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Is Your Agency Prepared for a RAC
Audit? Is your Coding Specific?
Susan Carmichael, MS, RN, CHCQM, COS-C, ICM, FAIHQ
Execu...
Learning Objectives
• Discuss what we might learn from the RAC
history
• Illustrate the purpose of the RAC audits
• Outlin...
What is a RAC: Recovery Audit
Contractor
• “The RACs detect and correct past improper
payments so that CMS and carriers, f...
RAC Program
• The RAC program has been mandated by:
– Section 302 of the Tax Relief and Health Care Act
of 2006 and
– Over...
3 year Demonstration Project
(March/05 – March/08)
• Required by the Medicare Modernization Act, Section
306
• Found over ...
The drive behind the RAC
• CMS processes $2 Billion in claims for 1 Billion
providers
• Baby Boomer have arrived
• RACs ha...
RAC Jurisdictions
Who are the RACs?
RAC A Website
• Region A: Recovery Inc. of Livermore CA, prior to August, 2012,
was known as Diversified...
The New RAC
• Effective 2014, CMS has established a RAC
team devoted exclusively to the Home Health,
Hospice, and Durable ...
What does a RAC do?
RAC review process
RACs review claims on a post-payment basis
• RACs use same policies as carriers, FI...
RAC Reviews
• There are two types of RAC reviews; automatic reviews and
• complex reviews. Each type of review is meant to...
RAC Review Process
• How many records will be open to review?
– Look back period limited to three years
– RACs able to loo...
What does a RAC do?
The review process
• RACs are required to employ a staff consisting of
nurses, therapists, certified c...
Extrapolation?
• RAC math can exacerbate damage…
• Extrapolation of the error rate means applying
a statistical sampling m...
5 LEVELS OF APPEAL
The Appeal Process
The Appeal Process
• Five levels in the RAC Appeal Process:
• Medicare offers a five level appeal process
and the RAC proc...
Level 1 Redetermination
42 CFR 405.940-58
• Level 1: Redetermination is an examination of a claim
by a FI or MAC using dif...
Level 2 Reconsideration
42 CFR 405.960-78
• Level 2: Reconsideration can be filed if there is dissatisfaction
with the fin...
Reconsideration: reviews involving
Medical Necessity
• Medical necessity reviews must be performed
“by a panel of physicia...
Reconsideration Binding Authority
• The QIC is bound by National Coverage Decisions,
CMS rulings, and applicable laws and ...
Level 3: ALJ Hearing
42 CFR 405.1000-64
• Level 3: Administrative Law Judge Hearing may be requested
within 60 days of rec...
ALJ delays
• It was reported recently that the 65 ALJs are
behind 3 years or 400,000 appeals. CMS is
aware, but no word as...
ALJ Hearing Discovery
• Remember that discovery is only permitted
when CMS elects to participate in the hearing
as a party...
Level 4 Appeals Council Review
42 CFR 405.1100-40
• Level 4: Appeals Council Review if there is dissatisfaction with
the r...
Level 5 Judicial Review
42 CFR 405.1136
• Level 5: Judicial Review in the US District
Court would require a disputed claim...
Appeal Timeframes
Know the timeframes involved in each level of
appeal. If you are late, you may have already
lost the app...
Appeals
• Agency needs to evaluate the financial net gain
of appeal
• Agency needs to evaluate future potential
ramificati...
Appeal Strategies
• Treating Physician Rule: CMS Ruling 93-1:
With respect to Part A claims states that
treating physician...
Appeal Strategies: Consider a
Challenge to the Statistics
• The Guidelines for conducting statistical
extrapolations are s...
Appeal Strategies Arguing the Merits
Preparation of Rationales
Expert Involvement
Reviewer Credential Issues:
The RAC team...
Appeals involving Position Papers
• Legal analysis of the denial
• Medical expert involvement
• Do you expect evidenced-ba...
What is different?
• Though RAC appeals process is same as other
CMS appeals, RACs will offer an opportunity
for the provi...
Responding to a RAC Request
• Notify your designated RAC
• Respond to the letter of request: 45 days
• Submit clinical rec...
