Medicare Madness 2014: What You Need to Know

March Medicare Madness: What You Need to Know

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)Presented by:

Kris Mastrangelo, OTR/L, MBA, LNHA President and CEO

Keri A. Hart, MS-CCC/SLP, RAC-CT, CHHRP-QT

Vice President of Clinical Operations/Education and Training

Harmony Healthcare International, Inc. 2

About Kris

Kris Mastrangelo, OTR/L, MBA, LNHA

Kris Mastrangelo, President and CEO, owns and

operates Harmony Healthcare International, (HHI)

an industry leader in Long Term Care consulting.

14,000 Medical records reviewed per year

Core Business Patient Centered

Follow Me! @KrisMastrangeloCopyright © 2014 All Rights Reserved

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About Keri

Keri Hart, MS-CCC, SLP, RAC-CT, CHHRP-QT

Keri Hart is the Vice President Clinical Operations/Education and Training at Harmony Healthcare International, (HHI) an industry leader in Long Term Care consulting.

Over 25 Years Experience in Long-term

Care

Rehabilitation Management

MDS

Follow Me! @CHHRPHart

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March Madness

Disclosure: The planners and presenters of this education activity have no relationship with commercial entities or conflicts of interest to disclosePlanners:

Elisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTKeri Hart, MS-CCC/SLP, RAC-CT, CHHRP-QT

Presenters: Kris Mastrangelo, OTR/L, MBA, LNHA Keri Hart, MS-CCC/SLP, RAC-CT,

CHHRP-QTCopyright © 2014 All Rights Reserved

Objectives

The learner will be able to:Identify CMS and OIG documents impacting Medicare in a Skilled Nursing Facility (SNF) Discuss the importance of the PEPPERDiscuss the impact of delays in Medicare appeals processDiscuss highlights of the 2014 OIG Work Plan

Harmony Healthcare International, Inc. 5Copyright © 2014 All Rights Reserved

SNF PEPPER

SNF PEPPER

TMF Health Quality Institute has announced that effective January 1, 2014 it will no longer resend copies of SNF PEPPERs (version Q4FY12) which were initially mailed to all Skilled Nursing Facilities on August 30, 2013


SNF PEPPER

The next SNF PEPPER (version Q4FY13) will be distributed in late April – early May 2014, and will be available for access in an electronic format by the Skilled Nursing Facility’s CEO/ Administrator/President TMF will send an email notification when the Q4FY13 SNF PEPPERs are availableIn order to receive this notification, facilities must sign up for notifications on the TMF websiteHarmony Healthcare International, Inc. 8Copyright © 2014 All Rights Reserved

PEPPER

PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper paymentsAllows providers to see how their facility compares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdiction. PEPPER data is also shared with both Medicare Audit Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs)


PEPPER

Expect the report to include the following comparative data:

Therapy RUGs with High ADLs Non-Therapy RUGs with High ADLs Change of Therapy AssessmentRehab RUG UtilizationRehab Ultra High Utilization90 Day+ Episodes of care


Take Away Nuggets

Ensure you are signed up to receive access to your SNF PEPPERReview with the TeamObtain a Harmony PEPPER Analysis


Jimmo v. Sebelius Settlement Agreement


CMS Released updated Fact Sheet (December 2013) “Jimmo v. Sebelius Settlement Agreement Program Manual Clarifications Fact Sheet”Released pursuant to the terms of the Jimmo v. Sebelius Settlement AgreementCMS must have completed manual revisions and “educational campaign” by January 23, 2014



Also CMS has “decided to use this opportunity to introduce additional guidance in this area, both generally and as it relates to particular clinical scenarios” CMS Webinar complete December 2013 and is available at http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2013-12-19-Jimmo-vs-Sebelius.html


http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2013-12-19-Jimmo-vs-Sebelius.html





