Presented by: Anne B Mattson, RN, MSN. Teresa Mack. Director Regulatory and Compliance. Director Revenue Cycle Management

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1 Minimize Reimbursement Risks: Keys to Developing a Successful Compliance Audit Program for Billing Presented by: Anne B Mattson, RN, MSN Director Regulatory and Compliance Teresa Mack Director Revenue Cycle Management Transpirus

2 Objectives Discuss the reasons for implementing a billing compliance audit program and how to begin this process. Describe the key elements in creating a successful billing compliance audit team. Explain the key steps in developing a billing compliance audit tool and process, including determination i of potential ilrisk ikand implementation i of specific action steps to identify potential areas of risk. 3 3 Program Focus This program focuses on how to design and implement a hospice billing compliance audit process. A properly constructed billing compliance program includes a combination of processes and measures that ensure the acceptance of patients and submission of billings within Medicare coverage guidelines. With increased oversight and scrutiny in hospice, comprehensive compliance strategies are essential to operational safety and success

3 Overview of Current Hospice Regulatory and Compliance Environment Increased ceasedscrutiny OIG Work Plan RAC Approved Issues New guidelines Examples of current fraud cases and effects of compliance scrutiny 5 5 Ongoing Focus on Medicare Fraud and Abuse Means Increased Scrutiny for Hospices Medicare Administrative Contractors (MACs) Recovery Auditor Contractors Program Safeguard Contractors Zone Program Integrity Contractors Comprehensive Error Rate Testing (CERT) review Contractors Other governmental organizations, such as the Office of Inspector General 6 6 3

4 OIG Work Plan Hospices 2012 Hospice Marketing Practices and Financial Relationships with Nursing Facilities (New) Will review hospices marketing materials il and practices and their hi financial relationships with nursing facilities OIG found that 82 percent of hospice claims for beneficiaries in nursing facilities did not meet Medicare coverage requirements Medicare Hospice General Inpatient Care Will review the use of hospice general inpatient care from 2005 to 2010 Will assess the appropriateness of hospices general inpatient care claims Will assess hospice beneficiaries drug claims billed under Part D. Will review if this level of hospice care is being misused and to determine the extent to which drugs are being inappropriately billed to Part D. 7 7 OIG Work Plan Hospices 2013 Marketing Practices and Financial Relationships withnursing Facilities Will review hospices marketing materials and practices and their financial relationships with nursing facilities General Inpatient Care Will review the use of hospice general inpatient care in 2011 Will also assess the appropriateness of hospices general inpatient care claims. Will review hospice medical records to address concerns that this level of hospice care is being misused 8 8 4

5 RAC Issues Connolly, the Recovery Audit Contractor for Region C issued its first hospice specific specific RAC audit in Feb 2013 The audit will determine whether hospice providers are billing with CBSA codes (from the hospice wage index each year) that are invalid or no longer in use. HDI, the Recovery Audit Contractors (RAC) for Region D, posted in May 2013, an approved issue for hospice providers The complex audit will focus on whether a face to face encounter occurred when a patient was recertified for hospice. 9 9 Changes in the RAC Program A recently announced change for RACs is that CMS will have recovery auditorsin in all four geographical RACregions, as currently configured, with a fifth nationwide RAC responsible for identifying overpayments among home health, hospice facilities and durable medical equipment (DME). The contract for a national RAC for DMEPOS, home health and hospice claims is scheduled to become active in early 2014 and run through

6 Headlines in the News Largest For Profit Hospice Provider Sued by DOJ for Medicare Fraud May 6, 2013 Slowly Dying Patients, An Audit And A Hospice's Undoing Jan 16, 2013 San Diego Hospice Files For Bankruptcy February 7, 2013 Hospice Self Reports False Claims Act Violations, i Repays $10M+ December 13, New Guidelines Coding Monthly Billing Requirements with sequential Billing Rules regarding Contracts with Nursing Facilities

