Be on Target, Not a Target: Surviving the Ongoing Focus on Medical Necessity and Short Stays

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1 Be on Target, Not a Target: Surviving the Ongoing Focus on Medical Necessity and Short Stays UT Systemwide Compliance Academy March 27, 2013 Deloitte & Touche LLP Presenters: Kelly Sauders, Partner John Valenta, Director Agenda Overview of the current regulatory environment and key Medicare requirements Common documentation, coding and billing challenges related to observation services and short inpatient stays Leading hospital practices to achieve compliance Question & answer session 1

2 Overview of the current regulatory environment and key Medicare requirements Overview Current Regulatory Environment Office of Inspector General (OIG) Compliance Reviews Provider Experiences with OIG Audits Government Enforcement Related to Short-Stays 4 2

3 Current Regulatory Environment Many "Eyes" are Looking at Short-stays The Medicare Administrative Contractors (MAC) via prepay reviews The Medicare Recovery Auditors (formerly RACs ) The OIG via the Hospital Compliance Reviews and other focused audits The Department of Justice through False Claims Act cases Other third party payers 6 3

4 The Consequences of Short-stay Denials Retro denials may result in total recoupment of inpatient payment If beyond one-year period, CMS says hospital may only receive Part B ancillaries (limited ancillaries, such as diagnostic x-rays and laboratory tests, prosthetic devices, outpatient physical, speech, occupational therapy, etc.) May result in higher outpatient co-insurance (vs. inpatient deductible) for patients No coverage of self-administered drugs No 3-day hospital stay for Skilled Nursing Facility ("SNF") coverage 7 The Consequences of Short-stay Denials (continued) Potential false claim liability for hospital PEPPER reports Data mining, no whistleblower needed Fines, settlements and Corporate Integrity Agreements (CIAs) 8 4

5 Recovery Auditors and Medical Necessity Recoveries CMS Recovery Audit (RA) Contractors Conduct automated reviews of Medicare payments to health care providers using computer software to detect improper payments Also conduct complex reviews of provider payments using human review of medical records and other medical documentation to identify improper payments to providers. The American Hospital Association (AHA) collects and distributes data on RA activities which began in 2010 Participants continue to report dramatic increases in RAC activity: Medical record requests are up 21% relative to last quarter The number of denials is up 23% relative to last quarter The dollar value of denials is up 26% relative to last quarter 10 Source: AHA RACTrac Survey November

6 RAC Regions HealthDataInsights CGI Technologies and Solutions Performant Recovery (formerly, DCS) Connolly 11 Source: AHA RACTrac Survey November 2012 Dollar Value of Denials by RAC Region AHA RACTrac Data through 3 rd Q 2012 $400 Millions $350 $300 $250 $200 $150 $231.4 $218.3 $190.2 $177.6 $174.4 $160.8 $342.1 $341.1 $294.0 $237.5 $221.1 $184.4 All activity through Quarter 1, 2012 All activity through Quarter 2, 2012 $100 $50 All activity through Quarter 3, 2012 $0 Region A Region B Region C Region D 12 Source: AHA RACTrac Survey November

7 Complex Denials AHA RACTrac Data through 3 rd Q 2012 Common Reasons 1. Short stay medically unnecessary 2. Inpatient coding 3. Other medically unnecessary 4. Discharge status 5. Medically unnecessary longer than 3 days 6. No documentation 7. Outpatient Coding 8. Other Medical Necessity Denials more than 60% of short stays were denied for medically necessary care provided in the wrong setting 13 Source: AHA RACTrac Survey November 2012 Monitoring of Short-Stay Hospitalizations DRG Target Diagnoses 069 Transient Ischemia 247 Surgical Cardiovascular Procedures (SCP), e.g. drug eluting stent 249 Percutaneous Cardiovascular Procedures (PCP) 251 SCP without Coronary Artery Stent, e.g. cath without stent 312 Syncope and Collapse (All severity and Risk of Morality Levels) 313 Chest Pain 377 GI Hemorrhage with MCC 378 GI Hemorrhage with CC 379 GI Hemorrhage with out CC/MCC 391 Esophagitis/ Gastroenteritis 552 Medical Back Problems with out MCC 641 Nutritional/ Metabolic 14 7

