7 th National RAC (and MAC) Summit December 5 6, 2012 Washington, DC Jane Snecinski P.O. Box 12078 Atlanta, GA 30355 www.postacuteadvisors.com
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 www.postacuteadvisors.com 2
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Connolly 580 issues HDI 540 Issues CGI 220 Issues DCS/PR 560 Issues www.postacuteadvisors.com 4
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 www.postacuteadvisors.com 5
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 www.postacuteadvisors.com 6
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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 www.postacuteadvisors.com 8
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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 www.postacuteadvisors.com 10
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% - 451 patients Average reimbursement - $13,364 $6 M recoupment requested www.postacuteadvisors.com 11
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 www.postacuteadvisors.com 12
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Jane Snecinski Post Acute Advisors P.O. Box 12078 Atlanta, GA 30355 (P) 678-472-0556 (F) 404-420-2200 Jane.snecinski@postacuteadvisors.com www.postacuteadvisors.com 14
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Diversified Collection Services, Inc./Permanent Recovery CGI Technologies and Solutions, Inc. A * D B C HealthDataInsights, Inc Connolly Consulting www.postacuteadvisors.com Associates, Inc. 16
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. www.dcsrac.com info@dcsrac.com 1 866 201 0580 Region B: CGI States: IL, IN, KY, MI, MN, OH and WI. http://racb.cgi.com racb@cgi.com 1 877 316 7222 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. www.connollyhealthcare.co m/rac RACinfo@connollyhealthca re.com 1 866 360 2507 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. http://racinfo.healthdatain sights.com racinfo@emailhdi.com Part A: 866 590 5598 Part B: 866 376 23 www.postacuteadvisors.com 17
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