HCCA 14 th Annual Compliance Institute April 18-21, 2010 Dallas, Texas

Transcription

1 HCCA 14 th Annual Compliance Institute April 18-21, 2010 Dallas, Texas Revenue Integrity and Safeguarding: Comprehensive Strategies for Contractor Combat (RACs, MICs, ZPICs and Others) Today s Speakers Christopher D. Thomason MBA, CHC Director, Office of Compliance and Corporate Integrity, Vanderbilt University Medical Center Denise Hall Shareholder, Pershing Yoakley & Associates, P.C Sara Kay Wheeler Partner, King & Spalding LLP 2

2 Goals of Session Understand contractors RACs MACs MICs ZPICs and PSCs For each contractor: Authority Audit approach Appeal opportunities Important developments Discuss issues that may be high priority for contractors Explore steps to be pursued by providers and counsel to prepare and respond to audits Questions and answers! 3 CONTRACTOR REFORM 4

3 Contractor Landscape Older Contractors FIs Fiscal Intermediaries (Medicare Part A) Carriers (Medicare Part B) DMERCs Durable Medical Equipment Regional Carriers PROs Peer Review Organizations QIOs Quality Improvement Organizations Many others 5 Contractor Landscape Newer Contractors MACs Medicare Administrative Contractors PSCs Program Safeguard Contractors ZPICs Zone Program Integrity Contractors RACs Recovery Audit Contractors MEDICs Medicare Drug Integrity Contractors RVCs Recovery Audit Validation Contractors QICs Qualified Independent Contractors MICs Medicaid Integrity Contractors MIG Federal Medicaid Integrity Group (engages MICs) 6

4 RECOVERY AUDIT CONTRACTORS (RACS) 7 NATIONAL RAC LANDSCAPE Region A - Diversified Collection Services (DCS) Region B - CGI Region C - Connolly Consulting, Inc. Region D - HealthDataInsights, Inc. 8

5 RAC Developments Issues to monitor Consolidation of contact requests RAC discussion period Efforts to limit recoupment and interest considerations CMS Code 432 versus Code 469 RAC licensing and use of clinical screening criteria (e.g., InterQual and Milliman) e.g., HealthDataInsights and Connolly OIG Report (February 2010) regarding lack of fraud referrals to CMS CMS rules and guidelines regarding exclusion and suppression of claims from RAC Data Warehouse (parallel audits, investigations and in certain voluntary refunds/disclosures) RAC expansion proposals in health care reform legislation (Medicare Part C, Medicare Part D, and Medicaid) 9 Connolly Process Update Case Study: Initial Connolly Request Letter Process Issues: Connolly has assigned a new Request number to the letter. This does not match the Request number assigned to the Medical Records Request Letter. The letter indicates a spreadsheet to show specific details of each review is attached. No spreadsheet was attached. Details of claims reviewed with recovery are attached, however, claims reviewed with no recovery were not listed or identified anywhere in the letter. According to Connolly s Provider Portal for claim s review status, not all claims included in the Original ADR Letter have had their review completed, but a results letter was received. It was anticipated that Results letters would not be generated until all the cases included in the request had been reviewed. Connolly s Provider Portal contains fields for Review Complete Date and Review Results Mailed. These fields have not been populated for any reviews, yet Results letters were sent and the reviews on those have been completed. The Connolly website is expected to be updated nightly. There is inconsistency among their coders as to how they are reporting their results. Some are indicating an un-revised procedure code as N/a, others are listing it again. One coder lists the amount that should be paid on the revised DRG. Other coders do not, which leads to the next problem. The detail lists the original reimbursement amount and the recovery amount. It does not list the revised reimbursement amount. It is unclear if the recovery is an underpayment or an overpayment.

