NGS Services: Septermber 2009

Greater New York Hospital AssociationAssociation

National Government Services Inpatient Review pSeptember 29, 2009

POEA0515 (09/09)

DisclaimerDisclaimer

National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error free and will bear nocompilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of y p gpublication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited i thi bli ti bj t t h ith t f th ti C tin this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.hhs.gov.

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Session ObjectivesSession Objectives

• To provide an overview of the NGS Inpatient Review

• To describe Medical Review tools and criteria for decision making

• To summarize Medical Review findings• To highlight implications for hospital providers

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AgendaAgenda

• Background InformationBackground Information– Transfer of review responsibility to FIs/MACs– Data analysisy– Targeted DRGs– Types of review

• Medical Review Tools and Decision Making• Key Findings• Learning Points for Hospitals

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Background InformationBackground Information

• The responsibility for review of Inpatient PPS claims p y pmoved from the Quality Improvement Organizations (QIOs) to the FIs/MACs based on CMS Change Request (CR) 5849 published 08/07/2008(CR) 5849, published 08/07/2008

• Data analysis targeted the review focus, using paid claims data covering January 1 – June 30, 2008

• Specific DRGs targeted and analyzed• Hospitals varying significantly from peers selected for

ireview• Pilot Project review began in January 2009

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Targeted DRGs Targeted DRGs

• Medical Necessity of Inpatient Admissions –Medical Necessity of Inpatient Admissions Brief Stay– DRGs:

• 313 – Chest pain• 391, 392 – Esophagitis, gastroenteritis and misc.

digestive disorders with and without MCCdigestive disorders, with and without MCC• 640, 641 – Nutritional & misc. metabolic disorders with

and without MCC

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Targeted DRGsTargeted DRGs

• DRG Validation Review– 061, 062 and 063 – stroke-related DRGs– 064, 065 and 066 – Intracranial hemorrhage DRGs– 067 and 068 – non-specific CVA DRGs– 069 – Transient cerebrovascular ischemia

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Types of ReviewTypes of Review

• Medical Necessity of Inpatient Admission, Brief Stay – review to determine if complexity of care, i t it f i d di l it fintensity of services and medical necessity of inpatient admission are supported in the medical recordrecord

• DRG Validation – review of medical record and coding to verify correct DRG assignmentcoding to verify correct DRG assignment

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Medical Review Tools and Decision M ki C it iMaking Criteria

Criteria for decision making medical necessit• Criteria for decision making – medical necessity of admission review– Use of InterQual criteria as first step in the medical– Use of InterQual criteria, as first step in the medical

necessity determination• Severity of illness• Intensity of services

– Clinical judgment of reviewers -- nurses, certified coders and contractor medical directorcoders, and contractor medical director

– Key Question: Does the medical record support the level of care provided?

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Medical Review Tools and Decision Making Criteria

• DRG Validation Review – a review of the medical record documentation to ensure that the DRG assignment is supportedDRG assignment is supported

• Performed by certified coders with inpatient coding and DRG validation experiencecoding and DRG validation experience

• Tools include:– ICD-9-CM Coding Manual– ICD-9-CM Coding Manual– Official Guidelines for Coding and Reporting– The Coding Clinic for ICD-9-CM

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Key Review StatisticsKey Review Statistics

• Medical Necessity of Inpatient Admissionsy p– Claims: reviewed: 472; denied: 448– Claim Denial Rate: 94.9%– Dollar Denial Rate: 97.9%

• DRG ValidationClaims: reviewed: 230– Claims: reviewed: 230

– DRGs changed: 20 (with error rate of 8.7%)– Claims denied: 12– Admission Denial Rate: 5.2% (admissions denied/

total cases reviewed)

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Key Review FindingsKey Review Findings

• Medical Necessity of Admission – Brief StaysMedical Necessity of Admission Brief Stays– Majority of claims reviewed showed services were

medically necessary, but did not require an inpatient level of care.

– DRG 313 – chest painConstituted significant percent of claims reviewed– Constituted significant percent of claims reviewed

– Laboratory and EKG results were negative– No acute findings– Clinical status was stable

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• DRG 640 – Nutritional & misc. metabolicDRG 640 Nutritional & misc. metabolic disorders with and without MCC– Patient evaluated and treated in a relatively brief

period of time– Laboratory results did not trigger inpatient criteria for

admissionadmission

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• DRG Validation Review– Overall, findings less dramatic– Errors reflected both DRG payment increases and

decreasesdecreases– Evidence of excellent physician documentation and

accurate coding in many cases– Some cases had insufficient, late or conflicting

documentation– Error rate varied significantly from hospital to hospitalError rate varied significantly from hospital to hospital – Surprise finding: Twelve admissions were denied –

medical necessity of IP admission not supported.

