RAC Audit Strategic Road Map for Leaders

RAC Audit Strategic Road Map for Leaders: Successfully Prevent

& Appeal Denied Claims

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)Presented by:

Elisa Bovee MS OTR/LVice President of Operations

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI) Presented by:

Elisa Bovee, MS OTR/LVice President of Operations

Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 2

RAC Audit Strategic Road Map for Leaders: Successfully Prevent & Appeal Denied Claims

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Agenda

Defense!Audit Triggers and Tools

Contractor Findings/Themes Potential Audit Triggers Medical Record Review Preparedness Audit Tools

Appeal Process; Medicare Denied Claims ADR Management PREP Letter Team Process Appeal Strategies For Success Levels of Medicare Appeals

A Successful ALJ Hearing


Objectives

Learner will be able to summarize SNF Medicare qualifiersLearner will be able to discuss key elements of skilled rehabilitation documentationLearner will be able to articulate Audit TriggersLearner will be able to Summarize the ADR and appeal process


Documenting Medicare Skilled Coverage

Requirements

DEFENSE!!

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Advice from Ben Franklin

Copyright © 2014 All Rights Reserved

“Either write something worth

reading or do something worth

writing.”

“An ounce of prevention is

worth a pound of cure.”

6Harmony Healthcare International, Inc.

Prevention

The key to preventing denials is documentation of skilled services provided The key to documenting skilled services provided is understanding the Medicare requirements for coverage


The Importance of Documentation

The key to ensuring accurate reimbursement for services provided is understanding

skilled coverage requirements


Technical Requirements

Technical requirements are not eligible for appeal—if the patient does not meet technical requirements, their stay will not be coveredResponsibility of the facility to determine if technical eligibility requirements are metThe facility should have a process for determining technical eligibility prior to or immediately upon admission



Beneficiary is enrolled in Medicare Part A and has available daysBeneficiary had a three-day qualifying hospital staySkilled care must begin within 30 days after discharge from a hospital or the last covered Medicare day of a SNF stay



Three-day qualifying stay does not include:

Nights spent in observation status or in an ER bedCan be in different hospitals, but nights must be consecutiveThe day of admission, but not the day of discharge, is counted in the three days


60 Day Wellness

Maintain 60 calendar days without inpatient hospital admissions (ER visits are allowable) and without receiving any skilled services (as defined by Medicare). The litmus test for this break in the spell of illness is to determine whether the services being provided to the resident meet the criteria for a Medicare skilled level of care, if Medicare benefit days were available.


Exhausted Benefit

Patients who have exhausted their Medicare benefits must be reviewed clinically to determine if they continue to meet the guidelines for a Medicare skilled level of careBusiness Office sends a bill to CMS communicating they have dropped in their level of care

Not automaticNot based on Diagnosis


Physician Certification

Physician Certification FrequencyAdmission14th DayEvery 30 Days (from last certification)

Addresses all skilled qualifiersRehabNursing


Additional Certifications to Support

Therapy CertificationPlan of Treatment/CareFrequency of ServicesPlanGoalsPhysician Involvement

Therapy Physician OrdersEvaluation Treatment clarification


Clinical (Level of Care) Requirements

The patient requires physician-ordered skilled nursing or rehabilitation services that relate to the hospital stay or a condition that arose while receiving post-hospital careThe services are provided on a daily basisAs a practical matter, the services must be delivered in the SNFThe services are reasonable and necessary for treatment of the illness/injury


Medicare Manual Source Document

Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance (Rev. 175, 12-06-13) Effective 1/7/14


Medicare Coverage/Skilled Care

Provided on a “daily” basis:Skilled nursing (or combination of nursing and rehabilitation) must be seven days per weekSkilled restorative nursing must be at least six days per weekRehabilitation (PT, OT and/or SLP) must be at least five days per week

An isolated break of “a day or two” is allowable


Chapter 8 Medicare Manual (2014) Rehabilitation Daily

Single type of skilled rehabilitation every day, or by furnishing various types of skilled services on different days that collectively add up to “daily” skilled services. “Arbitrarily staggering the timing of various therapy modalities though the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a “daily basis.” To meet this requirement, the patient must actually need skilled rehabilitation services to be furnished on each of the days that the facility makes such services available “Copyright © 2014 All Rights Reserved 19Harmony Healthcare International, Inc.

