Jimmo v. Sebelius. Glenda Mack, Division Vice President Clinical Operations

Transcription

1 Jimmo v. Sebelius Glenda Mack, Division Vice President Clinical Operations

2 Jimmo v. Sebelius Specifics 1. Settlement approved by Federal Judge on January 24 th Class action suit on behalf of beneficiaries with chronic and degenerative conditions 3. Confirms and requires that CMS adhere to regulations specific to skilled maintenance coverage 4. CMS is now tasked with revising Medicare Benefit Policy Manuals and numerous other documents 5. CMS is responsible for educating beneficiaries as well as providers regarding this clarification in policy 2

3 Settlement Explanation - CMS The Settlement Agreement - No Expansion of Medicare Coverage: The Jimmo v. Sebelius settlement agreement itself includes language specifying that Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage. The settlement agreement is intended to clarify that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration. As such, any actions undertaken in connection with this settlement do not represent an expansion of coverage, but rather, serve to clarify existing policy so that Medicare claims will be adjudicated consistently and appropriately.

4 Jimmo v. Sebelius What does the Jimmo settlement mean: The determining issue is whether the skilled services of a health care professional are needed not whether the beneficiary will improve. These services are provided by or under the supervision of skilled personnel and are covered by Medicare if the services are needed to maintain the individual s condition or prevent or slow their decline The goal of this settlement agreement is to ensure that claims are correctly adjudicated in accordance with existing Medicare policy, so that Medicare beneficiaries receive the full coverage to which they are entitled. Jimmo v. Sebelius Fact Sheet, accessed

5 Jimmo v. Sebelius Jimmo applies to the following settings under both Medicare Part A and Part B? Skilled Nursing Facility/Long Term Care 42 CFR (c), the level of care criteria for SNF coverage specify that the... restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. Home Health Outpatient Therapy coverage of therapy does not turn on the presence or absence of a beneficiary s potential for improvement from the therapy, but rather on the beneficiary s need for skilled care. Jimmo v. Sebelius Fact Sheet, accessed

6 Jimmo v. Sebelius The key component for coverage for maintenance therapy is that the services must be skilled meaning that the services must require the skills of a nurse or therapist. The complexity of patient needs and the risk to the patient while participating in the treatment or therapy service have a direct correlation to the skill sets required of the individual providing the service. Documentation of services provided should always be comprehensive, objective, and clearly define why the services are skilled in nature, require the skills of a nurse or a therapist and meet medical necessity requirements. 6

7 Next Steps CMS is required to finalize and issue the revised manual provisions provide education within one year of the approval date of Jimmo. All professional organizations are working to encourage CMS to accelerate this timeline. We have been providing the skilled maintenance care for our patients to date, Jimmo helps address rule of thumb denials related to the so-called improvement standard. It is important for us to note Jimmo is a clarification of current policy 7

8 MANUAL MEDICAL REVIEW APRIL 2013 CHANGES Glenda Mack, Division Vice President Clinical Operations

9 What happens with the Recovery Auditor Process and MMR? Effective April 1, 2013, the Recovery Auditors will conduct review for all claims processed on or after April 1, Recovery Audit Pre-payment Review: Post-payment Review: Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri. MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor. The Recovery Auditor will conduct manual medical review within 10 business days of receiving the additional documentation The Recovery Auditor will notify the MAC of the payment decision. Recovery Auditor will issue a detailed results letter to the provider MAC will issue the demand letter to the provider if a denial determination is made In the remaining states, CMS will grant an exception for all claims with a KX modifier and pay the claim upon receipt. The Recovery Auditors will then conduct postpayment manual medical review on the claim. In these states, the Recovery Auditor will request additional documentation and Recovery Auditor will conduct post-payment review and will notify the MAC of the payment decision. Recovery Auditor will issue a detailed results letter to the provider MAC will issue the demand letter to the provider if a denial determination is made

10 Additional Information Key Points: January 1 March 31, 2013 all Manual Medical Review of Claims was handled through a prepayment review process with the MAC. Nothing has changed with submission of claims between the $1900 therapy cap and the $3700 threshold the KX modifier still applies. The RAC process for MMR begins for all claims processed beginning April 1, 2013 that exceed the $3700 threshold. Providers located in a prepayment demonstration state that are serviced by the primary MAC in that state will have prepayment review conducted. Providers located in a prepayment demonstration state that are serviced by another MAC will have post-payment review conducted. The provider location and the MAC will determine the type of review. All four Recovery Auditors use the esmd system. The Recovery Auditors also accept fax, mail and CDs. Recovery Auditors have claim status portals where information such as if the additional documentation has been received and if the review results letter has been issued is posted. Providers using the PWK segment may expedite claim review process. Review/Downloads/FAQ_OutpatientTherapy_ pdf