Revised portions of the relevant chapters of the program manual used by Medicare contractors to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. SebeliusTransmittal 176, dated December 13, 2013, is being rescinded and replaced by Transmittal 179, dated January 14,2014 to correct an error in Chapter 8, Section 30.4.1.1.was sent to http://www.cms.gov/Regulations-and Guidance/Guidance/Transmittals/Downloads/R179BP.pdf


http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf


The revisions in Transmittal 176 incorrectly indicated that skilled physical therapy services in the skilled nursing facility (SNF) setting must “…require the skills of a qualified therapist (not an assistant) for the performance of a safe and effective maintenance program.” The regulations under 409.32(a) and (b) do not specify that an assistant cannot perform maintenance services in the SNF setting, unlike the home health and outpatient regulations which do make that distinction. Therefore, this updated transmittal corrects that particular language to eliminate the phrase “(not an assistant)”.


Take Away Nuggets

Ensure all Staff responsible for making Medicare Coverage Determinations read Chapter 8 of the Medicare ManualReview JIMMO Webinar provided by CMSTherapist Review of Chapter 15 Medicare Part B Update


Centers for Medicare & Medicaid Services (CMS) revised Chapter 8 “Coverage of Extended Care (SNF) Services Under Hospital Insurance” with implementation on January 7th 2014

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Overview of Changes

Chapter 8 "Medicare Benefit Policy Manual" (MBPM) now clarifies key components of SNF coverage requirements pursuant to the settlement agreement in the case of Jimmo v. Sebelius Also CMS has “decided to use this opportunity to introduce additional guidance in this area, both generally and as it relates to particular clinical scenarios”


Overview of Changes

The revised Chapter 8 now includes a new section (30.2.2.1) titled

“Documentation to Support Skilled Care Determinations”

which details the role of appropriate documentation in “facilitating accurate coverage determinations” for claims for skilled levels of care


Improvement Standard

“Improvement Standard” is not to be applied in determining Medicare coverage for maintenance claims in which skilled care is requiredMedicare has long recognized that even in situations where no improvement is expected, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition)


Importance of Chapter 8

This manual is the source document for making skilled coverage decisions and ensuring documentation supports the care providedRequirements detailed are for skilled rehabilitation and skilled nursing servicesSource document utilized by Medicare reviewers in detailing why a claim for skilled rehabilitation or nursing services is denied Harmony Healthcare International, Inc. 22Copyright © 2014 All Rights Reserved

Medicare Benefit Policy Manual, Chapter 8 (2014)-Rehabilitation Daily

Single type of skilled rehabilitation every day, or by furnishing various types of skilled services on different days that collectively add up to “daily” skilled services. “Arbitrarily staggering the timing of various therapy modalities though the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a “daily basis.” To meet this requirement, the patient must actually need skilled rehabilitation services to be furnished on each of the days that the facility makes such services available.” 23Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved

Take Away Nuggets

Skilled Chart ReviewsInterdisciplinary Documentation Process ReviewEnsure all Staff responsible for making Medicare Coverage Determinations read Chapter 8 of the Medicare Benefit Policy ManualEnsure daily skilled therapy requirements met (actually need skilled rehabilitation services to be furnished on each of the days)


RAI Manual/FY2014 Changes


Final Rule

On August 1, 2013, the Centers for Medicare & Medicaid Services (CMS) published the Final Rule for the Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) for FY 2014Effective October 1st, 2013 for FY 2014RAI Manual (November 05, 2013)

JIMMO Settlement Language, Section O (Sept)


Distinct Days of Therapy

Add MDS Item 00420 (Calendar Days of Therapy)

Distinct calendar days of therapyClarify that classification criteria for the Rehabilitation Medium RUG categories require that the resident receive 5 distinct calendar days of therapy (3 Low)

If not achieved, the RUG would reduce to a Nursing RUG

Applies to COT review and Management


Final Rule

Increased Lower 14 RUGsIncreased Nursing RUGs with Therapy involved

Clarification on Open Door Forum that COT Process Stops when RUG is Non-Therapy due to insufficient Minutes and days to meet a categoryPotential Default if completed when not required