What is Skilled Care?

Nature of service requires the skills of a licensed person (e.g. technical or professional personnel)Skilled services are provided directly by or under general supervision of a licensed nurse or therapist to assure the safety of the patient and to achieve the medically desired resultDiagnosis and prognosis do not determine what is skilled care – it is the care of the patient that is the deciding factor


“Practical Matter” Criterion

“As a practical matter, considering economy and efficiency, the daily skilled services can only be provided in a skilled nursing facility”



1.Outpatient services are not available in the area where the individual lives

2. Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective than placement in the skilled nursing facility



3.The availability at home of a capable and willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/patient to reside there safely

4.If the use of alternative services would adversely affect the patient/patient’s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis


Basic Medicare Requirements

If any one of these three factors is not supported by the documentation in the patient’s record, the SNF stay, even though it might include the delivery of daily skilled services, will not be covered.


RUG-IV

Resource Utilization GroupsEach MDS qualifies for multiple RUGs, and the software automatically chooses the highest reimbursement rateRehabilitation Intensity, Diagnoses, Nursing Services, and ADLs all contributeDocumentation must support all coding on the MDS 3.0 assessment


Presumption of Coverage

Medicare beneficiaries who are correctly assigned to one of the upper 52 RUG-IV groups on the initial 5-Day, Medicare required assessment are automatically classified as meeting the SNF level of care definition up to and including the assessment reference date on the 5-day Medicare-required assessment

Only applies when admitted from Acute Care Hospital (Not Swingbed or another SNF)Copyright © 2014 All Rights Reserved 26Harmony Healthcare International, Inc.


This presumption recognizes the strong likelihood that beneficiaries assigned to one of the upper 52 RUG-IV groups during the immediate post-hospital period require a covered level of care, which would be less likely for those beneficiaries assigned to one of the lower 14 RUG-IV groups



This administrative presumption policy does not supersede the SNF’s responsibility to ensure that its decisions relating to level of care are appropriate and timely, including a review to confirm that the services prompting the beneficiary’s assignment to one of the upper 52 RUG-IV groups


Totality

While it is true that dialysis is one of the discrete indicators for assignment to a RUG within the Special Care Low category – a category to which the level of care presumption applies for a short period of time at the start of a SNF stay – it is the totality of items and services included within a given RUG, not any one specific coded service, that actually serves to justify the presumption


What is Skilled Care ?

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


What is Skilled Care?

Nursing Anchors the SkillNeed to remain in a SNFMedical Complexity

Supports Non-Therapy RUG

Increased potential Lower 14 and reviews with October 1st Changes


Skilled Services Categories: Nursing Inherent Complexity

Inherent Complexity – Direct skilled nursing services including:

IV feedingIV medsSuctioningTracheostomy CareVentilator supportUlcers


Skilled Services Categories: Nursing 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


Observation and Assessment

Skilled services when the likelihood of change in a patient’s condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures, until the patient’s condition is essentially stabilized. Reasonable potential for a future complication or acute episode sufficient to justify the need for continued skilled observation and assessment.



Example (from Chapter 8 of the Medicare Benefit Policy Manual): A patient has been hospitalized following a heart attack, and following treatment but before mobilization, is transferred to the SNF



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



The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the stabilization of the patient's medical condition and safety (Effective 1/2014).



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



FeverDehydrationSepticemiaPneumoniaNutritional Risk

ChemotherapyWeight lossBlood sugar controlImpaired cognitionSevere Mood and Behavior conditions



NeurologicalRespiratoryCardiacCirculatoryPain/Sensation

NutritionalGastrointestinalGenitourinaryMusculoskeletalSkin


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


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 Rehabilitation OverviewDirectly related to a written plan of treatment.Requires knowledge/skills/judgment of qualified professional.Services must be considered under acceptable standards of clinical practice.Expectation of improvement of restorative potential in a reasonable and predictable amount of time…or…Establishment of a safe and effective maintenance program. 43Harmony Healthcare International, Inc.


Medicare Benefit Policy

The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist.