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You are Responsible forYou are Responsible for

• Knowledge of the requirements necessitating inpatientKnowledge of the requirements necessitating inpatient admissions

• Working in conjunction with physicians to ensure documentation of admission status is clearly defined by a signed and dated physician order.

• Monitoring the documentation of clinical rationale for• Monitoring the documentation of clinical rationale for level of care decisions in the medical record.

• Ensuring the documentation is complete and timely to support DRG assignment.

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Questions Questions

Thank you for the opportunity to discuss our review findings with you.g y

As additional questions arise contact usAs additional questions arise, contact us using the information that follows.

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Clinical POE Contact InformationClinical POE Contact Information

Telephone InquiriesTelephone InquiriesNGS Clinical POE Toll-Free Line

800-338-6101800-338-6101

E mail InquiriesE-mail [email protected]

No PHI Please!No PHI Please!

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Posted 09/15/2009 on NGS WebSite www.ngsmedicare.com

National Government Services Reviews Inpatient Claims -- What did the DRG Validation Review Reveal?

National Government Services (NGS) assumed responsibility for the review of Inpatient PPS services based upon CMS Change Request 5849, published in August 2008. The change request transferred the IP PPS review responsibility from the Quality Improvement Organizations (QIOs) to the Fiscal Intermediaries (FIs) and Medicare Administrative Contractors (MACs). During the initial pilot project, NGS initiated two reviews – one focusing on the medical necessity of inpatient admissions and the other focusing on validation of the DRG billed to Medicare. The second review, known as the DRG validation review, will be the focus of this article. The DRG validation review for the pilot project focused on hospitals in the states of Wisconsin, Michigan, New York and Connecticut. The DRG Validation review was initiated after data analysis first targeted specific DRGs and secondly, hospitals billing those DRGs. The DRGs included in the study are:

• 061, 062 & 063 – Stroke-related DRGs • 064, 065 & 066 -- Intracranial hemorrhage DRGs • 067 & 068 – Non-specific CVA DRGs • 069 – Transient ischemic attack (TIA)

Review Statistics The pilot project review included 396 cases from the four states. The overall denial rate was 5.8%; however, the denial rate does not fully reflect the severity of the errors identified in the review.

• The number of cases where the DRG decreased was balanced by a similar number of cases where the DRG increased.

• The net error rate, balancing increases and decreases, was only 5.8% • There were many examples where hospitals had excellent physician

documentation and high quality coding. Overall Findings Provide a Clearer Focus While the net increases and decreases result in only a 5.8% error rate, there were significant variances when comparing individual provider error rates. Error rates ranged from 0% for some providers to a high of 24%. A 24% error rate would not meet the standards for many hospital quality and compliance programs. Review the findings below for areas where your hospital can make changes.

• Untimely discharge summaries – A review of records indicates that discharge summaries are frequently dictated long after the patient’s

Posted 09/15/2009 on NGS WebSite www.ngsmedicare.com

discharge. This means that full information in not available to coders and the resulting bill to Medicare is not based full information from the physician. The Medicare Hospital Conditions of Participation section relating to medical record services (482.24 (c) (2) (vii) specifies that records must contain “’final diagnosis with completion of medical records within 30 days following discharge.”

• Incomplete or conflicting physician documentation – During the review, some records reflected inconsistent documentation on the patient’s major reason for admission. As an example, one physician progress note states the patient had a stroke while the other reflects the diagnosis of TIA, and both with equal frequency. In such cases, the record was reviewed by the contractor medical director to identify the principal diagnosis.

• Failure to query the attending physician – In situations where the physician’s documentation is incomplete or conflicting, the coder has the responsibility to query the physician for clarification. Only one provider documented the use of the query process.

• Inaccurate coding – Primary factors contributing to coding errors included the failure to use official coding guidelines for the appropriate timeframe and the failure to read physician documentation carefully and thoroughly.

