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All emergency transports are medically necessary, right? and other Myths about Compliance and Documentation.

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Presentation on theme: "All emergency transports are medically necessary, right? and other Myths about Compliance and Documentation."— Presentation transcript:

1 All emergency transports are medically necessary, right? and other Myths about Compliance and Documentation

2 Medical Necessity Recent Federal Fraud Cases Recent Federal Fraud Cases – False Claims includes submission of claim for services that did not meet the medical necessity requirements. – Providers must assure the medical necessity requirements are met prior to submitting a claim seeking reimbursement for the service.

3 Medical Necessity Emergency Emergency – 911 Call or Equivalent – Immediate Response – In Response to an Accident, Illness, Injury CMS Medicare Condition Codes CMS Medicare Condition Codes

4 Medical Necessity Contractor Review Findings: Contractor Review Findings: – Narrative Field is still vitally important – Beware of Fields Default Values – All Patient Care Reports must stand alone. – Be Cautious of Contradictory Information.

5 Narratives

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8 Emergency Condition Codes Assessments – Document Decision Making Assessments – Document Decision Making – Ex: Possible CVA - what lead you to that decision? Be Descriptive Be Descriptive – Patients actual quotes sometimes better describes the chief complaints Ask Questions Ask Questions – OPQRST – Onset, Provocation, Quality, Region, Severity, Time

9 Documentation Reminders Emergency Claims - Medicare Condition Codes (examples) Emergency Claims - Medicare Condition Codes (examples) – Abdominal Pain With associated Nausea, vomiting, mass, distention, rigidity, tenderness on exam, guarding With associated Nausea, vomiting, mass, distention, rigidity, tenderness on exam, guarding – Abnormal Skin Signs Diaphoresis, cyanosis, delayed cap refill, poor turgor, mottled Diaphoresis, cyanosis, delayed cap refill, poor turgor, mottled – Allergic Reaction – Rapid progression of symptoms, prior hx of anaphylaxis, wheezing, difficulty swallowing, hives, itching, rash, local swelling, redness, erythema

10 Documentation Reminders Medicare Condition Codes Medicare Condition Codes Chest Pain Chest Pain – Dull, severe, crushing, substernal, epigastric, associated pain, ie. Jaw, left arm, neck, back, with nausea vomiting, palpitations, diaphoresis Cardiac other than Chest Pain Cardiac other than Chest Pain – Persistent nausea and vomiting, weakness, hiccups, pleuritic pain, feeling of impending doom, palpitations, skipped beats Abnormal Cardiac Rhythm Abnormal Cardiac Rhythm

11 Documentation Reminders Medicare Condition Codes Medicare Condition Codes Neurologic Distress Neurologic Distress – Facial Drooping, aphasia, difficulty swallowing, tingling extremities, stupor, delirium, confusion, hallucinations, paralysis, vertigo, unsteady gait/balance, slurred speech Pain, Severe Pain, Severe – Acute onset, unable to ambulate or sit due to pain, severity scale (7-10 indicates severe), receiving pharmacological interventions Alcohol Alcohol – Unable to care for self, unable to ambulate, pharmacological intervention, decreased LOC potentially compromising airway

12 Documentation Reminders Medicare Condition Codes Medicare Condition Codes Abnormal Vital Signs Abnormal Vital Signs Blood Glucose ( 250) Blood Glucose ( 250) Altered Level of Consciousness (GCS <15) Altered Level of Consciousness (GCS <15) Convulsions, Seizures Convulsions, Seizures – Seizing, immediate post-seizure, postictal Suspected Fracture/Immobilization Suspected Fracture/Immobilization

13 Interfacility Transports Medical Necessity Medical Necessity Reason for Transfer Reason for Transfer – Medical or Patient Convenience Nearest Appropriate Facility Nearest Appropriate Facility Type of Response Type of Response

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15 Examples

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17 Patient Protection and Affordable Care Act (PPACA) Fraud and Abuse Provisions Fraud and Abuse Provisions Provider Enrollment Process Provider Enrollment Process Revalidation Process (every 3 years) Revalidation Process (every 3 years) Site Visit Site Visit $523 Fee $523 Fee Prepayment Reviews Prepayment Reviews Patient Care Report (PCR) must be submitted prior to payment Patient Care Report (PCR) must be submitted prior to payment Delayed Payments Delayed Payments

18 Patient Protection and Affordable Care Act (PPACA) Fraud and Abuse Provisions Fraud and Abuse Provisions Post-payment Reviews Post-payment Reviews Vulnerabilities in Medicare Vulnerabilities in Medicare Statistical Comparisons Statistical Comparisons Extrapolations Extrapolations Medicare Contractor Oversight Medicare Contractor Oversight Corrective Action Process for Vulnerabilities Corrective Action Process for Vulnerabilities Mandatory Compliance Plan Mandatory Compliance Plan

