CERT A/B Contractor Task Force

Transcription

1 CERT A/B Contractor Task Force Education Teleconference August 20, 2013 Presentation Version August 19,

2 Today s Presenters Michael Dorris, National Government Services, Inc. Barbara Horton, Noridian Healthcare Solutions Thaya Morant, CGS Administrators 2

3 Disclaimer Comprehensive Error Rate Testing (CERT) Part A and Part B (A/B) Contractor Task Force is independent from the Centers for Medicare & Medicaid Services (CMS) CERT team and CERT contractors, which are responsible for calculation of the Medicare fee-for-service improper payment rate. 3

4 Findings Improper payments occur when: Documentation is not available to support a payment Documentation is incomplete or missing a legible signature Documentation or orders indicate one service, but another one is performed and billed (including laboratory services) Funds go to the wrong provider or the right provider receives the incorrect amount of funds (including overpayments and underpayments) Provider uses funds in an improper manner 4

5 Findings All improper payments cause more work to be performed by the Medicare Administrative Contractors (MACs) and the provider community. When an error is found more research must be conducted to determine the impact of the error, including selecting claims with that service and requesting supporting medical records from the provider community. 5

6 Medicare Payments Medicare $349.7B total payments fiscal year (FY) 2012 $29.6B improper payments FY 2012 Improper Payment Rate FY 2012 rate: 8.5% Target for FY 2013: 8.3% Source: 6

7 Reducing Improper Payments CERT program Key program for measuring improper payment errors for Medicare Collaboration is key Reducing CERT errors requires all Medicare stakeholders to work together Collaboration is the inspiration for the CERT A/B Contractor Task Force 7

8 Meet the CERT A/B Contractor Task Force Barbara Horton, Noridian Healthcare Solutions 8

9 CERT A/B Contractor Task Force Two Task Forces A/B MACs Durable Medical Equipment (DME) MACs All MACs participate 9

10 CERT A/B Contractor Task Force Project Lead Michael Dorris, National Government Services, Inc. Manager, Congressional Affairs Facilitates meetings of Task Force Communicates with CMS 10

11 The Members Cahaba Government Benefit Administrators, LLC J10 CGS Administrators, LLC J15 First Coast Service Options, Inc. J9 National Government Services, Inc. J6, JK NHIC, Corp J14 Noridian Healthcare Solutions, LLC JF, JE Novitas Solutions, Inc. JL, JH Palmetto GBA J1, J11 Wisconsin Physicians Service Insurance Corporation J5, J8, T18 11

12 CERT A/B Contractor Task Force Meets monthly Educates on common billing errors Currently, the Task Force is working on top billing error examples CMS approval required Stay tuned for more information on education opportunities with your MAC Provides consistent education for providers across the country 12

13 CERT A/B Contractor Task Force Role Support CMS CERT error rate reduction goals Promote educational collaboration among MACs Important for MACs to be consistent and unified CERT A/B Contractor Task Force green logo Improve knowledge and performance of MACs through collaboration 13

14 CERT A/B Contractor Task Force Excluded from Task Force scope Policy discussions Audit review Education products will not replace or contradict local coverage determinations, coding rules, regulations, or laws 14

15 Education Strategy Thaya Morant, CGS Administrators 15

16 CERT A/B Contractor Task Force Education strategy Enhance, not replace, other CERT education conducted by CMS and MACs within its jurisdictions Identify one to four CERT hot error topics each year Publish scenario-driven articles and CMS Fast Facts Highlight scenarios into MAC s jurisdiction-specific education activities 16

17 CERT A/B Contractor Task Force Education strategy (Cont.) Each contactor will publish the educational products through their education channels and vehicles Listserv Website Educational events Associations and societies Task Force will solicit suggestions from providers through each MAC Provider Outreach and Education Advisory Groups Stay-tuned to your MAC s listserv 17

18 Examples of Education CMS Fast Facts Published by CMS on the Provider Compliance page Learning-Network-MLN/MLNProducts/ProviderCompliance.html CERT A/B Contractor Task Force develops and recommends to CMS for inclusion Posted once a month and remains on the web page for approximately 30 calendar days At least six Fast Facts will be created each year with content no more than 800 characters in length 18

19 Example of CMS Fast Fact Issue: Medicare Contractors are seeing an increase in errors identified by the CERT Contractor for Home Health Services. Most of these errors are due to insufficient documentation in the faceto-face encounter narrative by the certifying physician. Guidance: The narrative explanation must include the physician s description of how the clinical findings as seen during the face-to-face encounter support the beneficiary s homebound status and need for skilled services. Lists of diagnoses, recent injuries, or surgical procedures alone are not sufficient to explain why the findings from the face-to-face encounter support the medical necessity of the services ordered and the beneficiary s homebound status. For more information on documentation requirements for face-to-face encounters, refer to MLN Matters Article #SE MLN/MLNMattersArticles/downloads/SE1219.pdf 19

20 Example of Education Task Force scenarios More detailed than a Fast Fact Based on CERT hot topic and audit findings currently responsible for highest improper payments Provides background education on the hot topic with a general situation scenario Will be published on each MAC s dedicated website page for the Task Force 20

21 Providers can help reduce billing errors Use the education products (scenario articles, Fast Facts, etc.) as a guideline for appropriate billing Inform billers and providers on what documentation the CERT contractor is reviewing when auditing their claims Incorporate education products as a resource/tool in instructing new providers in your practice on proper documentation Communicate information in monthly/weekly newsletters Encourage medical school instructors to use information as an educational tool for prospective and veteran providers Encourage compliance officers to use information to educate large groups or providers in which they have oversight 21

22 Question & Answer Session Michael Dorris 22

23 Q&A Questions we have received What questions do you have? Individual MACs remain your first point-of-contact for specific, individual education Please complete evaluations Will be sent to your 23

24 Thank you for your participation 24