RAC Audits and Denials

Management

WHCA Fall Conference

September 9, 2014

JoLynn Munro, MS,OTR/L,

Regional Vice President Infinity Rehab

Carolyn Staples, CCC/SLP,

Area Rehab Director Infinity Rehab

Objectives

• Overview of the levels of the Medicare Appeals Process and procedures for appealing claims denials

• Understand appeal letter content • Understand the components of quality therapy

documentation • Understand how to implement a quality

response and tracking system for Additional Development Requests and Denials

• Identify opportunities to enhance the quality of your rehab documentation

How Did We Get Here?

• OIG Report: 2009

– Recommendations: Increase and expand reviews

– Use Fraud Prevention System to identify SNFs that are Billing for Higher Paying RUGs

– Monitor Compliance with the New Therapy Assessments (COT and EOT)

• MACs and RACs to closely monitor SNFs utilization of these assessments

– Education to all SNFs to improve accuracy of MDS

Medicare Administrative Contractors

CMS

Enroll Health Care Providers

Educate Providers on Billing

Requirements

Answer Provider and Beneficiary

Inquiries

MAC

Primary Operational Contact

MACs

Primary Contact Between

• Medicare 1.5 Million Providers

4.9 Million Medicare Claims/day

$365 Billion dispersed Annually

MAC 2013 Review

• MACs processed over 208 million Part A claims

– 15 million were denied

• MACs processed 831,000 Part A redeterminations

• Only 5.6% of denials resulted in requests for appeals

• Med B

– Similar results: only 2.9% of denials resulted in requests for an appeal

Health Care Reality

• If you bill fee-for-service programs, your claims will be subject to review by the Recovery Auditors

• Target Areas posted on the RACs websites

Recovery Auditor Contractors (RACs)

• The RACs are responsible for:

– Review

– Identifying improper claims

– Collection of overpayments

– Identification of underpayments

What Does A Recovery Auditor Do?

• Post – pay review

• Medicare Policies

• 3 Year Look Back

• Multi disciplinary staff

What Does A Recovery Auditor Do?

• Three types of review: oAutomated:

o No medical record needed

o Semi-Automated : o Claims review using data and potential human review of a

medical record or other documentation

oComplex: o Medical record required

RAC Distribution

CMS Updates

• August 4, 2014 –

– CMS initiating contract modifications to current RACs

– Allows RACs to restart some reviews

– Most will be automated with a limited number of complex reviews of topics selected by CMS

CMS Update

• 9/2/2014: CMS Offers Settlement to Acute Care Hospitals and CAHs to Resolve Appeals of Patient Status Denials

– Quickly reduce volume of ALJ claims for Critical Access Hospital and Acute Hospital

– Alleviate the burden of current appeals on both the Hospital and the Medicare System

CMS Updates

• Breaking News: 9/3/14

– Federal Court of appeals “enjoined CMS from awarding new contracts for the recovery auditor contractors (RAC), pending appeal by incumbent RAC CGI to the court of appeals”

– Process likely to take 12 months

– Speculation that CMS will forgo procurement process during review of CGI case and extend active auditing with incumbent RACs

Medical Reviews

• Significant increase in number of reviews

• Determination decisions are based on the content of the medical record

– Therapy documentation

– Nursing documentation

– Services coded on the MDS

– Services billed on the UB-04

Avoiding Denied Claims

• Strong Facility Processes

• Ongoing Education

• Ongoing Regulatory Update Knowledge

• Frequent Medical Record Review/Spot Checks

– Therapy Notes

– Nursing Supporting Documentation

Denials Management

What we have learned –

• RAC Auditors are focusing on the combination of:

– LOS >30 days and

– High RUG (UH)

• Must justify why it takes the skills of the therapist/nurse to provide services

• Incomplete Documentation submitted

What do I do if I get an ADR?

• Thoroughly read the ADR or denial letter

• Assign a lead to oversee the preparation and communication

• Work as a team to gather pertinent information

– Beware of Turnover

• Review the medical record

• Review items listed that need to be included in the appeal/ADR

What do I do if I get an ADR?

