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RELEVENT REIMBURSMENT CONCERNS. Presented By : The Division of Socioeconomic Affairs May 23 rd . 2010. Socioeconomic Affairs Staff. Yolanda Doss, MJ, RHIA, Director Division of Socioeconomic Affairs Kavin Williams, CPC, CCP Health Reimbursement Policy Specialist Michele Campbell, CPC

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RELEVENT REIMBURSMENT CONCERNS


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    1. RELEVENT REIMBURSMENT CONCERNS Presented By : The Division of Socioeconomic Affairs May 23rd. 2010

    2. Socioeconomic Affairs Staff • Yolanda Doss, MJ, RHIA, Director Division of Socioeconomic Affairs • Kavin Williams, CPC, CCP Health Reimbursement Policy Specialist • Michele Campbell, CPC Coding & Reimbursement Specialist

    3. Yolanda Doss, MJ, RHIA Responsibilities include: • Helping to secure reimbursement for osteopathic services • Securing the acceptance of osteopathic credentials • Addressing Medicare issues • HIPAA compliance • Fraud and Abuse

    4. Kavin T. Williams, CPC, CCP Responsibilities include: • Assists AOA members with reimbursement and health payment policies. • Oversees and assists AOA members with coding and payment disputes with carriers. • Oversees the AOA Coding and Reimbursement Advisory Panel. • Represents the AOA at national reimbursement policy meetings.

    5. Michele Campbell, CPC Responsibilities include: • Assists AOA members with accurate coding. • Assists AOA members with coding and payment disputes with carriers. • Medical record reviews. • Coordinates AOA’s responses to AMA CPT coding requests.

    6. The Objective is to Provide Informationon the Following Topics: • Impacts on 2010 Revenue • Elimination of the Consultation Codes • Evaluation & Management/Documentation • Medicare Audits • Recovery Audit Contractors (RAC) • “Incident To” Services • Federal Trade Commission’s Red Flag Rule

    7. 2010 Medicare Fee Schedule Update • The 2010 Fee Schedule remains at the same level as 2009 • Physician Quality Reporting Initiative (PQRI) Bonus Payment 2% • E-Prescribing Bonus Payment 2%

    8. Consultation Codes • CMS eliminated the consultation codes 99241-99245 and 99251-99255 effective January 1, 2010 • What does this mean for you? • Make sure you and your staff understand the difference between a new vs. an established patient

    9. Consultation Codes Updates • Some specialist will end up billing an established patient when they see a “referral” from a PCP unless the patient was not seen in the last three years by one of their partners. In that case this visit would be a new patient visit. • In the hospital setting, each physician that sees a patient will bill for an “initial hospital service” or sometimes referred to as an “admission”. This physician (admitting) will need to add modifier-AI, defined as Principal physician of record

    10. Consultations Codes Updates • We will have to wait and see what the private payers do, but the codes are still valid and are in the CPT book for 2010 with new commentary regarding transfer of care. • United Healthcare has announced that they will reimburse for the consultation codes for their commercial product. • The question will be how do you handle a claim where a commercial payer is primary and Medicare is secondary?

    11. Consultation Codes Updates • RVUs have increased 6% for the outpatient office visit codes 99201-99215 • RVUs have increased 2% for the inpatient initial hospital care codes (aka admissions) 99221-99223 and subsequent care for follow up visits

    12. Evaluation & Management (E/M) Coding • Coding for office visits • New patient visits, 99201-99205 • Established Patient visit, 99211-99215

    13. Documentation Rule One: If It Was Not Documented It Was Not Done!! Rule Two: Documentation Must Be Clear & Legible

    14. Chief Complaint (CC) • The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factors that is the reason for the encounter, usually stated in the “patient’s own” words. • Documentation Guidelines states that the medical record should clearly reflect the chief complaint

    15. Medical Necessity • Payers define “Medical Necessity” as services or supplies that are: • In accordance with standards of good medical practice • Consistent with the diagnosis • The most appropriate level of care provided in the most appropriate setting

    16. Chart Documentation

    17. What Is An Audit? An effective tool used by Medicare and other payors to recover monies lost to fraud and erroneous billings.

