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Reimbursement Primer for Compliance, Ethics and Legal Officers: Reimbursement Primer for Compliance, Ethics and Legal Officers: ““Everything You Have Always Wanted to Know AboutEverything You Have Always Wanted to Know About

Reimbursement but Were Afraid to Ask.Reimbursement but Were Afraid to Ask.””

Home Health and Hospice Home Health and Hospice Reimbursement Reimbursement

May 1, 2007May 1, 2007

►► Robin N. Seidman, Robin N. Seidman, RN, BSN, MSN, MBA, LNCCRN, BSN, MSN, MBA, LNCCDirector, Simione Consultants, LLCDirector, Simione Consultants, LLC

►► Betty BrennanBetty BrennanCEO, Beacon Hospice Inc.CEO, Beacon Hospice Inc.

►► Connie WoodworthConnie WoodworthCFO/Compliance Officer, Hospice of the North Shore, Inc.

►► Larry Vernaglia, ModeratorLarry Vernaglia, ModeratorPartner, Health Care Industry Team, Foley & Lardner, LLP

HOME HEALTHHOME HEALTH

REIMBURSEMENTREIMBURSEMENT

Home Health Prospective Pay SystemHome Health Prospective Pay System

►►Payment methodology for certified home Payment methodology for certified home health implemented October 2000health implemented October 2000

►►Affects Part A payment onlyAffects Part A payment only►►Consolidated billingConsolidated billing

Services, supplies, wound care treatmentsServices, supplies, wound care treatments

►►6060--Day Episodic Reimbursement SystemDay Episodic Reimbursement System►►Requires OASIS Requires OASIS (Outcomes & Assessment Information (Outcomes & Assessment Information

Set)Set)

►►Proposed PPS Reform Rule Proposed PPS Reform Rule 4/27/074/27/07Rule is labeled Rule is labeled ““SIGNFICANTSIGNFICANT””

PPS BILLING BASICSPPS BILLING BASICS

►►Payment includes all services and supplies Payment includes all services and supplies under a home health plan of careunder a home health plan of care

DME excluded from home health bundlingDME excluded from home health bundling178 non routine medical supply codes178 non routine medical supply codesDiabetic supplies excluded Diabetic supplies excluded Osteoarthritis drug excluded from payment but Osteoarthritis drug excluded from payment but bundledbundled

Episodic Reimbursement SystemEpisodic Reimbursement System►►Episode set at 60 day intervalsEpisode set at 60 day intervals►►Unlimited episodesUnlimited episodes►►Definition of episodeDefinition of episode

An episode begins with the first billable visit An episode begins with the first billable visit and ends with the 60th day from start of careand ends with the 60th day from start of careSubsequent episodes will begin on day: 61, Subsequent episodes will begin on day: 61, 121, 181, etc.121, 181, etc.Prospective Payment covers one individual Prospective Payment covers one individual regardless of number of days of care within the regardless of number of days of care within the episode unless the following exceptions occur:episode unless the following exceptions occur:

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Special Payment CircumstancesSpecial Payment Circumstances►► LUPA (Low Utilization Payment Adjustment)LUPA (Low Utilization Payment Adjustment)

Less than 5 visits occur during the episode Less than 5 visits occur during the episode

►► PEP (Partial Episode PaymentPEP (Partial Episode Payment))If a patient transfers to another agency or is discharged If a patient transfers to another agency or is discharged and readmitted during the same episode and readmitted during the same episode

►► OutliersOutliersLossLoss--sharing ratiosharing ratio5% of national total episode payment5% of national total episode payment

► SCIC (Significant Change in Condition)there is an unexpected major decline or improvement in the patient’s condition,the payment is affected, and POC changesOptional; requires case by case evaluation

Home Care is DifferentHome Care is DifferentMedicare reimbursement is driven by theMedicare reimbursement is driven by the

OASISOASIS

and supporting and supporting

Clinical DocumentationClinical Documentation

OASIS AssessmentOASIS Assessment►►Required at start of episode, resumption of Required at start of episode, resumption of

care, significant change in condition, and care, significant change in condition, and end of episodeend of episode

Specific time frames required for each Specific time frames required for each assessmentassessment

►►9393** items make up current versionitems make up current version►►Medicare payment is determined byMedicare payment is determined by

80 HHRG 80 HHRG (Home Health Resource Group)(Home Health Resource Group) ItemsItems►►Going to 153Going to 153

►►Assessment items grouped byAssessment items grouped by►►Clinical (C), Functional (F), and Service (S) DomainsClinical (C), Functional (F), and Service (S) Domains

HHRG OASIS ReimbursementHHRG OASIS Reimbursement►► Clinical Domain (C)Clinical Domain (C)

MO230/245 Primary DX, MO240(b) Secondary DXMO230/245 Primary DX, MO240(b) Secondary DX►►Orthopedic, neurological, diabetes, trauma codesOrthopedic, neurological, diabetes, trauma codes

WoundsWounds►►MO450/460 pressure ulcersMO450/460 pressure ulcers►►MO476 stasis ulcersMO476 stasis ulcers►►MO488 woundsMO488 wounds

►► Functional Domain (F)Functional Domain (F)MO650, MO660, MO670, MO680, MO690, MO700MO650, MO660, MO670, MO680, MO690, MO700Dressing, Bathing, Toileting, Transfers, and LocomotionDressing, Bathing, Toileting, Transfers, and Locomotion

