
pharmacy
supply/dispensing
fees
for
immunosuppressive, oral anti‐cancer,
chemotherapeutic, and oral anti‐emetic
drugs as well as drugs used as part of an
anti‐cancer chemotherapeutic regimen
when they are submitted on the same
claim as the drug being billed. A claim
submitted
with
a
pharmacy
supply/dispensing fee in the absence of
any of the previously mentioned drugs
represents an overpayment and will be
denied as not medically reasonable and
necessary.
Jurisdictions
Auditing
B
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Rescinded IVIG Audit
• IVIG
– Human Immunoglobulin G
– Administered by intravenous infusion
– Contains antibodies
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Rescinded IVIG Audit
• Claims Targeted:
– IVIG billed with chemotherapeutic administration codes
• Incorrect RAC Rational:
– IVIG infusion therapy should be billed with therapeutic administration codes, not chemotherapeutic
• Audit Rescinded July 5, 2011
Source: http://infusioncenter.net/index.php/news/nica‐news/105‐july52011
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ZPICs
• Zone Program Integrity Contractors (ZPICs):
– Formerly Program SafeGuard Contractors (PSCs)
– Review Parts A‐D, Home Health and Medi‐Medi
– Analyze data, look for outliers
– Conduct pre‐pay and post‐pay audits
– Main Objective = Identify Fraud
• Payments suspended pending investigation
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ZPICs
• Zone Program Integrity Contractors (ZPICS):
– Audits unannounced or limited notice
– Uses statistical sampling to estimate overpayments
– Payment demand letters come from your MAC
– Respond within 30 days of date on letter
– ZPICs no time limit
– No maximum records
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ZPIC Zones
• Safegaurd Services LLC
– Zone 1 – CA, NV, American Samoa, Guam, HI, and the Mariana Islands.
– Zone 7 – FL, Puerto Rico and Virgin Islands • AdvanceMed Corporation (Acquired by NCI, Inc.)
– Zone 2 – AK, WA, OR, MT, ID, WY, UT, AZ, ND, SD, NB, KS, IA and MO
– Zone 5 – AL, AK, GA, LA, MS, NC, SC, TN, VA and WV • Health Integrity, LLC
– Zone 4 – CO, NM, OK, and TX 21
ZPIC Zones
• TBD ‐ Currently Under Protest
– Zone 3 – MN, WI, IL, IN, MI, OH, and KY
• TBD – Currently Under Protest
– Zone 6 – PA, NY, MD, Washington DC, DE, ME, MA, NJ, CT, RI, NH, and VT
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CERT
• Comprehensive Error Rate Testing (CERT):
– Targets DME MACs more than suppliers
– Sample of suppliers audited
– Audits identify DME MAC overpayments
– Error rate identified
– High error rate = widespread DME MAC prepay reviews
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CERT
• Comprehensive Error Rate Testing (CERT):
– Always request additional documentation
– The requests identify patient and records under review
– Requests NOT limited to LCD
• Documents from other CMS Manuals may be cited
– Respond within 75‐Days of the date on the letter
– Respond via fax or mail
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DME MACs
• Durable Medical Equipment Medicare Administrative Contractors (DME MACs):
– Process claims
– Medical Reviews (MRs) = Nurse reviewers manually process responses
– Medically Unlikely Edits (MUEs) = Automated
• Excess units of service, span dates, Etc.
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DME MACs
• Jurisdictions Auditing for Enteral Nutrition:
– A – NHIC Prepay: B9000, B9002 (Pumps)
• Previous quarter charge denial rate 73.9%
– C – CIGNA Prepay: B4150, B4154 (Formula)
• Previous quarter charge denial rate 64%
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Top Reasons for Denial
• Jurisdiction A, NHIC:
– Insufficient clinical documentation
– No medical records submitted
– No proof of delivery
• Missing patient name, date or signature
• Item provided not listed
– Missing detailed written order
• Incomplete
• Order dated after delivery
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Top Reasons for Denial
• Jurisdiction A, NHIC:
– Incomplete or missing DIF
• HCPCS Code not on DIF
– Illegible Records & Patient Refusals
• Dates
• Signatures
• Medical records
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Top Reasons for Denial
• Jurisdiction C, CGS:
– No documentation of a non‐functioning GI tract (anatomical impairment or a motility disorder)
– Severity of condition not documented for specialty formula
• Patient history, physical exam, lab results
• No evidence standard formula tried
– Condition not permanent (at least 3 months)
– No records dated within 1 year of DOS verifying continued use and need
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Lessons Learned
• CGS, Jurisdiction C:
– Proof of delivery
• If shipped, DOS = shipping date
• In person, DOS = date delivered/picked up
– Nursing Home Patients • Combined delivery OK, BUT
• Break down individual nutrients/supplies per patient
• Refill requests must be documented so that refill quantities are based on the individual’s not facility’s needs
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Lessons Learned
• CGS, Jurisdiction C:
– Preliminary dispensing order OK for delivery
• Written, fax or verbal
• Transcribe verbal
– Detailed written order needed to bill
– Checklists do not equal medical records
– Do not alter DIF Form at all
• No company logo
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Will Your Documentation Cut the Mustard?