Suggestions for RAC Information
Submission
• Have your RAC contact information nearby
and already have reviewed the RAC si...
The Collection Process
• Same as for carrier, FI, and MAC identified
overpayments
• Carriers, Fis, and MACs issue Remittan...
YOU WILL RECOVER NOTHING FOR
CERTAIN, IF YOU DO NOT APPEAL
Remember
IDENTIFY RISK AREAS
Targets
We Can Learn from History
• Know where previous improper payments
were found:
-In 1995 -1999 Operation Restore Trust
recov...
We Can Learn from History and ORT
• ORT Findings included:
Homebound criteria not met
Services without Physician orders
La...
We Can Learn from History and ORT
• 140 Physicians signed POCs for claims not
allowed:
-65% physicians relied on agency to...
Focus on High Risk Areas
• Agencies with high volume of claims
• Agencies with history of survey and claim
problems
• Agen...
Again: RAC Targets
• Services are medically unnecessary or there is delayed
implementation (Focus: Therapy)
• Patients are...
Preparing for the RAC Attack
• 1. Establish a RAC Response Team
• 2. Choose a RAC Team leader
• 3. Review ORT and CERT fin...
Preparing for the RAC Attack
• 6. Monitor Physician exclusions
• 7. Analyze agency practices in the high risk
areas; look ...
Preparing for the RAC Attack
• 11. Look at HR practices:
-Hiring and orientation
-Make certain qualifications of personnel...
Preparing for the RAC Attack
• 12. Look at evidence-based practices utilized at agency
Look at Best-Practices used
• 13. L...
Preparing for the RAC Attack and
Medical Necessity
• Focus on reasonable and necessary care by
looking at current illness
...
Preparing for RAC Attack and Medical
Necessity
• Clearly document patient knowledge of
disease
• Clearly document patient ...
Preparing for RAC Attack and Medical
Necessity
• Full or partial denial because the clinical
documentation:
Did not suppor...
Preparing for a RAC Attack: Therapy
and Your Diagnoses
• 14. Therapy services:
• How many therapy visits are you averaging...
Take a Look at Therapy
continued…
• Do therapy treatment plans and progress notes have:
Clear functional goal statements? ...
Take a Look at Therapy
continued…
• Is therapy consistent with the nature and
severity of the condition? Any examples of P...
Preparing for a RAC Attack: ICD-9
Coding
• 15. Coding services: WHO is doing your
coding? How are you auditing them?
• In ...
In House Coders
• May tend to tolerate inadequate
documentation to support codes.
• Are You being put at Risk?
• What shou...
Coding Specificity and Co-morbidities
• The following are diagnoses/co-morbidites that should be
included and coded on a p...
Preparing for the RAC Attack and
Dependent Services
• 16. Look at Dependent Services; home health
aide and medical social ...
Preparing for the RAC Attack
Note: HHA services must have frequency and
duration approved by physician
Aide services canno...
Preparing for a RAC Attack: Billing
• 17. Conduct internal billing audits:
• Audit when RAPS are dropped/compliance
• Look...
RAC ATTACK
• The quality of your documentation will dictate
reimbursement.
• The quality of your documentation
determines ...
CMS
•Be a frequent visitor to the CMS website and
also the RAC website particular to your region
RAC CONTACT INFORMATION
The Four Approved RACS
Who are the RACs?
• Region A-Performant Recovery Inc. of Livermore, CA:
• Connecticut, Delaware, District of Columbia, Mai...
Who are the RACs?
• Region B- CGI Technologies and Solutions (CGI)
Illinois, Indiana, Kentucky, Michigan, Ohio, and
Wiscon...
Who are the RACs?
• Region C- Connolly Consulting Associates, Inc of
Wilton, Connecticut:
• Alabama, arkansas, Colorado, F...
Who are the RACs?
• Region D- Health Data Insights of Las Vegas,
Nevada
Alaska, American Samoa, Arizona, California,
Guam....
