RAC is BACK ... What Does That Mean?
RAC SummitJointly sponsored by the Kansas Hospital Association
and the Missouri Hospital Association
October 7 2014Overland Park, Kansas
Ernie de los Santos Appeal Academy/Recovery Analytics LLC
Review current audit climate
Review recent CMS transmittals
Learn strategies to prepare
Understand new issues and potential RAC targets
Give you a new attitude about what RAC means
Objectives
How Do You See Challenge?
How Do You View Your Job?
Or Can You See It This Way?
The Challenge
Increased Audit Scrutiny
Surviving Audit Scrutiny
Understanding the environment
Developing Meaningful tools
Regulatory impact
Documentation
Where is the burden?
RAC Results for FY2014
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html
Top RAC Issues for FY2014
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html
CHANGES ON THE HORIZON
!!!!
But…What KIND of
changes?
The CMS Provider Relations Coordinator is: Latesha Walker.
Providers may contact Latesha by sending an email to:• [email protected] (for Recovery Auditor review process concerns/suggestions)• [email protected] (for MAC review process concerns/suggestions)
Recent Updates
Due to the continued delay in awarding new Recovery Auditor contracts, the CMS is initiating contract modifications to the current Recovery Auditor contracts to allow the Recovery Auditors to restart some reviews. Most reviews will be done on an automated basis, but a limited number will be complex reviews of topics selected by CMS.
Work continues on the procurement process for the four Part A / Part B Regions and the national DMEPOS/HH&H Region. The CMS remains hopeful that the new round of Recovery Auditor contracts will be awarded this year.
Recent Updates
ADRs going out to providers soon
Automated reviews are in play
“CMS will not conduct post-payment patient status reviews for claims with dates of admission October 1, 2013 through October 1, 2014.”
Probe and educate for patient status underway –Round 2
At This Moment…
ADRs have gone out to multiple providers but…
At This Moment
CMS stated…
but a limited number will be complex reviews of topics selected by CMS.
o Statement of Work requires advanced knowledge
o CMS has not published a focus item list
HAVE THINGS CHANGED????
WHY???
Check your portal for ADR status
Contact your RAC or CMS Project Officer
Don’t share information unnecessarily
ADRs were for:
DRG Validations
Sepsis, Spinal Procedures, Dx unrelated to the procedure, debridement, to name a few
At This Moment
MAC Probe and Educate – 2 Midnight Reviews – Patient Status
MAC reviews
Supplemental Medical Review Contractor is VERY active
ZPICS VERY active primarily DME
Appeals are in play at all levels but SLOW
Providers taking a quick breath
Finding/performing other work
RAC In preparation for next round
At This Moment…
Awaiting New Guidance
Unsure of changes
Stay tuned
RAC SOW (Statement of Work)
RACs must:• Perform Post payment review of all Medicare claim and provider types
(excluding DME/HHH) AND a review of claims/providers that show a "high propensity for error" as shown in CERT and other CMS analysis measures.
• Perform Prepay review, per the Prepayment Review Demonstration --active only when CMS has authority to use the RACs for this.
• Support CMS at all level of appeals, including "taking party status" at the ALJ level in at least 25% of cases reaching that level.
• Share methods, algorithms and edits used to find errors, with CMS and the MACs.
• Perform "necessary provider outreach to notify provider[s]" of purpose, etc.
(from a version of the SOW found by Appeal Academy in April 2013)
RAC Draft SOW
RAC Draft SOW
New Transmittals
Transmittal R534PI The MAC and ZPIC have the discretion to deny other “related” claims submitted before or after the
claim ... If documentation associated with one claim can be used to validate another claim, those claims may be considered “related.”
Examples of “related” claims that may be denied as “related” are in the following situations: • The MAC performs post-payment review/recoupment of the admitting physician's and /or surgeon's Part B services. For services related to inpatient admissions that are denied because they are not appropriate for Part A payment (i.e., services could have been provided as outpatient or observation), the MAC reviews the hospital record and if the physician service was reasonable and necessary the service will be recoded to the appropriate outpatient evaluation and management service. For services where the patient’s history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, postpayment recoupment will occur for the performing physician’s Part B service.
.
Claims that are Related
Transmittal R534PI
• Reserved for future approved “related” claim review situations. The MAC shall report to their BFL
and COR prior to initiating denial of “related” claims situations
.
Claims that are Related
EFFECTIVE DATE: September 8, 2014*Unless otherwise specified, the effective date is the date of service.IMPLEMENTATION DATE: September 8, 2014
Transmittal R534PI The MAC and ZPIC shall await CMS approval prior to initiating requested “related” claim(s) review. Upon CMS approval, the MAC shall post the intent to conduct “related” claim review(s) to their Web site within 1 month of initiation. The MAC shall inform CMS of the implementation date of the “related” claim review 1 month prior to the implementation date.