Insufficient Documentation (Nutrition)
• Diagnosis codes ALONE
• Dispensing or prescription orders ALONE
• Supplier generated forms
– NOT a substitute for physician records!
• Stamped signatures
• Illegible signatures
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Ensure You Have (Nutrition):
• Dispensing/verbal order
• Detailed written order
– Listing Each Item Billed
• Supplier signed and dated DIF (Form 10126)
• Clinical records supporting coverage criteria
– Permanent non‐function or disease of the structures that normally permit food to reach the small bowel, or – Disease of the small bowel which impairs digestion and absorption of an oral diet.
• Justification for pump or special formulas
• Proof of delivery
– Contractors must be able to determine who, what and where.
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For Pumps
• Pumps (B900‐B9002):
– Physician must document conditions that justify need, such as:
• Gravity feeding is not satisfactory due to reflux and/or aspiration
• Severe diarrhea
• Dumping syndrome
• Administration rate less than 100 mL/hr
• Blood glucose fluctuations
• Circulatory overload
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For Pumps
• Pumps (B900‐B9002):
– If discontinued for two consecutive months and later resumed, a new initial DIF is required
• If nutrition is changed from syringe/gravity to a pump
– A new Initial DIF is required (for pump)
– A revised DIF is required (for nutrition)
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For Specialty Nutrients
• Specialty Nutrients (B4149, B4153‐B4157, B4161 and B4162):
– Covered for patients with specific diseases
– Requires additional documentation identifying the specific condition and need for the nutrient
– Auditors expect evidence of failure on standard formulas – No more LCA = meet requirements or ABN
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For Nutrients
• Revised DIF needed for ALL nutrients if:
– Number of calories per day changes
– Number of days per week the nutrient is administered changes
– Method of administration changes between syringe, gravity, or pump
– Route of administration changes from feeding tubes to oral tubes (if billing for a denial)
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For E0799
• Use JB modifier for subcutaneous immune globulin, and pump E0779
• LCA Removed for E0781/E0791 for subcutaneous immunoglobulin (must bill E0779 only)
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Refills and Supplies
• Patient must be contacted prior to delivery
– Contact no more than 14 days before expected depletion
– May deliver 10 days early (NOT routinely)
– Confirm supply is nearly depleted
– Obtain information on frequency of utilization
– Are you the only supplier?
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Refills and Supplies
• For telephone contact, document:
– The patient’s name
– The person contacted (patient or caregiver)
– General description of items requested
– Statement that refill is requested
– Date of contact
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Refills and Supplies
• For written contact, document:
– The patient’s name
– General description of items requested
– Statement that refill is requested
– Patient or caregiver’s signature and date
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Maintaining Documentation
• Documentation must be on file for 7‐years
• Cut back on paper files
• Consider a scanning solution
– Maintain electronic copies
• Faster recall of old documents
• More organized
• Less storage space
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Take a Proactive Approach
• Key in all patient information at intake
– Insurance information
– Address information
– ABNs
• Verify prescriptions/orders prior to delivery
– Get signed DIF on file
• Check for same or similar
– Already had a pump in the past 5 years?
• Real‐time eligibility checks for SNF or HH stays
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Take a Proactive Approach
• Don’t assume the system will catch all errors
• Make a diagnosis code & common HCPCs cheat sheet:
– Screen for every transmission!