8 Medicare Appeals Process Adds to the Confusion Administrative law judges (3 rd level of appeal) and Medicare Appeals Counsel (4 th level of appeal) have upheld denial of admission but also ordered payment to hospital as an outpatient, including observation services CMS recognized this in a memo and instructed contractors to follow decisions, although CMS does not agree Delays in scheduling hearings and issuing decisions at ALJ and MAC Hospital appeals to ALJs increased from 1,545 in FY 2011 to 40,386 in FY Administrative Law Judge (ALJ) Decisions There have been a number of ALJ decisions in recent months that uphold a claims administration contractor s denial of inpatient services as not reasonable and necessary, but require the contractor to pay for the services on an outpatient basis at an observation level of care. This applies to very specific ALJ decisions CMS notes this is not consistent with the Medicare Benefit Policy Manual and Claims Processing Manual It should not be construed or interpreted as a change in the policy continue to follow existing policy and practices in all situations where there is not a conflicting ALJ order CMS Memorandum July 13,

9 Medicare Appeals Process Adds to the Confusion (continued) OIG report in November re: Improvements Are Needed At the ALJ Level of Medicare Appeals ALJ decisions fully favorable to hospitals 72% of the time QIC favorable rate was only 20% OIG interprets this as evidence that ALJs are performing inadequately According to OIG, ALJ staff raised concerns about providers that appeal every denial 17 CMS Final Rule In the November 15, 2012 Federal Register, CMS issue its Medicare OPPS Final Update for 2013 The request for public comment to the proposed rule resulted in 350 comments Included comments on how to rectify the many well-known problems for providers and beneficiaries that result when a short-stay admission later is found to be inappropriate CMS summarized the comments but did not respond and did not propose any changes to the policy CMS will consider the comments as they move forward 18 9

10 The Recent CMS Administrative Ruling & Proposed Rule The Centers for Medicare and Medicaid Services (CMS) released an Administrative Ruling (CMS-1455-P) on March 13, The CMS ruling is in response to numerous recent decisions by administrative law judges and the Medicare Appeals Council that allow hospitals to rebill and be paid for some claims, even after the one-year timely filing deadline, when auditors determine that inpatient hospital care should have been provided in an outpatient setting. The agency ruling, effective 3/13/2013, will remain in effect until a final rule on the subject is issued. CMS also issued a Proposed Rule on March 13, Will continue to apply the current one-year timely filing deadline for billing of Part B inpatient services the preamble states CMS position that appeals adjudicators, such as ALJs and the Medicare Appeals Council, may not order payment for items and services not yet billed under Part B in the event of a denied admission. However, the proposed rule permits a hospital to rebill for Part B inpatient services in self-audit situations. 19 American Hospital Association (AHA) Lawsuit On November 1, 2012, the American Hospital Association issued a news release: o AHA filed suit against the Department of Health and Human Services (HHS) for refusing to meet its financial obligations for hospital services provided to some Medicare patients o At issue is the Administration s refusal to reimburse hospitals for reasonable and necessary care when the government in hindsight believes that such care could have been provided in an outpatient facility or department instead of in the inpatient portion of the hospital itself 20 10

11 OIG Compliance Reviews Program Overview and Select Results OIG Compliance Audit Risk Areas Inpatient Identified Risk Areas Inpatient Short hospital stays Same day discharge and readmission Transfers to post-acute care providers Transfers to inpatient hospice care Manufacturer medical device credits Claims paid amount in excess of claims charged amount Claims with payments greater than $150,000 Blood-clotting factor drugs Hospital acquired conditions and present on admission reporting Outlier payments 22 11

