F.O.R.C.E. Healthcare Resources, LLC (Founded on Regulatory Compliance and Ethics) CMS War on Fraud and Abuse 101 July 18,2012 1

About F.O.R.C.E.? Home Health Consulting Firm – Founded 2005 Services Provided: 1.Home Health Billing Webinars 2.Home Health Outsource Billing 3.Home Health Outsource Medical Coding 4.Home Health Billing Clean-up Projects 5.Home Health Operation / Process Consulting 6.Home Health CLIA Billing & Recovery Project 2

Contact Information F.O.R.C.E Healthcare Resource, LLC. –Website: (Terri Ready, Chief Operations Officer) -Direct: ext.104 -Mobile: (Jonathan Sellers, Sales & Marketing) - Direct: (Lynn Alley, Billing Supervisor) –Direct:

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CMS War on Fraud, Abuse & Substandard Care CMS has declared war on Medicare Billing Fraud & Abuse CMS Issued new State Survey Instructions – May 2011 HHA’s will see more deficiency citations on State Survey HHA’s should be prepared for more pre- payment medical record requests HHA’s should be prepared for post payment audits 5

Fraud Definition An intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself / herself or some other person. The most frequent kind of fraud arises from a false statement or representation that is material to entitlement or payment under the Medicare program. 6

Examples of Fraud Billing for services or supplies that were not provided. Altering claims to obtain higher payments Soliciting, offering or receiving a kickback, bribe or rebate (paying for referrals) Using another person’s Medicare card to obtain medical care Provider completing Certificates of Medical Necessity (CME) for patients not known to the provider Suppliers completing CME’s for the physician 7

Abuse Definition Behaviors or practices of providers, physicians, or suppliers of services and equipment that, although normally not considered fraudulent, are inconsistent with accepted sound medical, business or fiscal practices. The practices may directly or indirectly, result in unnecessary costs to the program, improper payment, or payment for services that fail to meet professionally recognized standards of care, or which are medically unnecessary. 8

Examples of Abuse Excessive charges for services or supplies Claims for services that don’t meet CMS medical necessity criteria Breach of the Medicare participation or assignment agreements Improper billing or coding practices Note: Most provider billing errors fall into the category of abuse. 9

CMS Direction to State Surveyors – Effective May 1, 2011 Data driven surveys Patient outcome oriented Less structure & process oriented Focus on those standards most directly related to the patient care process Increase use of information gathered from staff interviews 10

Survey “Continued ” Minimized review of non-clinical record documentation More specific guidelines for expanding the standard survey to partial or extended status Added guidance for issuing standard and condition-level deficiency citations 11

Survey “Continued” Guidelines for Citing Standard Level deficiencies: Because the Level 1 highest priority standards are identified as those most related to the delivery of high- quality patient care a single problematic finding with an actual (or potential) outcome(s) which would support a determination of non-compliance …. Guidelines for Citing Condition Level deficiencies: A COP may be considered out of compliance for one or more deficiencies, if, in a surveyor’s judgment, the deficiency constitutes a significant or a serious finding that adversely affects, or has the potential to adversely affect patient outcomes…. 12

CERT Audits Comprehensive Error Rate Testing Around since 1996 Designed to measure overall error rate for Medicare contractors claims processing divisions Medical Records requested from provider’s Overpayment determinations made 13

Probe Edit Audits Pre-Payment Review of Claims at RHHI May identify specific HIPPS to target Late Episodes Therapy Slows Cash Flow / Increase Admin burden Can result in 100% Medical Review Referral to ZPIC / RAC 14

ZPIC Audits Zone Program Integrity Contractors SafeGuard Services, AdvanceMed, Health Integrity, and Integriguard Active in southeast, southwest, northeast & west coast Expect activity nationwide in

ZPIC Audits Surprise on-site visits to providers & Medicare beneficiaries Targeted data analysis Random Audits Use extrapolation Overpayments determined 100% pre-payment holds 16

ZPIC Audits Responsible to Safeguard the Medicare program Pre or post payment reviews possible Hi-tech data analysis capabilities Benefit Integrity and / or fraud detection Cost report audits Provider education 17

ZPIC Audits Know your appeal rights 30 days to provide Medical Records at review onset ZPIC Determination RHHI overpayment Demand Follows 30 days to submit redetermination (1 st Level Appeal) Reconsideration (2 nd Level Appeal) ALJ – Administrative Law Judge (3 rd Level Appeal) 18

ZPIC Preparation  Documentation! Documentation!  Not Recorded, didn’t happen!  Conduct Internal Assessment to be sure compliance with Medicare regulations. 19

RAC Audits  Recovery Audit Contractors  CMS announced RAC’s activity to increase in HHA’s in 2012  RAC’s funding for Medicaid Claims

RAC Audit Preparation  Conduct an internal assessment to identify if you are in compliance with Medicare rules  Contract with a third-party to perform the assessment  At any rate, identify corrective actions that need to take place to be in compliance  File corrected billing where appropriate 21

RAC Audit Understand your rights and response timeliness guidelines Be prepared to submit Medical Record sample requested Know your appeal rights 22

RAC OASIS / Coding Accuracy / Compliance Homebound determinations Skilled Need / Medical necessity Therapy documentation Maintenance 23

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