• Respond Timely with complete documentation

• Track each ADR and outcome

• Manage audits

• Communicate

• Keep a copy of the packet sent

• Tab each section for better organization

6 Key MAC Appeal Steps

1. Highlight skilled care provided

2. Review the entire record

3. Include documentation from the denied period including the look back period

6 MAC Appeal Steps

4. Write a formal narrative summary

5. Proactive daily nursing documentation

6. Quality therapy documentation with daily modalities and weekly summaries of medically necessary and skilled services provided.

Appeal Packet

• Certs/Recerts

• Hospital H & P with supporting documentation of qualifying stay

• MDS documentation support

• Daily Nursing documentation

• ALL therapy logs for the period under review

• Mail early to allow for processing

Appeal Checklist

Appeal Checklist Completed

Include the following in this exact order:

Copy of RAC Letter

Copy of UB -04 for time period being reviewed

Copy of MDS (s) that cover the UB-04 for time period reviewed/signed by all disciplines and RN on the day interviews completed

If Therapy RUG Score:

Therapy Eval for Each Discipline

Therapy Grids with Minutes of therapy for the ARD time Period including look back (Sect O support)

Therapy Daily Notes for this time frame and D/C summaries

POC notes that back up Section G for the time period being reviewed or any supporting nursing notes

H&P, if “X” or “L” billed, highlight IV Med, IV Fluid, etc

Hospital Documentation

D/C Summary, H & P, Hospital Transfer Form, Hospital MAR’s, Consultations

Appeal Checklist Completed

SNF Information

Cert/Recert

Admission Orders

Physician Orders

Physician progress notes

Nursing Admission Database and Progress Notes

MAR’s

IV Records, TPN, Tube Feeding, TAR’s, Coumadin, Diabetic records, Skin Care/Wound treatment (Supports section K & O—from hospital if applicable)

Respiratory or O2 Records, Lab or X-Ray results

Care Plan and CAA’s

Documentation to support ADL coding in Section G

Verify

RUG Rate matches billed rate on UB - 04

Z0500B within 14 days of ARD

OMRAs completed when necessary and within appropriate time frames

Interviews completed (not dash filled)

Documentation present to support diagnoses coded in Section I

Documentation present to support Shortness of Breath in Section J

Formal Narrative Letter Outlining Skilled Services Required

RAC Appeal Process

• Same appeal process as for MAC denials

• RAC Discussion Period vs. the Appeals process

– Discussion letter

– Appeal

• If you disagree with the Recovery Auditor’s determination: – Do not stop with sending a discussion letter

– File an appeal before the 120th day after the Demand letter.

Denials Management

RAC Audit – “Discussion Period”

• First step in the appeals process

• Develop a letter of response ASAP and return within 10 business days of receiving initial denial letter

5 Levels of Claims Appeal Process

1. Redetermination

2. Reconsideration

3. ALJ

4. Appeals Council

5. Judicial Review

Appeal Status Info

• You can access information online through your MAC

– Obtain Current Status of Claim

– Obtain Decision and Decision Date

– Obtain how the appeal was handled

Common Reasons for Denials

• Documentation does not support RUG billed

• Documentation does not support that services were reasonable and necessary

• Documentation does not support that services were required on a inpatient basis as practical matter

Composing the Response to the Denial

• Carefully Read the Denial Notices and any responses to Appeals

• Address reason(s) for Denial

• Cite how the documentation meets the requirements found in Chapter 8

Tracking Tools

• Review at Least Weekly

• Track ARD dates

• Track Dates ADR packet sent to RAC or MAC

• Track Date of Denial or Notification of Overpayment

• Track Due Dates, Dates Appeal Sent and Responses/Outcomes

• Separate Appeals per claim Number

Denials Tracking Tool

Therapy Documentation

• Therapy evaluation

• Progress notes

• Daily notes

• Orders

• Questions?