Recovery Audit Program - The Process

Recovery Audit Program

Mission - The Recovery Audit Program’s mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states.

 

Background - The national Recovery Audit program is the product of a successful demonstration program that utilized Recovery Auditors to identify Medicare overpayments and underpayments to health care providers and suppliers in randomly selected states. The demonstration ran between 2005 and 2008 and resulted in over $900 million in overpayments being returned to the Medicare Trust Fund and nearly $38 million in underpayments returned to health care providers. As a result, Congress required the Secretary of the Department of Health and Human Services to institute (under Section 302 of the Tax Relief and Health Care Act of 2006) a permanent and national Recovery Audit program to recoup overpayments associated with services for which payment is made under part A or B of title XVIII of the Social Security Act.

 

Each Recovery Auditor is responsible for identifying overpayments and underpayments in approximately ¼ of the country. The Recovery Audit Program jurisdictions match the DME MAC jurisdictions. 

 

The Recovery Auditor in each region is as follows:

 

Region A:  Performant Recovery 

Region B:  CGI Federal, Inc.  

Region C:  Connolly, Inc.  

Region D:  Health Data Insights, Inc.

 

 

Q & A

 

Will The Recovery Auditors Affect Me?

 

 Yes, if you bill fee-for-service programs, your claims will be subject to review by the Recovery Auditors.

 

 

What Does A Recovery Auditor Do?

·         The Recovery Audit Review Process:

·         Recovery Auditors review claims on a post-payment basis

·         Recovery Auditors use the same Medicare policies as Carriers, FIs and MACs: NCDs, LCDs and the CMS Manuals

·         Three types of review:

o   Automated (no medical record needed)

o   Semi-Automated (claims review using data and potential human review of a medical record or other documentation)

o   Complex (medical record required)

·         Recovery Audits look back three years from the date the claim was paid

·         Recovery Auditors are required to employ a staff consisting of nurses, therapists, certified coders and a physician CMD

  

Ensure Accuracy 

·         Each Recovery Audit team employs:

o   Certified coders

o   Nurses

o   Therapists

o   A physician CMD

·         The CMS’ New Issue Review Board provides greater

oversight

·         Recovery Audit Validation Contractor provides annual

accuracy scores for each Recovery Audit organization

·         If a Recovery Auditor loses at any level of appeal, the

·         Recovery Auditor must return its contingency fee 

 

Have you taken the necessary steps to avoid an Audit?

Does your documentation support the level of service?

Does your coding qualify the various Quality Measures ?

 

Quality Measures are defined as: 

·         Meaningful Use

·         Core Measures

·         HEDIS

·         PQRS

·         National Quality Measures 

 

 

FOR MORE INFORMATION PLEASE CONTACT:

HPP Management Group, Corp.

Developers of the AccuChecker Product Line

Phone: (305) 227-2383

Email: sales@accuchecker.com

Website: http://www.accuchecker.com

 

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Understanding EHR

Understanding EHR

Regardless of format, whether paper, hybrid, or electronic, the health record must meet the requirements of the legal and business record for the organization.

Healthcare providers across the country recognize the benefits of electronic health records (EHRs) to improve care, reduce costs and improve efficiency. But as medical professionals, we know the challenges of keeping up with technology. The Healthcare Information and Management Systems Society (HIMSS) has developed some suggestions for you as you plan EHR implementation for your practice.

 

WHAT IS THE LEGAL ELECTRONIC HEALTH RECORD (EHR)?

• The health record is a healthcare organization’s most important business and legal record.

• Legal requirements, well defined for maintaining paper health records, are additionally complex for electronic records.

• Health records must be maintained in a way that is legally sound or they risk being challenged as invalid.

 

WHY DOES THE EHR NEED TO BE A LEGAL RECORD? 

Simply, a healthcare organization must have a health record. Its “health record” must, by definition, meet all statutory, regulatory, and professional requirements for clinical purposes as well as for business purposes. If the record does not qualify as a legal record, it becomes hearsay and therefore is much less legally valid for business or for medical-legal purposes. Unless the practice intends to maintain separate paper records that comply with legal requirements, its EHR, to be a legal record, must conform to the same requirements as health records in general and for business records on computers more specifically.

 

WHAT IF MY EHR DOES NOT MEET THE REQUIREMENTS FOR A LEGAL RECORD? 

• As an invalid business record, a problematic EHR can be challenged by payors for billing or Pay for Performance (P4P).

• With an invalid medical-legal record, risk of adverse litigation outcomes and costs rise. 

LEGAL EHR BASICS 

Don’t assume that a given EHR will meet your requirements for a legal record. As the EHR marketplace increases awareness of these matters, products will continue to improve. Here are four areas to look at: 

How is documentation created? 

• Is the author of each element of documentation accurately recorded, including vitals, chief complaint, history of present illness, orders, plans, and prescriptions?

• How are different, successive versions of the encounter (before signature) treated?

• Do signature procedures and tools meet your state’s and your organization’s requirements?

 

How is documentation managed and preserved over time?

• After signature, if a correction, clarification, or amendment is added, is it clear what is original and what is not and can all original documentation be recovered if needed?

