ZPIC RAC MAC Audits Proactive vs Reactive 5-13 NADONA ......Proactive vs. Reactive Approach Lisa...
Transcript of ZPIC RAC MAC Audits Proactive vs Reactive 5-13 NADONA ......Proactive vs. Reactive Approach Lisa...
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©Pathway Health 2013
ZPIC, RAC and MAC Audits
Proactive vs. Reactive Approach
Lisa Thomson
Vice President of Strategic Initiatives
Pathway Health Services, Inc.
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After attending this presentation, the attendees will be able to :
1. Understand the different types of audits related to reimbursement: ZPIC, RAC, and MAC
2. Determine proactive approaches for positive positioning to audits
3. Identify leadership monitoring protocols for ongoing compliance and quality outcomes
Objectives
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Current Healthcare Landscape
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• Leadership Tactics for this changing Environment
– Education and Knowledge
– Internal Review
– Data Agenda
– Preparedness and Protection
– Performance Improvement
Proactive vs. Reactive Approach
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Proactive vs. Reactive Approach
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Knowledge and Education
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Current Healthcare Landscape
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Current Healthcare Landscape
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Healthcare Landscape
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Healthcare Landscape
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Why External Government Audits?
• Improper payments
– Payments for services that were not medically necessary
– Payments for services that were incorrectly coded
– Providers failed to submit documentation to support the services provides OR failed to submit enough documentation to support the claim
– Other errors – (i.e. submitted twice/paid twice)
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Government Reaction
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• Fraud Prevention System (FPS)
– In place for over 2 years
– Outcome – $3 for every $1 spent
– Generated leads for additional 536 new ZPICs
• FPS collaboration with law enforcement
• OIG involvement and issuance of SNF based Reports
– Overpayment
– Reviewers found SNFs incorrect coding to higher RUGs in 20% of claims
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Government Reaction
Office of the Inspector General (OIG)
• Questionable billing by SNFs.
• Conduct a full review of SNF billing by end of FY 2011 and implement plan.
• Increased diligence on therapy utilization.
• Increased auditing of supporting documentation.
• NEW – HHS 2014 Budget!
– CMS and OIG (a new kind of Marriage)!
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Current Healthcare Landscape
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Medicare Fraud http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf
• “In general, fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person’s own benefit or for the benefit of some other party. In other words, fraud includes the obtaining of something of value through misrepresentation or concealment of material facts.”
• Examples of Medicare fraud may include:
– Knowingly billing for services that were not furnished and/or supplies not provided, including billing Medicare for appointments that the patient failed to keep; and
– Knowingly altering claims forms and/or receipts to receive a higher payment amount.
Medicare and Medicaid Fraud and Abuse
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Medicare Abusehttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf
• “Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced”.
• Examples of Medicare abuse may include:
– Misusing codes on a claim,
– Charging excessively for services or supplies, and
– Billing for services that were not medically necessary.
– Both fraud and abuse can expose providers to criminal and civil liability.
Medicare and Medicaid Fraud and Abuse
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Medicare Fraud and Abuse Laws
False Claims Act (FCA)
• The FCA (31 United States Code [U.S.C.] Sections 3729-3733) protects
the Government from being overcharged or sold substandard goods or services. The FCA imposes civil liability on any person who knowingly submits, or causes to be submitted, a false or fraudulent claim to the
Federal Government. The “knowing” standard includes acting in deliberate ignorance or reckless disregard of the truth related to the claim. https://oig.hhs.gov/fraud
Anti-Kickback Statute
• The Anti-Kickback Statute (42 U.S.C. Section 1320a-7b(b)) makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services
reimbursable by a Federal health care program. https://oig.hhs.gov/compliance/safe-harbor-regulations
Fraud and Abuse Laws
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Medicare Fraud and Abuse Laws
Civil Monetary Penalties (CMPs)
Under 42 U.S.C. Section 1320a-7a, CMPs may be imposed for a variety of
conduct, and different amounts of penalties and assessments may be authorized based on the type of violation at issue. Penalties range from up to $10,000 to $50,000 per violation. CMPs can also include an assessment of up to 3 times the
amount claimed for each item or service, or up to 3 times the amount of remuneration offered, paid, solicited, or received. Examples of CMP violations include:
• Presenting a claim that the person knows or should know is for an item or service that was not provided as claimed or is false and fraudulent,
• Presenting a claim that the person knows or should know is for an item or service for which payment may not be made, and
• Violating the Anti-Kickback Statute.