7 New Guidelines Coding CMS expects that hospices not use debility and adult failure to thrive as the primary diagnosis on hospice claims effective immediately Dementia is be coded according to coding conventions New Guidelines Monthly Billing Requirement Medicare requires hospices to submit their claims in sequential (calendar month) order (admit through discharge/death) If a subsequent claim is submitted before the prior claim is finalized, it will be suspended (sent to the Return to Provider (RTP) file) New claims system (FISS) edit effective 7/1/13 Enforces the monthly billing requirements for all hospice claims: Date span on claim must correspond to the calendar month for all active patients Date span on claim cannot span multiple months If a claim does not meet these requirements it will be suspended (sent to the RTP file)

8 New Guidelines Contracts with Nursing Facilities On June 27, 2013, the Centers for Medicare & Medicaid Services (CMS) published, in the Federal Register, a final rule requiring long term care facilities skilled nursing facilities (SNFs) and nursing facilities (NFs) that choose to arrange for the provision of hospice care with one or more Medicarecertified hospices, to enter into written agreements Recommendations for Hospice Compliance Programs ACA mandated providers implement a compliance and ethics program Dates for Hospice Implementation not determined Strongly recommend that Hospices voluntarily implement compliance program OIG published Guidelines for Hospice Compliance Programs in

9 Per OIG Comprehensive Hospice Compliance Programs Should Include: Implementing written policies, procedures and standards of conduct procedures Designating a compliance officer and compliance committee Conducting effective training and education Developing effective lines of communication (i.e., hotline or other reporting system) Enforcing standards through well publicized disciplinary guidelines Conducting internal monitoring and auditing Responding promptly to detected offenses and developing corrective action Reasons for Implementing Internal Monitoring as Part of a Compliance Program: Comply with component of compliance programs to monitor for non compliance Identify coverage issues prior to filing claim Submit compliant claims Monitor level of compliance with new requirements Proactively identify potential compliance issues

10 Developing the Audit Team and Program Determining subject matter experts Have the qualifications and experience necessary to adequately identify potential issues with the subject matter that is reviewed Be objective and independent of line management to the extent reasonably possible Have access to existing audit and health care resources Present written evaluative reports Specifically identify areas where corrective actions are needed OIG Identified Compliance Risk Areas Admission/Discharge Practices Uninformed consent to elect the Medicare Hospice Benefit Admitting patients to hospice care who are not terminally ill Pressure on a patient to revoke the Medicare Hospice Benefit when the patient is still eligible for and desires care, but the care has become too expensive for the hospice to deliver

11 OIG Identified Compliance Risk Areas Nursing Homes Overlap in the services that a nursing home provides, which results in insufficient care provided by a hospice to a nursing home resident Improper relinquishment of core services and professional management responsibilities to nursing homes, volunteers and privately paid professionals Providing hospice services in a nursing home before a written agreement has been finalized, if required OIG Identified Compliance Risk Areas Marketing Hospice incentives to actual or potential referral sources (e.g., physicians, nursing homes, hospitals, patients, etc.) that may violate the anti kickback statute or other similar Federal or State statute or regulation, including improper arrangements with nursing homes High pressure marketing of hospice care to ineligible beneficiaries Improper patient solicitation activities Sales commissions based upon length of stay in hospice

12 OIG Identified Compliance Risk Areas Billing Practices Billing for a higher level of care than was necessary Knowingly billing for inadequate or substandard care Billing for hospice care provided by unqualified or unlicensed clinical personnel False dating of amendments to medical records Knowing failure to return overpayments made by Federal health care programs. Improper indication of the location where hospice services were delivered OIG Identified Compliance Risk Areas Clinical Under utilization Inadequate or incomplete services rendered by the Interdisciplinary Group Insufficient oversight of patients, in particular, those patients receiving more than six consecutive months of hospice care Failure aueto comply with applicable requirements e e for verbal eba orders for hospice services Non response to late hospice referrals by physicians Deficient coordination of volunteers