19 OIG Work Plan 2013 Medicare Strike Force Teams Medicare Strike Force Teams Federal and State Collaborations Federal and State Collaborations OIG, Attorney General, Medicare and Medicaid Fraud Investigators, DOJ OIG, Attorney General, Medicare and Medicaid Fraud Investigators, DOJ $492 Million – including $49.2 Million in Ambulance $492 Million – including $49.2 Million in Ambulance Ambulance Review Ambulance Review Medical Necessity Medical Necessity Level of Care Level of Care ALS Assessments, Specialty Care Transports ALS Assessments, Specialty Care Transports

20 GAO Cost Study Government Accountability Office (GAO) Cost Study Government Accountability Office (GAO) Cost Study Based on 2010 Data Based on 2010 Data Median payments = 1% lower than Medicare Payment Median payments = 1% lower than Medicare Payment Wide Variance - $224 - $2,204 Wide Variance - $224 - $2,204 Rapid increase of 59% in non-emergency transfers between nursing homes and dialysis facilities Rapid increase of 59% in non-emergency transfers between nursing homes and dialysis facilities Rapid entry of for-profit suppliers Rapid entry of for-profit suppliers Uncompensated Care – 5% - 14% Uncompensated Care – 5% - 14%

21 USA Today $4.1 Billion Record Recovery in 2011 $4.1 Billion Record Recovery in 2011 $7.20 Recovery for every $1.00 spent – 2009 – 2011 $7.20 Recovery for every $1.00 spent – 2009 – 2011 $5.10 Recovery – $5.10 Recovery – $300 Million HHS Budget for Anti Fraud Teams $300 Million HHS Budget for Anti Fraud Teams Health Care Fraud Prevention and Enforcement Action Teams (HEAT) Health Care Fraud Prevention and Enforcement Action Teams (HEAT) 175 Prison Sentences – average 47 month sentence 175 Prison Sentences – average 47 month sentence

22 MEDPAC Recommendations: Recommendations: Allow current add-on payments to expire on 12/31/2012 Allow current add-on payments to expire on 12/31/2012 Restructure Non-Emergency Payment Structure Restructure Non-Emergency Payment Structure Lower Rates for Non-Emergency Transports Lower Rates for Non-Emergency Transports Emergency Transports would remain the same Emergency Transports would remain the same Develop Medical Necessity Guidelines for NE Transports Develop Medical Necessity Guidelines for NE Transports Lower Fee Structure for Dialysis Transports Lower Fee Structure for Dialysis Transports

23 Whose Looking at You? Prepayment Audits Prepayment Audits Postpayment Audits Postpayment Audits Medicare Administrative Contractors (MAC) Medicare Administrative Contractors (MAC) Recovery Audit Contractors (RAC) Recovery Audit Contractors (RAC) Program Safeguard Contractors (PSC) Program Safeguard Contractors (PSC) Zone Program Integrity Contractors (ZPIC) Zone Program Integrity Contractors (ZPIC) Comprehensive Error Rate Testing (CERT) Comprehensive Error Rate Testing (CERT) Statistical Reporting/High Risk Vulnerabilities Statistical Reporting/High Risk Vulnerabilities

24 Providers Reaction GAO Study of CMS Auditors GAO Study of CMS Auditors – Defective, redundant, administrative burdens – Goal: Coherent Strategic Plan Consistent Standards Active Coordination – Review: Audit Criteria Methodologies Clear and Consistent Process Not Duplicative

25 What are they Looking For? Patient Signatures Patient Signatures – Patient Signature – Authorized Representative Signature – Crew/Facility Signature – Lifetime? Physician Certification Statements Physician Certification Statements – Detailed Medical Condition – Signed with Appropriate Credentials – Legible Signature – Supported by Patient Care Report (PCR)

26 What are they looking for? Medical Necessity Medical Necessity – Condition Codes – Supported by Patient Care Report (PCR) ALS Assessment ALS Assessment – Dispatch Protocols – Medical Necessity Emergency vs. Non-Emergency Emergency vs. Non-Emergency – Immediate Dispatch

27 Appeals American Hospital Association (AHA) American Hospital Association (AHA) – 75% Appeal Rate – 48% of all Appeals are overturned Appeal Process Appeal Process – Redetermination – Reconsideration – Administrative Law Judge – Appeals Council Review – District Court

28 Compliance Plan Internal Monitoring and Auditing Internal Monitoring and Auditing Written Policies and Procedures Written Policies and Procedures Designated Compliance Officer Designated Compliance Officer Training and Education Programs Training and Education Programs Appropriate Response to Offenses and Corrective Action Appropriate Response to Offenses and Corrective Action Open Lines of Communication Open Lines of Communication Disciplinary Standards and Enforcement Disciplinary Standards and Enforcement

29 Questions???


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