unusual weather we are having: the medicare audit climate

Unusual Weather We Are Having:The Medicare Audit Climate

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)

Presented by:

Carrie MullinDirector of Denial Management

Elisa Bovee, MS OTR/L, Vice President of Operations

Housekeeping

Sign InContact Hours CertificateA Little About MeHandoutsContact Information for Questions

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2

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Speaker Bio (Elisa Bovee)

Vice President of Operations for Harmony Healthcare International (HHI), an industry leader in Long-Term Care consulting on a national level Over 20 years of experience in the long-term care industry, practicing and providing consulting services related to therapy services and Medicare Regulations and Guidelines Manager of a diversified team of consultants who have extensive knowledge in the areas of MDS 3.0, RUG-IV, Documentation, Therapy Program development and state-specific Medicaid Case mix Appeals Coordinator for a National nursing home companyProficient in Medicare Denials Professional in Reimbursement guidelines for Medicare and Medicaid in the skilled nursing facility Former Director of Education and Training and Regional Consultant for Harmony Healthcare International Author of many articles featured in select long-term care industry trade magazines Provider of public and private education on a national level focused on a multitude of topics including Medicare regulations, and therapy solutions for case management in the SNF Provider of extensive training for MDS Coordinators, Therapy Directors and Rehabilitation Staff on MDS coding, RUG-IV Intimacy, Skilled Nursing Therapy Documentation in the SNF and Denials Management for the SNF

Copyright © 2013 All Rights Reserved


Speaker Bio (Carrie Mullin)

Director of Denial Services for Harmony Healthcare International, Inc. and Corporate Consultant for HHI since 2008MS OTR/L, RAC-CT Education:

Masters of Science in Occupational Therapy from Spalding University in Louisville, KY Continuing Education in Contracture and Geriatric Therapeutic Exercise Courses

Experience:Senior Occupational Therapist and Director of Rehabilitation Services at Episcopal Senior Life Communities in Rochester, NYExpert in Denials, Appeal letters, and prepping facilities for ALJ hearings




Disclosure: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose:Planners:

Elisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTBeckie Dow, RN, RAC-MTKeri Hart, MS CCC, SLP, RAC-CT, Kristen Mastrangelo, OTR/L, MBA, MHA Christine Twombly, RNC, RAC-MT, LHRM

Presenters:Carrie MullinDirector of Denial Management

Elisa Bovee, MS OTR/L, Vice President of Operations


Harmony Healthcare International, Inc.

Unusual Weather We Are Having:The Medicare Audit Climate Disclosure

Speakers: Carrie MullinDirector of Denial ManagementElisa Bovee, MS OTR/L, Vice President of Operations

The speakers have no relevant financial relationships to disclose

The speakers have no relevant nonfinancial relationships to disclose

Copyright © 2013 All Rights Reserved 6

Objectives

The learner will be able to summarize the multiple types of Medicare Contractor Audits and associated Compliance themes.The learner will be able to summarize Trends and Triggers in Compliance Audits and Common Provider Pitfalls.The learner will be able to summarize strategies for appealing Medicare Claim Denials.

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Section IWhat is Skilled Care?


What is Skilled Care?

Why is this material important?Which team members should be aware of the Medicare Skilled Care criteria?How often will this criteria be relevant to current beneficiaries and applicable for denied claims?


What is Skilled Care? Requires the skills of qualified technical or professional health personnel such as RN, LPN, PT, OT or SLP Must be provided directly by or under the general supervision of a licensed nurse or skilled rehab personnel to assure the safety of the resident and to achieve the medically desired result

“General supervision” requires initial direction and periodic inspection of activity

Ordered by a physicianServices are needed and provided on a daily basis


What is Skilled Care?

The need for skilled care must be justified and documented in the medical recordConditions may have prompted the initial hospitalization, but also include the conditions that arose during recovery in the SNF



What is Skilled Care ?

Direct Skilled Nursing ServicesManagement and Evaluation of a Care PlanObservation and AssessmentTeaching and TrainingSkilled Rehabilitation


Skilled Services Categories: Inherent Complexity

Inherent Complexity – Direct skilled nursing services including:

IV feedingIV medsSuctioningTracheostomy CareVentilator supportUlcers


Skilled Services Categories: Inherent Complexity

Inherent ComplexityTube feedingsRespiratory Therapy 7 days per weekSurgical wound or open lesions with treatmentsUnstable clinically with diabetes with injectionsTransfusionsChemotherapyColostomy Care, early post op care


Skilled Services Categories:Skilled Observation and Assessment

Reasonable probability or possibility for complicationPotential for further acute episodesIdentify and Evaluate the need for modification of treatmentEvaluate initiation of additional medical proceduresSkilled observation can be required until the treatment regimen is essentially stabilized



FeverDehydrationSepticemiaPneumoniaNutritional Risk

ChemotherapyWeight lossBlood sugar controlImpaired cognitionSevere Mood and Behavior conditions

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Identify and outline daily skilled nursing observations and assessmentsRecord DAILY each itemized area listed on your outline



NeurologicalRespiratoryCardiacCirculatoryPain/Sensation

NutritionalGastrointestinalGenitourinaryMusculoskeletalSkin



A patient with arteriosclerotic heart disease with congestive heart failure requires close observation by skilled nursing personnel for signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication

Skilled observation is needed to determine when the digitalis dosage should be reviewed or whether other therapeutic measures should be considered, until the patient’s treatment regimen is essentially stabilized Harmony Healthcare International, Inc. 21Copyright © 2013 All Rights Reserved


A patient has been hospitalized following a heart attack. Following treatment but before mobilization, he is transferred to the SNF.

