4 Total Corrections (Millions) CMS RAC StatsTotal Corrections (Millions)October 2009 – September 2010FY 2010$92.3October 2010 – September 2011FY 2011$939.33October 2011 – September 2012FY 2012$2,400.7October 2012 – September 2013FY 2013$3,834.8October 2013 – September 2014FY 2014$2,404.6Total National Program$9,671.7
5 Region C: Connolly Stats Underpayments Collected (Millions)Underpayments Returned(Millions)Total Quarter CollectionsFY To Date CollectionsRegion C: Connolly$92.34$9.33$17.71$394.01
6 RAC Update Two mid-night delay in enforcement was lifted 3/31/15 Probe & Educate ended 3/31/15CMS has re-contracted with existing recovery auditors 3/31/15MACs will no longer be limited to chart pull limits when reviewing claims for patient status 3/31/15
7 New Rules – Be Careful Moratorium ended 3/31/15. Patient status reviews began 4/1/1510/1/13 through 3/31/15 are excluded from review for patient statusThey are NOT excluded from review for medical necessity, NCD/LCD, documentation, and other approved issues
8 New Rules – Be Careful Gaming the System Comprehensive Error Rate Testing (CERT)First-Look Analysis for Hospital Outlier Monitoring (FATHOM)Program for Evaluating Payment Patterns Electronic Report (PEPPER)
9 FATHOMFATHOM: First-Look Analysis Tool for Hospital Outlier Monitoring is a Microsoft Access application that allows CMS to provide each State with hospital-specific Medicare claims data statistics, which identify areas having high payment errors. These target area statistics serve as relative indicators of payment errors. FATHOM reports include: short-term acute care inpatient prospective payment system (IPPS) hospitals (ST FATHOM), long-term acute-care IPPS hospitals (LT FATHOM), CAHs, IRFs and IPF. FATHOMs contain administrative data extracted from the Standard Data Processing System data warehouse for three previous fiscal years (FYs) and the current FY to date (cumulative).
10 Review of Two Midnight rule “CMS-1599 F” NOT JUST FOR MEDICARE ADMISSIONSInpatient Admission OrderSigned/authenticated prior to dischargePhysician CertificationSeparately signed no longer requiredMedical NecessityExpectation of a Two-midnight Stay
11 Review of Two Midnight rule “CMS-1599 F” ExclusionsPatient’s Procedure in on the Inpatient Only List from CMSPatient left AMA(Against Medical Advice)Patient expiredPatient newly elected HospicePatient transferred to another acute care hospitalPatient unexpectedly improved
12 Two Midnight rule “CMS-1599 F” While CMS is saying to just have physician sign inpatient orders for 2 midnights, you still need to ensure medical necessity.You must ensure that you have sufficient documentation.You must have a consistent and 100% compliant method to get the CMS approved inpatient order, whether in CPOE or on paper.You should audit to minimize your risk of future denials.
13 Two Midnight rule Denial Results MAC Most Current Data Results27% Denial RateDenial Reasons37% missing, unsigned, invalid order63% failed to document 2 midnight expectationPROBE Results30-60% based on sample size of 10
14 2-Midnight Rule What is your facility’s PLAN? Written procedures for Case ManagersPhysiciansPatient Access (Registration) RepsPFS Medicare BillersConsider CM – Physician “team” for inpatient documentation!
15 2-Midnight RuleConsider pre-bill edit to hold Medicare inpatient claims that are one-day stays.Case Manager or Nurse Auditor Review prior to billingTake specific deficiencies in documentation and LOS back to physician for review (ideally, back to CM – Phys team)
17 Not Just for Acute Care Providers Denials are affecting all organizations along the continuum of careHospiceHome HealthDMEInpatient RehabLTAC
18 Best Practices Centralized Function Multi-Disciplinary Team Consisting of:RN/Case ManagersPhysician AdvisorsCodersBillersRevenue IntegrityClericalSystematic Methodology to approach appeal process
19 Best Practices - Continued Flow charted processRole ClarityState of the Art Software SystemEasy to useHas powerful reporting capabilitiesAlerts to ensure deadlines are metDollars at risk vs. dollars lost
20 Best Practices - Continued Focus should be on determining the root cause and putting preventative measures in placeRequires support at highest level and process changes in many facets of the organization
21 Change Physician Behavior Physicians are scientistsProvide hard facts and dataEvidenced based MedicinePhysicians do not like to be outliersLeave emotion and finances out of discussions
22 Denials Management Are you monitoring your metrics? Who is responsible?Have you flowcharted the processes?Have you assigned responsibility?How do you track deadlines?Who determines if a denial is worth the appeal cost?How is that determined?
23 Denials ManagementDo you use an external company? Is the cost worth it? Are you paying a contingency or flat fee?How do you track denials so you can determine root causes and implement improvement processes?MedPerformance has a system to help you.
24 iMAD Denial Management Program iMAD = interactive MedPerformance Appeals and Denials
30 The Appeal Process Appeal process Intentionally complex and deceptive process….Hard deadlinesLabor intensiveAllow recoupment or risk interest
31 Successful Appeals Strategy Must have tool to track denials and deadlinesNeed guidance from ExecutivesIf a medical necessity denial – paint a clear picture of patientInclude only abnormal dataInclude what is being done that can only be done in an acute care facility