Medicare Audits & Patient Access - PowerPoint Presentation

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Medicare Audits & Patient Access

Presented by : Michelle Way

,

Revenue Cycle Integrity Specialist

Otani Consulting Group, Inc.  

46th Annual

Educational Conference & Exhibition

Patient Access:  

The First Connection to a Lasting Impression

September 21 – 24, 2014Slide2

WelcomeSlide3

Let’s take a minute and discuss ICD-9 vs. ICD-10

Today under ICD-9 billing codes there are 13,000 diagnostic codes.

In order to smooth the billing process and reduce cost in healthcare, 68,000 ICD-10 codes were developed!

Let’s look at a few of these necessary codes….. Healthcare – Is Our Job Getting Easier?Slide4

V97.33XD

: Sucked into jet engine, subsequent encounter. What? A patient was sucked into a jet engine, survived, then sucked in again?

Y93.D: Activities involved arts and handcrafts. What? Arts and crafts are so dangerous they need a billing code … no hot glue guns or knitting needles.

ICD-10 Slide5

V00.01XD: Pedestrian on foot injured in collision with roller-skater, subsequent encounter. What?

W55.41XA: Bitten by pig, initial encounter. What? Do they have another code for subsequent encounter -- time to get away from the pig.

But let’s not pick on pigs---W61.62XD: Struck by duck, subsequent encounter. What?

ICD-10Slide6

W55.29XA: Other contact with cow, subsequent encounter. What? What, precisely, is the contact with the cow that has necessitated a hospital visit?

V91.07XD: Burn due to water-skis on fire, subsequent encounter. What/How? Can this really happen

W220.2XD: Walked into lamppost, subsequent encounter. OKAY this one is for me!

ICD-10Slide7

No

one likes to be audited, especially by the federal government. However, the increase in Medicare abuse has caused the Centers for Medicare and Medicaid Services (CMS) to consistently audit

healthcare providers that receive federal Medicare dollars. **Patient Financial Services audits are often meant to recover any inaccurate or improper

payments that were made via Medicare claims.

How to Prepare for Your Next Medicare Audit Slide8

The

best way to survive an audit and make yourself “audit-proof ” is to

manage your department as best you can in accordance with all applicable rules/requirements and regulations governing reimbursement.Here are a few

suggestions…“Au d i t- P ro o f i n g ” Your

DepartmentSlide9

Know and understand the requirements for Patient Access

The big ones are: Patients Rights, Advance Directives, Medicare Secondary

Payor, Important Message For Medicare, *Safe Surrender (DHS)Know and understand the flow of information from the registration system to clinical systems.Facility wide “Team” effort!

“Au d i t- P ro o f i n g ” Your Department Suggestions:Slide10

Take the time to write things down. Develop P&P as well as training documents to educate staff on requirements

Ensure your P&P’s are consistent with CMS guidelines

If you don’t document your process, the best explanations will be of little help during an auditDiscuss compliance at every staff meetingEnsure that your staff understand the importance of these job requirements

Elevate their position to a “profession” not just a “position”

“Au d i t- P ro o f i n g ” Your Department Suggestions:Slide11

Periodic self-audits are also required

Audit charts to ensure requirements are being adhered too

Follow up on areas needing improvementMaintain records of auditsTraining, training, training Medicare compliance should be comprehensive training upon hire and a mandatory refresher

annuallyTraining on Medicare and the purpose of auditing. Not only will this keep your staff informed, but training on the books will demonstrate to

CMS the seriousness with which you take the matter“Au d i t- P ro o f i n g ” Your Department Suggestions:Slide12

Typically the facility will receive a letter notifying them of anticipated audit

Once

CMS arrives a complete review will be conducted utilizing a “Surveyors On-Site Checklist”. This document has 5 sections with a total of 57 items listedFor ABC Hospital the Advance Directive (AD) information on the eHR did not match the documentation in the registration system - - PROBLEM!!

CMS Audit Process For Advance DirectivesSlide13

CMS cited the facility and the facility had 90

days torespond

to CMS with an action planImmediate corrective action was taking place at the facilityCMS had 30 days to

accept or reject the proposed facility action plan CMS could not agree to timelines, accuracy goals, improvement timelineWhen action plan was approved, CMS had any time after 90 days to come back and

audit againCMS Audit Process For Advance DirectivesSlide14

Facility started

weekly meetings with all managers that

had areas citedRegistration audited daily all charts on the floors (100%), then after staff accuracy increased the audits changed to weekly then monthly

Employees not improving were put on a PI PlanAudit results were submitted to Administration for record keeping and for submission to CMS on facility wide report

CMS Audit Process For Advance DirectivesSlide15

Audits continue today and anytime

compliance is below 95% facility returns to weekly auditing

A major issue at ABC Hospital was that the registration system and clinical charting system did not flow information back and forth.