Thank you
Susan Carmichael MS, RN, CHCQM, COS-C, ICM,
FAIHQ
EVP, CCO, Select Data
(714) 524-2500x235
susanc@selectdata.com
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Rac Audit Presentation- Select Data

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Rac Audit Presentation- Select Data

  1. 1. Is Your Agency Prepared for a RAC Audit? Is your Coding Specific? Susan Carmichael, MS, RN, CHCQM, COS-C, ICM, FAIHQ Executive Vice President Chief Compliance Officer Select Data History, Expectations, and Strategies to Assist The Home Health Leader to Prepare for the RAC Attack
  2. 2. Learning Objectives • Discuss what we might learn from the RAC history • Illustrate the purpose of the RAC audits • Outline the appeal process • Identify potential RAC targets and preventive strategies • Suggest strategies to help prepare for RAC audits
  3. 3. What is a RAC: Recovery Audit Contractor • “The RACs detect and correct past improper payments so that CMS and carriers, fiscal intermediaries (FI), and Medicare Administrative Contractors (MAC) can implement actions that will prevent future improper payments” (NGS, NAHC Convention, LA, 10/2009)
  4. 4. RAC Program • The RAC program has been mandated by: – Section 302 of the Tax Relief and Health Care Act of 2006 and – Overseen by CMS and – Statute approved contingency-based payments to RACs • The RAC rationale is to protect the Medicare trust fund as improper payments of the past are seen as exhausting the fund
  5. 5. 3 year Demonstration Project (March/05 – March/08) • Required by the Medicare Modernization Act, Section 306 • Found over $1.3 Billion dollars “improper payments” in 6 states • $900+ million in overpayments (96%) • $ 32+ million in underpayments • Demonstration states: Florida, California, Massachusetts, South Carolina, Arizona, and New York
  6. 6. The drive behind the RAC • CMS processes $2 Billion in claims for 1 Billion providers • Baby Boomer have arrived • RACs have been cost effective in demonstration: – $0.20/$1.00 recovered – RACs recovered on 96% of all claims audited = $1.3 Billion
  7. 7. RAC Jurisdictions
  8. 8. Who are the RACs? RAC A Website • Region A: Recovery Inc. of Livermore CA, prior to August, 2012, was known as Diversified Collection Services RAC B Website • Region B: CGI Technologies and Solutions Inc of Fairfax, Virginia http://racb.cgi.com racb@cgi.com RAC C Website • Region C: Connolly Consulting Associates, Inc. of Wilton, Connecticut www.connollyhealthcare.com/RAC RACinfo@connollyhealthcare.com RAC D Website • Region D: HealthDataInsights of Las Vegas, Nevada • racinfo@emailhdi.com
  9. 9. The New RAC • Effective 2014, CMS has established a RAC team devoted exclusively to the Home Health, Hospice, and Durable Medical industries. • 33% of RAC reviews under the demonstration project that had issues were coding related • How specific is your coding? • What do your quarterly coding audits reflect?