Because it is unknown whether exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated and continued until the patient’s treatment regimen is essentially stabilized



A frail 85-year-old man was hospitalized for pneumonia. The infection resolved, but the patient, who had previously maintained adequate nutrition, will not eat or eats poorly.

The patient is transferred to a SNF for monitoring of fluid and nutrient intake and the assessment of the need for tube feeding and assisted feeding if required. Observation and monitoring by skilled nursing personnel of the patient’s oral intake is required to prevent dehydration.


Skilled Services Categories:Skilled Observation and AssessmentA patient left the acute hospital on a high dosage of Coumadin with daily clotting time studies

Assessment and observation is needed until a maintenance dosage is attained and the patient/resident shows no adverse symptoms. Regulation is an integral part of this patient/resident’s coverage. Ongoing observation and assessment, notifying the physician and multiple changes in the plan of care, are also skilled in nature.



If a patient was admitted for skilled observation but did not develop a further acute episode or complication, the skilled observation services still are covered so long as there was reasonable probability for such a complication or further acute episode

“Reasonable probability” means that a potential complication or further acute episode is a likely possibility


Skilled Services Categories:Management and Evaluation of a Care Plan

Based on the Physician’s orders, these services require the involvement of skilled nursing to meet the resident’s

Medical needs Promote recovery Ensure medical safety


This area includes The sum total of unskilled servicesPotential for serious complicationsHigh probability of relapseRecovery and safety Meet medical needs Includes resident’s overall condition





Topic Areas to include:Surgical sitesCirculatory statusStatus of fracturesMaintenance of weight-bearing statusSkin CareLabsConsultant Recommendations


Skilled Services Categories: Management and Evaluation of a Care Plan

Although any of the required services could be performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the nature of the patient’s condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient’s recovery and safety. The management of this plan of care requires skilled nursing personnel until the patient’s treatment regimen is essentially stabilized, even though the individual services involved are supportive in nature and not require skilled nursing personnel.



Example: An aged patient is recovering from pneumonia, is lethargic, is disoriented, has residual chest congestion, is confined to bed as a result of his debilitated condition, and requires restraints at times

To decrease the chest congestion, the physician has prescribed frequent changes in position, coughing and deep breathing. While the residual chest congestion alone would not represent a high risk factor, the patient’s immobility and confusion represent complicating factors when coupled with the chest congestion, could create high probability of a relapse. Harmony Healthcare International, Inc. 30Copyright © 2013 All Rights Reserved

Skilled Services Categories: Teaching and Training

Teaching and Training: Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen


Skilled Services Categories: Teaching and Training

Colostomy careInsulin administrationProsthesis managementCatheter careG-tube feedingsIV access sites

Braces, splints and orthoticsWound dressings and skin treatmentsMedication ManagementOrthopedic Precautions


33

Skilled Rehabilitation

Transmittal 262On a daily basisServices rendered are reasonable and necessaryMD orderedPractical matterAn appropriately licensed or certified individual must provide or directly supervise the therapeutic service and coordinate the intervention with nursing services

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34

Skilled Rehabilitation/MD Involvement

The service must be ordered by a physician.The therapy intervention must relate directly and specifically to an active written treatment regimen established by the physician after any needed consultation with the qualified rehabilitation therapy professional and must be reasonable and necessary to the treatment of the beneficiary’s illness or injury necessary to the treatment of the beneficiary’s illness or injury


35

Skilled Rehabilitation/MD Involvement

MD involvement to prevent injuriesMedicare allows the professional therapist to develop a suggested plan of treatment and to begin providing services based on the plan prior to MD signatureMD signature required before facility bills Medicare.MD Faxed signatures acceptable


36

Skilled Rehabilitation Overview

Directly related to a written plan of treatmentRequires knowledge/skills/judgment of qualified professionalServices must be considered under acceptable standards clinical practiceExpectation of improvement of restorative potential in a reasonable and predictable period of time….or….Establishment of a safe and effective maintenance program


37

Basic Criteria for Rehabilitation Services

Must be specifically related to the Physician’s Treatment PlanSkill of a qualified therapist must be neededTreatment plan must expect the patient to improveServices must fall within accepted standards of medical practice and be specific to the patientThe services must be reasonable and necessary


Harmony Healthcare International

Section IIImprovement Standard



CMS Settlement

What does this mean for the SNF?How do you proceed?What can I do tomorrow to implement change in my facility?