Take Away Nuggets

Utilize Short Stay PolicyEnsure COT Rules are applied per ClarificationProvide RAI User’s Manual Section to Dietary, Therapy, and Social work to ensure instructions are followed


OIG Report: “Skilled Nursing Facilities

Often Fail to Meet Care Planning and Discharge Planning Requirements”

OIG Report

February 2013 OIG Report“Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Planning Requirements”This study is part of a larger body of work about SNF payments and quality of care

31Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved

OIG Study

Based this study on a medical record review of a stratified simple random sample of SNF stays from 2009

Sample of 190 stays that projects to 1,104,692 stays in the population83 stays in which the beneficiaries were discharged to another institutional setting

Reviewers determined the extent to which SNFs developed care plans that met Medicare requirements, provided services in accordance with care plans, and planned for beneficiaries’ discharges as required


OIG Findings

In 36.7 % of stays SNFs did not develop care plans that met requirements or did not provide services in accordance with care plans In 31 percent of stays SNFs did failed to meet discharge planning requirements Medicare paid approximately $5.1 billion for stays in which SNFs did not meet these quality-of-care requirements

Reviewers found examples of poor quality care related to wound care, medication management, and therapy


Percentage of Stays in Which SNFs Did Not Meet Discharge Planning Requirements, 2009

Discharge Planning Requirement

Percentage of Stays in Which SNFs Did Not Meet Discharge Planning Requirement

Summary of beneficiary’s stay and status at discharge

16.0%

Post-discharge Plan of Care 23.3%

Total 30.9%


Note: The rows do not sum to the total because some stays did not meet either requirement.Source: Office of Inspector General Medical Record Review, 2012

Copyright © 2014 All Rights Reserved

Discharge Summary

The discharge summary should include: Summary of the beneficiary’s stay

Beneficiary’s status at the time of dischargePost-discharge plan of care

When a SNF anticipates the discharge of a beneficiary to another care setting or home, it must plan for the dischargeThe SNF must develop a discharge summary to help ensure that the beneficiary’s care is coordinated and that the beneficiary transitions safely to his or her new setting


Post-Discharge Plan of Care

Post-discharge plan of care:Describe what the beneficiary’s and family’s preferences for care areHow the beneficiary and family will access these servicesHow care should be coordinated if continuing treatment involves multiple caregiversEducation or instructions


OIG Quality of Care

As part of the medical record review reviewers identified examples of poor care that that they determined to be egregious:

Based solely on a medical record review Does not identify all instances of poor quality care Reviewers did not systematically review the records for poor quality care provided during each stay


OIG Poor Quality Care

Wound care Developed Pressure UlcersProvided inadequate wound care and neglected to provide interventions aimed at relieving pressureDeveloped additional pressure ulcers Worsening pressure ulcersDid not include detailed information about wounds in the medical recordsSNFs may not want to call attention to any pressure ulcers acquired during a beneficiary’s stay for Quality Measure reporting Harmony Healthcare International, Inc. 38Copyright © 2014 All Rights Reserved


Medication ManagementGiven an antipsychotic drug during her SNF stay. This drug has a “black-box warning” that it is not approved for patients with dementia-related psychosis and may result in severe or life-threatening risksGiven an antipsychotic drug when she did not have a diagnosis for psychosis and her care plan did not indicate that she had a mood disorder



Therapy Provided inappropriately high levels of therapy to beneficiaries given their conditions SNF provided a hospice patient with physical therapy 5 days a week for 5 weeks. The medical record showed that the beneficiary participated in therapy at first, but at some point, she did not want to continue. However, the SNF continued the therapy at the same intensity for the remainder of her stay until she was discharged to home with hospice care.A patient dislocated a hip and could not bear weight on that side. Even though the beneficiary should not have been ambulating, the SNF provided “ultrahigh” levels of physical therapy to the beneficiary for the entire stay.Harmony Healthcare International, Inc. 40Copyright © 2014 All Rights Reserved


