1 THE UPSIDE OF MEDICARE AUDITS - resourcenter.net UPSIDE OF 1 MEDICARE AUDITS TARA MONDOCK VP OF...
Transcript of 1 THE UPSIDE OF MEDICARE AUDITS - resourcenter.net UPSIDE OF 1 MEDICARE AUDITS TARA MONDOCK VP OF...
THE UPSIDE OF 1
THE UPSIDE OF MEDICARE AUDITSTARA MONDOCKVP OF GOVERNMENT PROGRAMS & PAYER RELATIONSIVANS, INC.
AHIA 31st Annual Conference – August 26-29, 2012 – Philadelphia PAwww.ahia.org
Overview: Submitting Medical Documentation Electronically to MedicareDocumentation Electronically to Medicare
Today’s Agenda
Presentation Objectives
Background on Improper PaymentsBackground on Improper Payments
Medical Documentation Process
CMS esMD Program
esMD Demo
Medicare Review Contractor Perspective on esMD
Current and future use cases for esMD
Question & Answer
2If you experience any technical difficulties during the webinar, please call 203.698.7230
AcronymsyAcronym Term
ADMC Ad d D f M d CADMC Advanced Determination of Medicare Coverage
ADR Additional development or documentation request
CERT Comprehensive Error Rate Testingp g
CMS Centers for Medicare and Medicaid Services
DRG Diagnosis-related group
esMD Electronic Submission of Medical Documentation
FFS Fee for service
HIH Health Information Handler
IT Information Technology
MAC Medicare Administrative Contractor
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Acronymsy
Acronym TermAcronym Term
NHIN National Health Information Network
ONC Office of National Coordinator
PERM Payment Error Rate Measurement
RA Recovery Auditor
TPL Third Party LiabilityTPL Third Party Liability
ZPIC Zone Program Integrity Contractor
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esMD Presentation Objectivej
Increase provider awareness of Medicare Audits Increase provider awareness of Medicare Audits and the esMD PlatformHighlight the esMD use cases and positive workflow Highlight the esMD use cases and positive workflow implicationsProvide a forum for open discussion about the Provide a forum for open discussion about the Medicare Audit and esMD initiatives
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Background on Improper Payments
M di h b i l f h f d l ki Medicare has been consistently one of the top federal programs making improper payments
CMS has deployed review contractors to conduct audits of Medicare payments to healthcare providersto healthcare providers
Medicare receives 4.8 M claims per dayClaim review contractors issue over 1 million ADR requests each year
Improper payments include: Improper payments include: Incorrect payment amountsIncorrectly coded servicesNoncovered services (services that are not reasonable and necessary)Duplicate services
CMS has created a new division solely focused on program integrity including improper payments and fraud and abuse
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Audits are Big Business for the Government Government
The CMS Office of Financial Management estimates that each year g ythe Medicare FFS program issues more than $34.3 B in improper payments
$1 03 B found in Medicare improper payments during Recovery $1.03 B found in Medicare improper payments during Recovery Audit Demonstration Project in six states between 2006-2008
96% in overpayments
4% i d4% in underpayments
The Recovery Audit Program is now permanent and nationwide
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Different Types and Sizes of Hospitals Reported are Subject to RAC ReviewReported are Subject to RAC Review
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Percent Reporting RAC Activity vs No RAC Activity Percent Reporting RAC Activity vs. No RAC Activity by Type of Participating Hospital, through 1st Quarter 2012Quarter 2012
Number of RAC Audits Performed is on th Rithe Rise
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Number of Participating Hospitals Reporting RAC Number of Participating Hospitals Reporting RAC Activity by Region, through 1st Quarter 2012
Providers Continue to Report Dramatic Increases in RAC Denials and Medical Record Requestsin RAC Denials and Medical Record Requests
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Reported Automated Denials, Complex Denials and Reported Automated Denials, Complex Denials and Medical Records Requests by Participating Hospitals, through 1st Quarter 2012p , g
Number of Medical Records Requested i I i is Increasing
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Providers are at Risk to Loose Millions f D llof Dollars
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$4.3 billion in Medicare payments were targeted $4.3 billion in Medicare payments were targeted for medical record requests through the 1st quarter of 2012