CMS Settlement

Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the "Improvement Standard" case, Jimmo v. SebeliusA proposed settlement agreement was filed in federal District Court on October 16, 2012



CMS Settlement

The lawsuit, Jimmo v. Sebelius, was brought on behalf of a nationwide class of Medicare beneficiaries by six individual beneficiaries and seven national organizations Representing people with chronic conditions, to challenge the use of the Improvement Standard


http://www.medicareadvocacy.org/2011/07/jimmo-v-sebelius/

http://www.medicareadvocacy.org/2011/07/jimmo-v-sebelius/


CMS Settlement

CMS will revise the Medicare Benefit Policy Manual and other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a beneficiary "improving" New policy provisions will state that skilled nursing and therapy services necessary to maintain a person's condition can be covered by Medicare



CMS Settlement

CMS will undertake a comprehensive nationwide Educational Campaign to inform health care providers, Medicare contractors, and Medicare adjudicators they should not limit Medicare coverage to beneficiaries who have the potential for improvement



CMS Settlement

Instead, providers, contractors, and adjudicators must recognize "maintenance" coverage and a beneficiary's need for skilled care that is performed or supervised by professional nurses and therapists



CMS Settlement

Providers should apply the maintenance standard and provide medically necessary nursing services or therapy services, or both, to patients who need them to maintain their function, or prevent or slow their decline



CMS Settlement

Under the maintenance standard articulated in the settlement,

the important issue is whether the skilled services of a health care professional are needed, not whether the

Medicare beneficiary will "improve"



CMS Settlement

The CMS clarification will state:Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program



CMS Settlement

The CMS clarification will state:Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program



CMS Settlement

The settlement also establishes a process of "re-review" for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services (physical therapy, occupational therapy, or speech therapy)



CMS Settlement

Re-review only covers individuals who seek Medicare on their own behalf, and “specifically excludes providers or suppliers of Medicare services or a Medicaid State Agency.” The settlement agreement would specifically preclude providers, suppliers, and a Medicaid State Agency from receiving a re-review of claims on behalf of, or under assignment from, a beneficiary class memberCopyright © 2013 All Rights Reserved


CMS Settlement

BUT - the “revised” standard should be applied to future claims and/or those that are currently in the denial or appeal process Embrace the OBRA 87 regulations which require facilities to provide services to meet “the highest practicable physical, medical and psychological well-being” of every residentCopyright © 2013 All Rights Reserved


Section IIIAuditing Agencies and

Contractors



HEALTHCARE CORRUPTION


OIG Investigation


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OIG Report: Part A

OIG REPORTQuestionable Billing by

Skilled Nursing FacilitiesMedicare Part A


Background

An OIG report found that 26 percent of claims submitted by SNFs were not supported by the medical record, representing over $500 million in potential overpayments

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 57

Background

This study based on an analysis of Medicare Part A claims from 2006 and 2008 and on data from the Online Survey, Certification and Reporting system


FindingsFrom 2006 to 2008, SNFs increasingly billed for higher paying RUGs, even though beneficiary characteristics remained largely unchanged

Percentage of RUGs for ultra high therapy increased from 17 to 28 percent

Percentage of RUGs with high ADL scores increased from 30 percent in 2006 to 34 percent in 2008

Even though SNFs significantly increased their billing for these higher paying RUGs, beneficiaries’ ages and diagnoses at admission were largely unchanged from 2006 to 2008


FindingsFor-profit SNFs were far more likely than nonprofit or government SNFs to bill for higher paying RUGs

32 percent of RUGs from for-profit SNFs were for ultra high therapy, compared to 18 percent from nonprofit SNFs and 13 percent from government SNFs. In addition, for-profit SNFs had a higher use of RUGs with high ADL scores than both for profit and government SNFs. For-profit SNFs also had longer lengths of stay, on average, compared to those of the other types of SNFs.


FindingsA number of SNFs had questionable billing in 2008Some SNFs billed much more frequently for higher paying RUGs than other SNFs. Some SNFs also had unusually long average lengths of stay compared to those of other SNFsThey identified 348 SNFs that were in the top 1 percent for the use of ultra high therapy, RUGs with high ADL scores, or long average lengths of stay


Recommendations

1.Monitor overall payments to SNFs and adjust rates, if necessary

Adjust RUG rates annually, if necessary, to ensure that the changes do not significantly increase overall payments


Recommendations2. Change the current method for

determining how much therapy is needed to ensure appropriate payments

CMS should consider requiring each SNF to use the beneficiary’s hospital diagnosis and other information from the hospital stay to better predict the beneficiary’s therapy needsIn addition, CMS should consider requiring that therapists with no financial relationship to the SNF determine the amount of therapy needed throughout a beneficiary’s stay


Recommendations3. Strengthen monitoring of SNFs

that are billing for higher paying RUGs

CMS should instruct it’s contractors to monitor SNFs’ use of higher paying RUGs using the indicators discussed in this report. CMS should develop thresholds for the indicators and instruct its contractors to conduct additional reviews of SNFs that exceed them. If SNFs from a particular chain frequently exceed the thresholds, then additional reviews should be conducted of the other SNFs in that chain.


Agency Comments and Office of Inspector General Response

CMS concurred with three of the four recommendations1. Agree: CMS concurred and stated

that it would assess the impact of the recent changes on overall SNF payments as data became available and would expect to recalibrate RUG rates in future years, as appropriate

2. Not Agree: CMS noted several concerns with relying on information from the beneficiary’s hospital stay to determine the beneficiary’s therapy needs during a SNF stay


Agency Comments and Office of Inspector General Response

3. Agree: CMS concurred and stated that it would determine whether additional safeguards shall be put in place by the Medicare contractors to target their efforts

4. Agree: CMS concurred and stated that it would forward the list of SNFs with questionable billing to the appropriate contractors


Objectives

To determine the extent to which billing by skilled nursing facilities (SNF) changed from 2006 to 2008To determine the extent to which billing varied by type of SNF ownership in 2008To identify SNFs with questionable billing in 2008


BackgroundIn recent years, the Office of Inspector General (OIG) has identified a number of problems with SNF billing for Medicare Part A paymentsNotably, an OIG report found that 26 percent of claims submitted by SNFs in fiscal year (FY) 2002 were not supported by the medical record, representing $542 million in potential overpayments*

*Source: OIG, A Review of Nursing Facility Resource Utilization Groups, OE1-02-02-00830, February 2006.