If “related” claims are denied automatically, MACs shall count these denials as automated review. If the “related” claims are denied after manual intervention, MACs shall count these denials as routine review.
The Recovery Auditor shall utilize the review approval process as outlined in their SOW when performing reviews of “related” claims.
The MAC, Recovery Auditor, and ZPIC are not required to request additional documentation for the “related” claims before issuing a denial for the “related” claims. Contactors shall process appeals of the “related” claim(s) separately. .
Claims that are Related
Transmittal R534PI REVISED and UPDATED to Transmittal R541
The MAC and ZPIC shall await CMS approval prior to initiating requested “related” claim(s) review. Approved examples of “related” claims that may be denied as “related” are in the followingsituations:
When the Part A Inpatient surgical claim is denied as not reasonable and necessary, the MAC may recoup the surgeon's Part B services. For services where the patient’s history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, postpayment recoupment may occur for the performing physician’s Part B service.
.
Claims that are Related
KEY FACTS: The term ADR refers to all documentation requests associated with
prepayment review and postpayment review collect documentation related to the beneficiary’s condition before and
after a service in order to get a more complete picture of the beneficiary’s clinical condition
.
Claims that are Related
Related Claims Denials
Related Claims Denials
R1422OTN
Modifiers are used to bypass edits when they are set by NCCI as optional edits. The -59 modifier is both commonly used and commonly abused.
According to the 2013 CERT Report data, a projected $2.4 Billion in MPFS payments were made on lines with modifier -59, with a $320 Million projected error rate. In facility payments, primarily OPPS, a projected $11 Billion was billed on lines with a -59 modifier with a projected error of $450 Million. This is a projected 1 year error of $770 Million.
Modifier 59
EFFECTIVE DATE: January 1, 2015*Unless otherwise specified, the effective date is the date of service.IMPLEMENTATION DATE: January 5, 2015
R1422OTN
XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure
XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner
XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service
Modifier 59
Wading through the Appeal Backlog
Wading through the Appeal Backlog
Wading through the Appeal Backlog
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Wading through the Appeal Backlog
Wading through the Appeal Backlog
Wading through the Appeal Backlog
Key Considerations:
• Outstanding Volume • Outstanding Dollars• Previous Strategy• Interest Possible• Immediate Need for Cash• Costs of Appeal Process• Previous ALJ Win Rate• Time Available• Settle vs. Rebill• Volume of IP-Only Denials• Impact on Cost Reports• Can you meet the 10/31 deadline?
YOUR LOGO
CMS FY2013 Report to Congress on RAC
51%Percent of FY2013 RAC Denials
With Appeal Decisions
9%Percent of FY2013 RAC Denials
(Overpayment Determinations)
Overturned on Appeal
52%Percent of FY2013 Appeal Claims
Remanded to QIC
YOUR LOGO
CMS FY2013 Report to Congress on RAC
38,732Level 3 (ALJ) Appeals “Decided”
15.0%“Withdrawn/Dismissed” – by ???
52.7%“Remanded to QIC”
24.5%“Decided Claims” Overturned
YOUR LOGO
OMHA December 2013 Report at RAC Summit
215,562Level 3 (ALJ) Appeals Filed
and Received at OMHA
Through June 2013
38,732Level 3 (ALJ) Appeals “Decided”
as Reported by CMS
In FY2013 Report to Congress
YOUR LOGO
OMHA July 2014 Testimony to U.S. House
384,151Level 3 (ALJ) Appeals Filed
and Received at OMHA
through September 2013
509,124Level 3 (ALJ) Appeals “Received”
at OMHA by July 1, 2014
in addition to those received
in FY2013
YOUR LOGO
MY Conclusions by Adding It All Up
72%Percent of FY2013 RAC Denials
Appealed by Providers
77%Percent of Provider Appeals “Won”
vs. FY2013 RAC Denials
55%Percent of FY2013 RAC Denials
Found to be Improper
Content is KingDocumentation is still the key
Conclusion
What should it meanto YOU
Now thatThe RAC is back?
A New Attitude:
Thank You!!!
42 CFR Part 424 subpart B and 42 CFR 412.3.
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R534PI.pdf
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf
CMS transmittal 541
References
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Medicare-FFS-Recovery-Audit-Program-3rd-Qtr-2014.pdf
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/RAC-Program-Improvements.pdf
http://www.ehcca.com/presentations/predmodel5/boyce_pc2.pdf
References
Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM
Recovery Analytics LLC
888-474-8023 (O)
704-826-7497 (O)
704-779-8095 (M)
704-848-5284 (F)
Ernie de los Santos, MBA, SSA, SAC
Appeal Academy & Finally Friday!
http://appealacademy.com
760-792-3858 (M)
210-901-8603 (O)
