Session 303 How to Use Scorecards to Manage Revenue Cycle Compliance

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1 Session 303 Manage Revenue Cycle Compliance M. Aaron Little, CPA CPAs & ADVISORS BKD, LLP Managing Director Patrick Brown, MBA, MS Penn Home Care & Hospice Services Chief Financial Officer Source: Association of Certified Fraud Examiners Report to the Nations on Occupational Fraud and Abuse, 2014 Global Fraud Study 2 1

2 Source: OIG home page, June Source: Times-Picayune Source: OIG https://oig.hhs.gov/fraud/enforcement/criminal/index.asp#cea

3 Source: 2014 OIG Work Plan 5 6 OBJECTIVES 3

4 OBJECTIVES Identify key compliance risk areas influencing revenue cycle Identify key performance metrics for managing a revenue cycle compliance scorecard Describe key accountability strategies for managing compliance in revenue cycle 7 8 PROGRAM INTEGRITY CONTRACTORS 4

5 Coverage & billing compliance Revenue cycle risks People & process Program integrity 9 Care Documentation Claims Data 10 5

6 11 PROGRAM INTEGRITY MACs CERTs RAs ZPICs SMRCs MICs 12 Medicare Administrative Contractors Comprehensive Error Rate Testing contractors Recovery Auditors (formerly Recovery Audit Contractors) Zone Program Integrity Contractors Specialty Medical Review Contractors Medicaid Integrity Contractors PROGRAM INTEGRITY 6

7 MACs Medicare Administrative Contractors (MACs) CMS authorized contractors responsible for claims processing & other administrative functions for designated HH & hospice jurisdictions Typically conduct program integrity activities through on pre-payment medical review processes 13 Source: CGS Home health widespread probe edits for HIPPS codes: 1BGP*, 5CHK*, 5CGK*, 5BHK*, 5AHK*, 5BGK*, 5AGK*, 5BFK*, 5AFK*, 2CGL*, & 2BGL* Source: Palmetto GBA 9NNJBX6701?open&navmenu=Medical^Review Source: Palmetto GBA IU!/ 14 7

8 MACs CMS Change Request Guidance/Guidance/Transmittals/Downloads/R541PI.pdf 15 CERTs Comprehensive Error Rate Testing (CERT) Program contractors Program established by Centers for Medicare & Medicare Services (CMS) to monitor accuracy of Medicare claim payment Identify errors & assesses error rates Evaluate performance of MACs Randomly select statistical sample of paid claims to determine whether claims were paid properly 16 8

9 RAs Recovery Auditors (RAs) Review claims on post-payment basis to identify improper payments Three years from date claim paid Issues published & approved by CMS Contractors paid fee percent of amount recovered Fifth RA being created for to HH, hospice, & durable medical equipment 17 ZPICs Zone Program Integrity Contractors (ZPICs) Identify cases of suspected fraud, investigate, & take action to ensure any inappropriate Medicare payments are recouped 18 9

10 ZPICs Fraud includes Billing for services not furnished Billing appearing to be deliberate for duplicate payment Altering claims or medical records to obtain higher payment Soliciting, offering, or receiving kickbacks or rebates for patient referrals Billing non-covered or nonchargeable services as covered Actions may include Investigating potential fraud & abuse Medical review, typically on post-pay basis Data analysis Payment suspensions Prepayment or auto-denial edits Referring cases to law enforcement for civil or criminal prosecution

11 SMRCs Supplemental Medical Review Contractors (SMRCs) Contract awarded by CMS in October 2012 to StrategicHealthSolutions (SHS) Contract covers specialty review for nation Post-payment review determined based on data analysis Medicare Part A, Part B & DME SHS currently conducting review of Medicare HH compliance with physician face-to-face encounter documentation requirements Includes all Medicare certified HH agencies 21 MICs Medicaid Integrity Contractors (MICs) Entities with which CMS has contracted to conduct postpayment audits of Medicaid providers Goal is to identify overpayments & decrease inappropriate payments 22 11