13 OIG Identified Compliance Risk Areas Other Potential Fraud Issues Untimely and/or forged physician certifications on plans of care Knowing misuse of provider certification numbers, which results in improper billing Failure to adhere to hospice licensing requirements and Medicare conditions of participation Inadequate management and oversight of subcontracted services, which results in improper billing Falsifiedmedicalrecords or plans of care Arrangement with another health care provider who a hospice knows is submitting claims for services already covered by the Medicare Hospice Benefit Determining the risk areas that need to be audited in your agency Prior history of non compliance Designing to address the agency s compliance with: Medicare Coverage criteria and rules and regulations Coverage criteria Laws governing kickback arrangements Physician self referral prohibition Claim development and submission, reimbursement, and marketing Summarizing Data Determining reasons for deviations from requirements Reporting and follow up on potential over payments

14 What is a Clean Claim? Notice of Election (NOE) Filed Valid Certification of Certification of Terminal lillness Face to face (for 3 rd benefit period) Coverage criteria met All system edits cleared Notice of Election (NOE) The hospice agency must file the Notice of Election (NOE) withitsmedicareadministrativecontractor its (MAC) The NOE must be finalized in the MAC s claims processing system (FISS) before the hospice agency can submit its first claim

15 Certification of Terminal Illness (CTI) The Certification of Terminal Illness (CTI) applies to each benefit period The patient must be certified he/she has a life expectancy of six months or less For the first 90 day benefit period, the hospice medical director (or the physician who is a member of the interdisciplinary team) and the patient s attending physician, if applicable, must certify the patient Nurse practitioners are not allowed to certify the patient s life expectancy Certification of Terminal Illness (CTI) The hospice must obtain verbal or written certification of the terminal illness, no later than 2 calendar days (by the end of the third day) after the start of each benefit period (initial and subsequent). Initial certifications may be completed up to 15 days before hospice care is elected. Recertifications may be completed up to 15 days before the start of the next benefit period. The hospice agency cannot submit any claims until the certification/recertification is signed and dated dby the physician(s) i If the certification/recertification is not done timely, the days of care that are not covered are reported on the claim under occurrence code

16 Certification of Terminal Illness (CTI) For all subsequent benefit periods, only the hospice medical director (or the physician who is a member of the interdisciplinary team) must certify the patient The CTI must include a narrative from the physician The narrative must support the life expectancy of six months or less, and it must include an attestation statement Face to Face Encounter (F2F) F2F encounter is required for: Any patient t entering his/her 3 rd benefit period F2F encounter must be conducted by: A physician employed/contracted by or a volunteer of the hospice agency A nurse practitioner employed by the hospice agency TheF2F encounter must be conducted no morethan 30 days prior to the start of the 3 rd benefit period and every benefit period thereafter

17 Face to Face Encounter (F2F) If the F2F is not done timely: the hospice must discharge the patient continue to provide care to the patient at its own expense, until the F2F encounter is completed appropriately and the hospice is able to readmit the patient The patient must also complete a new election statement Pre Billing and Post Billing Audits Pre Billing Include technical and clinical i l 100% review of NOE, CTI and F2F Post Billing To determine if all requirements were met Determine sampling methods for audits

18 Pre Billing Audits Clinical Admission criteria does patient meet criteria for terminal illness? IDG Meets timely and documents individualized plan Documentation supports level of care provided Content of CTI supports terminal condition and documentation supports were obtained timely Other Possible Focused Audits Marketing Practices OIGChecksfor ExcludedProviders Relationships with SNFs Patients receiving services in nursing homes Pharmacy charges DME Provisions Hospice Physician i Billing Practices

19 Summarizing Data Determine reasons for deviations from requirements Implement tcorrective Action Ati Plan Responding to Non Compliant Claims Determine reasons for deviations from requirements Correct prior to submitting claim li Adjusting individual claims Watch effect on sequential billing Follow instructions when face to face encounter not conducted timely Reporting and follow up on potential over payments

20 Resources OIG s Compliance Guidance for Hospice Providers (1999) Medicare and Medicaid Programs; Requirements for Long term Care Facilities; Hospice Services /pdf/ pdf

21 If you would like to learn more about how Transpirus can help you minimize survey risk and improve regulatory compliance for your agency, please contact us at: or

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