So if Patient Access asked the AD question, documented the response - then the nurses

inquired about AD and documented the outcome the documentation often did not match the registration system = ISSUE!CMS Audit Process For Advance DirectivesSlide16

It was found

that when CMS identified one deficiency in

an area they tended to dig really deep in anything that fell under that umbrella. For example: When CMS found that restraints were not done correctly, they started digging deep into all Patient Rights areas, which resulted with the findings and tremendous focus on Advanced directives.

Each time CMS came back to review the status of the action plan they would survey a different area and potentially find another item to add.

Lesson Learned at ABC HospitalSlide17

Why Does CMS Audit For MSP

The Medicare Secondary Payer (MSP) program is designed to

reduce costs to the Medicare program by requiring other insurers of health care for beneficiaries to pay primary to Medicare. It applies in three situations: where there is liability

insurance, e.g. for an accident; where there is workers compensation coverage, e.g., for a job related injury; and where there is an employer’s large group health plan (EGHP)

Source: http://www.medicareadvocacy.org/medicare-info/medicare-secondary-payer-program/Slide18

Reality

NOT A QUESTION OF IF BUT WHEN

YOU WILL BE AUDITED Slide19

MSP Audit

at Hospital X

Written notice sent to hospital CFO

Advises CFO to expect a listing of claims selected and a letter of instruction, which arrives within 2 weeks with a deadline to return selected claimsAuditor completes claim desk review – 40 claims

CMS then sends next notice to hospital of on-site reviewOn-site review and exit interview followed by written conclusion of hospital’s compliance with MSP regulationsSlide20

Hospital

X - MSP Audit

Claim Selection LetterHospital

Reviewer requested 40 claims per hospital with supporting documents:UB04MSP Admission Questionnaire

Beneficiary’s Medicare Summary Notice (MSN) Admission Policies that identify “Other Payer” primary to MedicareRegistration Policies that describe the process and systems used to meet complianceBilling policies that identify “Other Payer” primary to Medicare and Medicare “No Pay” billing proceduresMedicare Secondary Payer Training Manuals and policiesSlide21

Hospital X -

Internal Preparation

Informed Management of pending reviewDispersed audit letter

to all related departmentsAssigned a point person for audit coordination- PFS AuditorEstablished an MSP Review Committee composed of Billing, Registration and Audit Team. Weekly meeting scheduled

to keep all informedAssigned teams to gather requested documentationPFS Auditor coordinated assembling audit material Teams reviewed all related policies & training material Scheduled in-services with Billing and RegistrationPFS Audit and Managers reviewed signage, brochures, and team delivery of required materials & explanation of forms being signed during admission interviewsSlide22

Hospital X - Points

to Remember

Anything you discuss with Hospital Reviewer should be reviewed in advance for

correctnessBe truthful, state facts, and don’t give

opinionsKeep all answers short and to the pointMeet all deadlines indicated in the submission documentsKeep copies of all submissionsOur reviewer was new and needed to see lots of detail to verify our processes were thoroughYour team members do these functions everydaySlide23

Dear Mr. Lawson:

Office of inspector General Office of Audit Services

REGION IV Room 3T41 61 Forsyth Street, S.W. Atlanta, Georgia 30303-8909 This final report provides you the results of our Review of Hospital Medicare Secondary Payer Issues. EXECUTIVE SUMMARY

OBJECTIVE The objective of this review was to determine whether XXXX Medical Center (the hospital) complied with Medicare Secondary Payer (MSP) regulations regarding both inpatient and outpatient settings during its Fiscal Year (FY) ended June 30,2012.

FINDINGS Our review showed that, for 64 percent of the claims reviewed, the hospital could not provide sufficient documentation to demonstrate compliance with Medicare guidelines and it’s policies and procedures regarding the completion and adequacy of MSP questionnaires. We are concerned that this condition could lead to Medicare absorbing a share of the costs applicable to other payers and to credit balances being generated and requiring unnecessary administrative expenses to resolve. In this respect, a review of 25 credit balances showed that in 7 instances, Medicare was billed in the wrong order. In reviewing these credit balances, we also found that the hospital did not always refund Medicare credit balances in a timely fashion. We are recommending that the hospital: not bill Medicare unless hospital personnel have obtained and filed a completed MSP questionnaire; implement and provide, within 60 days, effective education and training to every staff person associated with collecting admission information What We Don’t Want to SeeSlide24

Questions?