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Maintenance Therapy

Maintenance Therapy. The repetitive services required to maintain function sometimes involve the use of complex and sophisticated therapy procedures and consequently, the judgment and skill of a physical therapist might be required for the safe and effective rendition of such services (see §214.1.B). Must be necessary for the establishment of a safe and effective maintenance program; or, the services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program (Effective 1/2014).


Maintenance Therapy

Therapy services in connection with a maintenance program are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) If all other requirements for coverage under the SNF benefit are met, 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 are necessary for the performance of a safe and effective maintenance program.


Jimmo v. Sebelius

The Jimmo v. Sebelius lawsuit was brought on behalf of a nationwide class of Medicare beneficiaries by six individual Medicare beneficiaries and seven national organizations representing people with chronic conditions The Jimmo v. Sebelius case challenged Medicare's use of an "Improvement Standard" to make coverage determinations


Jimmo v. Sebelius

On January 24, 2013, a settlement was approved by the federal district court in Vermont in the case of Jimmo v. Sebelius regarding the "Improvement Standard" Addresses the ability to terminate or deny coverage to beneficiaries who are not improving for Medicare Part A and Part B


Jimmo v. Sebelius

Expands Medicare Part A and Part B coverage to include the rendering of skilled nursing and therapy services necessary to maintain a person's condition and is not dependent on whether the Medicare beneficiary will ". improve“. CMS Fact Sheet States this is simply a clarification


Jimmo v. Sebelius

The judgment indicates that as long as a patient requires skills of a therapist or a nurse a patient would meet skilled coverage criteria despite not making functional gainsDocumentation must support the need for skilled therapy intervention


Skills of a Therapist or a Nurse

Must require, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist or a nurse that qualified personnel, trained caretakers or the patient cannot provide independently


Skilled Nursing Documentation What To Consider Including

Patient is at high risk for …Skilled assessment of …Daily skilled monitoring of …Potential for recurrence of …Potential for the following complications…There is a likelihood of change related to…The medical regimen is not essentially stabilized as evidenced by…Copyright © 2014 All Rights Reserved 52Harmony Healthcare International, Inc.


Patient continues to require daily skilled rehab for …Observation and assessment for potential complications related to …Potential for medical complications related to the diagnosis of …Plan of care is being monitored to promote recovery and ensure medical safety related to …The patient requires daily skilled management and evaluation of the plan of care related to …



Skilled neurological assessment resulted in…Daily skilled monitoring for signs and symptoms of exacerbation of _____ secondary to _______Patient is high risk for ______ secondary to _______Medications adjusted to _____________, ongoing skilled assessment of regimen to promote recovery and ensure medical safetyPatient continues to require daily skilled nursing as his treatment regimen is not essentially stabilized and there is a potential for recurrence of ________


Non-Supportive Nursing Documentation

Plateau in progressVoiced no complaintsPatient requires custodial carePatient requires intermittent carePatient is unable to follow directionsPatient requires intermittent services

Patient has poor rehabilitation potentialPatients medical treatment is essentially stabilizedRefuses to participate in therapy (instead give the reason the patient is unable)Condition stableSlept well/family into visit


UB-04Pulling It All Together

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UB-04 Diagnosis

Does it all work together?Physician CertificationsMDS Diagnoses (Section I)Skilled Nursing DocumentationTherapy ICD-9 CodingSkilled Therapy DocumentationUB-04


UB-04

Submitted by the SNF to the MAC Multipurpose form used for all Medicare providersNot all fields pertain to the SNF


FL 66 – 69

FL 66 – 68 ICD-9 CodesPrinciple Diagnosis goes in FL 67, secondary codes to followSequentially ordered by importance (top 5)

FL 69 = Admission Diagnosis ICD-9


Code Order

Codes should be ordered according to most skilled to least skilled need.The top 5 codes are the most vital to have ordered appropriately.ICD-9 coding is one way auditors select records to review.


Principle Diagnosis

Governed by the condition chiefly responsible for the admission to the SNF and that is primarily responsible for the need for skilled services. This may or may not be the same as the Admission Diagnosis.


Principle Diagnosis

It is not acceptable to use acute care conditions as the Principle Diagnosis. For example, the facility would not want to use CVA (435.9), they would use the Late effects of cerebrovascular disease codes that start with 438.xx.


