THE UPSIDE OF 1

THE UPSIDE OF MEDICARE AUDITSTARA MONDOCKVP OF GOVERNMENT PROGRAMS & PAYER RELATIONSIVANS, INC.

AHIA 31st Annual Conference – August 26-29, 2012 – Philadelphia PAwww.ahia.org

Overview: Submitting Medical Documentation Electronically to MedicareDocumentation Electronically to Medicare

Today’s Agenda

Presentation Objectives

Background on Improper PaymentsBackground on Improper Payments

Medical Documentation Process

CMS esMD Program

esMD Demo

Medicare Review Contractor Perspective on esMD

Current and future use cases for esMD

Question & Answer

2If you experience any technical difficulties during the webinar, please call 203.698.7230

AcronymsyAcronym Term

ADMC Ad d D f M d CADMC Advanced Determination of Medicare Coverage

ADR Additional development or documentation request

CERT Comprehensive Error Rate Testingp g

CMS Centers for Medicare and Medicaid Services

DRG Diagnosis-related group

esMD Electronic Submission of Medical Documentation

FFS Fee for service

HIH Health Information Handler

IT Information Technology

MAC Medicare Administrative Contractor

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Acronymsy

Acronym TermAcronym Term

NHIN National Health Information Network

ONC Office of National Coordinator

PERM Payment Error Rate Measurement

RA Recovery Auditor

TPL Third Party LiabilityTPL Third Party Liability

ZPIC Zone Program Integrity Contractor

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esMD Presentation Objectivej

Increase provider awareness of Medicare Audits Increase provider awareness of Medicare Audits and the esMD PlatformHighlight the esMD use cases and positive workflow Highlight the esMD use cases and positive workflow implicationsProvide a forum for open discussion about the Provide a forum for open discussion about the Medicare Audit and esMD initiatives

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Background on Improper Payments

M di h b i l f h f d l ki Medicare has been consistently one of the top federal programs making improper payments

CMS has deployed review contractors to conduct audits of Medicare payments to healthcare providersto healthcare providers

Medicare receives 4.8 M claims per dayClaim review contractors issue over 1 million ADR requests each year

Improper payments include: Improper payments include: Incorrect payment amountsIncorrectly coded servicesNoncovered services (services that are not reasonable and necessary)Duplicate services

CMS has created a new division solely focused on program integrity including improper payments and fraud and abuse

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Audits are Big Business for the Government Government

The CMS Office of Financial Management estimates that each year g ythe Medicare FFS program issues more than $34.3 B in improper payments

$1 03 B found in Medicare improper payments during Recovery $1.03 B found in Medicare improper payments during Recovery Audit Demonstration Project in six states between 2006-2008

96% in overpayments

4% i d4% in underpayments

The Recovery Audit Program is now permanent and nationwide

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Different Types and Sizes of Hospitals Reported are Subject to RAC ReviewReported are Subject to RAC Review

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Percent Reporting RAC Activity vs No RAC Activity Percent Reporting RAC Activity vs. No RAC Activity by Type of Participating Hospital, through 1st Quarter 2012Quarter 2012

Number of RAC Audits Performed is on th Rithe Rise

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Number of Participating Hospitals Reporting RAC Number of Participating Hospitals Reporting RAC Activity by Region, through 1st Quarter 2012

Providers Continue to Report Dramatic Increases in RAC Denials and Medical Record Requestsin RAC Denials and Medical Record Requests

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Reported Automated Denials, Complex Denials and Reported Automated Denials, Complex Denials and Medical Records Requests by Participating Hospitals, through 1st Quarter 2012p , g

Number of Medical Records Requested i I i is Increasing

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Providers are at Risk to Loose Millions f D llof Dollars

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$4.3 billion in Medicare payments were targeted $4.3 billion in Medicare payments were targeted for medical record requests through the 1st quarter of 2012

The average value of a medical record t d i l irequested in a complex review

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Average Value of a Medical Record Requested in a Average Value of a Medical Record Requested in a Complex Review Among Hospitals Reporting RAC Activity, through 1st Quarter 2012y, g

The Hunt for Improper Payments is Ongoing and ExpandingOngoing and Expanding

The Prepayment Review demo will allow Medicare Recovery p y yAuditors to review claims before they are paid