  10. 10. What does a RAC do? RAC review process RACs review claims on a post-payment basis • RACs use same policies as carriers, FIs, and MACs: National Coverage Determinations (NDC) and Local Coverage Determinations (LDC), and CMS Manuals • RACs are required to employ a staff consisting of nurses, therapists, certified coders, and a physician medical director (CMD). Must provide credentials of reviewers upon request. • Two types of review: – Automated (no medical record needed) – Complex (medical record required)
  11. 11. RAC Reviews • There are two types of RAC reviews; automatic reviews and • complex reviews. Each type of review is meant to have a different • focus. • The automatic reviews require no person to review the records • because the audits are driven by a computer generated • algorithm with a focus on the easier incorrect claims, where an • obvious overpayment exists; e.g. duplicate claim. • The complex reviews are more time consuming requiring the RAC • team of clinicians and coders to actually review the medical • records of the audited claims. A record request will be sent to an • agency. The focus of this audit is more indepth, expected to • involve areas of medical necessity, therapy, and coding errors,
  12. 12. RAC Review Process • How many records will be open to review? – Look back period limited to three years – RACs able to look back three years from date claim was paid – Home Health Care: 1% of average monthly Medicare services every 45 days, maximum 200 claims – Hospice: 10% of average monthly claims every 45 days with a maximum of 200
  13. 13. What does a RAC do? The review process • RACs are required to employ a staff consisting of nurses, therapists, certified coders, and a physician medical director (CMD). Must provide credentials of reviewers upon request. • RACs must return the contingency fee if the provider prevails at any step of the appeal process • CMS has hired a program validation contractor (located in Erie, PA) to produce accuracy scores for each RAC • RACs can apply extrapolation to collect overpayments
  14. 14. Extrapolation? • RAC math can exacerbate damage… • Extrapolation of the error rate means applying a statistical sampling methodology retroactively and prospectively, assuming that existing trend will continue or has occurred in the past. In this case, a denial rate will be applied. • Source: Beacon Health, February 5, 2010
  15. 15. 5 LEVELS OF APPEAL The Appeal Process
  16. 16. The Appeal Process • Five levels in the RAC Appeal Process: • Medicare offers a five level appeal process and the RAC process is no different. • Redetermination by an FI, carrier, or MAC • Reconsideration by a QIC • Hearing by an Administrative Law Judge (ALJ) • Review by the Medicare Appeals Council • Judicial Review
  17. 17. Level 1 Redetermination 42 CFR 405.940-58 • Level 1: Redetermination is an examination of a claim by a FI or MAC using different personnel than those who made the initial determination. The appeal must be filed within 120 days from the date of receipt of the initial claim determination. To make the request, download form CMS -20027 from CMS. Include any supporting documentation that would aid in the redetermination decision. There is no minimum monetary threshold and expect a decision within 60 days. (Contractor may extend timeframe by 14 days)
  18. 18. Level 2 Reconsideration 42 CFR 405.960-78 • Level 2: Reconsideration can be filed if there is dissatisfaction with the findings of the redetermination. In requesting a reconsideration, which will be completed by a QIC, follow all instructions on the Medicare Redetermination Notice received. Clearly explain why there is disagreement and include any support documentation for review. If evidence is not included at this appeal stage, it may be excluded from all further appeals. Must file within 180 calendar days (or 60 days to avoid recoupment) There is no minimum monetary threshold and a decision is usually completed within 60 days of the reconsideration request. If the QIC cannot render a decision within that timeframe, a notice will be sent stating the right to elevate the case to an ALJ.
  19. 19. Reconsideration: reviews involving Medical Necessity • Medical necessity reviews must be performed “by a panel of physicians or other health care professionals, and be based on clinical experience, the patient’s medical records, and medical, technical, and scientific evidence of record to the extent applicable” • 42 CFR 405.908 (a)
  20. 20. Reconsideration Binding Authority • The QIC is bound by National Coverage Decisions, CMS rulings, and applicable laws and regulations • The QIC is not bound by Local Coverage Decisions, Local Medical Review Policies, or CMS program guidance such as program manuals. (The QIC is not bound to follow coverage decisions of the Intermediary regarding Hospice)
  21. 21. Level 3: ALJ Hearing 42 CFR 405.1000-64 • Level 3: Administrative Law Judge Hearing may be requested within 60 days of receipt of the reconsideration provided the dollars in dispute exceed $130. For post-payment audit cases, the intermediary can begin to withhold after the QIC issues its reconsideration decision. Follow the directions closely for this appeal, such as notifying all parties of the QIO reconsideration and so note it on the written request for the ALJ. These hearings may be held by telephone or video-teleconference or a face to face hearing may be requested. That decision is at the discretion of the ALJ. CMS, after notifying the ALJ, of their intent, may attend the hearing. A decision is usually rendered within 90 days of the hearing request. 42 CFR 405. 1016
  22. 22. ALJ delays • It was reported recently that the 65 ALJs are behind 3 years or 400,000 appeals. CMS is aware, but no word as to a remedy for the situation.