12 OIG Compliance Audit Risk Areas - Outpatient Identified Risk Areas Outpatient Observation outlier payments Facility E&M coding and new vs. established patient Manufacturer medical device credits Services billed with modifier-59 E&M services billed with surgical services (modifier - 25) Claims paid amount in excess of claims charged amount Outpatient services billed during inpatient stays 72- hour rule Surgeries billed with units greater than one Services bill during skilled nursing facility stays Outpatient dental services 23 OIG Audit Risk Areas Other Target Topics Other Risk-Areas identified in the OIG Work Plan and Current Audit Experiences Inpatient psychiatric facility interrupted stays Inpatient psychiatric facility emergency department adjustments Inpatient high severity level DRGs Major complication and co-morbidities Outpatient brachytherapy reimbursement Outpatient claims billed using J codes Observation services during outpatient visits Hemophilia services and septicemia services Intensity modulated radiation therapy planning services Claim payments greater than $25,

13 Provider Experiences with OIG Audits Providers Typical Experience with OIG Reviews Audit notice and initial request received via telephone call and facsimile OIG is typically onsite within two weeks after provider receives notification, although more recently it s 4-6 weeks The initial request includes approximately 300 records ~ 66% Inpatient ~ 33% Outpatient The OIG audit team is typically on-site for four weeks, but this can vary The OIG audit team may not always include individuals with a clinical or coding background Disagreement on findings may go to the MAC for additional review OIG typically expects the provider to review all of the records first and have the provider complete an OIG worksheet/audit tool 26 13

14 OIG/Medicare Expectations Orders are specific as to level of care (e.g., admit or place in observation ) Physicians are actively engaged in determining the level of care, issuing orders and documenting in the medical record Documentation of physician intent/thought processes at the time of admission is critical Case managers review Medicare admissions for appropriateness (concurrent review) There is an operating Utilization Review Committee (URC) to override an inpatient admission ordered by a physician and with overall responsibility for the hospital s utilization of inpatient services 27 OIG Review of Inpatient Orders Findings from medical record review of short stays There is no order or clear intent for inpatient admission. Admit to Telemetry does not imply level of services but rather a place The intensity of services provided was not consistent with Inpatient level of care There is no order for Inpatient admission as such. The documentation does not imply or infer Inpatient status was ordered or required. The order to admit to EP- PAS is not defined as to what it means 28 14

15 Medicare: Inpatient or Outpatient? An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services Generally, a patient is considered an inpatient if formally admitted as inpatient A hospital outpatient is a person who has not been admitted by the hospital and receives services Sources: Inpatient definitions CMS Medicare Benefit Policy Manual 100-2; Chapter 1: Inpatient Hospital Services, 10 Outpatient definitions CMS Medicare Benefit Policy Manual 100-2; Chapter 6: Hospital Services Covered, OIG Review of Physician Documentation Medicare definitions for inpatient and observation are unclear For both observation and admission, facility must show the thinking of the clinician as to why the patient's status and anticipated course requires observation care (outpatient) or admission (inpatient) and should include Anticipated time course Trajectory Intensity of care Comorbidities 30 15

16 Utilization Review Efforts are Critical Case managers must apply admission criteria to Medicare patients placed in a hospital bed and document this review in an auditable format (entry points such as the Emergency Department are critical) All cases that do not pass criteria are referred to a Physician Advisor designated by the Utilization Review ( UR ) Committee The Physician Advisor reviews cases, speaks with admitting physician, renders final decision or seeks additional UR Committee input UR Committee undertakes periodic assessment to determine if the UR plan is effective 31 Potential Directions of Audits Expand the review to look at issues identified through the record reviews that were not anticipated Expand the case sample to look at more claims in similar areas (they do have all the hospital s data) Extrapolate to a larger universe of claims (some examples in published OIG reports to date) Make a referral for civil or criminal investigation 32 16

17 Overview of Key Medicare Requirements So What Exactly is Observation? Inpatient vs. Observation o Medicare standards for inpatient in various regulations and manual provisions are ambiguous and contradictory o Observation standards similarly amorphous 34 17