    18. Why Audits Are Initiated? • Suspicion (Billing Pattern) • Outlier Physicians • The Senior Patrol • Whistleblowers • Procedure Codes

    19. Who Are The Auditors? • The Office of the Inspector General (OIG) • Medicare • The Department of Justice (DOJ) • The Federal Bureau of Investigation (FBI) • Carriers

    20. Types of Audits • Prepayment Audits • Post-Payment Audits • Statistical Sampling Method

    21. What Auditors Look For? • Billing for services or supplies that were not provided. • Billing for non-allowable or non-covered services. • Altering claim forms to receive a higher payment amount. • Unbundling claims.

    22. How To Respond To A Request For Documentation • Reply to the audit notice in a timely fashion. • Gather and submit Only the requested documentation. • Be cooperative. • You may want to conduct an internal audit.

    23. How to Respond to the Audit Findings • If the findings are not favorable: • Attempt to discuss the findings with the reviewer. • If necessary request redetermination. • If necessary request a level one appeal.

    24. Medicare Recovery AuditContractors (RACs) 24

    25. RAC Legislation The RAC program was created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 which pays incentive fees to third-party auditors that identify and correct improper payments paid to healthcare providers in fee-for-service Medicare. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 also requires permanent and nationwide RAC program by no later than 2010 25

    26. The RAC Demonstration Project • The RAC demonstration project to place of New York, Florida, and California. • By 2010 the RAC will cover all 50 states.

    27. RAC Program Mission To detect and correct past improper payments, To implement actions that will preventfutureimproper payments. Providers can avoid submitting claims that don’t comply with Medicare rules CMS can lower its error rate Taxpayers & future Medicare beneficiaries are protected 27

    28. The New RAC’s Are: • Diversified Collection Services, Inc. of Livermore, California, in Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York. • CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B, initially working in Michigan, Indiana and Minnesota. • Connolly Consulting Associates, Inc. of Wilton, Connecticut, in Region C, initially working in South Carolina, Florida, Colorado and New Mexico. • HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona. Additional states will be added to each RAC region in 2009

    29. Timeframes A B D C Provider Outreach Earliest Correspondence Claims Available for Analysis March 1, 2009 March 1, 2009 March 1, 2009 March 1, 2009 March 1, 2009 March 1, 2009 August 1, 2009 August 1, 2009 August 1, 2009 *RACs may not begin reviewing until there is provider outreach in the state 29

    30. Minimize Provider Burden Limit the RAC “look back period” to three years Maximum look back date is October 1, 2007 RACs will accept imaged medical records on CD/DVD Limit the number of medical record requests 30

    31. Medical Record Limit Example Outpatient Hospital 360,000 Medicare paid services in 2007 Divided by 12 = average 30,000 Medicare paid services per month x .01 = 300 Limit = 200 records/45 days (hit the max) 31

    32. Summary of Medical Record Limits (for FY 2009) Inpatient Hospital, IRF, SNF, Hospice 10% of the average monthly Medicare claims (max 200) per 45 days per NPI Other Part A Billers (HH) 1% of the average monthly Medicare episodes of care (max 200) per 45 days per NPI 32

    33. Summary of Medical Record Limits (for FY 2009) Continued Physicians (including podiatrists, chiropractors) Sole Practitioner: 10 medical records per 45 days per NPI Partnership 2-5 individuals: 20 medical records per 45 days per NPI Group 6-15 individuals: 30 medical records per 45 days per NPI Large Group 16+ individuals: 50 medical records per 45 days per NPI Other Part B Billers (DME, Lab, Outpatient hospitals) 1% of the average monthly Medicare services (max 200) per NPI per 45 days 33

    34. RAC Validation Contractor (RVC) • CMS has contracted with Provider Resources, Inc. of Erie, PA, to work as the Recovery Audit Contractor (RAC) Validation Contractor. • The RAC Validation Contractor (RVC) will work with CMS and the RAC to approve new issues the RACs want to pursue for improper payments, as well as perform accuracy reviews on a sample of randomly selected claims on which the RACs have already collected overpayment. • The RVC is another tool CMS will use to provide additional oversight and ensure that the RACs are making accurate claim determinations in the permanent program.

