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MEDICARE SECONDARY PAYER AUDITS October 12, 2012 St. Joseph’s Hospital, Tampa Florida AAHAM - FAHAM - HFMA Workshop Marty Lassiter, B.A. CPAM Claire Lester,

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Presentation on theme: "MEDICARE SECONDARY PAYER AUDITS October 12, 2012 St. Joseph’s Hospital, Tampa Florida AAHAM - FAHAM - HFMA Workshop Marty Lassiter, B.A. CPAM Claire Lester,"— Presentation transcript:

1 MEDICARE SECONDARY PAYER AUDITS October 12, 2012 St. Joseph’s Hospital, Tampa Florida AAHAM - FAHAM - HFMA Workshop Marty Lassiter, B.A. CPAM Claire Lester, B.A. CPAM

2 History of Medicare Secondary Payer Regulations In the beginning, Medicare providers billed Medicare first for all services rendered to Medicare beneficiaries. In 1980, the Omnibus Budget Reconciliation Act established Medicare as Secondary payer in Auto Accidents and Liability cases. Additional federal laws modified the Medicare secondary payer regulations even further. Medicare is only responsible after other primary payers have made payment. Medicare calculates any additional amount due from the program. Federal Law takes precedence over State law and private contracts.

3 Medicare-Provider Relationship Every health-care facility that receives reimbursement from Medicare adheres to the Center for Medicare/Medicaid Services (CMS) regulations. The Conditions of Participation (CoP) is the provider contract. Hospitals and other medical providers agree to follow the CoP contract regulations. These rules are published in the Federal Register, and require regular inspections to verify regulations are followed consistently. Failure to follow CMS regulations can result in Civil and Monetary penalties. Medicare Secondary Payer is a focus area for CMS.

4 Provider Compliance Training Requirements All CMS Providers must provide compliance training New Hire Training Course -Registration 12 days - CBO 9 Days – A department course required for all new employees covering compliance guidance, HIPAA, Medicare Condition of Participation, Fraud and Abuse, MSP, Three Day Rule, and department policies. – Computer Based Training, Web resources- forms, policies, Medicare Information, hyper links to payers, on line training manuals. – Competency Testing Annual One Day Refresher Training Course – The annual Medicare compliance training course consists of a review of the training materials, taken from the New Hire Training sessions, for the Admitting, Registration and Patient Financial Team members, and any new regulations.

5 How CMS Selects Providers For MSP Audits Each state has to review 10% of its total hospital population or 20 hospitals, which ever is less. For 2012, Florida has 176 hospitals 10% = 18 hospitals 21 hospitals were reviewed 10 from Miami-Dade and Broward counties 11 selected from Tampa Bay and surrounding counties

6 Medicare MSP Review History A standard provider review of Hospital Admitting and Billing practices by the Medicare Administrative Contractor. MSP Audits in the past were done by the First Coast Service Option’s Jacksonville office. The one hospital reviewer’s title was Hospital Reviewer, MSP Recovery. This department recently expanded and moved to four new Provider Audit and Reimbursement (PARD) Offices. There are offices in Jacksonville, Orlando, Miami, and Tampa. The Hospital Reviewer we had is a CPA.

7 BayCare’s Claim Submission Selection Hospital Reviewer selected the Claim Sample from previous month(s) of paid claims- minimum of 20 to a max of 60. 2/3 were Inpatient Claims-mixture of bill types; included HMO “No Pay” bills. 1/3 were Outpatient Claims-mixture of bill types. Various primary and secondary cases with Hospice, liability, HMO, etc.

8 Reality

9 MSP Audit Timeline FCSO Written notice to hospital CFO Advises CFO to expect a listing of claims selected and a letter of instruction, which arrives within 2 weeks with a deadline to return selected claims. FCSO completes claim desk review. FCSO then sends next notice to hospital of on-site review. On-site review and exit interview followed by written conclusion of hospital’s compliance with MSP regulations.