  23. 23. ALJ Hearing Discovery • Remember that discovery is only permitted when CMS elects to participate in the hearing as a party • Providers, under 42 CFR 405.1037, can request a copy of QIC notes and the ALJ hearing file • CMS (or its contractors) may participate in an ALJ hearing without joining as a party (42 CFR 405.1010
  24. 24. Level 4 Appeals Council Review 42 CFR 405.1100-40 • Level 4: Appeals Council Review if there is dissatisfaction with the results of the ALJ hearing. The request for this level of appeal must be made within 60 days of receipt of the ALJ decision and must clearly list the issues being contested. The ALJ decision letter will identify the exact procedures to follow when filing the request to the Appeals Council. There is no specific monetary requirement required for this step and the Council will usually issue a decision within 90 days. If the Council fails to act within 90 days, the appellant may request that the appeal, other than an ALJ dismissal, be escalated to federal district court. 42 CFR 405.1132
  25. 25. Level 5 Judicial Review 42 CFR 405.1136 • Level 5: Judicial Review in the US District Court would require a disputed claim in excess of $1260.00. • A request for this level of appeal must occur within 60 days of receipt of the decision from the Appeals Council.
  26. 26. Appeal Timeframes Know the timeframes involved in each level of appeal. If you are late, you may have already lost the appeal.
  27. 27. Appeals • Agency needs to evaluate the financial net gain of appeal • Agency needs to evaluate future potential ramifications • First three steps of the appeal usually most viable • Rebuttal should occur during first 15 days after demand letter is issued • Rebuttal is best when new documentation is available but not usually effective for medical necessity denials
  28. 28. Appeal Strategies • Treating Physician Rule: CMS Ruling 93-1: With respect to Part A claims states that treating physician opinion is evidence, but not presumptive, so there remains a need to make a case specific argument why the physician’s opinion is the best evidence. (No similar rulings seen with respect to Parts B, C, and D). Providers should consider the argument that the opinion of the treating physician is the best evidence.
  29. 29. Appeal Strategies: Consider a Challenge to the Statistics • The Guidelines for conducting statistical extrapolations are set forth in the Medicare Program Integrity Manual (CMS Publication 100-08, Chapter 3, 3.10.1 through 3.10.11.2
  30. 30. Appeal Strategies Arguing the Merits Preparation of Rationales Expert Involvement Reviewer Credential Issues: The RAC teams must have clinicians (not necessarily home health RNs) and credentialed coders (not necessarily home health coders)
  31. 31. Appeals involving Position Papers • Legal analysis of the denial • Medical expert involvement • Do you expect evidenced-based arguments in highlighted portions of the record.
  32. 32. What is different? • Though RAC appeals process is same as other CMS appeals, RACs will offer an opportunity for the provider to discuss the improper payment determination. This does not alter timeline. • Issues reviewed by the RAC will be approved by CMS prior to widespread review • Approved issues will be posted to a RAC Website before widespread review
  33. 33. Responding to a RAC Request • Notify your designated RAC • Respond to the letter of request: 45 days • Submit clinical record copies: via photocopies, CDs, or DVD • Track the records submitted on the RAC website or phone • Can request reimbursement for copies • RAC response within 60 days
  34. 34. Suggestions for RAC Information Submission • Have your RAC contact information nearby and already have reviewed the RAC site • Do not wait the 45 days to submit the requested clinical records. • Assemble the RAC Response Team • Start to review the record(s) and the issue(s) under focus. • Duplicate the information submitted • Maintain the RAC Log and track info/records submitted
  35. 35. The Collection Process • Same as for carrier, FI, and MAC identified overpayments • Carriers, Fis, and MACs issue Remittance Advice -Remark Code N432: Adjustment based on Recovery Audit” -Carrier, FI, and MAC recoups by offset unless provider has submitted a check or a valid appeal
  36. 36. YOU WILL RECOVER NOTHING FOR CERTAIN, IF YOU DO NOT APPEAL Remember
  37. 37. IDENTIFY RISK AREAS Targets
  38. 38. We Can Learn from History • Know where previous improper payments were found: -In 1995 -1999 Operation Restore Trust recovered $524 million in fines, recoveries, and audit disallowances, and settlements -Achieved a 45% drop in improper payments -Is credited with preventing $11 billion in inappropriate claims paid