    35. For Additional Information on RAC • http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6125.pdf • http://www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf • http://www.cms.hhs.gov/rac/

    36. Medicare “Incident to” Physician Services The OIG reviews Medicare services that are “incident to” physicians services to determine the qualificationsand appropriateness of the staff whoperformed them.

    37. Physician Defined The “physician” refers to physician or other practitioner (listed below), who are authorized to receive payment for services “incident to” his or her own services. • physician assistants • nurse practitioners • clinical nurse specialist • nurse midwife, and • clinical psychologist

    38. Professional Service • A direct, personal, professional service which is rendered by the physician • To meet the “incident to” guidelines, the physician must initiate the course of treatment, and • Conduct subsequent physician services to show ongoing involvement

    39. Coverage Requirements To be covered, service and supplies must be: • An integral, though incidental, part of the physician’s or on-physician practitioner’s professional services • Commonly furnished in a physician’s office or clinic • Furnished by the practitioner or auxiliary personnel under the physician’s direct supervision

    40. Supervision Requirements Direct physician supervision of auxiliary personnel is required. Auxiliary personnel: • any individual (employee, leased employee, or independent contractor) who is acting under the supervision of a physician • Auxiliary personnel include nurses, medical assistants, technicians, etc.

    41. Direct Supervision in the Office • Physician must be present in the office suite • Physician must be immediately available to assist if needed • Does not require that the physician be in the same room

    42. Direct Supervision in the Office Continued Scenarios that do not meet the direct supervision requirement: • Availability of a physician by telephone • Physician presence somewhere in an institution

    43. Documentation To support the use of the incident to provision, the documentation should clearly indicate: • Who performed the “Incident to” service • The physician’s presence in the office suite during the service/procedure

    44. Federal Trade Commission (FTC)“Red Flag” Rule As many as nine million Americans have their identities stolen each year. Identity thieves may drain their accounts, damage their credit, and even endanger their medical treatment. The cost to businesses left with unpaid bills racked up by scam artists can be staggering.

    45. Federal Trade Commission (FTC)“Red Flag Rule” Continued The “Red Flags” Rule, requires many businesses and organizations to implement a written Identity Theft Program designed to detect the warning signs-or “red flags”- of identity theft in their day-to-day operations, take steps to prevent the crime, and mitigate the damages it inflicts.

    46. The Red Flags Rule: An Overview The Red Flags Rule sets out how certain businesses and organizations must develop, implement, and administer their Identity Theft Prevention Programs. Your Program must include four basis elements, which together create a framework to address the threat of identity thief.

    47. First, • Your program must include reasonable policies and procedures to identify the “red flags” of identify theft you may run across in the day-to-day operation of your business. • Red flags are suspicious patterns or practices, or specific activities, that indicate the possibility of identify theft. • For example, if a new patient arrives at your office and you request the insurance cards along with identification and the ID looks like it might be fake would be a “red flag” for your practice.

    48. Second, • Your program must be designed to detect the red flags you’ve identified. • For example, if you’ve identified fake IDs as a red flag, you must have procedures in place to detect possible fake, forged, or altered identification.

    49. Third, • Your program must spell out appropriate actions you’ll take when you detect red flags

    50. Lastly, • Because identity theft is an ever-changing threat, you must address how you will re-evaluate your program periodically to reflect new risks from this crime. • The Red Flags Rule gives you the flexibility to design a program appropriate for your practice, its size and potential risks of identify theft.