Inpatient review will continue to be a key focus in the Fiscal Year 2010 Medical Review Strategy. Review your policies and procedures to ensure that inpatient records support an accurate Medicare claim.

Limitation on Recoupment (935) for Providers, Physicians, ( ) , y ,

and Suppliers Overpayment

POEA0520 (09/09)

DisclaimerDisclaimer

National Government Services, Inc. has produced this material as anNational Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements Any regulations policies and/or guidelines citedprogram requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www cms hhs gov

2 National Government Services, Inc.

Medicaid Services (CMS) Web site at http://www.cms.hhs.gov.

AcronymsAcronyms

Centers for Medicare & MedicaidCMS Centers for Medicare & Medicaid Services

EFT Electronic Funds TransferEFT Electronic Funds TransferERP Extended Repayment Plan (Loan)FI Fiscal IntermediaryFI Fiscal IntermediaryHHA Home Health Agency

H H lth P ti P tHHPPS Home Health Prospective Payment System

MAC Medicare Administrative Contractor


MAC Medicare Administrative Contractor

AcronymsAcronyms

Medicare Prescription DrugMMA Medicare Prescription Drug, Improvement, and Modernization Act

MSP Medicare Secondary PayerMSP Medicare Secondary PayerQIC Qualified Independent ContractorRA Remittance AdviceRAP Request for Anticipated PaymentRHHI Regional Home Health IntermediarySSA Social Security Administration


SSA Social Security Administration

ObjectiveObjective

• Give providers a better understanding of• Give providers a better understanding of the 935 recoupment process and how it relates to the appeal processrelates to the appeal process


AgendaAgenda

• Background• Background• Definitions• Overpayment Steps• Appeals and how it pertains to limitation pp p

on recoupment (935)• Provider Payment Summary ScreensProvider Payment Summary Screens


Background – 935Background 935

• Medicare Prescription Drug Improvement and• Medicare Prescription Drug, Improvement, and Modernization Act of 2003, (MMA) Section 935 amended Title XVIII of Social Security Act to add ya new paragraph to Section 1893, (f)(2)(a)– Requires CMS to change

• How it recoups certain overpayments to providers, physicians, suppliers

• How it pays interest to provider physician supplierHow it pays interest to provider, physician, supplier whose overpayment is reversed at subsequent administrative or judicial levels of appeal


Background – 935Background 935

• Final Rule defines• Final Rule defines– Overpayments to which limitation applies– How limitation works in concert with appeal– How limitation works in concert with appeal

process– Change in obligation to pay interest to g g p y

provider or supplier whose appeal is successful at levels above QIC

R f 42 CFR P t 401 (S b t F)• Reference: 42 CFR Part 401 (Subpart F), Part 405 Section 405.378


What is an Overpayment?What is an Overpayment?

• Medicare monies a provider has received• Medicare monies a provider has received in excess of amounts due and payable under Medicareunder Medicare – Amount of overpayment is debt owed to

Federal GovernmentFederal Government– CMS is required to seek recovery of

overpayment regardless of how it wasoverpayment regardless of how it was identified or caused


Examples of OverpaymentsExamples of Overpayments

• Payment for excluded or medically• Payment for excluded or medically unnecessary servicesP t d i h• Payment made as primary payer when Medicare should have paid as secondary payer


What is Recoupment?What is Recoupment?

• Recovery by Medicare of any outstanding• Recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare remittance advicefuture Medicare remittance advice payments and applying amount withheld to the indebtednessthe indebtedness


Limitation on Recoupment (935)

Limitation on Recoupment For P id O tProviders Overpayments

• SSA section 1893 (f) (2) (a) provides limitationsSSA section 1893 (f) (2) (a) provides limitations on recoupment of Medicare overpayments

• Providers are protected during initial stages of p g gappeal process– At redetermination and reconsideration level– Limitations do not affect providers appeal

rights and timeframes for appeals are not affectedaffected• Providers must decide to appeal to stop

recoupment


p

Overpayments Subject toLi it ti R tLimitation on Recoupment

• Determined post-pay denial of claims for• Determined post-pay denial of claims for benefits for which a written demand letter was issuedwas issued– Medicare Part A (Inpatient)– Medicare Part B (Outpatient)( p )

• Final claims associated with HHA RAP under HH PPS, but not the RAP itself,– CMS Publication 100-04, Chapter 10,

Sections 10.10-10.12, 40.1, and 50


Overpayments Subject toLi it ti R tLimitation on Recoupment

• MSP recovery• MSP recovery – Where provider or supplier received a

duplicate primary payment and for which aduplicate primary payment and for which a written demand letter was issued, or

– Based on provider’s or supplier’s failure to file– Based on provider s or supplier s failure to file a proper claim with a third party payer plan, program, or insurer for payment for Part A p g , p yclaims


Scenarios – Post-Pay DenialScenarios Post Pay Denial

• ABC hospital was paid for an inpatient• ABC hospital was paid for an inpatient claim. Medical records were requested and upon review it was determined thatand upon review it was determined that the hospital stay was not reasonable and necessarynecessary.