The average value of a medical record t d i l irequested in a complex review
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Average Value of a Medical Record Requested in a Average Value of a Medical Record Requested in a Complex Review Among Hospitals Reporting RAC Activity, through 1st Quarter 2012y, g
The Hunt for Improper Payments is Ongoing and ExpandingOngoing and Expanding
The Prepayment Review demo will allow Medicare Recovery p y yAuditors to review claims before they are paid
Preventing improper payments rather than the traditional “pay and chase” methods of looking for improper payments after they occurchase methods of looking for improper payments after they occur
These reviews will focus on seven states with high populations of fraud- and error-prone providers
FL, CA, MI, TX, NY, LA, IL
And four states with high claims volumes of short inpatient hospital stays y
PA, OH, NC, MO
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Providers Can Receive Audits From Many Types of Review Contractors
Review Contractors include:
Types of Review Contractors
1. RA – Recovery Auditor (Post-Payment and Pre-Payment NEW)
2. MAC – Medicare Administrative Contractor (Pre-Payment)
3. CERT – Comprehensive Error Rate Testing program• Review Across All MAC Jurisdiction with focus on incorrect coding of claims,
DRG upcoding or downcoding, and medical necessity
4. PERM – Payment Error Rate Measurement program• A claim is reviewed to determine if it was processed correctly, and the
services were actually provided, medically necessary, coded correctly, and y p , y y, y,properly paid or denied.
5. ZPIC – Zone Program Integrity Contractor• Fraud and Abuseaud a d buse
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Providers are Subject to an Audit by R A dit E 45 DRecovery Auditors Every 45 Days
• All providers that bill Medicare and Medicaid are eligible to be audited by various Review Contractors
Audits often require medical documentation to support claims
Hi t i ll th d t ti ld l b il d ( ith i Historically, the documentation could only be mailed (either paper copies or on CD/DVD)
The amount of paperwork submitted in 2010 by the average hospital was p p y g psignificant
150 di l d 225 f di l 150 medical record requests every audit cycle (45 days)
225 pages of medical documentation per request
33,750 total pages submitted on average
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Today’s Audit Request and Response PProcess
R i C t t
Doc’ n Request
Time and money that could be Review ContractorLetter better spent
delivering higher quality
healthcare
No record of receipt
P
Provider
Paper Medical Record Printing and shipping costs
Administrative burdens
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Provider
Providers Can Use Many Tools to Improve the Audit ExperienceImprove the Audit Experience
Audit preparationAudit preparationHire external consultants to do an audit and gap analysis
Analyze past audit results to uncover areas for improvement in processes d d t tiand documentation
Organize a multi-functional team with an audit process champion to lead audit preparation and response
Audit managementBuild or buy software tools to assist with the audit response process
D t tDocument management
Release of information
Electronic submission
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CMS Built the esMD Gateway To Address The Administrative BurdensThe Administrative Burdens
• CMS has built an Exchange Gateway to accept esMD transactions from providersfrom providers.
• The CMS esMD gateway went live in September 2011.
• CMS uses the “CONNECT” brand of gateway
Exchange
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The Nationwide Health Information N t kNetwork
• Set of standards, protocols, legal agreements, and specifications that a consortium of health information organizations have agreed are necessary for secure and private exchange of health information over the public internet.
• Overseen by the ONC for Health IT
Ensures that esMD transactions are SAFE and SECURE as they y
travel from point A to point B.
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Providers Have Two Options for Accessing the esMD GatewayAccessing the esMD Gateway
Build your own esMDGateway
Engage an HIH
A Health Information Handler (HIH) is any company that handles company that handles health information on behalf of a provider
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esMD – How Does it Work?