18 Medicare Definition Inpatient The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services A patient is considered an inpatient if formally admitted as inpatient with the expectation will remain at least overnight and occupy a bed even if it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight Source: Inpatient definitions CMS Medicare Benefit Policy Manual 100-2; Chapter 1: Inpatient Hospital Services, Medicare Inpatient Status The CMS Medicare Benefit Policy Manual highlights five key pieces of documentation for Medicare cases and determining medical necessity of Inpatient Status Medical history Current medical needs Severity of signs and symptoms Facilities available for adequate care and Predictability of an adverse outcome Risk assessment Prior Response Concern for a serious outcome if the patient is not closely monitored on admission Notation that the standard of care is being met 36 18

19 Medicare Inpatient Status Physician responsibility The physician responsible for the patient s care is also responsible for deciding whether patient should be admitted as an inpatient Physician should use a 24-hour period as a benchmark, i.e., order admission for patients expected to need hospital care for 24 hours or more Admissions are not covered or non-covered solely on the basis of the length of time the patient actually spends in the hospital However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors 37 Medicare Inpatient Status Can any physician be certain of the right answer? Limitation of liability should physician have known that admission was not appropriate and not in accordance with acceptable standards of practice? Medicare contractors, in determining what acceptable standards of practice exist within the local medical community, rely on published medical literature, a consensus of expert medical opinion, and consultations with their medical staff, medical associations, including local medical societies, and other health experts. Medicare Claims Processing Manual, Ch. 30, Section

20 Medicare Inpatient Status However, reviewers point to: Review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis. Inpatient care rather than outpatient care is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. Medicare Program Integrity Manual, CMS , Ch. 6, Sec Medicare Definition Outpatient A hospital outpatient is a person who has not been admitted by the hospital and receives services A patient enters hospital for a minor surgical procedure or other treatment that is expected to keep them for less than 24 hours Renal dialysis treatments are usually outpatient services A hospital may have a patient in a bed with an outpatient billing status such as OPIB (outpatient in a bed) Sources: Outpatient definitions CMS Medicare Benefit Policy Manual 100-2; Chapter 6: Hospital Services Covered, 20.2 Inpatient definitions CMS Medicare Benefit Policy Manual 100-2; Chapter 1: Inpatient Hospital Services,

21 Medicare Definition Observation Services which include ongoing short term treatment, assessment, and reassessment before a decision can be made whether patients require further treatment or if able to be discharged Commonly ordered for patients who present to the ED and require a significant period of treatment or monitoring to make a decision concerning their admission or discharge Patient s condition may be evaluated/ treated within 24 hours and/or if rapid improvement of patient s condition anticipated within 24 hours Patient requires at least eight hours of monitoring Sources: Medicare Benefit Policy Manual 100-2; Chapter 6 Medicare Claims Processing Manual, Pub , chapter 4 41 Utilization Review Committee (URC) All hospitals are required to have a Utilization Review (UR) plan o The guidelines require the hospital to perform an internal utilization review to change patient status from inpatient to outpatient The determination that an admission is not medically necessary can be made by: o One member of UR Committee if treating physician concurs or fails to present a view, or o Two members of the UR Committee in all other cases The UR Committee must consult with practitioner 42 21

22 Medicare and Condition Code 44 In some instances, a physician may order a Medicare beneficiary to be admitted to an inpatient bed, but upon subsequent review, it is determined that an inpatient level of care does not meet the hospital s admission criteria Definition of Condition Code 44: inpatient admission changed to outpatient Source: CMS Manual Systemwww.cms.gov/transmittals/downloads/R299CP.pdf 43 Medicare & Condition Code 44 (cont.) If the UR Committee determines that the inpatient admission does not meet inpatient criteria, the Medical Center may change the patient s status to outpatient and submit a claim provided that all of the following are met: o Change in patient status from inpatient to outpatient is made prior to discharge, while the beneficiary is still a patient of the hospital; o Hospital has not yet submitted a claim to Medicare for the inpatient admission o Physician concurs with the UR Committee s decision o Physician s concurrence with UR Committee s decision is documented in the patient s medical record 44 22

