The Changing CMS Landscape

Transcription

1 The Changing CMS Landscape Managing Medicare and Other Payer Audits Presenter: Carol Endahl Product Manager HFMA ANI June, 2010

2 Medicare and Other Payer Audits Objectives» Audit Landscape» Types of CMS Audits» Comparison RACs vs MICs» Medicaid Integrity Contractor (MIC) Process Overview» Audit Management Modules for Other Payer Audits» Consulting Services

3 Audit Landscape The government continues to pass laws and implement policies to recoup past and prevent future improperly paid claims.» Health Care Reform passed in March paves the way for additional CMS reviews designed to reduce fraud and abuse: Expands RACs to Medicaid and Medicare Parts C (Medicare HMO, Medicare Advantage Plans) and D (Prescription Drug Program) Repealed sec. 1874A(h) of the SSA which placed limitations on MAC prepayment medical reviews. For Medicare and Medicaid, the HHS estimates improper payments for fiscal year 2008 to represent¹:» $10.4 billion in Medicare Fee-for-Service» $6.8 billion in Medicare Advantage» $18.6 billion for the Federal share of Medicaid expenditures» $14.1 billion for the State share of Medicaid expenditures

4 Audit Landscape Multiple audit entities make a complex process even more complex» Providers can be audited by multiple entities simultaneously Different programs (e.g., Medicaid versus Medicare) Different audit issues (e.g., one-day stays versus post-mortem payments) or Different audit periods Other payers plan to institute similar reviews» National Health Care Anti-Fraud Association states that for every $2 invested in fighting fraud produces $17.3 in recoveries and courtordered judgments, plus there are the claims that are not paid. In today s financial environment, government agencies want to stretch dollars and shore up program funding. What is better than recovering dollars that have already been spent?

5 Audit Landscape RAC Update As of June 3, 2010, over 351 new issues have been approved by CMS and posted to RAC web-sites» Most target DRG validation (complex - medical record requests) CMS RAC 101 Calls (April-May)» Physician Audits CMS project officer reports that physician complex reviews have not started Pending the establishment of medical record request (ADR) limits» Medical Necessity Reviews Providers might see medical necessity reviews within the next month or so, per Scott Wakefield of CMS. We don t have a specific timeframe for it but it will begin soon.

6 Audit Landscape Other Medicare FI/MAC Medicare Administrative Contractors RAC/MAC duo creates a bigger tool box for assuring correct Medicare claims payments ¹» 15 A/B MAC Jurisdictions (9 MACs implemented and processing 65% of national claims volume)» Perform probe reviews (often announced in newsletters), targeted probes, ADR letters, prepayment reviews» Audit Process: Providers must respond to MRR within 30 days; denial occurs day 45» Appeals Process: Same for all Medicare Some of our Audit Management customers have seen an uptick in the number of ADR requests from MAC/FIs

7 Audit Landscape Other Medicare CERT Comprehensive Error Rate Testing contractor» Purpose: To improve the processing and medical decision making involved with payment by intermediary» Audit Process: Providers receive medical record request letter and up to 3 reminders (75 day deadline to respond)» Appeals Process: Same for all Medicare ZPIC Zone Program Integrity Contractor (formerly PSC)» Purpose: To look at billing trends and patterns and refer cases to OIG» Aligned with MACs» Only Zones 4, 5, & 7 have been awarded contracts concentrated in Texas and Plains states, Southeast, Florida» Audit Process: Unknown» Appeals Process: Same for all Medicare

8 Audit Landscape MICs Medicaid Integrity Contractors (MICs)» MICs were created via the Deficit Reduction Act of 2005 GAO estimated that 2008 improper Medicaid payments to exceed $32.7 billion $18.6 billion in federal monies $14.1 billion in state monies» Program is managed by CMS but executed by the MICs» MICs are paid a fee for services rendered (not a contingency fee)

9 Other Payer Audits - MICs Provider Review MICs» Conduct claims data analysis of historical claims to identify billing vulnerabilities & aberrant claims» Review MICs identify high risk areas and provide leads to Audit MICs Audit MICs» Conduct post-payment audits to identify overpayments Field audits (medical records requested for on-site review) Desk audits (medical records requested for off-site review)» Targets: Physicians, Home Health, SNF, Hospice, Hospital, DME, Ambulance, Lab/X-Ray, Pharmacy, Renal Dialysis

10 Other Payer Audits - MICs Audit MICs» Audit MICs are organized by Region Regions I/II (New York, NJ, New England): IPRO Regions III/IV (Mid-Atlantic/Southeast): Health Integrity Regions V/VII (Midwest): Health Integrity Regions VI/VIII (TX, Mountain States): HMS Regions IX/X (West Coast, HI, AK): HMS» As of December 2009, audits were underway in 31 States; Audits in remaining States were to begin no sooner than January Exception: TN to begin June 2010 The majority of audits are hospitals One-third of audits are long term care facilities

11 Summary of RACs vs MICs RACs Provider outreach mandatory Formal process for establishing/ consolidating provider contacts Look-back period set Time to produce medical records - set at 45 days (with possible extensions) Limits established for the number of medical record requests Copy costs reimbursed Cannot audit the same claim under review by another entity Discussion/Rebuttal Period (timelines defined) Appeals process 5 Levels of Appeal consistent across Medicare program MICs Provider outreach not mandatory No formal process for establishing/ consolidating provider contacts Look-back period varies by State Time to produce medical records - generally shorter (with possible extensions) but based on State law No limits established for medical record requests No reimbursement for copy costs Can duplicate other claim audits Comment Period (timeline not defined) Appeals process mirrors state Medicaid appeal process [varies]

12 Audit Management Other Payer Audit Module Configuring Master Files

13 Other Payer Audit Module Master Files» Almost entirely configurable by the user» Intended to provide users with ability to add, edit and delete various data elements that drive the audit process

14 Other Payer Audit Module Master Files Reason for Audit Other Payer» This is entirely configurable by the user and should reflect the primary reasons claims are being audited by the MICs or other payers.