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HIH’s are Simplifying the Audit Submission Process for ProvidersProcess for Providers
Medical record requests are sent to providers through the mail, responses are returned to Review Contractors electronically
Providers upload files into the IVANS AuditDocs application, files then sent securely to Review Contractor using NHIN standards
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esMD DEMOesMD DEMO
Electronic Submission in 4 Easy Stepsy p
1. Enter the audit information from the letter you received from the review contractor
2 E t i l i i f ti tt h d t th dit2. Enter in claim information attached to the audit
3. Attach supporting medical documents to appropriate claims
4. Click submit you have successfully completed your electronic submission of medical documentation
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AuditDocs UI – Case/Claim ID Fields t d f ADR l ttare entered from ADR letter
If Case ID is found in the ADR Letter; this is not a required field
For RAC Audits, the A di ID ill b d Audit ID will be noted; for MAC Audits, the ‘Claim ID’ will generally also be the ‘Case ID’
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Completion of Workflow: Creating a N D tNew Document
Once the Metadata is entered, the user will proceed to the file upload part of the process – click on ‘New Document’
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Completion of Workflow: File Uploadp p
The user will ‘Browse’ and ‘Assign’ the documents
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Audit Trail Provides A Return Receipt Confirming Documents Were Sent By Provider & Received by Contractor
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Reporting Provides Tracking C bilitiCapabilities
The ‘Search’ function allows the user to conveniently retrieve data on past audits, by applying various filters and then clicking ‘Search’various filters, and then clicking Search
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From the Providers From the Providers Perspective
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Providers Using esMD Appreciate its P iti I t W kflPositive Impact on Workflow
“When we previously received an Additional W p v y vDocumentation Request (ADR) from CMS, we had to research, print and make copies of each document for h l l d h h h h that particular claim and then ship everything to the review contractor. Now, we just scan in our documents and upload everything, saving us hundreds of dollars in upload everything, saving us hundreds of dollars in shipping and labor charges, and freeing up our staff to focus on more pressing healthcare responsibilities.”
Anthony Pryce, President of American Home Health Agency
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From the Review C t t P tiContractor Perspective
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The Review Contractor Perspective on MDesMD
Reduces workloads for the provider cutting down Reduces workloads for the provider cutting down on printing and shipping costs
Quicker response time due to faster delivery
Fewer denials due to missing filing deadlinesFewer denials due to missing filing deadlines
Fewer appeals
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The Submission of Medical Documentation is Only the BeginningDocumentation is Only the Beginning
Ph 1 Phase 1: Doc’n
Request Letter
Live September, 2011
electronic
electronic
Phase 2:
Live 2013
electronic
Live 2013
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From the CMS Perspectivep
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Current and Future Use Cases for esMD
hINBOUND We
are here
N OUN•Responses to Documentation Request Letters in PDF •Appeal Requests in PDF •Unsolicited Documentation in PDF (called paperwork or “PWK”) S d O d P N ADMC R •Structured Orders, Progress Notes, ADMC Requests
•Structured esMD Phase 2 Registration
OUTBOUND •Structured Outbound Documentation Requests •Review Results Letters •Demand Letters
LOOKUP •Request\Receive Documentation Status •Request\Receive Claim Status •Request\Receive Appeals Status •Request\Receive Eligibility Info
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CMS Resources
• Articles– Medicare Learning Network (MLN) Special Edition Article
SE1110, “Medicare Pilot Project for Electronic Submission of Medical Documentation (esMD)”
http //www cms gov/MLNMattersArticles/downloads/SE1110 pdfhttp://www.cms.gov/MLNMattersArticles/downloads/SE1110.pdf– MLN Matters Article MM7254, “Additional Fields for
Additional Documentation Request (ADR) Letters”http://www.cms.gov/MLNMattersArticles/Downloads/MM7254.pp // g / / / pdf
• Web www.CMS.gov/esMD– Explanation of esMD concepts and terms
Li t f M di i t t ti MD – List of Medicare review contractors accepting esMD transactions
– List of CMS-approved HIHs– Frequently asked questionsFrequently asked questions
Alabama Quality Improvement
Alaska Quality Improvement
Arkansas Quality Improvement
Organization Organization Improvement Organization
MedicareRecovery
Auditor Contractor (RAC) PERM Central
Unit
Medicare Secondary
Payer Review
Contractor(MSPRC)
Medicare Part D
Review Contractors (MEDICs)
Medicare Part C
Review Contractors
(RADV)
Medicare Administrative
Contractors (MAC) Unit (MSPRC) (MEDICs) (RADV)(MAC)
CMS Private Network
Content Transport Services
ECM
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Exchange
For More Information
CMS esMD Web site:
http://www.cms.gov/esMD
Learn about IVANS http://www.ivans.com
IVANS AuditDocs™
http://www.ivans.com/auditdocs
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Thank YouThank YouQuestions From the Audience
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Save the Date: August 25-28 2013August 25-28, 2013
32nd Annual Conference Chi ILChicago, IL
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