• XYZ hospital was paid for an outpatient l i hi h b tl i d tclaim which subsequently received a post-

pay denial.


Scenarios – Post-Pay Denial AAnswer:

• Claims will be subject to 935 process• Claims will be subject to 935 process• Claims will be adjusted• Adjustments will appear on remittance

advice as 935 eligible• Demand letters will be issued, advising

providers that an overpayment occurredp p y


Overpayments NOT Subject to Li it ti R tLimitation on Recoupment

• Provider-initiated adjustments• Provider-initiated adjustments• All other MSP recoveries except those

previously identifiedpreviously identified• Overpayments arising from a cost report

determinationdetermination• HHA RAP under HH PPS

Hospice Cap calculations• Hospice Cap calculations• Accelerated/Advanced Payments


Rebuttal ProcessRebuttal Process

• Opportunity for provider to rebut any• Opportunity for provider to rebut any proposed recoupment action – Is not an appeal of overpaymentIs not an appeal of overpayment

determination – Will not delay recoupment before a rebuttal y

response has been rendered– Provider advised of decision in 15 days from

receipt date of rebuttalreceipt date of rebuttal• 42 CFR, Part 405.373 through 405.375


Steps in Overpayment Process Steps in Overpayment Process

Step One – Overpayments, Part AStep One Overpayments, Part A

• As a result of post pay review or MSP• As a result of post-pay review or MSP recoveries and during Part A claim adjustment processadjustment process – If adjustment results in refund to provider

Existing underpayment policies are followed• Existing underpayment policies are followed– If adjustment considered to be an

overpayment and 935 rules applyoverpayment and 935 rules apply• Claim will be marked as being eligible for limitation

on recoupment protections


Step Two – Overpayments, D d L ttDemand Letter

• Adjustment triggers creation of demand letterAdjustment triggers creation of demand letter and accounts receivable

• First demand letter will state– To stop recoupment under provisions of Section 935

of MMA, providers must submit a valid appeal request (redetermination) of the overpayment within 30 days from date of demand letter

• Interest begins to accrue after 30 days– Provider may submit a rebuttal statement (which is y (

not an appeal request) to any proposed recoupment action

• Rebuttal rarely used and does not stop recoupment


Rebuttal rarely used and does not stop recoupment

Step Two – Overpayments, D d L ttDemand Letter

• Recoupment will begin on the 41st day from dateRecoupment will begin on the 41 day from date of first demand letter if– Payment is not received in full, or– Acceptable request for ERP, or valid request for a

contractor redetermination is not date-stamped in our mailroom by day 30 from date of demand lettery y

• If an appeal is filed later than 30 days, Medicare will stop recoupment at whatever point appeal is

i d d lid t dreceived and validated– Medicare may not refund any recoupment already

taken


Scenario – Overpayment Part AScenario Overpayment Part A

• It has been determined that the inpatient• It has been determined that the inpatient claim from ABC hospital should not have been paid What is going to happen next inbeen paid. What is going to happen next in the 935 process?

• Answer: Claim will be adjusted and this overpayment will trigger a demand letteroverpayment will trigger a demand letter be sent, which will provide all of the details on 935 process.


o 935 p ocess

Overpayment Demand Letter TipsOverpayment Demand Letter Tips

• Timeliness of the appeal request is important• Timeliness of the appeal request is important– During appeal process, interest continues to accrue– Once first two levels of appeal are completed, ifOnce first two levels of appeal are completed, if

appeal decision is Affirmation, collection may resume within designated timeframes

• Provider who has filed a bankruptcy petition or is involved in a bankruptcy proceeding, should contact National Government Servicescontact National Government Services immediately


Step Three – How to Stop Medicare R t ft Fi t D d L ttRecoupment after First Demand Letter