11 What happens if a claim is denied? 1. Findings Letter 2. Rebuttal Process 3. Demand Letter 4. Standard Appeal Process

12 Rebuttal Process FINDINGS LETTER - explains the RAC s reasons for claim denial and the plan for recoupment of paid funds. REBUTTAL provider can submit a statement within 15 days of findings letter. (You must use the RAC form) This is the providers chance to submit any additional documents that may have been inadvertently left out of the initial packet. The RAC will complete an additional review This process is completed at the facility level by the facility team with assistance from the ADO.

13 RAC denied the claim, now what? As soon as the response is received, the Program Director should work with the facility team to prepare the Rebuttal response as appropriate, remember this is the chance to submit records that may have been omitted The RAC has a specific form to use in your response use it as your format for response State in 1-2 paragraphs why this claim needs to be paid Attach pertinent items noted as missing or incomplete If need be, attach signed attestation statements to rectify a perceived error or omission Monitor the mail for the Rebuttal Response and/or the DEMAND LETTER Notify the RehabCare appeals department using our standard process, we help you manage through this.

14 DEMAND LETTERS Whether or not the provider responds timely to the FINDINGS LETTER, an automatic DEMAND LETTER from the MAC is sent demanding recoupment for that claim s payment. Sometimes, even before the provider has received a response to their rebuttal, a DEMAND LETTER will arrive. Do not wait for the rebuttal response before responding to the Demand letter. MAC may initiate the Demand and Recoupment process because the MAC is responding automatically to the initial Findings letter.» There is a presumption that the reviewers will prevail for some types of audits. The DATE on the DEMAND LETTER is CRUCIAL this is the date that starts the clock on the appeal process Please ensure you have notified the RehabCare appeals team immediately

15 How do I respond to a Demand Letter? Once the demand letter arrives, the provider must start the appeal process by requesting a REDETERMINATION Redeterminations cannot be requested before you receive a demand letter. If you attempt to request a redetermination based upon the findings letter, the claim will be dismissed REDETERMINATION request - must be date-stamped in the Medicare contractor s mailroom by day 30 from the date of the demand letter in order to stop recoupment IF not received within 30 days, Medicare can begin to recoup on the 41 st day from the date of the demand letter The provider has 120 days to request REDETERMINATION and initiate the Standard Appeal Process

16 Appeal Time Frames Level Provider Time to Respond Payer Time to Respond* ADR/RAC request 30 days 30 days Redetermination Reconsideration 120 days 180 days (30 days to stop recoupment) (60 days to stop recoupment) 60 days 60 days ALJ 60 days 90 days *Currently the contractors are not meeting statutory timelines. 16

17 What if the Appeal is Unfavorable? Whether or not the provider appeals to the ALJ, or higher, the Medicare contractor will continue to recoup until the debt is satisfied in full If the provider is unable to prevail, Medicare will collect interest on the monies if the provider stopped recoupment. Conversely, if the provider wins, Medicare will owe interest to the provider for the time the monies were withheld

18 FUNCTIONAL REPORTING G-CODES Matt Sivret, Division Vice President Clinical Operations

19 RehabCare G-Code Training Middle Class Tax Relief and Job Creation Act of 2012 requires a claims-based data collection system of patients function during the course of PT, OT, and SLP services Required for all beneficiaries with Medicare Part B and All patients with Medicare Part B as a secondary payer Required for all Claims submitted on or after July 1, 2013 Functional data is captured through submission of G-Code (HCPCS codes) plus a Modifier on a claim

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22 Important Items to Review Payer verification Medicare Part B primary and secondary payers Claims will be Returned/Rejected without G codes and modifiers Timely billing All claims submitted after July 1 require codes and modifiers G codes required at specific intervals Eval (When eval codes billed, G-codes required) By 10 th visit or with Recertification Planned discharges

23 G-Code Reference Information Additional CMS Resources Refer to Functional Reporting National Provider Call presentation Education/Outreach/NPC/Downloads/FunctionalReportingNPC.pdf Transmittal Guidance/Guidance/Transmittals/Downloads/R2622CP.pdf

24 Questions?