BackgroundAdditionally, OIG audits of five SNFs

found that 20 to 94 percent of sampled claims from 2002 through 2004 were medically unnecessary, were submitted at an inappropriate payment rate, or were insufficiently documented*

OIG estimated that overpayments to these SNFs totaled nearly $2.5 million

*Source: OIG, Review of Rehabilitation Services at Gulf Health Care, Texas City, TX, A-06-03-00078, July 2007; Review of Rehabilitation Services at Skilled Nursing Facilities – Avante at Leesburg, A-06-06-00107, May 2007; Review of Skilled Services at Heartland Health Care Center of Bedford, TX, A-06-07-00045, April 2008; Review of Skilled Services at Four Seasons Nursing Center of Durant, OK, A-06-07-00046, May 2008; and Review of Skilled Services at Regent Care Center of Laredo, TX, A-06-06-00047, August 2006.

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BackgroundFurther, the Medicare Payment Advisory Commission (MedPAC) has raised concerns about SNFs’ improperly billing for therapy to obtain additional Medicare paymentsSpecifically, MedPAC noted that the current system “encourages SNFs to furnish therapy, even when it is of little or no benefit”*

*Source: MedPAC, Report to Congress: Promoting Greater Efficiency in Medicare, June 2007,

ch. 8, p. 192.Accessed at http://www.medpac.gov/chapters/Jun07_Ch08.pdf on May 29, 2009.

http://www.medpac.gov/chapters/Jun07_Ch08.pdf


BackgroundIn addition, staff at the Centers for Medicare & Medicaid Services (CMS) noted that some facilities, to increase payments, may be inappropriately overstating a beneficiary’s need for assistance with certain activities of daily living (ADL) Staff also noted that certain SNFs might be keeping beneficiaries in Part A stays longer than necessary


BackgroundThis study is the first of a three-part series that focuses on Medicaid Part A payments to SNFs

The other two studies will be based on medical record reviews

Source: OIG, Medicare Part A Payments to Skilled Nursing Facilities, OEI-02-09-00200, and Medicare

Requirements for Quality of Care in Skilled Nursing Facilities, OEI-02-09-00201, forthcoming.


Identification of SNFs With Questionable Billing

Analysis based on the 12,286 SNFs that had at least 50 Part A stays in 2008* For each SNF, they determined:

The percentage of RUGs for ultra high therapy,The percentage of RUGs with high ADL scores and The average length of stay

They considered a SNF to have questionable billing if it was in the top 1 percent for any of the three measures

*We established a minimum of 50 Part A stays per SNF to ensure the reliability of the measures. For SNFs with fewer Part A stays, changes in the characteristics of a small number of Part A stays could have a large effect on the measures, making the measures loss reliable.


Identification of SNFs With Questionable Billing

They determined whether these SNFs had beneficiary populations that indicated a need for a particularly high use of higher paying RUGs or for longer lengths of stay


Limitations

This study assesses SNF billing based on an analysis of Medicare Part A claims. It does not, however, determine whether the claims were appropriate. A companion study, based on a medical review, will address this question and determine whether Part A SNF claims met Medicare coverage requirements.


FindingsBilling for ultra high therapy increased substantially from 2006 to 2008. In 2006, 17 percent of all RUGs were for ultra high therapy. In 2008, this share increased to 28 percent. Over the same period, SNFs’ use of the other levels of therapy – very high, high, medium and low – decreased or stayed about the same. For example, SNFs’ use of high therapy decreased from 16 percent in 2006 to 11 percent in 2008. Similarly, the percentage of RUGs in the nontherapy categories decreased from 16 percent in 2006 to 12 percent in 2008.


Findings

Changes in SNF Billing From 2006 to 2008

25%

17% 16%

26%

<1%

16%

28%

25%

11%

24%

<1%

12%

0%

5%

10%

15%

20%

25%

30%

Ultra HighTherapy

Very HighTherapy

HighTherapy

MediumTherapy

Low Therapy Nontherapy

Perc

en

tag

e o

f R

UG

s

2006

2008


FindingsOverall, payments increased by $4.3 billion, or 18 percent from 2006 to 2008. As shown in the below table, payments to SNFs for ultra high therapy rose from $5.7 billion in 2006 to $10.7 billion in 2008, an increase of nearly 90 percent.

Changes in Medicare Payments From 2006 to 2008

RUGs Total Medicare Payments 2006

Total Medicare Payments 2008

Difference in Payments

Ultra high therapy RUGs $5.7 billion $10.7 billion $5.04 billion Other therapy RUGs $15.6 billion $15.3 billion -$0.25 billion Nontherapy RUGs $2.5 billion $2.0 billion $-0.46 billion Total* $23.8 billion $28.1 billion $4.32 billion *Medicare payments in 2008 do not sum to total because of rounding. Source: OIG analysis of Part A SNF claims, 2010.


Findings

The shift to ultra high therapy RUGs was also associated with an increased use of grace periods. SNFs’ use of grace periods increased substantially, from 51 percent in 2006 to 61 percent in 2008 for 5 day assessments.