15 Other Payer Audit Module Master Files Other Payer Maintenance» This is entirely configurable by the user. This tool is used to add, edit, and delete Other Payer entities. It populates the Audit Initiated By menu on the Manage Audit Case Screen.

16 MIC Audit & Appeals Process Overview

17 How it Works: MIC Review Process Intake Questionnaire Exit Conference (Audit Findings) Draft Report Issued Comments on Report 2 nd Draft Report Issued No Stated Timelines Notification Letter Request for Med Recs No Limits Minimum of 15 days Submit Med Recs File Extension Deadline varies by State Entrance Conference Desk or Field Audit State Reviews 2 nd Draft CMS Issues Final State Notifies Provider State Recoups From Provider Demand letter From Medicaid Deadline varies by State State Appeal Process

18 Other Payer Audits - MICs Audit MIC Audit Process Overview» Once identified by the Review MIC, the provider is referred to the Audit MIC» Audit MIC sends the provider a Notification Letter identifying the records being requested for audit Provider must respond to requests within stated timeframes in the letter Notification Letter also includes Intake Questionnaire.» Audit MIC sets up Entrance Conference with provider, usually by telephone Providers have 2 weeks prior to the start of an audit to prepare documents

19 Other Payer Audits - MICs Audit MIC Audit Process Overview» Intake Questionnaire Provider must complete Questionnaire and return to the MIC Representative at the Entrance conference or by mail following the Entrance Conference Questionnaire is lengthy and asks for details related to: Provider s legal name Medicaid provider agreement Where is it located? Pharmacy and radiology services Medicaid recipient volume, revenue & reimbursement, Billing procedures, if ever audited or had to pay back an overpayment

20 Other Payer Audits - MICs Audit MIC Audit Findings Process Overview» Audit occurs» Audit MIC shares initial draft report with State Medicaid for review and comment» Audit MIC prepares draft audit report of findings and conclusions and shares with provider for review and comment Provider is given 30 days to comment and submit additional information» CMS prepares second draft incorporating any changes resulting from comments Draft report issued to State

21 Other Payer Audits - MICs Audit MIC Audit Findings Process Overview» State reviews revised draft report and makes additional comments.» CMS issues final audit report (with overpayment specified) and submits to the State» State notifies the provider of overpayments Appeal period begins» Audit MICs do not recoup overpayments Federal government collects its portion directly from State Medicaid State Medicaid recoups its portion from the provider

22 Other Payer Audits - MICs Audit MIC Appeal Process Overview» Provider appeals of MIC audit determinations are handled based on State law» Claims appeals processes differ from Medicare appeals process Some are governed by State s administrative procedures or other specific regulations Some provide opportunity for a Fair Hearing before an ALJ Some provide for review of written record Some must be challenged in State court» Audit MICs support the State during the appeals process

23 Audit Management Other Payer Audit Module Managing an Audit Case

24 Other Payer Audit Module Manage Audit Case» Selection of Other Payer Audits will open the Search Selection screen» The Work Claims option provides worklists based on the audit process and appeal steps.

25 Other Payer Audit Module Manage Audit Case Audit Case Screen Complete the audit case to see how the Menus and Deadline Dates are populated with userconfigured data elements The Audit Initiated By menu provides the list of Other Payers set up from your Master File.

26 Other Payer Audit Module Manage Audit Case Audit Case Screen Select the Audit Initiated Date and enter the date of the Notification Letter. Enter the Letter Receipt Date so you can see how many days it takes for you to receive the Letter. Deadline Dates are automatically populated based on Master File configuration

27 Other Payer Audit Module Manage Audit Case Appeal Deadline days from the Payer Maintenan ce Tool drive the deadline date on the Appeal tab.

28 Audit Management - Summary Helps you manage institutional audit cases and appeals initiated by the MICs, Other Medicaid, Medicare Advantage, Commercial plans Audit & Appeals Management tools include:» Worklists» Audit Case Information and Tracking Audit cases linked to claims & payments for net payment impact calculation: Manual or Automated backload of 837s/835s» Appeal Tracking & Information» Payment Information» Attachments

29 A Comprehensive Audit Solution In addition to the Audit Management solution, Ingenix Consulting provides Audit Support Programs to save you valuable time and resources in the audit and appeal processes. They include:» Audit Process Mapping and Gap Analysis helps ensure that software and workflow are maximized» Risk Assessment of coding and compliance issues help you take proactive steps to prevent losses» Other Audit Services Defense Audit Reviews Mock Audits, Shadow Audits Appeals Support

30 Audit Management Visit for a list of upcoming Audit Management Webinars Contact Information: Carol Endahl Product Manager, Ingenix carol.endahl@ingenix.com Phone: Contact Information: Don P. Perrini Consulting Sales, Ingenix donald.perrini@ingenix.com Phone: Audit Management Solution Audit Support Programs