23 Medicare & Condition Code 44 (cont.) The patient must receive notification of any status change while they are in the hospital, as this impacts their financial obligations If all conditions are met to change the patient status from inpatient to outpatient, an outpatient claim may be submitted with all medically necessary outpatient services o Bill type 13X o Condition Code 44 When Condition Code 44 is appropriately used, the hospital reports on the outpatient bill the services that were ordered and provided to the patient for the entire patient encounter Condition Code 44 should be used infrequently 45 Medicare Expectations Orders are specific as to level of care (e.g. admit or place in observation ) Physicians are actively engaged in determining the level of care, issuing orders and documenting in the medical record. Documentation of physician intent/thought processes at the time of admission is critical Case managers review Medicare admissions for appropriateness (concurrent review) There is an operating utilization review committee (URC) to override an inpatient admission ordered by a physician and with overall responsibility for the Hospital s utilization of inpatient services

24 Medical Necessity Short Stays Challenges and Leading Practices Challenges For Hospitals Hospitals may not have consistent processes and controls to ensure that the appropriate patient status is determined and documented appropriately Hospitals may lack procedures to evaluate a patient s status from the various points of entry into the system ED Direct admissions Ambulatory surgery units Diagnostic procedures units 48 24

25 Challenges For Hospitals (continued) Hospitals may not appropriately utilize accepted industry guidelines for assessing and determining level of care The hospital may lack physician buy-in and physician advisor coverage Multiple information systems may not talk to each other There is not alignment between hospital and physician coding rules Physicians may be hesitant to document risks vs. patient is stable due to concerns about malpractice 49 Patient presentation to hospital emergency department (ED) Place in Observation/ Outpatient Admit to Inpatient Emergency Department Case Manager Discharge to Skilled Nursing Facility Discharge with Home Care Treat and Release 50 25

26 ED Case Management Since a high percentage of admissions come from the ED, it is essential that Case Managers be assigned to the ED to assist physicians in making the appropriate patient-status decisions The ED CM position is a critical role, requiring accuracy and timeliness in evaluating and documenting Level of Care (LOC) This may include case management coverage in the ED for 16 to 24 hours/day, 7 days a week* Patients who presented overnight should be reviewed by the ED Case Manager in the morning to asses the patient s LOC *This should be based on hospital ED volumes, admission rate and peak volume days/times 51 Inpatient Admissions (Other than ED) Direct Admission Admissions Case Manager Transfer Electrophysiology Lab Surgery Outpatient Clinics GI Procedure Unit Outpatient Surgery (ASU) PACU Radiology 52 26

27 Admissions Case Management Point person for admissions from all points of entry units (other than the ED) to evaluate LOC for observation or inpatient prior to bed placement Works closely with the admissions office and bed placement staff Communicates with nurses and physicians to evaluate LOC for Observation or Inpatient from all admission sources When a PCP calls the hospital to directly admit a patient, these calls are routed to the Admissions CM for assistance with appropriate LOC PACU Charge Nurse calls Admissions CM for assessment of appropriate LOC ASU, CATH/EP, Radiology, GI Lab, etc. 53 Admissions Case Management (continued) Reviews all scheduled elective surgical admissions to assess for inpatient LOC one week to several days before scheduled procedure Surgeons offices should be required to include HCPCS/CPT code when booking Compares HCPCS/ CPT codes for patients scheduled for elective procedures with Medicare s Addendum E: Inpatient-Only Procedure List to assess inpatient LOC o Procedures with status indicator C are inpatient only procedures and are required to be admitted prior to surgery o Hospital cannot bill if procedure is done as an outpatient Sources: April 7, 2000 Final Rules (65 FR 18455) WPS Medicare Ask the Contractor: Inpatient Admission Decisions Feb 8,

28 Leading Hospital Practices for Short-Stays Leading Practices to Consider Use of current InterQual guidelines by the Case Management nurses Nurses and others using InterQual should be certified and trained to use it Case Management should strive to review nearly 100% of potential admissions before the physician order is written Case Management reviews should be documented real-time If a case does not appear to meet the guidelines, it is critical for Case Management to discuss the case with the Attending physician on a timely basis and involve the Physician Advisor when needed 56 28