Findings

Billing for high levels of assistance with daily activities also increased from 2006 to 2008In 2006, 30 percent of RUGs had high ADL scores, compared to 34 percent of RUGs in 2008


FindingsThe shift toward higher paying RUGs did not appear to be the result of changes in beneficiary characteristicsBeneficiaries’ ages and diagnoses at admission were largely unchanged from 2006 to 2008The average age of beneficiaries changed minimally, from 79.9 to 79.8 years of age, and the distribution of beneficiaries’ ages also did not change significantly during this timeAdditionally, the top 20 admitting diagnoses of beneficiaries were identical and accounted for over half of all admissions in both years


Findings

Billing for Ultra High Intensity RUGs With High ADL

Scores, by Type of SNF Ownership, 200832%

13%

18%

0%

10%

20%

30%

40%

For-Profit SNFs Nonprofit SNFs Government SNFsPe

rce

nta

ge

of

RU

Gs

fo

r U

ltra

Hig

h T

he

rap

y

35%31%31%

0%

10%

20%

30%

40%

For-Profit SNFs Nonprofit SNFs Government SNFsPer

cen

tag

e o

f R

UG

s W

ith

Hig

h A

DL

Sco

res

Source: OIG analysis of Part A SNF claims, 2010.


Findings

Billing by For-Profit SNFs, 2008

Independently Owned SNFs

(n = 3,678)

SNFs Owned by Small Chains

(n = 4,579)

SNFs Owned by Large Chains

(n = 2,048) Percentage of RUGs for ultra high therapy

28% 29% 43%

Percentage of RUGs with high ADL scores

33% 34% 38%

Average length of stay 28 days 29 days 31 days Source: OIG analysis of Part A SNF claims, 2010.


OIG Report: Part B

OIG REPORTQuestionable Billing for

MedicareOutpatient Therapy Services

Medicare Part B


Background

Medicare expenditures for outpatient therapy increased 133 percent between 2000 and 2009, from $2.1 billion to $4.9 billion, while the number of Medicare beneficiaries receiving outpatient therapy increased only 26 percent from 3.6 million to 4.5 million


BackgroundMedicare limits (i.e., caps) its annual per beneficiary outpatient therapy expendituresProviders may exceed a beneficiary’s cap if the services are medically necessary and are supported by medical record documentationIf services are expected to exceed an annual cap, providers must indicate this when submitting the claim to Medicare


BackgroundIdentified 20 counties that had in 2009:

The highest average Medicare payment per beneficiary andMore than $1 million in total Medicare payments for outpatient therapy (i.e., high utilization counties)Analyzed Miami-Dade County, Florida, separately because it had the highest average Medicare payments per beneficiary among the high utilization counties and the highest total Medicare payments for outpatient therapy in 2009


BackgroundSix questionable billing characteristics that may indicate fraud:

(1) Services for which providers indicated that an annual cap would be exceeded(2) Beneficiaries whose providers indicated that an annual therapy cap would be exceeded on the beneficiaries first date of service(3) Payments for beneficiaries who received outpatient therapy from multiple providers


Background

(4) Payments for therapy services provided throughout the year(5) Payments for services that exceeded an annual cap(6) Providers who were paid for more than 8 hours of outpatient therapy provided in a single day


FindingsMedicare per-beneficiary spending on outpatient therapy services in Miami-Dade County was three times the national average in 2009Medicare paid an average of $3,459 per Miami-Dade beneficiary for outpatient therapy, compared to an average of $1,078 nationallyEach therapy beneficiary in Miami-Dade County received an average of 158 services during 2009, while the national average was 49 services per beneficiary


RecommendationsTarget outpatient therapy claims in high utilization areas for further reviewTarget outpatient therapy claims with questionable billing characteristics for further reviewReview geographic areas and providers with questionable billing and take appropriate action based on resultsRevise the current therapy cap exception process


Background

Outpatient therapy is designed to improve, restore, and/or compensate for loss of functioning following illness or injuryMedicare beneficiaries are eligible to receive outpatient therapy under Medicare Part B. Medicare covers three types of outpatient therapy.


BackgroundPhysical Therapy (PT): Diagnosis and treatment of impairments, functional limitations, disabilities, or changes in physical function and health status*

Occupational Therapy (OT): Treatment to improve or restore functions that have been impaired (or permanently lost or reduced) because of illness or injury, to improve the individual’s ability to perform tasks required for independent functioning**; and

Speech Therapy (SLP): Diagnosis and treatment of speech and language disorders, that result in communication disabilities or swallowing disorders***

*CMS, Medicare Benefits Policy Manual, Pub. No. 100-02, ch. 15, § 230.1. **Ibid., § 230.2. ***Ibid., § 230.3.


Counties With Highest Utilization


FindingsMedicare Outpatient Therapy Services in Miami-Dade County

Compared to National Levels, 2009

Outpatient Therapy Utilization Miami-Dade

County Average National Average*

Ratio of Miami-Dade County Average to National Average

Medicare payments per beneficiary $3,459 $1,078 3:1 Number of services per beneficiary 158 49 3:1 Medicare payments per provider serving beneficiaries in a county

$83,867 $10,131 8:1

Number of services per provider serving beneficiaries in a county

3,828 458 8:1

*Beneficiaries who received services in more than one county and providers that served beneficiaries in more than one county during 2009 are included in multiple counties in the national averages. In 2009, 4,531,609 beneficiaries received outpatient therapy from 81,170 providers. Less than 1 percent of these beneficiaries lived in more than one county. Providers served outpatient therapy beneficiaries in an average of six counties. Note: All figures have been rounded to nearest whole number. Source: OIG analysis of 2009 Medicare outpatient therapy claims, 2010.