6 MEDICARE ADMINISTRATIVE CONTRACTORS (MACS) 11 A/B MAC Jurisdictions Awarded National Government Services (Jurisdictions 8 & 13) First Coast Service Options (Jurisdiction 9) Cahaba Government Benefit Administrators (Jurisdiction 10) Palmetto GBA (Jurisdictions 1 & 11) National Heritage Insurance Corporation (Jurisdictions 2* & 14) Noridian Administrative Services (Jurisdictions 3 & 6*) TrailBlazer Health Enterprises (Jurisdictions 4 & 7) Wisconsin Physicians Health Insurance Corporation (Jurisdiction 5) Highmark Medicare Services (Jurisdictions 12 & 15*) * Denotes award involved in protest 12

7 MAC Developments MACs have authority to audit As the FIs and Carriers transition to MACs, the MACs have a limited window to conduct random audits to obtain baseline data on utilization After the transition period, MAC audits will be targeted to claims with suspected improper payments MAC probe audit activity increasing in some jurisdictions MACs can refer provider activity to PSCs, ZPICs and law enforcement for further investigation Providers should independently verify appeal deadlines and other points emphasized during MAC educational efforts 13 MEDICAID INTEGRITY CONTRACTORS (MICS) 14

8 History and Context of Medicaid Integrity Initiative Deficit Reduction Act of 2005 established Medicaid Integrity Program (MIP) Medicaid was identified as large payment risk area Resources to support Medicaid enforcement were uneven compared to those resources dedicated to Medicare enforcement Medicaid enforcement approaches varied widely across states MIP Goals Review the actions for fraud, waste or abuse Audit claims for payment Identify overpayments Educate other government entities, contractors and providers on issues relevant to Medicaid integrity 15 MICs - Categories of MICs REVIEW MICs Medicaid data analysis, application of data mining algorithms to Medicaid MSIS data Recommendation of candidates for audit Coordinate with state Medicare programs to avoid duplication of effort AUDIT MICs Desk reviews and field audits, applied to audit candidates recommended by Review MIC and approved by CMS MIG EDUCATION MICs Conduct gap analysis of existing education and training effort Develop fraud, waste and abuse training programs Develop educational curriculum via web-based and traditional methods Educate Medicaid providers about Medicaid integrity and quality of care

9 MIC Jurisdictions Regional Organization (Different from RACs and MACs) Region 1 and 2: New York / Boston Region 3 and 4: Atlanta / Philadelphia Region 5 and 7: Chicago / Kansas City Region 6 and 8: Dallas / Denver Region 9 and 10: San Francisco / Seattle Review of Provider MIC Zones Awarded AdvanceMed Corporation Thomson Reuters Umbrella Contracts Also Awarded to: ACS Healthcare Analytics IMS Government Solutions SafeGuard Services 18

10 Audit MIC Zones Awarded Health Management Systems (HMS) Health Integrity IPRO Umbrella Contracts Also Awarded to: Fox & Associates Health Integrity Booz Allen Hamilton 19 Education MIC Zones Awarded Strategic Health Solutions Umbrella Contracts Also Awarded to: Information Experts Strategic Health Solutions

11 What is the MIG? MIG is CMS s Medicaid Integrity Group that was created in July of 2006 to implement the MIP The MIG is organized in four divisions: Office of the Group Director Division of Medicaid Integrity Contracting (DMIC) Division of Fraud Research & Detection (DFRD) Division of Field Operations (DFO) MIC Developments Efforts to improve provider outreach (announced during July 15, 2009 Open Door Forum) Hosting of Open Door Forum Conference Calls Publishing of documents to assist providers FAQs on Medicaid Integrity Program Procurement timelines Audit A-Z Look for documents: Addressing provider questions submitted through Medicaid Integrity Program mailbox: medicaid_integrity_program@cms.hhs.gov 22

12 MIC Audits Unique Governed by Government Auditing Standards (Yellow Book) Desk audits Field audits Opportunity to inquire about compliance and governance issues Explore In-take Questionnaire Process influenced by state law MIC Audits: Influence of State Law General Considerations Record retention requirements Look back period Limitation on records requested Production expectations Reimbursement for records Authority to extrapolate Unique reimbursement rules and requirements Open Record and Open Meeting Related issues Appeal Process See below