• How is documentation protected from being altered, in all parts of the system including the underlying     database?

• How are new templates, guidelines, forms, etc., created, preserved, retired?

• Are all clinical messages and clinical behaviors (prompts, etc.) reproducible and recoverable?

• Do other periodic and necessary tasks, such as report creation and auditing, also expose  documentation to additional security risks?

• Are critical support functions, such as auditing, always operable and reasonably accesible or do they require vendor supports or other extra costs?

 

How does documentation interact with billing? 

• Does the system prompt users to add documentation for “improved revenue”?

• Does the system allow the sending of billing information without completion of documentation?

• Does the system send billing information for tests without means to ensure the tests were actually done?

 

How is documentation presented? 

• When asked to produce a view or a printout of an encounter, does the system offer a view that conforms to your organization’s definition of its legal record?

• If documentation has been amended or otherwise altered, is that clearly identified in the viewed and printed version?

 

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5 ways to increase your EMR efficiency

5 ways to increase your EMR efficiency

 

1. Start on time.  Consider the idea that if a provider can cut just 30 seconds from each patient encounter, it enables that provider to see an additional patient every day. Naturally, some patients require more time, but they can be balanced with those who require less time. But all of this is for naught if a provider starts late. In fact, not only should providers start on time, but they should have two patients “front-loaded” to get the day off to a running start. You should also give patients an arrival time ten minutes before the first appointment, so they’re ready to go when the provider is. 

2. Have cross-trained staff that can handle intake and documentation. Cross-training staff so they are capable of filling in for different providers at different times on a variety of tasks leads to a smoother patient flow, less chaos, and fewer frustrations. Providers’ workflow preferences need to be communicated upfront and clarified often so that stronger, more flexible relationships with their support staff will develop. Providers need to be flexible, too, and be willing to work with whichever staff member is available at any given time, rather than always relying on one person. 

It is also important to have more than one staff support person available right from start of the day, in order to help providers stay on time — especially when the schedule is full. One important task that staff can assume is inputting some patient documentation. Handing off some of this responsibility would enable providers to spend more time with patients and still have documentation completed by close of business. 

A simpler, more efficient workflow that aligns the right tasks with the right stages on the intake process helps ensure more efficient handoffs of tasks among administrative staff, clinical support staff, and providers. And constant visibility into patient status, location, and stage of visit — which ought to be available via your EMR — can also make it easier to stay ahead of the game and hand off tasks more efficiently. 

3. Document encounters in real-time, but be cognizant of time and detail. Completing patient documentation is an important component of running a successful practice. 

There are important benefits to completing documentation by close of business, but some providers are overly zealous about completing it in real-time — something that an EMR makes much easier to do. However, complex documentation may take more time to complete than is good for your patient flow. You should consider putting off finishing documentation in real-time when necessary, and hand off more of the documentation to staff, in order to reduce patient wait times. 

Knowing which data fields you need to fill in your EMR will also increase efficiency. Just because there are a lot of fields doesn’t mean you need to fill every one of them in. Don’t get bogged down by information overload. You should also look for an EMR that automatically provides pay-for-performance or quality rules so that as you document patient encounters, you know you’re capturing the data that will ensure that additional revenue. 

4. Close all patient encounters at the end of each business day. As I just discussed, providers shouldn’t try to complete complex documentation that consumes a lot of time while trying to see patients. They should, however, try to close all encounters by the end of the business day. This requires completing as much documentation as they can during the day without holding up the flow of patients, leaving themselves just the wrap-up of complex documentation at day’s end. Not only does closing encounters clear the decks for patients coming the following day, but it also moves the encounter into the administrative phase, where it can be billed. The sooner encounters are closed, the sooner billing can be done, and the sooner the practice will get paid. It’s that simple. And, as mentioned previously, the providers’ ability to close encounters on the same day is the leading indicator of the overall efficiency of a practice’s patient workflow. 

5. Route documents appropriately and delegate effectively. Handling charts, faxes, lab work requests and results, and so on is time-consuming in a busy office. Providers should hand off to staff as much of the responsibility for handling routing documents as possible. Providers will always need to review and handle certain types of documents, of course, but staff should be able to handle administrative forms and routine negative test results without the physician involvement.

2015-2016 Star Ratings

Key Points from the CMS Memo about 2015-2016 Star Ratings

 

CMS released details about enhancements to the Star Ratings in 2015 and beyond.  CMS has provided advanced notice of these proposed changes ahead of the draft 2015 Call Letter in order to provide time to receive and review comments.  Comments must be submitted by Thursday, December 19th. 

New 2015 Measures

CMS intends to add the following to the 2015 Star Ratings.  Each will be assigned a weight of ‘1’ since they will be first year measures.

Part C

• Pharmacotherapy Management of COPD Exacerbation
• Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
• Special Needs Plan (SNP) Care Management
• Completion of annual health risk assessments

Part D

• Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews

Changes to Measures for 2015

CMS is modifying the methodology for the following measures.