Preventing improper payments rather than the traditional “pay and chase” methods of looking for improper payments after they occurchase methods of looking for improper payments after they occur

These reviews will focus on seven states with high populations of fraud- and error-prone providers

FL, CA, MI, TX, NY, LA, IL

And four states with high claims volumes of short inpatient hospital stays y

PA, OH, NC, MO

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Providers Can Receive Audits From Many Types of Review Contractors

Review Contractors include:

Types of Review Contractors

1. RA – Recovery Auditor (Post-Payment and Pre-Payment NEW)

2. MAC – Medicare Administrative Contractor (Pre-Payment)

3. CERT – Comprehensive Error Rate Testing program• Review Across All MAC Jurisdiction with focus on incorrect coding of claims,

DRG upcoding or downcoding, and medical necessity

4. PERM – Payment Error Rate Measurement program• A claim is reviewed to determine if it was processed correctly, and the

services were actually provided, medically necessary, coded correctly, and y p , y y, y,properly paid or denied.

5. ZPIC – Zone Program Integrity Contractor• Fraud and Abuseaud a d buse

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Providers are Subject to an Audit by R A dit E 45 DRecovery Auditors Every 45 Days

• All providers that bill Medicare and Medicaid are eligible to be audited by various Review Contractors

Audits often require medical documentation to support claims

Hi t i ll th d t ti ld l b il d ( ith i Historically, the documentation could only be mailed (either paper copies or on CD/DVD)

The amount of paperwork submitted in 2010 by the average hospital was p p y g psignificant

150 di l d 225 f di l 150 medical record requests every audit cycle (45 days)

225 pages of medical documentation per request

33,750 total pages submitted on average

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Today’s Audit Request and Response PProcess

R i C t t

Doc’ n Request

Time and money that could be Review ContractorLetter better spent

delivering higher quality

healthcare

No record of receipt

P

Provider

Paper Medical Record Printing and shipping costs

Administrative burdens

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Provider

Providers Can Use Many Tools to Improve the Audit ExperienceImprove the Audit Experience

Audit preparationAudit preparationHire external consultants to do an audit and gap analysis

Analyze past audit results to uncover areas for improvement in processes d d t tiand documentation

Organize a multi-functional team with an audit process champion to lead audit preparation and response

Audit managementBuild or buy software tools to assist with the audit response process

D t tDocument management

Release of information

Electronic submission

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CMS Built the esMD Gateway To Address The Administrative BurdensThe Administrative Burdens

• CMS has built an Exchange Gateway to accept esMD transactions from providersfrom providers.

• The CMS esMD gateway went live in September 2011.

• CMS uses the “CONNECT” brand of gateway

Exchange

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The Nationwide Health Information N t kNetwork

• Set of standards, protocols, legal agreements, and specifications that a consortium of health information organizations have agreed are necessary for secure and private exchange of health information over the public internet.

• Overseen by the ONC for Health IT

Ensures that esMD transactions are SAFE and SECURE as they y

travel from point A to point B.

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Providers Have Two Options for Accessing the esMD GatewayAccessing the esMD Gateway

Build your own esMDGateway

Engage an HIH

A Health Information Handler (HIH) is any company that handles company that handles health information on behalf of a provider

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esMD – How Does it Work?

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HIH’s are Simplifying the Audit Submission Process for ProvidersProcess for Providers

Medical record requests are sent to providers through the mail, responses are returned to Review Contractors electronically

Providers upload files into the IVANS AuditDocs application, files then sent securely to Review Contractor using NHIN standards

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esMD DEMOesMD DEMO

Electronic Submission in 4 Easy Stepsy p

1. Enter the audit information from the letter you received from the review contractor

2 E t i l i i f ti tt h d t th dit2. Enter in claim information attached to the audit

3. Attach supporting medical documents to appropriate claims

4. Click submit you have successfully completed your electronic submission of medical documentation

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AuditDocs UI – Case/Claim ID Fields t d f ADR l ttare entered from ADR letter

If Case ID is found in the ADR Letter; this is not a required field

For RAC Audits, the A di ID ill b d Audit ID will be noted; for MAC Audits, the ‘Claim ID’ will generally also be the ‘Case ID’