FindingsQuestionable Outpatient Therapy Billing in Miami-Dade County

Compared to National Levels, 2009

Characteristic Miami-Dade

County National Ratio of Miami-Date County to National

Average number of outpatient therapy services per beneficiary that providers indicated would exceed an annual cap

60 14 4:1

Percentage of outpatient therapy beneficiaries whose providers indicated that an annual cap would be exceeded on the beneficiaries’ first date of service in 2009

20% 5% 4:1

Average Medicare payment per beneficiary who received outpatient therapy from multiple providers

$5,664 $1,670 3:1

Percentage of outpatient therapy beneficiaries whose providers were paid for services provided throughout the year

10% 3% 3:1

Percentage of outpatient therapy beneficiaries whose providers were paid for services that exceeded an annual cap

63% 22% 3:1

Percentage of outpatient therapy beneficiaries whose providers were paid for more than 8 hours of outpatient therapy provided in a single day

0.3% 0.7% <1:1

Note: All figures have been rounded to nearest whole number. Source: OIG analysis of 2009 Medicare outpatient therapy claims, 2010.

Findings

As a result of the OIG investigations CMS launched multiple Medical Review Initiatives


Common Auditors

Significant increase in frequency of Medical Review

Office of Inspector General (OIG) ReportsDepartment of Justice (DOJ) ReviewZone Program Integrity Contractor (ZPIC)Recovery Audit Contractor (RAC)Budget cuts

Expect to be ReviewedCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 97



What is PEPPER?

PEPPER Program for Evaluating

Payment Patterns Electronic Report


PEPPER

CMS has announced that they have mailed all SNFs a “Program for Evaluating Payment Patterns Electronic Report” (PEPPER). This report details Medicare claims data in certain targeted areas and compare your facility to other SNFs nationally.


PEPPER

This report will the SNFs detailed Medicare claims data in certain targeted areas and compare he SNF to other SNFs nationally.Skilled Nursing Facilities (SNFs) should have received via mail on or about August 30, 2013Envelope with red print on the outside containing your facility specific PEPPER


Where is My PEPPER


Where is My Pepper?

From TMF Health Quality InstituteThese reports are only distributed to Skilled Nursing Facilities via traditional mail delivery. Many facilities did not identify the document mailed as important and may have even discarded the report as junk mail. PEPPERResources.org from the PEPPER HELP Desk(http://pepperresources.org/HelpContactUs.aspx).


http://pepperresources.org/HelpContactUs.aspx

PEPPER

PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper paymentsAllows providers to see how their facility compares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdiction. PEPPER data is also shared with both Medicare Audit Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs).


PEPPER

Targeted areas were derived from two recent Office of Inspector General (OIG) Reports:

“Inappropriate Payments to skilled Nursing Facilities Cost Medicare than a Billion Dollars in 2009” (November 2012)“Questionable Billing by Skilled Nursing Facilities” (December 2010).


Claims Data

The SNF PEPPER provides SNFs with their jurisdiction, state and national percentile values for each target area with reportable data for the most recent three fiscal years

FY 2012 (October 1 2011 through September 30th )is displayed on the first tableWhen the target (numerator) count is less than 11 for a target area for a time period, statistics are not displayedCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 106

Compare Target Report


Skilled Nursing Facility PEPPER

Compare Targets Report, Four Quarters Ending Q4 FY 2012

Target DescriptionTarget Count Percent

SNF National

%ile

SNF State %ile

SNF Jursidict.

%ileTherapy High ADL

Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to RUX, RVX, RHX, RMX, RUC, RVC, RHC, RMC, RLB, to days billed w ithin episodes of care ending in the report period for all therapy RUGs

2,730 51.6% 85.3 83.1 82.7

Nontherapy High ADL

Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to SSC, CC2, CC1, BB2, BB1, PE2, PE1, IB2, IB1 in RUG III; HE2, HE1, LE2, LE1, CE2, CE1, BB2, BB1, PE2, PE1 in RUG IV, to days billed w ithin episodes of care ending in the report period for all nontherapy RUGs

528 26.7% 58.3 40.0 46.1

Change of Therapy Assessment

Proportion of assessments w ith AI second digit equal to D w ithin episodes of care ending in the report period, to all assessments w ithin episodes of care ending in the report period

60 6.9% 21.8 40.0 34.0

Ultrahigh Therapy RUGs

Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to RUX, RUL, RUC, RUB, RUA, to days billed w ithin episodes of care ending in the report period for all therapy RUGs

3,097 58.5% 64.6 69.3 71.4

Therapy RUGs Proportion of days billed w ithin episodes of care ending in the report period for therapy RUGs, to days billed w ithin episodes of care ending in the report period for all therapy and nontherapy RUGs

5,292 72.8% 8.8 15.0 13.7

90+ Day Episodes of Care

Proportion of episodes of care ending in the report period at the SNF w ith a length of stay of 90+ days, to all episodes of care ending in the report period at the SNF

19 9.0% 25.9 32.9 36.9

Harmony Healthcare International (HHI) The Compare Targets Report displays statistics for target areas that have reportable data (11+ target numerator count) in the most recent time period. Percentiles indicate how a Skilled Nursing Facility's (SNFs) target area percent compares to the target area percents for all SNFs in the respective comparison group. For example, if a SNF's national percentile (see below) is 80.0, 80% of the SNFs in the nation have a lower percent value than that SNF. The SNF's state percentile (if displayed) and the Medicare Administrative Contractor (MAC) jurisdiction percentile values should be interpreted in the same manner. Percentiles at or above the 80th percentile for any target areas, or at or below the 20th percentile for areas at risk for undercoding, indicate that the SNF may be at a higher risk for improper Medicare payments. The greater (or smaller, for areas at risk for undercoding) the percentile value, in particular the national and/or jurisdiction percentile, the greater consideration should be given to that target area.