Fraud and Abuse Laws
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Centers for Medicare & Medicaid Services (CMS)
Government agencies partner to fight fraud and abuse, uphold the Medicare Program’s integrity, save and recoup taxpayer funds, and maintain health care costs and quality of care.
CMS partners with the following entities and law enforcement agencies, among others, to prevent and detect fraud and abuse:
• Program Safeguard Contractors
• (PSCs)/Zone Program Integrity Contractors (ZPICs);
• Medicare Drug Integrity Contractors (MEDICs);
• State and Federal law enforcement agencies, such as the
• OIG, Federal Bureau of Investigation (FBI), Department of Justice (DOJ), and State Medicaid Fraud Control Units (MFCUs);
CMS Fraud and Abuse Partners
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Centers for Medicare & Medicaid Services (CMS)
Partners (continued):
• Medicare beneficiaries and caregivers;
• Senior Medicare Patrol (SMP) program;
• Physicians, suppliers, and other providers;
• Medicare Carriers, Fiscal Intermediaries (FIs), and Medicare Administrative Contractors (MACs) who pay claims and enroll providers and suppliers;
• Accreditation Organizations (AOs);
• Recovery Audit Program Recovery Auditors; and
• Comprehensive Error Rate Testing (CERT) Contractors.
Medicare and Medicaid Fraud and Abuse
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RAC Recovery Audit Contractors
– Medicare RACs
– Medicaid RACs
ZPIC Zone Program Integrity Contractors
– PSC – Program Safeguard Contractor
MIC Medicaid Integrity Contractors
MAC Medicare Administrative Contractor
– FI – Fiscal Intermediary (now MAC)
HEAT Health Care Fraud Prevention and Enforcement Action Team (HEAT) 19
Acronyms
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Healthcare Landscape
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Focus on Overpayment as well as Fraud and Abuse
From: Hooper, Lundy & Bookman, PC
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Let’s Take a Closer Look!
Types of Audits
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MAC
RAC
ZPIC
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• Medicare Administrative Contractor –MAC
– Primary Role
• Primary contact for provider enrollment
• Part A and Part B FFS billing claims in a geographic region
• Replaced FIs
– Focus
• Medicare payment accuracy
• Recoveries and process 1st level of appeals
• Additional Development Request (ADR)
• Reviews facility and professional claims related to a beneficiary
Types of Audits
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• Medicare Administrative Contractor –MAC
– Scope
• Process claims
• Review claims, data, history, comparisons
• Audit claims
• Re Determination Requests
• Educate
• Provide Leads to next level of Audit Partners!
– Penalties
• Claim denials
• Referral to other audit partner
Types of Audits
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• Medicare Administrative Contractor –MAC
– Appeals Process
• 1st - Re determination by MAC
• 2nd - Reconsideration by Qualified Independent Contractor (QIC)
• 3rd – Hearing by Administrative Law Judge
• 4th – Review by Medicare Appeals Court
• 5th – Judicial Review in Federal Court
Types of Audits
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• Recovery Audit Contractor – RAC
– Primary Role
• “Independent collection agency”
• Started in demonstration project, now permanent
• 1 primary contractor for each of 4 regions
• Improper Payment Identification and collection
• % for both overpayments and underpayments they correct
– Focus
• Medicare and Medicaid overpayments and underpayments
• Detect and correct past improper payments so MAC can recover overpayments and implement further actions
Types of Audits
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• Recovery Audit Contractor – RAC
– Scope
• Apply statutes, regulations, CMS coverage/billing to make determinations
• 2 types
– Automated claims history review (no medical record review)
– Complex review (medical record review)
• Pre and /or Post Payment
• Look back – up to 3 years after the date the claim was filed
Types of Audits
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• Recovery Audit Contractor – RAC
– Penalties
• Medicare
– No penalties if provider agrees with RAC determination and pays back monies
– If miss deadline in appeals process, CMS can automatically recoup alleged overpayment – 31st day after receipt of initial demand letter
• Medicaid
– No penalties if provider agrees with RAC determination and pays back monies
– States have flexibility to decide penalty process
Types of Audits
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• Recovery Audit Contractor – RAC
– Appeals
• Medicare
– Mirrors the five level MAC appeals process
• Medicaid
– States have the flexibility to decide the structure of the appeals process
Types of Audits
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• Zone Program Integrity Contractor (ZPIC)
– Primary Role
• Fraud detection, prevention and correction
• Contracted payment, non contingent (no performance %)
• ZPICs combine Program Safeguard Contractors (PSCs) and Medicare drug integrity contractors (MEDICs)
• ZPICs oversee all Medicare claims in their
zone
• 7 ZPIC Zones
Types of Audits
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• Zone Program Integrity Contractor (ZPIC)
– Focus
• Medicare fraud, waste and abuse
• Identify fraud within service area – review past and pending claims by investigation and audit
• Compare billings with similar providers
• NEVER random audit - if you are chosen
there is a reason – potential fraud
• ZPIC initial request is indication of scope
of investigation!