Principle Diagnosis

When the reason for skilled care is Rehabilitation Services, codes from the V57.xx category are appropriate.The condition therapy is treating should be listed as an additional diagnosis.

Parkinson’s Disease (332.x)Lack of coordination (781.3)Abnormality of gait (781.2)


Rehabilitation Diagnosis

Medical diagnosis supports deficits identified on evaluation being treatedReported on the UB-04. What is the process between therapy and billing?Ensure chronic codes that are not related are not used

DementiaUTI

Only a Therapist can DetermineNot always the “first code” in Discharge Summary or Face sheetMay need to request Physician Clarification (e.g. Dysphagia)


Rehabilitation Diagnosis

Indicate the Medical DX that has resulted in the therapy disorder.

Relate to the current plan of care for therapy.Represent the most intensive services (over 50% of the revenue code billed)Relevant to the problem to be treated E.g. O.A. with treatment diagnosis of “pain in the joint” or “difficulty walking”


Sometimes have to dig!

Psychiatric hospitalizations can be difficult to code. Remember Principle and Admission don’t have to be the same diagnosis.Recent RAC audits for psych diagnosis reveal a number of additional diagnoses treated during hospitalizations:

Pneumonia, Dysphagia, Pressure Ulcers, Cardiac Episodes, Hypotension, Dehydration, Malnutrition, UTI, MRSA, and Extrapyramidal Disease.


Key Point!

The ICD-9 Coding needs to tell the story of the skilled services in the SNF.Needs to tell the story behind the RUG score and make sense with the RUG billed.DO include the necessary ICD-9 codes to support skill and DO NOT to include unrelated codes (e.g. Chronic Codes).Beware! A code for Personality Disorder with an RUC – High Risk to get reviewed!


Audit Triggers and Tools



HEALTHCARE CORRUPTION

Harmony Healthcare International

OIG Investigation


Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 71Harmony Healthcare International, Inc. 71

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 © 2014 All Rights Reserved Harmony Healthcare International, Inc. 73Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 73

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


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.

Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 77Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 77

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


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.

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OIG Report: Part B

OIG REPORTQuestionable Billing for

MedicareOutpatient Therapy Services

Medicare Part B


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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



Background

Medicare 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


Background

Identified 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


Background

Six 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


Findings

Medicare 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.


Background

Physical 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.

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 © 2014 All Rights Reserved Harmony Healthcare International, Inc. 92



Recovery Audit Contractors



The Recovery Auditors Program Mission The Recovery Auditor detect and correct past improper payments so that CMS can implement actions that will prevent future improper payments: Providers can avoid submitting claims that do not comply with Medicare rules CMS can lower its error rate Taxpayers and future Medicare beneficiaries are protected.



If you bill fee-for-service programs, your claims will be subject to review by the Recovery Auditors.


Recovery Audit ContractorsThe Recovery Audit Review Process:

Recovery Auditors review claims on a post-payment basisRecovery Auditors use the same Medicare policies as Carriers, FIs and MACs: NCDs, LCDs and the CMS ManualsThree types of review:

Automated (no medical record needed)Semi-Automated (claims review using data and potential human review of a medical record or other documentation)Complex (medical record required)

Recovery Audits look back three years from the date the claim was paid Recovery Auditors are required to employ a staff consisting of nurses, therapists, certified coders and a physician CMD



The appeal process for Recovery Audit denials is the same as the appeal process for Carrier/FI/MAC denials Do not confuse the “Recovery Audit Programs’ Discussion Period” with the Appeals process If you disagree with the Recovery Auditor’s determination:

Do not stop with sending a discussion letter File an appeal before the 120th day after the Demand letter.



Recovery Auditors will offer an opportunity for the provider to discuss the improper payment determination with the Recovery Auditors (this is outside the normal appeal process)



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 Reasons

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

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


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

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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



Skilled Interventions

Medicare will support continued services when the patient is not making progress if there is documentation that multiple skilled interventions have been trialedIt is appropriate to give each trial an adequate amount of time to determine if the patient will progress

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 113Harmony Healthcare International, Inc.Copyright © 2014 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


Documentation to Support Identified Risk Areas

Identify potential denial risk areasWhat might the reviewer have not seen in the documentation provided to lead the reviewer to deny services?