Timeframe NGS ProviderTimeframe NGS Provider

Day 1 Date of Demand Letter

Notification received of overpayment determination

Day 30 Day 30 – Interest begins to accrue

Provider can pay by check within 30 days and avoid interest

Day 1-40 No recoupment occurs

Provider can appeal and potentially limit recoupment from occurringfrom occurring

Day 41 Recoupment begins Provider can appeal and potentially stop recoupment


Did You Know…Did You Know…

• Providers have a choice regarding how• Providers have a choice regarding how they want to respond to demand letter

P b h k ithi 30 d ( t i t t)– Pay by check within 30 days (stop interest)– Allow recoupment from future payments

R t E t d d R t Pl (l )– Request Extended Repayment Plan (loan)


Appeals and How They Pertain to Limitation on Recoupment

First Level Appeal – RedeterminationFirst Level Appeal Redetermination

• Upon receiving your valid request for aUpon receiving your valid request for a redetermination of overpayment, we will take the following actions

Cease recoupment of overpayment that is subject of– Cease recoupment of overpayment that is subject of appeal, or will not initiate recoupment if it has not yet started

– Retain any amounts recouped, if already collected before receiving request for redetermination, and apply them first to interest and then to principal

– Continue to collect any other debts providers might owe, but will not withhold or place in suspense any monies related to this debt, while it is in appeal status


, pp

First Level Appeal – RedeterminationFirst Level Appeal Redetermination

• Redetermination can have three possible• Redetermination can have three possible outcomes

F ll l (f bl )– Full reversal (favorable)– Partial reversal (partially favorable)

F ll Affi ti ( f bl )– Full Affirmation (unfavorable)


Scenario – First Level AppealScenario First Level Appeal

• ABC hospital received a demand letter statingABC hospital received a demand letter stating that an overpayment occurred and the hospital does not agree. What should be done to ensure th i t t k b k?the monies are not taken back?

• Answer: Within 30 days of receiving a demand y gletter an appeal must be submitted. On the appeal request indicate that this is an overpayment appeal and you are requesting aoverpayment appeal and you are requesting a redetermination. This will stop recoupment until a decision is made on the appeal


Full Reversal of Overpayment DecisionFull Reversal of Overpayment Decision

• In this instance we will:• In this instance we will:– Reimburse provider for covered

items/servicesitems/services– Any recouped funds and interest paid will be

repaid to the providerrepaid to the provider


Partial Reversal of the Overpayment D i iDecision

• In this instance (in which debt is reduced• In this instance (in which debt is reduced below initial stated amount) we will:

R l l t t t f b th– Recalculate correct amounts of both underpayment and overpaymentMake appropriate payments to provider if due– Make appropriate payments to provider if due

– If necessary, issue a revised demand letter for the newly calculated overpayment amountthe newly calculated overpayment amount


Full Affirmation of the Overpayment D i iDecision

• With this “unfavorable” decision that• With this unfavorable decision that upholds the overpayment determination, we willwe will– Issue the second or third demand letter (as

appropriate)appropriate)


Timeframe for Medicare Recoupment P Aft R d t i tiProcess After Redetermination

Timeframe NGS ProviderTimeframe NGS ProviderDay 60 following revised notice of

t

Date NGS is notified by QIC that they h i d

Must pay overpayment or must h b itt doverpayment

following redetermination

have received a request for reconsideration

have submitted request for second level appeal

Day 61-75 Recoupment could begin on the 61st day Appeal or pay

Can still appeal and

Day 76 Recoupment begins or resumes

Can still appeal and recoupment will stop on receipt date of appeal


appeal

Second Level Appeal – ReconsiderationSecond Level Appeal Reconsideration

• Providers can stop Medicare from• Providers can stop Medicare from recouping any payments at a second point in the recoupment process by filing a validin the recoupment process by filing a valid request for reconsideration with the QIC within 60 days of the Medicarewithin 60 days of the Medicare Redetermination Notice



• When we receive notification from the QIC ofWhen we receive notification from the QIC of your valid and timely request for reconsideration, we will

Cease recoupment of overpayment or not initiate– Cease recoupment of overpayment, or not initiate recoupment if it has not yet begun

– Retain amount recouped, and apply it first to interest and then to principal (if recoupment process hadand then to principal (if recoupment process had begun before reconsideration request was received)