13 MIC Appeal Process Audit MIC contacts provider Provider produces records Audit MIC analyzes info Audit MIC generates draft audit report and submits to CMS MIG CMS MIG reviews and sends to state Medicaid agency State may make comment Audit MIC sends draft report to provider Provider has 30 days to review and provide comments Additional review by CMS MIG CMS MIG issues final audit report to state Medicaid agency for "execution CMS MIG can also refer to law enforcement at this time State issues demand to provider regarding alleged overpayment which triggers appeal procedures 25 RACs and MICs Compared RACs Provider outreach mandatory Review period set Time to produce records 45 days (possible extensions) Number of records limited Appeal process consistent across regions MICs Provider outreach not mandatory Review period not set Time to produce records shorter (possible extensions) Number of records no limit Appeal process mirrors state Medicaid appeal process 26

14 ZONE PROGRAM INTEGRITY AND PROGRAM SAFEGUARD CONTRACTORS 27 ZPICs Health Integrity LLC (Zone 4) AdvanceMed Corporation (Zone 2*) (Zone 5*) SafeGuard Services LLC (Zone 7) * Denotes Zone award involved in protest 28

15 ZPIC Zones Zone 1 Zone 2 Zone 3 Zone 4 Zone 5 Zone 6 Zone 7 California, Nevada, American Samoa, Guam, Hawaii and the Mariana Islands Alaska, Washington, Oregon, Montana, Idaho, Wyoming, Utah, Arizona, North Dakota, South Dakota, Nebraska, Kansas, Iowa and Missouri Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio and Kentucky Colorado, New Mexico, Oklahoma and Texas Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia and West Virginia Pennsylvania, Massachusetts, New Jersey, Connecticut, Rhode Island, New Hampshire, Delaware, District of Columbia, Maine, Maryland, New York and Vermont Florida, Puerto Rico and Virgin Islands Zone Awarded 29 ZPICs Replacing current Program Safeguard Contractors (PSCs) Combined oversight of Medicare Parts A, B, DME, Home Health and Hospice Potentially will combine oversight of Medicare Parts C and D CMS will award 7 umbrella contracts with each containing 2 simultaneously awarded task orders Task Order 1 is Medicare Parts A, B, DME, Home Health and Hospice Task Order 2 is Medicare / Medicaid Data Matching Projects Future task orders will be awarded at CMS discretion for activities related to fraud, waste and abuse detection and prevention 30

16 ZPIC Statement of Work Highlights Reactive and proactive identification of potential fraud, waste and abuse Data analysis Evaluation of complaints Referrals from law enforcement Fraud alerts Referrals from MACs and ACs Support for law enforcement during investigation and prosecution of healthcare fraud cases Medical review, data analysis, overpayment determination, subject matter expert testimony Fraud, waste and abuse training for MAC and AC staff 31 PREPARATION STRATEGIES 32

17 Reality Issue: Increased number of entities (federal agencies, state agencies and government contractors) actively trying to identify Medicare and Medicaid improper payments President Obama stressed on March 10, 2010 the critical importance of recapture audits. Not limited to inpatient and outpatient hospital claims Scrutiny will come from all directions Solution: Organizations need effective processes to prepare for audits and manage interaction with RACs, MACs, MICs, MIG, ZPICs, PSCs and others 33 Core Areas: Overview Core areas critical to successfully managing this complex process Master government contractor landscape (players, current developments, etc.) Manage audit process from the front end - respond effectively to audit inquiries Manage claims data Develop effective strategies for analyzing internal and external audit findings Master and navigate multiple administrative appeal processes Develop federal and state litigation strategies Pursue compliance oriented processes to help organize effort Carefully consider potential fraud and abuse implications 34