The OIG Linked the care plan to contributing to care provision that that they determined to be “egregious”


OIG Findings

These findings raise concerns about what Medicare is paying forSNF oversight needs to be strengthened to ensure that SNFs perform appropriate care planning and discharge planninghttps://oig.hhs.gov/oei/reports/oei-02-09-00201.pdf


https://oig.hhs.gov/oei/reports/oei-02-09-00201.pdf

https://oig.hhs.gov/oei/reports/oei-02-09-00201.pdf

OIG Recommendations

Centers for Medicare & Medicaid Services (CMS):

Strengthen the regulations on care planning and discharge planningProvide guidance to SNFs to improve care planning and discharge planningIncrease surveyor efforts to identify SNFsLink payments to meeting quality-of-care requirementsFollow up on the SNFs that failed to meet care planning and discharge planning requirements or that provided poor quality care


Take Away Nuggets

Prepare for Focus on State SurveyPrepare for Focus on Medicare Part A ReviewsEnsure Care Plans meet RequirementsEnsure Discharge Process includes a Discharge Summary Post-discharge plan of care Expect CMS to “link payments to meeting quality-of-care requirements”


The Department of Health and Human Services (HHS) Office of Inspector General

(OIG)“Strategic Plan for Fiscal Year 2014”

OIG Strategic Plan

January 31, 2014The OIG Strategic Plan focuses on four goals:

Fight Fraud, Waste, and Abuse Promote Quality, Safety, and Value Secure the Future Advance Excellence and Innovation

http://oig.hhs.gov/reports-and-publications/archives/workplan/2014/Work-Plan-2014.pdf




OIG Strategic PlanSNF

Medicare Part A billing by skilled nursing facilities Policies and Practices: We will describe SNF billing practices in selected years and will describe variation in billing among SNFs in those yearsCMS has made substantial changes to how SNFs bill for services for Medicare Part A stays



Questionable Billing Patterns for Medicare Part BWe will identify questionable billing patterns associated with nursing homes and Medicare Part B Providers in Nursing HomesTherapy and Medical Services (2014)



State agency verification of deficiency corrections Quality of Care and SafetyOIG will determine whether State survey agencies verified correction plans for deficiencies identified during nursing home recertification surveys (2014)



Program for National background checks for long-term-care employees Review the procedures implemented by participating States for long-term-care facilities or providers to conduct background checks on prospective employees and providers who would have direct access to patients and determine the costs of conducting background checks Determine the outcomes of the States' programs and determine whether the programs led to any unintended consequences (2017)



Hospitalizations of nursing home residents for manageable and preventable conditions Determine the extent to which Medicare beneficiaries residing in nursing homes are hospitalized as a result of conditions thought to be manageable or preventable in the nursing home setting Hospitalizations of nursing home residents are costly to Medicare and may indicate quality-of-care problems in the nursing homes (2014)Harmony Healthcare International, Inc. 51Copyright © 2014 All Rights Reserved

OIG Strategic Plan-MAC

Ensure Part A and Part B claims are paid correctly. MACs are responsible for developing, inputting, and turning on local edits within their jurisdictions, as well as evaluating the effectiveness of medical review editsReview benefit integrity activity performed by Medicare benefit integrity contractors in calendar years 2012 and 2013 Safeguard the Medicare program against fraud, waste, and abuse


Information Technology Security, Protected Health Information, and Data Accuracy

We will review independent evaluations of information systems security programs of Medicare fiscal intermediaries, carriers, and MACsMedicare and Medicaid contractors and at hospitals for security of portable devices containing personal health information


Medicare Secondary Payer

Improper Medicare payments for beneficiaries with other insurance coverage Medicare as Secondary PayerIdentify Medicare payments made for services to beneficiaries who have certain types of other insurance coverage to assess the effectiveness of Medicare’s controls to prevent such payments


