Transcript Presentation Title - Virginia Osteopathic Medical Association

RELEVENT REIMBURSMENT
CONCERNS
Presented By :
The Division of Socioeconomic Affairs
May 23rd. 2010
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
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
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.
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.
The Objective is to Provide Information
on the Following Topics:
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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
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%
Consultation Codes
• CMS eliminated the consultation codes 9924199245 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
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
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?
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
Evaluation & Management (E/M) Coding
• Coding for office visits
• New patient visits, 99201-99205
• Established Patient visit, 99211-99215
Documentation
Rule One:
If It Was Not Documented It Was Not Done!!
Rule Two:
Documentation Must Be Clear & Legible
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
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
Chart Documentation
What Is An Audit?
An effective tool used by Medicare and other
payors to recover monies lost to fraud and
erroneous billings.
Why Audits Are Initiated?
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Suspicion (Billing Pattern)
Outlier Physicians
The Senior Patrol
Whistleblowers
Procedure Codes
Who Are The Auditors?
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The Office of the Inspector General (OIG)
Medicare
The Department of Justice (DOJ)
The Federal Bureau of Investigation (FBI)
Carriers
Types of Audits
• Prepayment Audits
• Post-Payment Audits
• Statistical Sampling Method
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.
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.
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.
Medicare
Recovery Audit
Contractors (RACs)
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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
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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.
RAC Program Mission
• To detect and correct past improper payments,
• To implement actions that will prevent future
improper 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
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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
Timeframes
A
B
D
C
Claims Available for Analysis
Provider Outreach
*RACs may not begin
reviewing until there is
provider outreach in
the state
Earliest Correspondence
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
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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
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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)
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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
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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
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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.
For Additional Information on RAC
• http://www.cms.hhs.gov/MLNMattersArticle
s/downloads/MM6125.pdf
• http://www.cms.hhs.gov/RAC/Downloads/
RAC%20Evaluation%20Report.pdf
• http://www.cms.hhs.gov/rac/
Medicare “Incident to” Physician
Services
The OIG reviews Medicare services that are
“incident to” physicians services to determine
the qualifications and appropriateness of
the staff who performed them.
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.
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physician assistants
nurse practitioners
clinical nurse specialist
nurse midwife, and
clinical psychologist
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
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
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.
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
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
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
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.
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.
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.
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.
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.
Third,
• Your program must spell out appropriate
actions you’ll take when you detect red flags
Lastly,
• Because identity theft is an ever-changing
threat, you must address how you will reevaluate 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.
Who Must Comply With The Red
Flags Rule?
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Financial Institutions
Creditors
Covered Accounts
The determination of whether a business or
organization is covered by the Red Flags Rule isn’t
based on the industry or sector, but rather on
whether the activities of the business fall within the
relevant definition.
Financial Institution:
The Red Flags Rule defines a “financial
institution” as a state or national bank, a state
or federal savings and loan association, a
mutual savings bank, a sate or federal credit
union, or any other person that, directly or
indirectly, hold a transaction account
belonging to a consumer.
Creditor:
• According to the final rule, a creditor is “any person
who regularly extends, renews, or continues credit;
any person who regularly arranges for the extension,
renewal of continuation of credit; or any assignee of
an original creditor who participates in the decision
to extend, renew or continue credit.”
• The FTC has taken the position that physicians are
creditors, if they do not require full payment upfront
at the time they see patients, but bill patients after
the services are rendered.
Covered Accounts:
• Once you have concluded that your business
or organization is a financial institution or
creditor, you must determine if you have any
covered accounts.
Covered Account Continued:
• Two categories of accounts are covered:
• The first is a consumer account you offer your
customers that’s primarily for personal, family, or
households purposes that involves or is designed to
permit multiple payments or transactions
• The second kind of “covered account” is any other
account that a financial institution or creditor offer
or maintains for which there is a reasonable
foreseeable risk to customers or to the safety and
soundness of the financial institution or creditor
from identify theft
How To Comply
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Identify relevant red flags
Detect red flags
Prevent and mitigate identify theft
Update your program
Identify Relevant Red Flags
• What are “Red Flags”?. They’re the potential
patters, practices, or specific activities
indicating the possibility of indentify theft
Identify Relevant Red Flags
Continued
• Consider the following when identifying
relevant red flags:
• Risk Factors
• Sources of Red Flags
• Categories of Common Red Flags
Detect Red Flags
Once you’ve identified the red flags of
indentify for your business, it time to lay out
procedures for detecting them in your dayto-day operations. Sometimes using identity
verification and authentication is taking
place in person or at a distance – say, by
telephone, mail, internet, or wireless system
Prevent and Mitigate Identify Theft
When you spot a red flag, be prepared to
respond appropriately. Your respond will
depend upon the degree of risk posed. In
determining your response, consider
whether any aggravating factors heighten
the risk of identify theft.
Update The Program
The rule recognizes that new red flags
emerge as technology changes or identity
thieves change their tactics. Therefore, it
requires periodic updates to your program
to ensure that it keeps current with
identity theft risks.
Red Flag Rule Resources
• Fighting Fraud with the Red Flag Rules
http://ftc.gov/redflagsrule
Division Website
• Go to www.do-online.org and sign onto DOOnline.
• First time users will need their AOA member
number to sign up.
• On DO-Online, click on Practice Management
for the division website.
• There is also a Division email address:
[email protected].
What the DO-Online Practice
Management Website has for You
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Billing and Coding
E/M documentation
ICD-9-CM code updates
OMT information
Legal
Litigation fund
Updates on class action
suits
• CMS/Medicare
• Links to local carrier
information
• Information on each CPT
code
• Enrollment information
• CMS Medlearn
• CCI link
• Fee schedules, new and prior
What the DO-Online Practice
Management Website has for You
• Preventive health
services
• Demonstration
projects
• CERT- fraud and
abuse information
• HIPPA
• Managed care
• Osteopathic
Advocacy Resources
Division CME Seminars
• Conducted in conjunction with state associations
and specialty colleges.
• Seminars available include Medicare Compliance,
HIPAA Privacy Compliance, and Documentation
Guidelines and Coding Reimbursement.
• Call Yolanda Doss, MJ, RHIA at 800-621-1773
ext. 8187 or [email protected] for info.
My Contact Information
• Kavin T. Williams, CPC, CCP, Health
Reimbursement Policy Specialist
1-800-621-1773 X 8194 Toll Free
1-312-202-8194 Direct
[email protected]