– Continue to collect other debts that provider might if t i l d d towe, if overpayment is appealed and recoupment

stopped, but will not withhold or place in suspense any monies related to this debt while it is in appeal status


status


• QIC reconsideration can have three• QIC reconsideration can have three possible outcomes

F ll R l (f bl )– Full Reversal (favorable)– Partial Reversal (partially favorable)

Affi ti ( f bl )– Affirmation (unfavorable)


Full ReversalFull Reversal

• National Government Services will adjust• National Government Services will adjust the overpayment and amount of interest charged once notified by QIC that thecharged once notified by QIC that the decision resulted in an adjustment


Partial ReversalPartial Reversal

• This decision reduces the overpayment• This decision reduces the overpayment• Medicare:

Reprocesses based on QIC reconsideration decision– Reprocesses based on QIC reconsideration decision– If necessary issues a revised demand letter for

revised overpayment amount or make appropriate payments of underpayment amount, if due

– May apply excess to any other debt (including interest) that a provider might owe before releasinginterest) that a provider might owe before releasing payment


Full AffirmationFull Affirmation

• If QIC reconsideration results in• If QIC reconsideration results in “unfavorable” overpayment decision– Recoupment may be resumed on the

30th calendar day after the date of notice of reconsideration

– Gives providers time to make payment p p yor to request a repayment plan


Third Level of Appeal – Administrative L J d (ALJ)Law Judge (ALJ)

• Whether or not a provider subsequently• Whether or not a provider subsequently appeals overpayment to ALJ, Medicare Appeals Council or Federal courtAppeals Council, or Federal court– Medicare will continue to recoup until debt is

satisfied in fullsatisfied in full


Third Level of Appeal – Administrative L J d (ALJ)Law Judge (ALJ)

• If ALJ reverses the Medicare overpaymentIf ALJ reverses the Medicare overpayment determination, Medicare will– Refund both principal and interest collected– Also pay 935 interest on any recouped funds that

Medicare took from ongoing Medicare payments• If provider has any other outstanding• If provider has any other outstanding

overpayments, Medicare will– Apply the amount collected first to those

overpayments, and– Any excess monies will then be refunded back to the

provider


p

Status of DebtStatus of Debt

• During redetermination and• During redetermination and reconsideration process, status is appealWh t b i / t t• When recoupment begins/resumes, status will be changed to eligible for offset


Voluntary RefundVoluntary Refund

• A voluntary refund submitted within 30• A voluntary refund submitted within 30 days avoids having to pay interest

Connecticut New York Providers:Connecticut, New York Providers: National Government Services, Inc.

J13 Part A-Voluntary Refund P O B 13078

• http://www ngsmedicare com/NGSMedicar

P.O. Box 13078 Newark, NJ 07188

• http://www.ngsmedicare.com/NGSMedicare/PartA/Resources/Forms/0409_PartA_VRF V1.pdf


_ pd

Extended Repayment Schedule (ERS)Extended Repayment Schedule (ERS)

• Any time a provider needs longer than 30• Any time a provider needs longer than 30 days to repay the full amount of an overpayment, the provider should requestoverpayment, the provider should request an extended repayment plan (ERP)– Can be requested at any time during debt q y g

collection process– Submission within first 15 days may decrease

it t ithh ld ll i t i tnecessity to withhold all interim payments– Demand letter includes contact information


Did You Know…Did You Know…

• When a claim for an overpayment has• When a claim for an overpayment has been adjusted and appears on remittance advice overpayment shown appears as ifadvice, overpayment shown appears as if monies have already been recouped. That is not the caseis not the case.


Remittance Advice and 935Remittance Advice and 935

• Claim adjustment correcting the claim data• Claim adjustment correcting the claim data will appear on the remittance advice generated on the date of the demand lettergenerated on the date of the demand letter– Reason Code N469

O t t i NOT bt t d• Overpayment amount is NOT subtracted from the remittance payment


Provider Payment Summary Screens

Provider PaymentSummary ScreensSummary Screens

PHI

PHI

PHI


Provider PaymentS SSummary Screens


What We’ve Learned Today…What We ve Learned Today…

• Appeal rights and timeframes for filing an• Appeal rights and timeframes for filing an appeal have not changedP id h t t iti t t• Providers have two opportunities to stop recoupment

• Interest will begin to accrue on day 31(and every 30 days after) but recoupment will not start until after day 41