Types of Audits
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• Zone Program Integrity Contractor (ZPIC)
– Scope
• Investigate
• Audit claims
• Authorized to initiate administrative sanctions
– Payment suspensions
– Determine overpayments returned
– Refer for exclusion form government
health care programs
– Support and refer to LAW ENFORCEMENT
Types of Audits
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• Zone Program Integrity Contractor (ZPIC)
– Audit initiated by:
• Complaints
– OIG hotline, whistleblower, fraud alerts, direct to ZPIC
– Referral from MAC, RAC, beneficiary
• Data analysis
• LOS out of norm
• ZIPCs may
– Use a statistician
– Review small number of records to determine
fraud
– Conduct interviews – staff, beneficiaries, etc.
Types of Audits
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• Zone Program Integrity Contractor (ZPIC)
– Scope
• No specific look back periods
• Refer finding of fraud to law enforcement for civil, criminal, CMP, other administrative sanction
• Involve OIG and US Attorney offices
– Penalties
• Recoupment
• Civil and criminal action/sanctions
– Appeals
• Mirror 5 level Medicare appeal process
Types of Audits
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Proactive vs. Reactive
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Internal Review ©Pathway Health 2013
• Minimize Risk!
1. Review internal processes
• Admission screening and assessment
• Nursing and Rehabilitation integration
– Medicare Meeting observation
– Medical Record Documentation
– Therapy logs
• Assess Staff knowledge and competency
– MDS Coordinator
– MDS succession planning
– IDT knowledge of RAI
Internal Review
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• Minimize Risk!
1. Review internal processes
• Claims error process
– MDS Coordinator process
– Business office
– Rehabilitation
• Adherence to RAI Manual
– Assessment Reference Date process
– OBRA scheduling
– ADL Tracking – accuracy
Internal Review
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• Minimize Risk!
1. Review internal processes
• Medical necessity
– Ensure records accurately reflect care and services
– Consistent with clinical conditions
– MDS documentation per RAI and clinical documentation
– Accurate ADL’s!!!!
Internal Review
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• Minimize Risk!
2. Self Audit High Risk Areas
• Accuracy of claims
– “high” RUGs
– Sudden changes in billing
– Spikes in billing
– Compromised identities (provider/beneficiary)
– High error rates
– RUG changes or discrepancies
– Overpayments/underpayments
Internal Review
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• Minimize Risk!
2. Self Audit High Risk Areas (random audits)
• Medical necessity
– Ensure records accurately reflect care and services
– Consistent with clinical conditions
– MDS documentation per RAI and clinical documentation
– Accurate ADL’s!!!!
Internal Review
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• Minimize Risk!