  39. 39. We Can Learn from History and ORT • ORT Findings included: Homebound criteria not met Services without Physician orders Lack of adequate documentation for care Coding Inappropriate visits and unnecessary services
  40. 40. We Can Learn from History and ORT • 140 Physicians signed POCs for claims not allowed: -65% physicians relied on agency to prepare POC -60% of physicians denied knowledge of homebound requirement for home health care -8% admitted no knowledge of patient condition
  41. 41. Focus on High Risk Areas • Agencies with high volume of claims • Agencies with history of survey and claim problems • Agencies with outliers, LUPAs, and exceeding therapy thresholds • Agencies with coding inconsistencies and errors
  42. 42. Again: RAC Targets • Services are medically unnecessary or there is delayed implementation (Focus: Therapy) • Patients are not Homebound • Services are incorrectly coded and sequenced • Failure to provide claim supportive documentation • Duplicate claims submitted • Medicare secondary pay or improper payments • Lack of order centricity
  43. 43. Preparing for the RAC Attack • 1. Establish a RAC Response Team • 2. Choose a RAC Team leader • 3. Review ORT and CERT findings of the past • 4. Study problem areas/vulnerabilities posted on both the CMS and RAC websites • 5. Study Medicare Benefit Policy Manual (CMS Publication 100-2, Chapter 7)
  44. 44. Preparing for the RAC Attack • 6. Monitor Physician exclusions • 7. Analyze agency practices in the high risk areas; look for vulnerability such as Coding lacking substantive documentation • 8. Calculate and track case mix weights • 9. Analyze QA findings • 10. Educate and reeducate personnel
  45. 45. Preparing for the RAC Attack • 11. Look at HR practices: -Hiring and orientation -Make certain qualifications of personnel meet all federal rules and state licensing or certification requirements - Knowledge and support of the Corporate Compliance Plan with emphasis on no tolerance for fraudulent behavior -Certifications and Continuing Education -Personnel knowledge of home health requirements -Annual Evaluations and clinical competency reviews
  46. 46. Preparing for the RAC Attack • 12. Look at evidence-based practices utilized at agency Look at Best-Practices used • 13. Look at QA of outcomes based on the above especially admissions and medical necessity Comments by physicians re POC Admissions/recertifications and Medical Necessity Review RFA>discipline specific careplan> POC> clinical notes> physician orders> outcomes
  47. 47. Preparing for the RAC Attack and Medical Necessity • Focus on reasonable and necessary care by looking at current illness • Focus on ICD-9 Coding and sequencing with adequacy of substantiation for every code • Should you be looking at third party coding experts? • Look at needs of patient and clinician interventions • Look at med profile: new, changed, review
  48. 48. Preparing for RAC Attack and Medical Necessity • Clearly document patient knowledge of disease • Clearly document patient teaching/learning • Identify involvement of caregivers/family/friends • Verify goals are clear, measureable, and worthy of an episodic payment
  49. 49. Preparing for RAC Attack and Medical Necessity • Full or partial denial because the clinical documentation: Did not support the medical necessity of the skilled services billed Did not demonstrate a reasonable potential for change (improvement) in the medical condition or Sufficient time had been allowed for teaching or observation of response to treatment in prior episodes of care.
  50. 50. Preparing for a RAC Attack: Therapy and Your Diagnoses • 14. Therapy services: • How many therapy visits are you averaging per episode? Percentage of patients Low Utilization episodes – 6, 7, 8 visits? (how frequently)  Of the patients who receive therapy, what is the distribution (%) across the ranges?  How does your agency compare with your peers regionally or nationally?  Do response levels on functional M items correlate with therapy referrals? High-Low levels of impairment?
  51. 51. Take a Look at Therapy continued… • Do therapy treatment plans and progress notes have: Clear functional goal statements? Any recerts with no changes? Document progress toward goals objectively?  How is care coordinated among therapists? Among all disciplines?  How can you support “reasonableness and medical necessity?” What is the patient treatment: diagnoses? Restoration/maintenance of function affected by illness? Frequency and duration of services consistent with home care client’s: medical history, disease, prior to end of episode level of function, and risk identification.