– Use software to flag when diagnoses & HCPCs don’t match
• Make a list of HCPCs to check for policy specific modifiers (BA, BO, KX, etc)
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Take a Proactive Approach
• Obtain notes from all sources
– High calorie diets (exceeding 2000 calories)
•
•
•
•
Physical therapy
Oncologist notes
Cal/kg requirements
Dietitian
• Call 10 Days ahead to confirm refills needed
– Document patient response
• Protocol for date stamping documentation
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Educating Referral Sources
• Audit physician records • Are you comfortable?
– Long or short turn around time?
– Support medical necessity?
– Missing required pieces of information?
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Educating Referral Sources
• Check your DME mac’s website:
– Physician documentation request letters
– Enteral nutrition dear physician letter
• Include cover letters quoting LCD coverage requirements
– Not regulated, but be broad‐based
• Provide documentation checklist
– Although not considered part of medical record
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Obtaining Documentation
• Myth: – HIPPA prevents physicians from supplying requested documents
• Truth: – HIPPA allows disclosure of PHI for:
• Treatment
• Payment • Health care operations
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Obtaining Documentation
• SSA mandates physicians comply with documentation requests
– Section 1842(p)(4):
• [i]n case of an item or service…ordered by a physician or a practitioner…but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.
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Make it Easy to Send
•
•
•
•
•
Ask up front, while fresh
Include pre‐addressed, pre‐stamped envelope
Accept faxes
Electronic medical records are acceptable
Get the patient involved
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Understanding Your Rights
Your Rights
You have every right to appeal a denial
There is NO fee to appeal a denial at any level
You do NOT need a lawyer to appeal
Submitting an appeal does NOT increase your audit vulnerability
• Success increases at higher levels
•
•
•
•
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Your Rights
• You can delay recoupments from post payment audits
• Collection attempts must stop when an appeal is filed at levels 1 or 2
– Redeterminations (level 1):
• Contractors must wait 41‐days to collect
– You have 120 days to appeal from the EOB date
– Reconsiderations (level 2):
• Contractors must wait 60‐days to collect
– You have 180 days to appeal from the EOB date
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Details Are Critical
• Pay attention to dates:
– Anywhere from 14‐120 days to respond
– Date = date response must be received
• Pay attention to requirements:
– Know the reason for denial
– Only submit what is requested
– Submit all documents at one time
– Follow submission guidelines to a “T”
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Be Prepared to Submit
•
•
•
•
•
•
The preliminary dispensing/verbal order
Detailed written order
Physician progress notes to verify medical necessity
Signed DIFs
Proof of delivery
Requested medical records from:
– Physician’s office, nursing home, HHA, hospital, lab, dietitian
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Levels
of Appeal
Redetermination
Reconsideration
Administrative Law
Judge
Departmental Appeals Board
Judicial Review
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Levels of Appeal
• Redeterminations (1st level)
– 120 days from the date on the EOB
– Medicare has 60 days to respond
• Reconsiderations (2nd level)
– 180 days from the date on the EOB
– Qualified Independent Contractor (QIC)
– Medicare has 60 days to respond
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Levels of Appeal
• Administrative Law Judge (ALJ) (3rd Level)
– Appeal within 60 days of Level 2 decision
– $130 minimum
– Video or telephone hearing (in person on a case‐
by‐case basis)
– Generally held within 90 days
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Levels of Appeal
• Departmental appeals board (DAB) (4th level)
– Appeal within 60 days of Level 3 decision
– No minimum amount
– Appeals generally processed within 90 days
– File with local Social Security office or address in ALJ Decision Letter
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Levels of Appeal
• Judicial Review/US District Court (5th Level)
– Appeal within 60 days of Level 4 Decision
– $1350 minimum
– Follow instructions in DAB Decision Letter
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Putting Together Your Response
• Gather documents to support your claim
– Claim forms, EOBs, progress notes
– DIFs, delivery tickets, hospital records
– Physician evaluations, communication logs, etc.
• Keep copies for your records
• Verify receipt
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Putting Together Your Response
• Be organized!
– Number all pages (X of Y)
– Include a summary paragraph (what and why?)
– Include a table of contents (where?)
– Underline relevant information
– Prescreen your documentation
• Is it relevant?