12 UPICs Unified Program Integrity Contractor (UPIC) New contractor coming soon that consolidates ZPIC & MIC activities To predict, detect, prevent & deter fraud, waste & abuse in Medicare & Medicaid programs By consolidating Medicare & Medicaid program integrity activities Sharing & coordinating information among Medicare & Medicaid partners Emphasizing timely administrative actions Strengthening data matching across programs to expand view of provider billing patterns KEY PERFORMANCE METRICS 12

13 OVERVIEW o Documentation & Billing o Referral Process o Homebound Status o Plan of Care (CMS Form 485) o Face to Face Encounter o Progress Notes o Medical Necessity o Therapy Reassessment o Aide Supervisory Visit o Coding & Documentation o Additional Information REFERRAL/ADMISSION SCORECARD Scorecard reviews on a monthly basis the percentage of patients with an identified Face to Face Physician. Intake process documents whether the patient has a Face to Face encounter; if not, this is the trigger for the alert to the clinical team to ensure that the patient has a scheduled follow up visit. Scorecard documents percentage of Patient Consents returned within Seven Days. Business Staff sends a weekly report with missing consents listed; project reduced write offs for lack of consent by $25K in past fiscal year. Scorecard details the percentage of 485s where the Physician on 485 matches the MD listed in the Referral documentation. Any subsequent change to the MD on the 485 may necessitate a countersignature for the Face to Face. 13

14 ACTIVE PATIENT SCORECARD Scorecard details percentage of physician orders returned signed within Thirty Days. Report designed to ensure compliance with State regulation; report details the number of days to send both returned and unreturned orders. Scorecard reviews number of unlocked visits on a weekly basis. Scorecard documents number of patients without activity in past seven days. Documentation designed to ensure that clinical staff discharge patients when care is completed and that caseloads are accurate. Scorecard details the number of unsent orders by team. Report designed to ensure that clinical staff complete documentation for any interim orders-this allows for timely delivery of services, as the interim order is the trigger for staff scheduling. BILLING SCORECARD Scorecard reviews the percentage of clean claims. This measure is intended to break down the silos between the departments and identify barriers to billing. Scorecard documents days to lock OASIS. Measurement is a proxy for days to RAP. Scorecard details days to Final Claim. Scorecard details audit of patient paper chart. Audit to confirm patient consent, all signed orders and all Home Health Aide Plans of Care are present in the chart. 14

15 HOSPICE SCORECARD Scorecard documenting percentage of Patient Consents returned within Seven Days includes Hospice patients. Plan is to add component that measures compliance with Notice of Election submission requirement. Other Measurements: Daily Report regarding patients in Hospice Inpatient Unit with length of stay greater than five days. Ongoing audit of patients in third or more certification period regarding eligibility: Although the patient s clinical condition upon admission to hospice may have supported the trajectory of decline to be six months or less, it is important to ensure the documentation for patients with long lengths of stay clearly supports an ongoing trajectory of decline versus a chronic stable patient with significant custodial care needs whose trajectory has plateaued. 30 PEOPLE AND PROCESS 15

16 Department of Justice HEAT Settlement: Agency allegedly billed Medicare for nursing and therapy services that were medically unnecessary or provided to patients who were not homebound, and otherwise misrepresented patients conditions to increase its Medicare payments. These billing violations were the alleged result of management pressure on nurses and therapists to provide care based on the financial benefits to Agency, rather than the needs of patients. COMPLIANCE ORIENTATION Information Line Reporting (Confidential) Website General Counsel Reporting & Help Line UPENN Institutional Compliance 215-P-Comply ( ) Privacy Questions/Concerns: UPHS Privacy Officer (215) Each Entity also has a designated Entity Privacy Officer. UPHS Privacy Policies can be found at: Security, data breach, laptop thefts, etc. Mike Moran, UPHS Dir. of IT Security (215)

