Jennifer Leatherbarrow, RN, BSN, RAC-CT Carolyn Lookabill RISKY BUSINESS: A TEAM APPROACH TO CLINICAL AND BILLING COMPLIANCE

Transcription

1 Jennifer Leatherbarrow, RN, BSN, RAC-CT Carolyn Lookabill 1 RISKY BUSINESS: A TEAM APPROACH TO CLINICAL AND BILLING COMPLIANCE

2 Notice of Disclosure 2 Richter Healthcare Consultants has produced this material as an informational reference. Richter Healthcare Consultants employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the healthcare environment is constantly changing, and it is the responsibility of each individual to remain abreast of the regulatory and reimbursement compliance. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice.

3 Objectives for the Day 3 Participants will be able to: Name at least three compliance audit programs and describe primary focus area for each Identify three risk areas related to the Revenue Cycle Management process including Red Flag areas Describe methods of engaging IDT members in working together to achieve overall compliance Name five key components of the Triple Check process and how each discipline impacts the process

4 Where s the Risk? 4 Fraud, Waste & Abuse Audit Agencies Common OIG RA CERT ZPIC GAO Audit Agencies Not so Common DPOA NBI MEDIC SMRC PERM

5 Where s the Risk? 5

6 Where s the Risk? 6 OIG Priority Issues 2015 Maximize recovery of Medicare overpayments (2014) Medicare Part A billing by skilled nursing facilities Questionable billing patterns for Part B services during nursing home stays State agency verification of deficiency corrections Program for national background checks for long-term employees Hospitalizations of nursing home residents for manageable and preventable conditions

7 Where s the Risk? 7 Red Flags High therapy utilization High hospital re-admission rates High RUG scores High ADL s Antipsychotic drug use CMS Five Star Rating

8 Minimize the Risk 8 Focus on Compliance Corporate Compliance Plan Compliance Officer/authority Monitor compliance Think like an auditor Internal audit & tracking Identify trends Implement Corrective Action Plans

9 Minimize the Risk 9 Education OIG Work Plan False Claims Act HIPAA Documentation Care plans & discharge plans Patient-centered approach

10 A Team Approach 10 IDT Members Physician Nurse Managers MDS Coordinators Therapy Social Services Dietary Activities Administrator/ ED Business Office Medical Records Pastoral Care Certified Nursing Assistants NP/ PA

11 A Team Approach 11 Holistic Approach Care Planning The Facility is responsible for addressing all needs and strengths of residents regardless of whether the issue is included in the MDS or CAA s [42CFR483.20(b)]

12 A Team Approach 12 Holistic Approach Facility Cooperation and Communication Provide cross training on clinical and billing compliance issues Facilitate effective intra-facility communication Implement zero tolerance policy No Politics Allowed

13 A Team Approach 13 Documentation Supports skilled services Nursing Individualized, patient-centric Therapy Frequency & duration, measurable goals Supports billing

14 Monitor the Risk 14 COMPLIANCE PLAN Job descriptions include compliance responsibilities Quality Assurance Committee Watch dogs of compliance Report to Compliance Officer/authority Quality improvement initiatives Intra-facility participation Triple Check/Internal Audits

15 Monitor the Risk 15 THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISPREPRESENATION OR FALSIFICATION OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR CIVIL MONETARY PENALITES AND ASSESMENTS AND MAY UPON CONVICTION INCLUDE FINES AND/OR IMRISONMENT UNDER FEDERAL AND/OR STATE LAW(S). Submission of this claim constitutes certification that the billing information as shown on the face hereof is true, accurate and complete. That the submitter did not knowingly or recklessly disregard or misrepresent or conceal material facts. The following certifications or verifications apply where pertinent to this Bill: For Medicare Purposes: If the patient has indicated that other health Insurance or a state medical assistance agency will pay part of his/her medical expenses and he/she wants information about his/her claim released to them upon request, necessary authorization is on file. The patient s signature on the provider s request to bill Medicare medical and non-medical information, including employment status, and whether the person has employer group health insurance which is responsible to pay for the services for which this Medicare claim is made.

16 Monitor the Risk 16 What does your Triple Check Process look like? What preparation can be completed ahead of time? Weekly reviews Peer reviews Compile information prior to meeting Focus on MDS, cert/re-certs, diagnoses, care planning, etc. Telling the SAME story

17 Monitor the Risk 17 What your Triple Check Process should look like IDT, Admissions, Billing Office Meeting documentation Checklist Error tracking log Outcome tracking log MDS UB04 Chart Pre-submission

18 Monitor the Risk 18 Beneficiary verification Hospitalization and prior benefit utilization Validity of MDS information Service detail Diagnosis coding Physician certification

19 Monitor the Risk 19 Document outcomes Root cause analysis Error rate calculation Identify trends Focused internal audits Peer review Implement improvement plan QAPI

20 Mitigate the Risk 20 Ongoing education List-servs, MedLearn Matters, MAC Education, Medicare University, HCPro Team building Utilize available resources PEPPER, OIG Work Plan Trade association website & updates Member websites and newsletters, etc.

21 Recap 21 Participants will be able to: Name at least three compliance audit programs and describe primary focus area for each Identify three risk areas related to the Revenue Cycle Management process including Red Flag areas Describe methods of engaging IDT members in working together to achieve overall compliance Name five key components of the Triple Check process and how each discipline impacts the process

22 Resources 22 Centers for Medicare & Medicaid Services (CMS) Office of the Inspector General (OIG) Medicare University LeadingAge

23 Carolyn Lookabill 23 Phone: (216) Toll Free: Connect: LinkedIn and Facebook Web:

24 Jennifer Leatherbarrow, RN, BSN, RAC-CT 24 Phone: (216) Toll Free: Connect: LinkedIn and Facebook Web:

25 Contact Richter Healthcare Consultants Today! 25 Phone: (216) Toll Free: Fax: (216) Web: Connect: Linked In, Facebook Visit: 8948 Canyon Falls Blvd. Suite 400 Twinsburg, OH 44087