Target Areas





SNF National

%ile

SNF State %ile

SNF Jursidict.



2,730 51.6% 85.3 83.1 82.7

Nontherapy High ADL


528 26.7% 58.3 40.0 46.1



60 6.9% 21.8 40.0 34.0



3,097 58.5% 64.6 69.3 71.4


5,292 72.8% 8.8 15.0 13.7



19 9.0% 25.9 32.9 36.9


Target Count and Percent

Percentiles





SNF National

%ile

SNF State %ile

SNF Jursidict.



2,730 51.6% 85.3 83.1 82.7

Nontherapy High ADL


528 26.7% 58.3 40.0 46.1



60 6.9% 21.8 40.0 34.0



3,097 58.5% 64.6 69.3 71.4


5,292 72.8% 8.8 15.0 13.7



19 9.0% 25.9 32.9 36.9


A Closer Look at Target Areas


HHI Analysis


HHI Comparative Data


HHI State and Jurisdiction Data


PEPPER

Skilled Nursing Facilities (SNFs) received via mail on or about August 30, 2013Envelope with red print on the outside containing your facility specific PEPPER


PEPPER

PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper paymentsAllows providers to see how their facility compares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdiction. PEPPER data is also shared with both Medicare Audit Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs).


PEPPER

Targeted areas were derived from two recent Office of Inspector General (OIG) Reports:

“Inappropriate Payments to skilled Nursing Facilities Cost Medicare than a Billion Dollars in 2009” (November 2012)“Questionable Billing by Skilled Nursing Facilities” (December 2010).




ZPIC Audit

Frequency of Medical of Review

Significant increase in frequency of Medical Review

Office of Inspector General (OIG) ReportsDepartment of Justice (DOJ) ReviewZone Program Integrity Contractor (ZPIC)Recovery Audit Contractor (RAC)Budget cuts

Expect to be ReviewedCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 119


Insulate, Insulate, Insulate!!

Zone Program Integrity Contractor (ZPIC)

CMS launched another major initiative to target providers other than the hospital setting as the RAC auditors have been focusing on hospital auditsSoutheast, south central, midwest, northeast and west coast regions of the U.S. are seeing the most ZPIC audits at this time


Zone Program Integrity Contractor (ZPIC)

ZPICs SafeGuard Services AdvanceMedHealth Integrity Integriguard

Surprise on-site visitsTargeted data analysisRandom audits100% pre-payment holds


On-site Medical Record Review Audits

AdvanceMedRequest for 160-170 Medical Records14 Days to SubmitRequesting ONLY Therapy DocumentationTherapy Staffing levels were requestedAdvanceMed interviews with Staff



Rehab and MDS QuestionsSample therapy staff interview questions:1. Do you feel pressure to meet your

RUG levels?2. Who has the say on discharge from

therapy?



Sample MDS staff interview questions:1. Who decides the ARD?2. Do they provide group and

concurrent treatments?



Appeal Determinations

Technical Denial Reasons

Response to Additional Documentation Request (ADR) did contain documentation requestedDocumentation not received within requested time framePhysician Certification not signed or missingTherapy Billing logs do not support billing

Part A – MDS AssessmentPart B - 8 Minute Rule

Illegible documentationHospital documentation was not submitted


Clinical Denial Reasons

Documentation did not support medical necessityDocumentation does not support daily skilled intervention by a qualified therapistDocumentation in the medical records must support continued progress


Denial ReasonsReasonable and Necessary

The amount, frequency and duration of services were not reasonable, given the patient’s current statusST documentation demonstrates that the therapist worked long enough with the beneficiary to develop a restorative program


Denial Reasons Skills of A Therapist

ST minutes were reduced based on clinical judgment because documentation did not support the billed minutes were reasonable and necessary. The beneficiary could not participate in self feeding during this period and required the speech therapist to assist with 100% of the feeding.Documentation did not support medical necessity and need for continued skilled therapy. Patient needs assistance and supervision.