29 Leading Practices to Consider (continued) Verify that your hospital has an up-to-date UR Plan and a URC that meets and reviews short stay admissions, unnecessary admissions, and performance on the quarterly PEPPER report Develop a plan of action if these reviews reveal a high percentage of one-day stays or unnecessary admissions Recruit key physicians to the UR Committee (e.g., cardiology, neurology, emergency medicine) Education and ongoing training for the emergency room physicians, treating physicians, and UR/care management nurses regarding the differences between inpatient and observation status as well as Condition Code Leading Practices to Consider (continued) Emphasize importance of clear documentation in physician admission orders o Physician order to simply admit is not clear o Physician order should specify inpatient, outpatient, or observation and should include the admitting diagnosis A robust clinical documentation improvement program Use of physician advisors when disagreements occur between the physicians and utilization review/care management nurses regarding patient status 58 29

30 Leading Practices to Consider (continued) Create a multi-disciplinary short stay work group to tackle this issue one department cannot do it alone Review short stays prior to submitting claim to Medicare and promptly correct short stay claims that do not meet medical necessity Verify the patient s status in the billing system matches the patient status ordered Review applicable policies and procedures Continually assess hospital denials, particularly those from the pre-pay reviews which involve current cases 59 Ensure Strong Physician Advisor Support The physician advisor role is critical maybe full-time or part-time depending on the needs of the organization There should be a formal job description and employment contract and a defined reporting relationship to the CMO or similar level Formal training in utilization review, compliance, quality Versed in Medicare Conditions of Participation (COPs) Works closely and collaboratively as a partner with Care Management 60 30

31 Ensure Physician Advisor Support (cont.) The physician advisor should lead the UR Committee and play a leading role in: o Length of stay reviews o PEPPER Report review, analysis, and development of corrective plans o Managing denials and appeals, including assisting in drafting appeal letters and appearing at ALJ or other hearings o Communicating decisions to the medical staff o Clinical documentation improvement efforts Assessing Short-Stay Risk Evaluate your hospital s current processes and controls Are clinical guidelines being utilized consistently and accurately? Are findings based on clinical guidelines documented consistently and accurately? Evaluate ED Case Manager Determine Case Management coverage for ED, Admissions, and Units Hours/days of week Skill set Timeliness of leveling Culture/current practices Examine the secondary review processes in Case Management 31

32 Monitoring of Short-Stays Ongoing effort is required Roles and responsibilities need to be clearly defined Determine what data will be monitored and reported (e.g., one-day stays, all short stays up to 48 hours, observation stays exceeding 48 hours, etc.) PEPPER outliers Creating an Internal PEPPER report The UR Committee is required to review all outlier cases Case Management Documentation Audit all 1 and 2 day claims prior to submission Denials (e.g., MAC, RA, other) 63 Question & Answers 32

33 Contact Information and Speaker Biographies Contact Information and Bios Kelly Sauders, Partner (mobile) Deloitte & Touche LLP Kelly has over 17 years of experience in the health science industry. Kelly has worked with numerous providers and external counsel on a wide variety of short-stay projects over the past several years including RAC-readiness assessments, short-stay process and chart assessments, developing monitoring processes for providers for shortstay admissions and observation cases, OIG investigations, OIG audits and provider s proactive efforts to implement front-end controls related to short stays. Kelly routinely works with hospitals and health systems on a variety of compliance topics including program structure and resource assessments, specific issues or compliance auditing of coding and billing matters and evaluating risk to develop risk-focused compliance and internal audit work plans. John Valenta, Director jvalenta@deloitte.com (mobile) Deloitte & Touche LLP John has over 23 years of experience in the healthcare and life sciences industries and advises clients on financial, risk management, regulatory and compliance issues. He has participated on numerous engagements with healthcare providers, payers and life sciences organizations and has extensive consulting experience on issues related to enterprise risk management (ERM), revenue optimization, government program reimbursement, compliance, government regulations, internal controls and other financial and operational issues. John has assisted organizations with performing risk assessments, compliance program effectiveness assessments, ERM readiness assessments, developing policies and procedures, providing education and evaluating the organizational structure of the compliance and internal audit functions

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