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Audit Proofing Your Business
Conduct Internal Audits
• Query claims in batch mode monthly or quarterly
• Review patient files to catch errors internally
– Pull patients from specific product categories with various EOB dates
• Standardize the forms you use:
–
–
–
–
Be consistent
Use checks and balances
Appoint a Compliance Officer
Have work independently reviewed
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Review and Verify
• Review:
– Client charts, billing records, EOBs
– Product coding, chart notes, LCDs
• Verify:
– Patient information
• Eligibility
– AOB • Signatures and dates
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Review and Verify
• Verify:
– Dispensing/verbal order
• Descriptions, alterations, signatures and dates
– Detailed written order
• Quantity, options/accessories, frequency of replacement, LON etc.
– Billing accuracy
• Modifiers, HCPCS, quantity, ICD‐9 = match
• Medical documentation, DIF, ABN = on file 67
Review and Verify
• Verify:
– Delivery documentation
•
•
•
•
•
Patient signatures and dates
Who signed? Relationship on file
Delivery service (FedEx®) DOS = date shipped
Quantities, charges, descriptions = match
SNF = identified for specific patient, records account for supply utilization
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Educational Resources for Staff
• DME MAC Tools:
– Documentation checklists – Capped rental calculator
– Enteral units of service calculator
– Redetermination request calculator
– Reconsideration request calculator
– Physician education letters
– Modifier finder tools and usage tables
– Appeals time limit calculators
– Timely filing calculators
– Supply refill and contact calculators
– DME FAQs
– “Ask‐the‐Contractor” teleconferences
– Free, product specific webinars
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Educational Resources for Staff
• RSS Feeds E‐mail Feeds
– MiraVista News Blog
– HME News, Homecare Mag, HME Business
– AAHomecare Blog
• Sign‐up for List Serves
– NHIA Listserv
– CMS List Serves
– DME MAC List Serves
• Join LinkedIn® Groups
–
–
–
–
Durable Medical Equipment Group
HME Industry Network Group
Medicaid and Medicare Network Group
Medical Billing and Coding Forum
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Educational Resources for Staff
• This site will allow you to look up HCPCS product classifications, fee schedules and modifiers.
– Click on the DMECS tab (DME Coding System)
– Select “Search for codes or fees”
– Bookmark this site to your favorites: http://www.dmepdac.com/dmecsapp/do/search
• In many cases, a manufacturer’s product has to be specifically approved by PDAC prior to being covered by Medicare 71
Educational Resources for Staff
• Join an Association
– NHIA—tools and resources specific to the home infusion industry www.nhia.org
– Your state association will help you fight local and national battles and give you access to Medicaid agencies and local payers to name a few benefits. Find your association here: http://www.hmenews.com/index.php?p=resources&resid=17
– American Association for Homecare http://www.aahomecare.org
• Member Services Organizations –
–
–
–
Hold workshops and webinars
Coordinate discounted purchasing Provide support to the business as a whole
Offer contracting services to get you in network with more payers 72
Educational Resources for Staff
• DME Pricing Data Analysis and Coding (PDAC)
– www.dmepdac.com
• CMS Quarterly HCPCS Updates
– https://www.cms.gov/hcpcsreleasecodesets/02_hcpcs_quarterly_update.asp
• Annual HCPS Updates
– https://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp
– Look for the 2012 Alpha‐Numeric HCPCS File.
• These are great resources that will allow you to maintain a current in‐house database that your staff may verify coding against
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Educational Resources for Staff
• MLN Matters Articles (Search by Dates and Keywords):
– https://www.cms.gov/MLNMattersArticles/2011MMan/list.asp
• LCDs and Policy Articles
– Bookmark Your DME MACs LCD website
• (My favorite: https://www.noridianmedicare.com/dme/coverage/lcd.html)
– Check for Revised LCDs:
• http://www.cms.gov/medicare‐coverage‐database/
• Select the Indexes tab and look for LCDs by contractor (i.e. NGS DME MAC)
• Here you can see Active, Future and Draft LCDs.
• To see all recently revised LCDs, sort by Last Updated.
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Learning Assessment Questions & Answers
Please refer to the NHIA Annual Conference & Exposition 2012 On‐Site Program for a brief post‐test.
[email protected]
803.462.9959 x 240
4/8/2012
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Disclaimer
These materials and links to other sources are provided for informational purposes only and are not intended to be and should not be construed as legal advice. MiraVISTA does not guarantee or warrant that the materials are without error or present a complete explanation of all aspects of coverage or billing. Laws and procedures change frequently and are subject to differing interpretations. Content and information is subject to change without notice.
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