How To Get A National Rac (And Mac)

Transcription

1 7 th National RAC (and MAC) Summit December 5 6, 2012 Washington, DC Jane Snecinski P.O. Box Atlanta, GA

2 National client base (both public and private sector) based in Atlanta, GA Focused on the unique needs of the post acute continuum of care Inpatient and outpatient rehabilitation Skilled Nursing Long term acute care hospitals Scope of Experience Hospitals/health care systems & Physicians Compliance/medical necessity audits, corrective actions, appeal assistance Training and Education 2

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4 Connolly 580 issues HDI 540 Issues CGI 220 Issues DCS/PR 560 Issues 4

5 Inpatient Rehabilitation Medical Necessity Complex/medical necessity reviews (HDI, Connolly) Late submission PAIs semi-automated review (CGI, HDI, DCS/PR) Incorrect patient discharge status (HDI) Hospice Marketing and relationships with LTC providers 5

6 Skilled Nursing Facilities and Nursing Homes Mandatory compliance and ethics program that is effective to: prevent and detect criminal, civil and administrative violations; and Promote quality of care Visit to patients in Nursing Facilities (physicians) (Connolly) Ambulance transport during a SNF stay (Connolly) Excessive Units SNF 30 and 60 day assessments (HDI) - Automated CT scans (DCS/PR) - Automated Vitamin D Assay Testing (DCS/PR) - Automated 6

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8 RACs Limited requests for medical records Relatively small number Most denials are being appealed (with success at the ALJ level) MACs Probe audits No strong evidence of trends being pursued ZPICS Significantly larger number of records requested Medicaid RACs Limited requests for medical records 8

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10 Who Can Extrapolate? RACs ZPICs What is Extrapolation Random sample of records requested Trends identified Trends extended to larger number of records (not reviewed) Dollars recouped reflect the larger number of records, including those not reviewed 10

11 100 Inpatient Rehabilitation records requested/reviewed 80 found to not clearly demonstrate medical necessity of admission (80%) 80% of all records for a given period of time denied 564 patients admitted during the identified period of time 80% patients Average reimbursement - $13,364 $6 M recoupment requested 11

12 Total number of IP rehab beds = 15 ADC = 5 Inaccurate scoring identified in a majority of 50 records Reassignment of payment categories (CMGs) resulted in inaccurate payment having been received in some records No trends noted 200 additional records reviewed Approximately $250,000 identified in overpayments Repaid MAC It would be an undue hardship to have to review all patients admitted in the past X number of years 12

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14 Jane Snecinski Post Acute Advisors P.O. Box Atlanta, GA (P) (F)

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16 Diversified Collection Services, Inc./Permanent Recovery CGI Technologies and Solutions, Inc. A * D B C HealthDataInsights, Inc Connolly Consulting Associates, Inc. 16

17 RAC Website E mail Telephone Number Region A: Diversified Collection Services States: CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI and VT. [email protected] Region B: CGI States: IL, IN, KY, MI, MN, OH and WI. [email protected] Region C: Connolly, Inc. States: AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico and U.S. Virgin Islands. m/rac RACinfo@connollyhealthca re.com Region D: HealthDataInsights States: AK, AZ, CA, HI, ID, IA, KS, MO, MT, ND, NE, NV, OR, SD, UT, WA, WY, Guam, American Samoa and Northern Marianas. sights.com racinfo@ hdi.com Part A: Part B:

18 Zone Geographic Area 1 American Samoa, California, Guam, Hawaii, Mariana Islands, Nevada 2 Alaska, Arizona, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming 3 Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin 4 Colorado, New Mexico, Oklahoma, Texas 5 Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, West Virginia 6 Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont 7 Florida, Puerto Rico, U.S. Virgin Islands