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Completion of Workflow: Creating a N D tNew Document

Once the Metadata is entered, the user will proceed to the file upload part of the process – click on ‘New Document’

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Completion of Workflow: File Uploadp p

The user will ‘Browse’ and ‘Assign’ the documents

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Audit Trail Provides A Return Receipt Confirming Documents Were Sent By Provider & Received by Contractor

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Reporting Provides Tracking C bilitiCapabilities

The ‘Search’ function allows the user to conveniently retrieve data on past audits, by applying various filters and then clicking ‘Search’various filters, and then clicking Search

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From the Providers From the Providers Perspective

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Providers Using esMD Appreciate its P iti I t W kflPositive Impact on Workflow

“When we previously received an Additional W p v y vDocumentation Request (ADR) from CMS, we had to research, print and make copies of each document for h l l d h h h h that particular claim and then ship everything to the review contractor. Now, we just scan in our documents and upload everything, saving us hundreds of dollars in upload everything, saving us hundreds of dollars in shipping and labor charges, and freeing up our staff to focus on more pressing healthcare responsibilities.”

Anthony Pryce, President of American Home Health Agency

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From the Review C t t P tiContractor Perspective

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The Review Contractor Perspective on MDesMD

Reduces workloads for the provider cutting down Reduces workloads for the provider cutting down on printing and shipping costs

Quicker response time due to faster delivery

Fewer denials due to missing filing deadlinesFewer denials due to missing filing deadlines

Fewer appeals

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The Submission of Medical Documentation is Only the BeginningDocumentation is Only the Beginning

Ph 1 Phase 1: Doc’n

Request Letter

Live September, 2011

electronic

electronic

Phase 2:

Live 2013

electronic

Live 2013

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From the CMS Perspectivep

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Current and Future Use Cases for esMD

hINBOUND We

are here

N OUN•Responses to Documentation Request Letters in PDF •Appeal Requests in PDF •Unsolicited Documentation in PDF (called paperwork or “PWK”) S d O d P N ADMC R •Structured Orders, Progress Notes, ADMC Requests

•Structured esMD Phase 2 Registration

OUTBOUND •Structured Outbound Documentation Requests •Review Results Letters •Demand Letters

LOOKUP •Request\Receive Documentation Status •Request\Receive Claim Status •Request\Receive Appeals Status •Request\Receive Eligibility Info

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CMS Resources

• Articles– Medicare Learning Network (MLN) Special Edition Article

SE1110, “Medicare Pilot Project for Electronic Submission of Medical Documentation (esMD)”

http //www cms gov/MLNMattersArticles/downloads/SE1110 pdfhttp://www.cms.gov/MLNMattersArticles/downloads/SE1110.pdf– MLN Matters Article MM7254, “Additional Fields for

Additional Documentation Request (ADR) Letters”http://www.cms.gov/MLNMattersArticles/Downloads/MM7254.pp // g / / / pdf

• Web www.CMS.gov/esMD– Explanation of esMD concepts and terms

Li t f M di i t t ti MD – List of Medicare review contractors accepting esMD transactions

– List of CMS-approved HIHs– Frequently asked questionsFrequently asked questions

Alabama Quality Improvement

Alaska Quality Improvement

Arkansas Quality Improvement

Organization Organization Improvement Organization

MedicareRecovery

Auditor Contractor (RAC) PERM Central

Unit

Medicare Secondary

Payer Review

Contractor(MSPRC)

Medicare Part D

Review Contractors (MEDICs)

Medicare Part C

Review Contractors

(RADV)

Medicare Administrative

Contractors (MAC) Unit (MSPRC) (MEDICs) (RADV)(MAC)

CMS Private Network

Content Transport Services

ECM

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Exchange

For More Information

CMS esMD Web site:

http://www.cms.gov/esMD

Learn about IVANS http://www.ivans.com

IVANS AuditDocs™

http://www.ivans.com/auditdocs

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Thank YouThank YouQuestions From the Audience

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Save the Date: August 25-28 2013August 25-28, 2013

32nd Annual Conference Chi ILChicago, IL

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