17 CMS TRAINING MATERIALS Medicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Available at Network-MLN/MLNProducts/ProviderCompliance.html The training module covers both Fraud/Waste/Abuse and General Compliance Training. Completion of this or comparable program required by one of our contracted Medicare Advantage Programs 34 RISK MANAGEMENT 17

18 Foster a culture of compliance Identify at risk areas Maintain concurrent focused compliance monitoring processes Maintain objective & accountable tracking systems Periodically test compliance processes 35 Periodically test compliance processes Define sample Time period Number of claims Select random or targeted sample Gather source documentation Conduct review Paid claim to documentation Document, track & trend findings Report results Act on results Validate physician face-toface encounter documentation Re-score OASIS & validate HIPPS code billed & paid Verify all visits billed on claim are supported by documentation Verify all visits were performed within physician ordered frequencies Verify claim was submitted after receipt of all signed orders Review claim coding Diagnosis & HCPCS codes, physician information, etc

19

20 CHART AUDIT SCORECARD Chart Audit Focuses on Four Key Elements: ICD Coding Homebound Status, Medical Necessity Therapy Reassessment Home Health Aide Supervisory Visits Chart Audits selected for patients with Five to Seven visits (LUPA Avoidance population), patients with Fourteen or More therapy visits (High Therapy Population), and patients with six or more Home Health Aide visits (HHA population). Chart audits separate from Medical Record review. CODING COMPLIANCE Vendor Audit to Ensure compliance with ICD-9: Verify following coding guidelines when assigning primary (OASIS M1020) and secondary diagnoses (OASIS M1022) Review Sequencing requirements List secondary diagnoses in the order which best reflects the seriousness of the patient s condition Coding Documents: Diagnoses that are unresolved Relevant medical diagnoses Diagnoses supported by the patient s medical record documentation 20

21 HOMEBOUND STATUS/MEDICAL NECESSITY Review progress notes for documentation of homebound status and medical necessity: Ensure that the Intake/Admission documentation details patient need for service Review gaps in service Confirm skilled service in last visit(s) Macro-look Is episode appropriate for Medicare coverage Micro-look Does documentation of each visit support reasonable and necessary medical necessity THERAPY REASSESSMENT Performed to ensure therapy services are effective, required at defined points during a course of treatment, for each therapy discipline for which services are provided Medicare Benefits Policy Manual Chapter 7 Section 40.2 Must include: Date of functional reassessment Patient s functional measurement with comparison to prior assessment Effectiveness of therapy, or lack thereof 21

22 LESSONS LEARNED Ensure that you are: Timely in performance of reassessments Aware of reassessment due dates If services are outsourced, provide this information to the covering therapist(s) Compliant by: Reviewing your progress note to confirm that it is complete and addresses the CMS documentation requirements AIDE SUPERVISION REQUIREMENTS Supervisory onsite visits: o When patient is receiving skilled services: Must be performed at least every 2 weeks by RN and aide does not need to be present If patient is not receiving nursing care but is receiving home therapy, then the appropriate therapist performs the supervisory visit 22

23 UNFAVORABLE AUDIT FINDINGS Intake referral: Lacks detail regarding: Point of referral Patient current condition Current HC needs Homebound status Progress notes: Incomplete notes Computer syncing Frequent cut / paste Template statements Lacks patient specific detail 46 SUMMARY 23

24 Non-compliant documentation received Compliance error identified Documentation accepted into software system/medical record Failure of process, personnel or product? Compliance audit completed Pre-billing compliance audit completed Claim billed & paid 47 SUMMARY Identify key compliance risk areas influencing your agency s revenue cycle Identify key performance metrics for managing your agency s revenue cycle compliance scorecard Describe key accountability strategies for managing compliance in your agency s revenue cycle 48 24

25 49 QUESTIONS Session 303 Manage Revenue Cycle Compliance M. Aaron Little, CPA CPAs & ADVISORS BKD, LLP Managing Director Patrick Brown, MBA, MS Penn Home Care & Hospice Services Chief Financial Officer 25

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