F.O.R.C.E. Healthcare Resources, LLC (Founded on Regulatory Compliance and Ethics) Home Health ADR’s Webinar August 8,2012 1

About F.O.R.C.E.? Home Health Consulting Firm – Founded 2005 Services Provided: 1.Home Health Billing Seminars & Training (J.V. w/ Medicare Training & Consulting) 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 Financial Consulting 7.Home Health CLIA Billing & Recovery Project 2

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

ADR’s What generates ADR’s? When RHHI claims department is unable to make an initial claims determination When Medical Review Department conducts a pre- payment review (Ex. Probe Edit Sample) When processing claims for high dollar amounts When processing claims containing NOC – Not Otherwise Classified Codes When the NPI does not match the information in their claims system 4

ADR’s Probe Edit Sample Audits: Palmetto GBA 16 States Compares Days of Service & Disbursements per beneficiary to your State Average Palmetto GBA Texas, Louisiana, Oklahoma & Mississippi Compares DOS & Disbursement per bene to Palmetto overall HIPPS Code Specific May be others All RHHI’s will conduct these pre-payment reviews in 2012 ff 5

ADR’s How will ADR’s impact the HHA? Pre-payment review/cash flow will be impacted Administrative burden to pull/copy/submit requested documentation Documentation MUST be submitted within 30 days of request Automatic denials on 46 th day from request if information not submitted RHHI Clinician will review info within 60 days 6

ADR’s Most Common Denials: 1.Missing or illegible provider signature or use of a signature stamp -Verify all documentation signed prior to submission -Print or type provider’s full name near the signature if illegible 2. Missing, Unsigned physician orders or F2F “non- compliant” - Verify necessary orders are legibly signed and submitted with requested documentation, verify data as needed 7

ADR’s 3. Illegible Documentation -Print or clearly write progress notes and all medical documentation -If you deem documentation may be illegible, you may submit typed exact copies of any written documentation -Ensure documentation is clean and dark enough to be legible when received as a fax transmission 4. Failure to provide documentation for all dates of service requested - Review ADR letter carefully and submit all documentation - Keep copies of all submitted data 8

ADR’s Respond timely Provide all information requested Document delivery of medical documentation (certified return receipt / fax confirmation) Agencies getting denials in spite of filing timely Hardship Cases given consideration 33% dollar to dollar denial rate results in Focused Medical Review 9

ADR’s Process at RHHI: Claims data fits edit parameters/selected for review Claim moved to S B6001 > ADR generated Provider notified via FISS/Letter Provider’s may check for ADR’s on FISS (recommend if any ADR received) If documentation received by 45 th day – reviewed by RHHI clinician RHHI issues response within 60 days If documentation not received by 46 th day – automatic denial generated 10

ADR’s RHHI Responses: Documentation supports all services (P B9997) > Claim paid Documentation supports some services (P B9997) > Claim partially paid Documentation does not support services (D B9997) > Claim fully denied Provider notified via RA/ERA for all responses 11

ADR’s Provider remedies: May appeal denied services within 120 days Redetermination – RHHI Reconsideration – Qualified Independent Contractor (QIC) Can proceed to Administrative Law Judge (ALJ) Note: RHHI appeals departments seriously backed up! 12

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