18 Preparedness Tips: Overview Infrastructure Contractor committee(s) Information management Records collection Control Production HIPAA Document and records hosting Chain of responsibility Management of overlapping deadlines Other Activities Governance considerations Pre-audit testing Data mining Contractor intelligence CMS website Individual contractor website Focused Entity Initiatives: Detailed Considerations Not limited to inpatient and outpatient hospital claims Physician Office visit increased scrutiny Bundled Payment Demonstration Project (ACE Demonstration) MAC = ability to review professional and facility charge concordance Post Acute SNF Three Day / Seven Day qualifying Stay Physical Therapy / MDS Substantiation LTC / Rehab Medical Necessity DMERC Medical Necessity / Physician Orders / Delivery Home Health Medical Necessity / Physician Orders / Delivery

19 Revenue Integrity Response Team The Compliance Response Team A committee with the authority to make changes as needed Evaluate the possibility of developing an AUDIT database and tracking tool, including report capabilities Do we build something in-house? Do we buy a product? Do we partner with another party? The Organizational culture shift Recognize the need to design our processes and systems to support all audit activity (MAC, OIG, MIC, ZPICS). Needs are greater than just the RAC. Plan the management of all audits. Evaluate an audit management tool. Determine proactive management of the audit process. Explore internal data-mining capabilities. Clinical Focused Response to Inquiries / Appeals Requires physician, case management, and HIM response / analysis Communication of all areas of impact is critical Complex DRG Validation Audits Increased prospective focus on targeted DRGs (e.g. procedures unrelated to principal diagnoses) Preemptive review of all requested accounts to determine liability Prompt review of results letter following all Complex Reviews» Evaluate principal diagnosis compare to principal procedure» Evaluate principal procedure assigned and compare to other existing conditions Patient Status Medical Necessity Analysis Combination Analysis of medical and InterQual and/or Milliman Criteria to determine need for response

20 Additional Considerations Annual establishment of internal audit plans OIG RAC Focus Other reviews / interest level Examples of Proactive Reviews 1 day stay vs. observation Carotid Artery Stent Placement High Dollar Outpatient Accounts Remicade Pharmacy Analysis Physician Evaluation and Management level assignment / Utilization Focus Clinical Medical Necessity Clinical Trial Documentation Excessive or unnecessary charges Units billed or LCD guidelines Documentation of E/M Coding Components Neulasta Usage High Dollar MRI / CT testing in ED Medical Necessity of testing Effective Strategies for Analyzing Internal / External Findings Critical to proactively assess interactions with government contractors Involve team of financial, clinical, and legal resources Proactive analysis of findings time is of utmost importance Consider sample population (representative, targeted, statistical validity) Identify where the holes in data or available information exists Consider impact on financial reserves in worst case scenario Correct the problem (Sounds easy, right?)

21 Panel Discussion Topics Contractor interaction: suppression and exclusion of claims from RAC Data Warehouse Contractor authority: issuance of demand Potential damages: role of extrapolation Medicaid audits: potential points of confusion Fraud and abuse considerations 41 Ancillary Documents Relevant to Revenue Integrity Discussion Yellow Book Audit Standards See Comprehensive Medicaid Integrity Plan (FYs ) Medicaid Integrity Program A-Z Comprehensive Integrity Review Schedule Example: MIC Audit-Entrance Conference Agenda Example: MIC Audit-Institutional Provider In-Take Questionnaire 42

22 Ancillary Documents Relevant to Revenue Integrity Discussion (cont d) CMS Recovery Audit Contractor Evaluation Report June 2008 GAO report on Q10 accuracy Medlearn Matters on Condition Code 44 Expansion of Admit to Case Management Protocol Article Surgical Setting Report Template Transfer DRG White Paper Thank You Questions & Answers Christopher D. Thomason MBA, CHC Denise J. Hall Director, Office of Compliance and Corporate Integrity Shareholder Vanderbilt University Medical Center Pershing Yoakley & Associates, P.C st Avenue South Two Ravinia Drive 3100 Village at Vanderbilt Atlanta, GA Nashville, TN Phone: (678) Phone: (615) Sara Kay Wheeler Partner King & Spalding LLP 40 th Floor 1180 Peachtree Street Atlanta, GA Atlanta, Phone: (404) v1 44