2. Self Audit High Risk Areas
• Physician orders support MDS sections
– Therapy
– Ancillaries
– Specialty services
• Rehabilitation Documentation
– Nursing and Rehabilitation
3. Triple Check Process
4. Update Policies and Procedures
5. Train staff
Internal Review
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Internal Review
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6. Develop quality strategy for improvement
– Goals based off of internal review
• Prioritize
• Impact
– Systems and tools needed to change processes
– Resources applied or needed
– Time frames
– Approval/Agreement
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Proactive vs. Reactive
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Data Agenda
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Data Agenda
“We are transforming Medicare from a passive payer, to an active
purchaser of value” – Tom Valuck Assistant CMS Administrator
Quality Care + Data = Reimbursement
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Data Agenda
Organizational Data: The New Path to Value and Reimbursement!
1. Determine Quality Profile: Assess Organization Data
2. Review Internal Processes: Data Collection, Review and Response
3. Establish an Information Agenda for Planning
Your data is key to positive outcomes!
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• Organization Data used by Auditors
– MDS
– RUGs distribution
– Therapy Utilization
– Quality Measures
– Claims submissions
– Patterns of errors
– Spike in reimbursement
– Readmission/Discharge data
– Survey Results!
Data Agenda
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Preparedness and Protection
Proactive vs. Reactive
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Preparedness and Protection
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1. Establish an Audit Response Team
• Compliance Officer/Lead
• Documentation Manager
• Administrator
• Director of Nursing
• Rehabilitation Director
• Business Office
• MDS Coordinator(s)
• Admission/Discharge
• Clinical, financial, legal expertise
– Determine Roles and Responsibilities
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2. Monitor MAC and Government trends
www.oig.hhs.gov/reports/html
www.cms.hhs.gov/rac
www.cms.hhs.gove/zpic
www.cms.hhs/gov/cert
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-items/CMS019033.html
Preparedness and Protection
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3. Audit Response Process
• Establish Timeframes and Response Reaction
• Track ALL Deadlines
• Prepare for large volume of requests
• Keep Complete record
– What requested
– Who sent
– When sent
– How sent
• Copies of all records and correspondence
• Communication point person
• Legal Counsel
Preparedness and Protection
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3. Corporate Compliance culture
• Established corporate compliance plan
– Updated and reviewed per requirements
– Staff trained
» Orientation
» Annually
» As needed based upon monitoring activities
– Code of Conduct
– Adherance to Medicare and Medicaid requirements
– RAI manual/MDS assessments/ARD, etc
– Documentation – medical necessity
Preparedness and Protection
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3. Corporate Compliance culture
• External audits – good faith for compliance!
– Contract outside organization to conduct external review of MDS/RAI process
» Admission to discharge
» Record accurately reflects care, services, coding and billing
» Staff knowledge and adherence to requirements
» Identification of opportunities for improvement
– On going training and professional growth
Preparedness and Protection
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Proactive vs. Reactive
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Performance Improvement ©Pathway Health 2013
Performance Improvement
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• Minimize Risk of Recoupments
– Proactive steps to ensure highest level of claim accuracy
– Leadership Monitoring
• Medical Necessity
• Admission/Discharge processes
• MDS Coding and Documentation
• Pre-bill screening process
• Denials and Appeals management
Performance Improvement
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• Minimize Risk of Recoupments
– Leadership Monitoring
• Track denied claims
• Review data – leadership review “big picture”
• Look for patterns, trends
– Monitor Corporate Compliance processes and outcomes
– Focus on current/significant payment recoveries emerging from revenue audits
Performance Improvement
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OIG and fraud, https://oig.hhs.gov/fraud
OIG e-mail updates, https://oig.hhs.gov/contact-us
CMS, http://www.cms.gov
CMS Fraud Prevention Toolkit, which contains information for providers and information providers can give to beneficiaries, http://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/FraudPreventionToolkit.html
HEAT, http://www.stopmedicarefraud.gov/aboutfraud/heattaskforce
CMS Electronic Mailing Lists, http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MailingLists_FactSheet.pdf
Provider compliance educational materials, http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html
OIG Advisory Opinions, https://oig.hhs.gov/compliance/advisoryopinions
Performance Improvement
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• Leadership Tactics for this changing Environment
– Education and Knowledge
– Internal Review
– Data Agenda
– Preparedness and Protection
– Performance Improvement
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Lisa Thomson Vice President of Strategic Initiatives
Pathway Health Services877-777-5463
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Thank you for your participation!