Denial ReasonsDeconditioning

Skills of a therapist are not required to maintain function or improve strength and enduranceServices related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation), do not constitute physical therapy services for Medicare purposesPracticing of previously taught exercises does not require the skills of a therapist


Denial ReasonsRestorative Level of Care

Skilled therapy was provided when non-skilled maintenance services would have been more appropriateRestorative level of care provided Documentation supports that restorative nursing could have helped the beneficiary progress versus skilled rehabilitation services

131Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved

Denial ReasonsCustodial Level of Care

Skilled rehabilitation and nursing services were custodial in nature and could have been met with restorative nursing, family member, or nursing provision of intermittent skilled rehabilitation and nursing services and that needs were custodial in nature and could have been met with restorative nursing, family member, or nursing assistant


Denial ReasonsPrior Level of Function

The therapist ignored the patient’s prior level of function and set unrealistic goals Prior level of function was illegible. Prior level of function was blank.Patient's functional level had not changed when compared to his prior level of functioning documented in the medical recordWeekly nursing progress notes demonstrate that the beneficiary required the same amount of assistance (extensive assistance) prior to and after the hospital stay


Denial ReasonsRehab Potential

The medical record did not support that the condition of the patient would improve materially in a reasonable and generally predictable period of timePoor Rehab potential


Denial Reasons Goals

Goals are not functional (i.e., patient will perform 10 repetitions of upper extremity exercises with the yellow theraband)Duplication of services between disciplines


Denial Reasons Lack of Functional Progress

Gains were not significant and there was no indication of carryover of the functional taskLack of documentation relating to the patient having the potential to show significant progress No significant improvement with functional ability The outcome of therapy treatment was not documented Failure to document a complete treatment plan as outlined in Documentation Required section


Denial Reasons Modalities

Electrical Stimulation used to treat motor function disorders, such as multiple sclerosis, is considered investigational and therefore, non-covered

Electrical Stimulation used in the treatment of facial nerve paralysis, commonly known as Bell’s Palsy, is considered investigational and therefore, non-covered

Diathermy and Ultrasound heat treatments for the treatment of asthma, bronchitis, or any other pulmonary condition are considered not reasonable and necessary, and therefore, non-covered 137Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved

Denial Reasons Cognitive Therapy

The record documented a diagnosis of Alzheimer’s disease. SLP documentation does not support further significant practical improvement could be expected. Medical justification for ST services is not establishedSpeech treatment cognition for dementiaPoor progress with cognition


Denial ReasonsInpatient Level of Care

Documentation did not support the need for inpatient level of careNo daily skilled care requiring a stay in the SNFSupervised level of care


Denial ReasonsMedical Record Conflicts

Nursing notes mostly dependent ADLs/functional tasks throughout the SNF stay. Nursing note indicated there was no improvement and fluctuation of progress with self-care tasks.MDS assessments indicate that the beneficiary's ability to perform functional tasks/ADLs did not improve from the 5-day to the 90-day assessment


Denial Reasons

Services provided were likely clinically appropriate but the documentation did not support:

Technical requirementsMedical necessity The skills of a therapist were requiredFunctional outcomeNeed to receive an inpatient level of care



Section IVAppealing Medicare

Denied Claims


Proactive Management of the Appeal Process

Raise Facility AwarenessFunction as a TEAMCommunicationOrganization


Appeal Process

Common practice to receive communications from Medicare review agencies requesting proof of skilled servicesUnderstand the process to manage the inquiry in a timely and detailed manner in order to minimize lost Revenue


CMS Overview Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) included provision aimed at improving the Medicare fee-for-service appeals processPart of the provisions mandate that all second-level appeals (for both Part A and Part B), also known as reconsiderations, be conducted by Qualified Independent Contractors (QICs) Harmony Healthcare International, Inc. 145Copyright © 2013 All Rights Reserved

CMS Overview

Centers for Medicare & Medicaid Services (CMS) contracts with Medicare Administrative Contractors (MACs) to assist with local claims processing and the first level appeals adjudication function


Medical Review

Many times the process starts with an Additional Development Request (ADR)These can be triggered by items specific to the patient, such as:

RUG score ICD-9 code billed Wide spread probe


Probe Reviews

Under probe reviews, contractors may examine 20-40 claims per provider for provider-specific problemsContractors also conduct widespread probe reviews (involving approx. 100 claims) when a larger problem, such as a spike in billing for a specific procedure, is identified


Medical Review

It is not uncommon for an ADR to result in the denial of part or all of a claimOnce an initial claim determination is made providers have the right to appeal



Section VThe Appeal



The Appeal


Assign a team leader to oversee the preparation of the denial packageWork as a team to gather pertinent information for the Medicare Appeal Review the medical record to ensure completeness

The Appeal

It is important to read the ADR or denial letter thoroughly as the letters will assist the facility in gathering the appropriate informationReview the list of items provided in the decision statement to include in the medical record

Consider additional info not listed that will support the services provided


Monitor the Appeal

Internal tracking system to monitor

When ADR or denial was receivedWhen package was sent outFinal results of the review


Conclusion

Educate, Discuss and PrepareDon’t Wait for Medicare Medical ReviewCommunicate to all Staff Medicare Skilled Care Criteria Refine Interdisciplinary Management of Medicare AppealsEstablish and Maintain Peer Review and External Review of Records to Assure Insulation of ClaimsHarmony Healthcare International, Inc. 154Copyright © 2013 All Rights Reserved

Keys to Success

Provide clinically appropriate careDocument

Medical necessityDeficitsOutcomes

Meet technical requirementsReview entire medical recordRespond to ADRs timely


Questions/Answers

Harmony Healthcare International1 (800) 530 – [email protected]@Harmony-Healthcare.com


mailto:[email protected]





Harmony Healthcare InternationalHave you Considered a Customized Complimentary

HARMONY(HHI) MEDICARE PROGRAM EVALUATION

or CASE MIX ANALYSIS

for your Facility?Perhaps your facility has potential for additional

revenue Assess your facility against key indicators and national

norms

Email us at for more [email protected]

Analysis is cost & obligation freeCopyright © 2012 All Rights Reserved Harmony Healthcare International, Inc.