What additional documentation may be included to further support skilled Rehabilitation and Nursing services provided? Consultations/ED VisitsCare PlanPhysician Progress NotesSocial Services/Dietary Notes


Appeal Process


Appeal Rights


Appeal Rights

Right to Appeal:If the Beneficiaries is the only one with the right to appeal given specific situations, provider must obtain transfer from beneficiaryBeneficiaries may transfer appeal rights to providers who provide the items or services and do not otherwise have appeal rights Form CMS-20031 must be completed and signed by the beneficiary and supplier to transfer the beneficiary’s appeal rights


Appeal Rights

Right to Appeal All appeal requests must be made in writing


Appeal RightsMedicare offers five levels in the Part A and Part B Appeals Process:1. Redetermination by a MAC2. Reconsideration by a QIC3. Hearing by an Administrative Law

Judge (ALJ)4. Review by the Medicare Appeals

Council, within the Department Appeals Board

5. Judicial review in U.S. District Court


Appeal RightsRedetermination

A review of the claim by the MAC utilizing personnel who are different from the personnel who made the initial determinationThe appellant (individual filing the appeal) has 120 days from the date of receipt of initial denial to file an appealA minimum monetary threshold is not required to request a redetermination


Appeal Rights

ReconsiderationIf the facility is dissatisfied with result of redetermination, they may request a reconsiderationA Qualified Independent Contractor (QIC) will conduct the reconsiderationThe reconsideration process is an independent review of medical necessity by a panel of physicians or other health care professionalsA minimum monetary threshold is not required to request a reconsideration


Appeal Rights

ALJ HearingIf at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsiderationThe facility must also send a notice of the ALJ hearing request to the QIC and verify this on the hearing request form or in the written request



The Appeal


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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


Additional Development Requests



Medicare Contractors send providers additional development request (ADR) letters requesting additional documentation The ADR letters will be mailed and /or the claim in question will be in status location S B6001 that identifies claims in FISS that are in an ADR status/location



Do not submit replacement/duplicate claims for the ones pending in medical reviewThe submission of replacement/duplicate claims will result in claim denial, rejection or recoupmentThis will p r o l o n g the medical review process Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 132


When the claim is finalized, the claim will have paid in full or part, or denied If you disagree with the decision, you can request a redetermination/1st level of appeal within 120 days of the determination (date on the remittance advice)



After the 45th day, if the documentation needed to make a medical determination is not received, the claim may be denied as records not received timely and these claim denials are issued with Remittance Advice Code N102/56900



CMS guidelines allow contractors the time frame of 60 days to complete the review from the date on which the last of the requested medical records is received



ADR ResponseAnd

Appeal Packages


The Appeal

In order to effectively manage a Medicare denial, the facility must work as a team to gather pertinent informationAssign a team leader to oversee the preparation of the denial packageAll members of the team should review the medical record to ensure completeness


The Appeal

The following team members are beneficial in this process:

MDS CoordinatorDirector of Nursing

Unit Managers (consider)

Restorative Nursing program ManagerDirector of Therapy

Any therapy professionals involved in the patient’s care

Social ServicesDietaryAdditional team members who participated in care Harmony Healthcare International, Inc. 138Copyright © 2014 All Rights Reserved

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 listed in the ADR/decision statement to include in the medical record

Consider additional info not listed that will support the services provided


ADR/Help Letter Checklist


HELP LETTER REVIEW CHECK LIST Period Skilled Nursing Chart Review: From: __________________ To: _________________ Medicare Admission Date: ___________ Diagnosis: ________________________________

MDS Reference Dates Review

5 day 14 day 30 day 60 day 90 day

SOT/EOT OMRA

ARD Billing Dates

RUG/HIPPS

COT COT COT COT COT COT ARD Billing Dates

RUG/HIPPS

ICD-9 Codes __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The Appeal Package

List of items typically requested:Initial MDS and any MDS that corresponds to the billed dates of service and look backAll physician documentation for dates of service in question

Physician’s orders MD certifications MD progress notesHistory and Physical


The Appeal Package

Important to know the consequences if the facility does not submit all necessary paperwork

Facility needs to review the packet carefully to avoid a technical denial based on missing information including signatures


The Appeal Package

Each team member should review the package as a wholeThe team leader should have a final look prior to submitting the appealPREP Letter