10 BayCare’s MSP Experience Audit Claim Selection Letter FCSO Hospital Reviewer requested 40 claims per hospital with supporting documents: UB04 MSP Admission Questionnaire Beneficiary’s Medicare Summary Notice (MSN) Admission Policies that identify “Other Payer” primary to Medicare Registration Policies that describe the process and systems used to meet compliance Billing policies that identify “Other Payer” primary to Medicare and Medicare “No Pay” billing procedures Medicare Secondary Payer Training Manuals and policies

11 MSP Audit Claims and Supporting Documents Submission Process The Hospital Reviewer notice shows a postal date deadline for receipt of claim selection documents Our submission was scanned to a CD The Hospital Reviewer had a specific contact to answer questions (PFS Auditor) on submitted claim documents The Hospital Reviewer sent a list of detailed questions for further information on individual claims The PFS Auditor coordinated all responses which included copies of insurance verification, insurance cards copies, and some account history notes. More detail was provided in the 2012 reviews

12 BayCare’s Internal Preparation – Informed Management of pending review – Dispersed FCSO letters to all related departments – Assigned a point person for audit coordination- PFS Auditor – Established an MSP Review Committee composed of Billing, Registration and Audit Team. Weekly teleconferences scheduled to keep all informed. – Assigned teams to gather requested documentation. – PFS Auditor coordinated assembling audit material. – Teams reviewed all related policies & training material. – Scheduled in-services with Billing and Registration. – PFS Audit and Managers reviewed signage, brochures, and team delivery of required materials & explanation of forms being signed during admission interviews.

13 Submission to FCSO Reviewer Check and recheck the documents for correct name and admission date. Verify all required material is gathered and questions regarding supporting documents were clarified. Once the claim submission was validated, we made a file copy of the documents. We supplied all requested information to the FCSO reviewer. The FCSO reviewers established a cordial and helpful relationship.

14 Team Preparation Team members are trained on interview and mentally prepared. When not sure on a response, check with management, or review the policy. The Hospital Reviewer uses standard questions from the Manual. Golden Rule- only answer the questions asked in simple terms. If it requires only a yes or no answer - that is enough. Think before you answer, ask for clarification if unsure, and speak slowly. Be prepared to defend any claims that might be outside the standard procedures. We had an LCD projector to show the on-line Patient Accounts systems available and how our verification system software detected the primary payer on preselected claims.

15 Receipt of Facility Notice Letter This letter acknowledges receipt by Hospital Reviewer of requested documentation. Shows an on-site review date & approximate time line. The letter asks if the meeting facility will be different from facility address- if so, supply correct address. Requires that Registration and Billing staff be present for interview and mentions a patient registration observation will be done.

16 BayCare’s Site Review Hospital Reviewer sent meeting agenda in advance. Hospital team appointed a point person (welcome) from the hospital and basic information about facility. Admitting and Billing people (Managers and Coordinators ) will meet with the reviewers. Most questions on the claim sample were covered prior to the Q & A by Hospital Reviewer with PFS Auditor. Billing interviews were independent of Admitting interviews. A copy of the Medicare Quarterly Credit Balance 838 was requested either in advance or at interview. Direct Observation completed of a Medicare registration. Closing statements and exit conference with the group.

17 Points to Remember Anything you discuss with Hospital Reviewer should be reviewed in advance for correctness. Be truthful, state facts, and don’t give opinions. Keep all answers short and to the point. Meet all deadlines indicated in the submission documents. Keep copies of all submissions. Our reviewer was new and needed to see lots of detail to verify our processes were thorough. Your team members do these functions everyday.

18 Assessment of Hospital MSP Review We were given an unofficial conclusion at the exit conference. A formal letter is sent using a format from the MSP Manual Ch. 5 sec Any adverse findings will have a follow-up action plan and an action date. Facility will be expected to reply, if follow- up items are required. The Hospital Reviewer will continue follow-up every thirty days; after three months with no resolution a higher level of reporting begins (70.4). MSP Review information and Flow Sheet provided as a hand out. All hospitals should prepare for the Spring of 2013.

19 MSP Audits Questions or comments?? ************************************************** Marty and Claire are BayCare PFS auditors for the inpatient and outpatient Registration and the Central Business Office for all BayCare hospitals. They conduct policy/procedure/compliance auditing and monitoring, and assist with team member training. Paul Tucker (Uncle Sam) volunteer


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