Take Away Nuggets

Prepare for additional Medicare Part A and B reviewsReview process for meeting Medicare Secondary Payer requirementsReview HIPAA requirementsAnalyze your hospitalization and re-hospitalization rates and analyze


ICD-10 Codes

ICD-10 code

On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code setsThe transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA)Note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services


http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/index.html

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/index.html

ICD-10 code

CMS ICD-10 resourcesToolsPlanningImplementationVideosTalk Ten Tuesday Podcast

http://www.cms.gov/Medicare/Coding/ICD10/Latest_News.html




Take Away Nuggets

Prepare for upcoming ChangesHow will ICD-10 Impact:

Therapy codingMDS CodingUB-04 CodingFace Sheets

Set implementation timeline


Pause Medicare Recovery Audit Program

February 18, 2014 – CMS is in the procurement process for the next round of Recovery Audit Program contracts. It is important that CMS transition down the current contracts so that the Recovery Auditors can complete all outstanding claim reviews and other processes by the end date of the current contracts. Pause in operations will allow CMS to continue to refine and improve the Medicare Recovery Audit Program. Several years ago, CMS made substantial changes to improve the Medicare Recovery Audit program.



February 21st is the last day a Recovery Auditor may send a postpayment Additional Documentation Request (ADR)February 28th is the last day a MAC may send prepayment ADRs for the Recovery Auditor Prepayment Review DemonstrationJune 1st is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment.CMS will continue to update this Website with more information on the procurement and awards as information is available. Providers should contact [email protected] for additional questions.Harmony Healthcare International, Inc. 61Copyright © 2014 All Rights Reserved


CMS will continue to review and refine the process as necessary. For example, CMS is reviewing the Additional Documentation Request (ADR) limits, timeframes for review and communications between Recovery Auditors and providers. http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html?siteTool


http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html?siteTool





Medicare Hearings and Appeals

February 12, 2014 Office of Medicare Hearings and Appeals Medicare Appellant Forum


Medicare Hearings and Appeals

Due to the volume of receipts and substantial backlog, implemented deferred ASSIGNMENT process Affects requests for hearing received on and after April of 2013 Requests for hearing held until an ALJ docket can accommodate As of January 24, 2014, estimated delay of up to 28 months until assignment to an ALJ Exceptions: Beneficiary-initiated appealshttp://www.hhs.gov/omha/omha_medicare_appellant_forum_presentations.pdf


http://www.hhs.gov/omha/omha_medicare_appellant_forum_presentations.pdf

http://www.hhs.gov/omha/omha_medicare_appellant_forum_presentations.pdf

Take Away Nuggets

Chart reviewsEnsure 1st Level of Additional Documentation Requests (ADR) and Appeals are responded to appropriatelyPlan for a delay in ALJ. Take detailed notes of case now for review when actually scheduledKeep your guard up. Reviews for now can come later ! Harmony Healthcare International, Inc. 65Copyright © 2014 All Rights Reserved

“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to

change.”

Charles Darwin


Copyright © 2014 All Rights Reserved 67

References

Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance(Rev. 161, 10-26-12)Jimmo v. Sebelius Settlement Agreement Fact Sheet, CMS, April 2013CMS MDS 3.0 RAI Manual v1.11 September 2013Harmony Healthcare International, Inc.

Questions/Answers

Harmony Healthcare International1 (800) 530 – [email protected]

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http://www.harmony-healthcare.com/

http://www.harmony-healthcare.com/

Harmony Healthcare International (HHI)

For attending this seminar, you are eligible for one of the following:

Free PEPPER AnalysisFree RUGS Analysis

Assess your facility against key indicators and national norms. Contact us at:

[email protected] is cost & obligation free

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Medicare Madness 2014: What You Need to Know

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Transcript of Medicare Madness 2014: What You Need to Know