Part C

• Breast Cancer Screening – Change to impact 2016 Star Ratings.  Display measure for 2015 Star Ratings.
• Modification reflects changes in HEDIS 2014
• Annual Flu Vaccine – Change to impact 2015 Star Ratings
• The flu shot question in CAHPS will be changed to ask members if they have received a flu shot since July of each year instead of September.
• The pre-determined 4 star threshold will be eliminated for the 2015 Star Ratings due to the change. 

Part D

• High Risk Medication – Change to impact 2015 Star Ratings
• This measure will use the updated PQA HRM list
• Medication Adherence for Diabetes Medication – Change to impact 2015 Star Ratings
• CMS is adding two additional drug classes
• Appeals Upheld – Change to impact 2015 Star Ratings
• Change from 6-month to 12-month measurement period.
• The pre-determined 4 star threshold will be eliminated for the 2015 Star Ratings due to the change.
• Medicare Plan Finder Accuracy – Change to impact 2015 Star Ratings
• CMS proposes to include PDE claims from retail pharmacies that are also reported by sponsors as being long term care, mail order, or home infusion pharmacies.
• CMS will also remove the restriction to evaluate only claims for 30-day supplies, and will evaluate claims for 30, 60, and 90-day supplies.
• Beneficiary Access and Performance Problems (Part C & D) – Change to impact 2015 Star Ratings
• Change to the audit score calculation.
• Medication Adherence Measures – Change to impact 2015 Star Ratings
• The three medication adherence measures will be adjusted to account for members with hospice enrollment or Skilled Nursing Facility (SNF) stays. The Part D sponsor would not be responsible for providing prescription refills for these medications.
• Only standalone PDPs have SNF data available for the adjustment.  All plans offering Part D will have hospice information available.
• Obsolete National Drug Codes (NDCs) – Change to impact 2015 Star Ratings
• CMS will implement the PQA’s specification change to account for obsolete NDCs.

Retirement of Measures

• CMS plans to remove the Glaucoma Testing measure for the 2015 Star Ratings.

Contracts with Low Enrollment

• Contracts with 500 or more enrollees as of July 2013 will be included in the 2015 Star Ratings. These contracts in most cases will have sufficient data to produce both overall and Part C and D ratings. The HEDIS data for contracts with less than 500 enrollees will continue to be posted on the display page. 

Data Integrity

• CMS will continue to take steps necessary to protect the integrity of the data.  CMS’ audits and other investigations have consistently shown that sponsors fail to follow requirements for forwarding Part C denials and auto-forwarding untimely Part D initial coverage determination or redetermination requests to the IRE. Other areas of concern are the two new proposed measures that focus on SNP care management and MTM CMRs which are also based on organization/sponsor reported data.  If erroneous or biased data has been submitted, it is CMS’s policy to reduce the measure rating to 1.

Changes to Display Measures

• Measures that may be added to 2015 display page and then to the 2016 Star Ratings:
• CAHPS measures about contact from a doctor’s office, health plan, pharmacy, or prescription drug plan
• CAHPS – Complaint Resolution
• CAHPS – Health Information Technology – EHR measures
• Transition monitoring
• Combined MPF Price Accuracy
• Disenrollment Reasons
• There may be a change to the measure specification of the Drug-Drug Interactions Measure.

Forecasting to 2016 and Beyond

• CMS may remove the pre-determined 4 star thresholds beginning with the 2016 star ratings.
• CMS is concerned that using whole-star individual measures and pre-determined 4 star thresholds results in a loss of information when aggregating to the levels of overall and summary ratings.
• There will be no changes to the 4 star thresholds for the 2015 Star Ratings.
• CMS will provide contract-specific information on the impact of removing the 4 star thresholds prior to the comment period for the 2015 draft Call Letter.
• Expected changes to measure specifications or calculations based on possible NCQA revisions to HEDIS 2015.
• Osteoporosis Management in Women who had a Fracture
• Treatment with estrogen may be removed, an upper age limit may be added, and dementia may be excluded.
• Monitoring Physical Activity
• The HOS questions may be revised to include an outcome indicator that assesses whether patients increased their level of physical activity.
• Plan All-Cause Readmissions
• Two changes possible: 1) excluding planned readmissions 2) removing current exclusion from the denominator for hospitalizations with a discharge date in the 30 days prior to the Index Admission Date.
• Improving Bladder Control
• HOS questions will be revised for the 2015 data collection.  As such, data will not be available for this measure for the 2016 and 2017 Star Ratings.

 

How can AccuChecker help you today ?

 

“Having an integrated Coding Tool is absolutely wonderful, you don’t have to flip back and forth between systems—all of your information is at hand when needed.” 

No need for a CPT Coding Book, ICD-9 (Soon to be ICD-10), and other materials to reference today’s Medical Billing.

 

AccuChecker , the Complete Tool For Medical Reimbursement :

 

ü  Coding Technique

ü  CCI

ü  LCD

ü  HEDIS

ü  PQRS

ü  ICD-10

ü  Medicare Fee Schedule

 

AccuChecker has two (2) Versions:

 

ü  State Version

ü  National Version 

All of your information is at hand! 

For more information call 305-227-2383 or 1-877-938-9311

 

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