Proper Reimbursement Explanation Paper

Always keep a copy of the packet sent to the reviewing agencyHarmony Healthcare International, Inc. 143Copyright © 2014 All Rights Reserved

Appeals Process

PREPInclude a statement of position letter with the medical record documentation to the reviewing agency explaining the services provided to the patient


Monitor the Appeal


Monitor the Appeal

Internal tracking system to monitor

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



Redetermination and

Reconsideration


Redetermination and Reconsideration

If a claim is initially denied, there is action the facility can takeThe first stage is the RedeterminationThe next step is a Reconsideration


Redetermination

An examination of a claim by a review agency who is different from the agency who made the initial determinationThe facility has 120 days from the date of receipt of the initial claim determination to file an appealA minimum monetary threshold is not required to request a determinationHarmony Healthcare International, Inc. 149Copyright © 2014 All Rights Reserved

Redetermination

Request for redetermination may be filled on Form CMS-20027 available at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp#TopOfPage


http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp

http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp

Redetermination

Requests not made on Form CMS-20027 must include:

Beneficiary nameMedicare Health Insurance Claim (HIC) numberSpecific service and/or items(s) for which a redetermination is being requested.Specific date(s) of service


Redetermination

Requests not made on Form CMS-20027 must include

Name and signature of the party or the representative of the party (Usually the administrator of the building)The name and address of the facility


Redetermination

Include an appeal letter that outlines the argument for coverage

Brief explanation of the hospitalization (if one occurred)Past medical historyStatus of patient on admissionList of the skilled nursing services provided to the patient


Redetermination

Appeal Letter An explanation of skilled therapy services provided to the patientMedicare guidelines used in the skilled care decision making process, if applicable


Redetermination

Any additional supporting documentation not submitted during the Help letter phase from the medical record should be submitted along with the redetermination request

HighlightAdd sticky tabs

The redetermination request should be sent to the contractor that issued the initial determination


Redetermination

Contractors will generally issue a decision within 60 days of receipt of redetermination request in the form of :

A letterA Medicare Redetermination Notice (MRN)Revised remittance advice


Reconsideration

If the request for redetermination results in a denial, a reconsideration can be requestedA QIC will conduct the reconsideration requestThe QIC reconsideration process allows for an independent review of medical necessity by a panel of physicians or other health-care professionsA minimum monetary threshold is not required to request a reconsideration


Reconsideration

A written reconsideration request must be filed within 180 days of receipt of the redeterminationInstructions are provided on the Medicare Redetermination Notice (MRN)A Request for reconsideration may be made on Form CMS-20033. This form will be mailed with the MRN Harmony Healthcare International, Inc. 158Copyright © 2014 All Rights Reserved

Reconsideration

If Form 20033 is not used, request must contain:

Beneficiary nameMedicare Health Insurance Claim (HIC) numberSpecific service(s) and/or item(s) for which the reconsideration is requestedSpecific date(s) of service


Reconsideration

Documents to include Name and signature of the party or the representative of the party (usually the administrator of the building)Name of the contractor that made the determinationName and address of the facility


Reconsideration

Include a letter outlining the argument for paymentThe request should clearly explain why the facility disagrees with the redeterminationA copy of the MRN, and any other supportive documentation, should be sent with the reconsideration request to the QIC identified in the MRN Harmony Healthcare International, Inc. 161Copyright © 2014 All Rights Reserved

Reconsideration

Reconsiderations are conducted on-the-record; and in most cases, the QIC will send its decision to all parties within 60 days of receipt of the re quest for reconsiderationThe decision will contain detailed info on further appeal rights if the decision is not fully favorable


Reconsideration

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


A Successful ALJ Hearing


ALJ Overview

After the redetermination and reconsideration process, if at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsiderationThe facility must send a notice of the ALJ hearing request to the QIC on the hearing request form or in the written request


ALJ Overview

A letter to request the ALJ hearing should simply highlight the most pertinent reasons justifying payment


ALJ Overview

ALJ hearings are generally held by video-teleconference (VTC) or by telephoneIf the facility prefers not to have a VTC or telephone hearing, they may ask for an in-person hearing, but they must demonstrate the necessity for an in-person hearing