ResourcesResources

• Change Request 6183• Change Request 6183– http://www.cms.hhs.gov/transmittals/download

s/R141FM pdfs/R141FM.pdf

• MLN Matters 6183– http://www.cms.hhs.gov/MLNMattersArticles/

downloads/MM6183.pdf


ResourcesResources

• Appeals Process Flowchart• Appeals Process Flowchart– http://www.cms.hhs.gov/OrgMedFFSAppeals/

Downloads/AppealsprocessflowchartAB pdfDownloads/AppealsprocessflowchartAB.pdf

• Medicare Appeals Process brochurepp– http://www.cms.hhs.gov/MLNProducts/

downloads/MedicareAppealsprocess.pdf


ResourcesResources

• FI Appeals and QIC mailing addresses• FI Appeals and QIC mailing addresses– http://www.ngsmedicare.com/NGSMedicare/

PartA/Resources/ContactInformation/PartA/Resources/ContactInformation/Appeals%20_ContactInfo_PartA.aspx

• Recovery Audit Contractor Web site– http://www.cms.hhs.gov/RAC


ResourcesResources

• Voluntary Refund Forms• Voluntary Refund Forms– Part A & FQHC

http://www ngsmedicare com/NGSMedicare/PartA/• http://www.ngsmedicare.com/NGSMedicare/PartA/Resources/Forms/0409_PartA_VRF_V1.pdf

H H lth/H i– Home Health/Hospice• http://www.ngsmedicare.com/NGSMedicare/RHHI/

Resources/Forms/0409 HHH VRF V1 pdfResources/Forms/0409_HHH_VRF_V1.pdf


How to Calculate 935 Interest

Interest paid under 935 is only applicable at the Administrative Law Judge (ALJ) or further appeal level when that decision results in a full or partial reversal of the prior decision and National Government Services has retained recouped funds. Medicare has the obligation to pay providers interest if the overpayment determination is reversed at the first (redetermination) and second (reconsideration) level of the administrative appeal process and the decisions are not put into effect timely. At these levels of appeal, interest would continue to be payable by Medicare if the underpayment is not paid within 30 days of the final determination decision. The formula for calculating interest is simple ‐ Time x Rate x Amount ‐ For each recoupment action: 1. TIME: Determine the total Julian days starting from the recoupment date and ending with the

ALJ decision date or the date on the revised notice with the new overpayment, if applicable. Divide the number of Julian days by 30 to compute the number of 30‐day periods. The interest will not be payable for any periods of less than 30 days in which National Government Services had possession of the recouped funds.

2. RATE: Use the annual rate of interest in effect at the time of the ALJ decision date or from the

revised New Written Determination date and convert interest rate to a monthly interest rate. (For example: The rate of interest as of July 17, 2009 is 11.25%. Convert annual Rate to a monthly rate by dividing by 12.)

3. AMOUNT: The amounts that are to be used as the basis on which to compute interest earned

by the provider are those amounts that are credited to principal resulting from any involuntary payments from the provider after the elimination/satisfaction of all Medicare debt. Recouped monies applied to interest are not included in the determining the 935 interest. Only those principal funds recouped via withholding (e.g., payments recouped under a defaulted ERS or offset) are included. Do not include payments a provider makes under an ERS or other voluntary payments made by the provider.

How to Calculate 935 Interest:

(935 interest at the ALJ and higher levels)

Fully Favorable Decision

Recoupment Amounts

Recoupment Date

Rate of interest from ALJ

decision date

Length of time money held

Interest Owed to Provider

1. $9,062.00 March 7, 2007 12.5% 301 Julian Days

(10 months, 1 day) $943.95

2. $9,806.00 May 18, 2007 12.5% 230 Julian Days (7 months, 20 days)

$715.02

3. $9,136.00 August 8, 2007 12.5% 148 Julian Days

(4 months, 28 days) $380.66

Total 935 Interest owed to Provider $2,039.63

Calculation Example

Time x Rate x Amount = Interest

Time Rate Amount Interest

1. 10 months .125 divided by 12 $9,062.00 $943.95



935 Interest Owed to Provider $2,039.63 Reference: CMS Internet‐Only Manual (IOM) Publication 100‐06, Medicare Financial Management Manual, Chapter 3, Section 200.6.2

NGS Services: Septermber 2009

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Transcript of NGS Services: Septermber 2009