  52. 52. Take a Look at Therapy continued… • Is therapy consistent with the nature and severity of the condition? Any examples of PT discharge as soon as thresholds met? • Therapy services must be provided, expecting that the condition of the patient will improve in a reasonable period of time. • Documentation of medical necessity should be documented through evaluation, treatment plan, and progress notes. • Has your agency identified high risk diagnosis, number of visits, or number of episodes?
  53. 53. Preparing for a RAC Attack: ICD-9 Coding • 15. Coding services: WHO is doing your coding? How are you auditing them? • In the demonstration project over 1/3 or 33% of findings were linked to coding • Look at Primary Diagnosis and documentation support/congruence with OASIS integrated assessment. Do the same for co-morbidities.
  54. 54. In House Coders • May tend to tolerate inadequate documentation to support codes. • Are You being put at Risk? • What should you do? Do you want to continue inhouse coding risk? • Have you spoken to third party coding specialists who are part of a professional services company, like Select Data?
  55. 55. Coding Specificity and Co-morbidities • The following are diagnoses/co-morbidites that should be included and coded on a plan of care of a patient with these DX: • DM • CAD • COPD • CHF • Blindness • HTN • Upper and lower limb amputation status • Chronic diseases such as Parkinsons, MS, Lupus • Hx of neoplasm if care is directed toward a current neoplasm • What do your quarterly coding audits show? Source: The Coding Clinic
  56. 56. Preparing for the RAC Attack and Dependent Services • 16. Look at Dependent Services; home health aide and medical social worker services These services can be denied if there is no identified medical necessity These services are automatically denied if the qualifying service is denied
  57. 57. Preparing for the RAC Attack Note: HHA services must have frequency and duration approved by physician Aide services cannot be paid simultaneously for both Medicare and Medicaid RN assigns all tasks on aide assignment as “PRN” only Note: MSW denials include: Having MSW apply for patient Medicaid MSW services to families/CG instead of patient
  58. 58. Preparing for a RAC Attack: Billing • 17. Conduct internal billing audits: • Audit when RAPS are dropped/compliance • Look for duplicate bills • Look for order centricity • Look for 1 visit bills • Look at outlier payments; insulin injection payments • Choose Medicare rules and verify compliance
  59. 59. RAC ATTACK • The quality of your documentation will dictate reimbursement. • The quality of your documentation determines if you will survive an audit. • When all is said and done …….. • It is not the revenue you generate that is as important, as the revenue you will keep.
  60. 60. CMS •Be a frequent visitor to the CMS website and also the RAC website particular to your region
  61. 61. RAC CONTACT INFORMATION The Four Approved RACS
  62. 62. Who are the RACs? • Region A-Performant Recovery Inc. of Livermore, CA: • Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersy, New York, Pennsylvania, Rhode Island, and Vermont Email: DCSRAC@dcswins.com Before August 12,2012, the company name was Diversified Collection Services, Inc
  63. 63. Who are the RACs? • Region B- CGI Technologies and Solutions (CGI) Illinois, Indiana, Kentucky, Michigan, Ohio, and Wisconsin Email: racb@cgi.com (customer support)
  64. 64. Who are the RACs? • Region C- Connolly Consulting Associates, Inc of Wilton, Connecticut: • Alabama, arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, US Virgin Islands, Virginia, and West Virginia www.connollyhealthcare.com Email: RACinfo@connollyhealthcare.com
  65. 65. Who are the RACs? • Region D- Health Data Insights of Las Vegas, Nevada Alaska, American Samoa, Arizona, California, Guam. Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington, and Wyoming www.healthdatainsights.com/RAC.aspx Email: racinfo@emailhdi.com (customer support)
  66. 66. Thank you Susan Carmichael MS, RN, CHCQM, COS-C, ICM, FAIHQ EVP, CCO, Select Data (714) 524-2500x235 susanc@selectdata.com

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