ALJ Overview

The ALJ will determine whether an in-person hearing is warranted on a case-by-case basisFacilities may also ask the ALJ to make a decision without a hearing (on-the-record).CMS or its contractors may participate in an ALJ hearing, but they must provide notice to the ALJ and all parties of the hearing


ALJ Overview

ALJ will generally issue a decision within 90 days of receipt of the hearing requestThe timeframe may be extended for a variety of reasons including, but not limited to:

The case being escalated from the reconsideration levelThe submission of additional evidence not included with the hearing requestThe request for an in-person hearingThe facility’s failure to send notice of the hearing request to other parties andThe initiation of discovery if CMS is a party


ALJ Overview

If the ALJ does not issue a decision within the applicable timeframe, you may ask the ALJ to escalate the case to the Appeals Council level


ALJ

Hearing Preparation


ALJ

Office of Medicare Hearings and Appeals (OHMA)Administrative law judge hearings will not be assigned to a judge for at least two yearsOMHA stopped assigning new hearing requests from providers as of July 15, 2013The weekly influx of hearing requests surged from an average of 1,250 in January 2012 to more than 15,000 in December 2013Medicare Appellant Forum to provide updates to OMHA appellants on the status of OMHA operations http://www.hhs.gov/omha/omha_medicare_appellant_forum.htmlCopyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 172

http://www.hhs.gov/omha/omha_medicare_appellant_forum.html



ALJ Hearing Preparation

Appeal ProcessDiscuss and study CMS GuidelinesDiscuss type of ALJ hearing (video, phone, in person) to anticipate the format

Goals of the HearingInform the Judge of skilled servicesGet the claim paidHarmony Healthcare International, Inc. 173Copyright © 2014 All Rights Reserved

ALJ Hearing Preparation

Team PreparationMedical record reviewOutline of speaking pointsSelect a point person for the hearing

Team input


ALJ Hearing

Hearing ProcessPrepare the facility designated hearing room for video or phone hearingsJudge’s assistant will initiate the phone contact (test phone lines and speakers)IntroductionsStatement by facilityOffer to fax any pertinent documents discussed during the hearingHarmony Healthcare International, Inc. 175Copyright © 2014 All Rights Reserved

ALJ Hearing

Organize documentation Keep pertinent notes or forms at your finger tipsNumber the pages for referenceHave the staff that worked with patient on the callSpeak respectfully, clearly, slowlyProvide a concise summary


ALJ Hearing

Be prepared to answer questions prepared by the Judge

Why did the patient require skilled therapy when they were hospitalized for a UTI?Where does the medical record state that continued therapy services were necessary after the initial date in question?Explain why skilled care continued although the notes indicate the patient did not have an exacerbation of medical condition?


ALJ Hearing

Be prepared to answer questions asked by the Judge

When did the patient get discharged from therapy services? Why do the daily nursing notes state the patient was ambulating ad lib, yet physical therapy continued to provide skilled treatment?Harmony Healthcare International, Inc. 178Copyright © 2014 All Rights Reserved

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. 179Copyright © 2014 All Rights Reserved

Keys to Success

Provide clinically appropriate careDocument

Medical necessityDeficitsOutcomes

Meet technical requirementsReview entire medical recordRespond to ADRs timely


Harmony Healthcare International, Inc. 181

Upcoming webinars…

Top 5 Ways to Prevent Falls January 28, 2014 1:00 p.m. – 2:00 p.m.

Medicare Skilled Nursing Documentation February 20, 2014 1:00 p.m. – 2:00 p.m.

Medicare Rehabilitation Documentation February 25, 2014 1:00 p.m. – 2:00 p.m.

Rehabilitation in a SNF Setting: Skilled Medicare Coverage Criteria

March 20, 10:00 a.m. – 11:00 a.m.


Questions/Answers

Harmony Healthcare International1 (800) 530 – [email protected]

Harmony Healthcare International, Inc. 182182Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc.

http://www.harmony-healthcare.com/

http://www.harmony-healthcare.com/

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Harmony Healthcare InternationalHave you Considered a Customized Complimentary

HARMONY(HHI) MEDICARE PROGRAM EVALUATION

or CASE MIX ANALYSIS

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norms

Email us at for more [email protected]

Analysis is cost & obligation freeHarmony Healthcare International, Inc. 183Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc.