►► Service (S)Service (S)MO175 Inpatient discharges in the past 14 days MO175 Inpatient discharges in the past 14 days ►► (Inpatient rehabilitation, skilled nursing facility)(Inpatient rehabilitation, skilled nursing facility)

MO825 MO825 -- 10 or more therapy visits10 or more therapy visits►► Therapy Thresholds at 6, 14, and 20 visitsTherapy Thresholds at 6, 14, and 20 visits

HHRG HHRG -- HIPPS HIPPS -- RAP RAP -- FINAL FINAL ►►HHRG translated to HIPPS code for billing HHRG translated to HIPPS code for billing

purposespurposes►►Payments are casePayments are case--mix and wage adjustedmix and wage adjusted►►Reimbursement split into Request for Reimbursement split into Request for

Anticipated Payment (RAP) and Final ClaimAnticipated Payment (RAP) and Final ClaimInitial RAP payment 60% of reimbursementInitial RAP payment 60% of reimbursementRAP payment 50% with subsequent episodesRAP payment 50% with subsequent episodesRAP not considered claim except for purposes RAP not considered claim except for purposes of False Claims Actof False Claims Act

HHRG TO HIPPSHHRG TO HIPPS►► First position: always First position: always ““HH””►► 22--4 position4 positionDomain LevelDomain Level Position 2Position 2 Position 3Position 3 Position 4Position 4MinimalMinimal C0 = AC0 = A F0 = EF0 = E S0 = JS0 = JLowLow C1 = BC1 = B F1 = FF1 = F S1 = KS1 = KModerateModerate C2 = CC2 = C F2 = GF2 = G S2 = LS2 = LHighHigh C3 = DC3 = D F3 = HF3 = H S3 = MS3 = MMaximumMaximum F4 = IF4 = I

C0F0S0 / HAEJ = Lowest CaseC0F0S0 / HAEJ = Lowest Case--Mix Adjustment (0.52560)Mix Adjustment (0.52560)

C3F4S3 / HDIM C3F4S3 / HDIM –– Highest CaseHighest Case--Mix Adjustment (2.81130)Mix Adjustment (2.81130)

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HHRG Calculation ExampleHHRG Calculation ExampleClinical Severity Score: 11 - Low Functional Status Score: 0 - Min Service Utilization Score: 0 - Min HHRG Group: C1F0S0Case Mix Weight: 0.6131 MSA or Rural Area: 5600 Wage Index Rate: 1.4461 PPS Total: $1681.63

Clinical Severity Score: 10 - Low Functional Status Score: 26 - High Service Utilization Score: 4 - Mod HHRG Group: C1F3S2Case Mix Weight: 1.7677 MSA or Rural Area: 5600 Wage Index Rate: 1.4461 PPS Total: $4848.50

HOME HEALTH CARE

Conditions of Participation Conditions of Participation --COPsCOPs

►►Skilled Care (RN, PT, SLP)Skilled Care (RN, PT, SLP)►►Reasonable and Medically Necessary Reasonable and Medically Necessary

CareCare►►Intermittent ServicesIntermittent Services

No 1No 1--time only visitstime only visitsCan be daily for short durationCan be daily for short duration

►►HomeboundHomebound►►Services provided in a place of residenceServices provided in a place of residence►►Plan of Care (Form 485)Plan of Care (Form 485)

PLAN OF CARE (POC)PLAN OF CARE (POC)►► POC must be completed prior to provision of carePOC must be completed prior to provision of care►► Must indicate:Must indicate:

Type of ServicesType of ServicesDuration and Frequency of all servicesDuration and Frequency of all servicesTreatment ordersTreatment orders

►► May be verbal order initiallyMay be verbal order initially►► With subsequent episodes of care, new or updated With subsequent episodes of care, new or updated

POC required, along with new ordersPOC required, along with new orders►► Intermittent and other verbal orders received Intermittent and other verbal orders received

during episode of care modify the POCduring episode of care modify the POC►► Physician MUST sign the Plan of Care and all Physician MUST sign the Plan of Care and all

verbal orders prior to final claim submissionverbal orders prior to final claim submission

Hospice Hospice ReimbursementReimbursement

Enrollment in HospiceEnrollment in Hospice

Any patient who is eligible for Medicare Any patient who is eligible for Medicare (Part A) is eligible to elect the hospice benefit.(Part A) is eligible to elect the hospice benefit.

Beneficiary must have: Beneficiary must have: ►►A prognosis of less than 6 months or less if the A prognosis of less than 6 months or less if the

disease runs its normal course.disease runs its normal course.►►Certification of the terminal illness by two physicians Certification of the terminal illness by two physicians

(attending physician and medical director of hospice)(attending physician and medical director of hospice)►►A Statement of choice by the beneficiary choosing A Statement of choice by the beneficiary choosing

hospice rather than a curative treatment.hospice rather than a curative treatment.

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Services CoveredServices Covered►► Core ServicesCore Services

Nursing Nursing Medical Social WorkMedical Social WorkCounseling (bereavement, dietary, spiritual)Counseling (bereavement, dietary, spiritual)PhysicianPhysician

►► Other ServicesOther ServicesHome Health AideHome Health AidePT,OT, ST servicesPT,OT, ST servicesMedications related to the terminal diagnosisMedications related to the terminal diagnosisDurable medical equipment including oxygenDurable medical equipment including oxygen

All diagnostic and therapeutic services needed to All diagnostic and therapeutic services needed to manage the terminal diagnosis.manage the terminal diagnosis.TransportTransportGeneral Inpatient hospital/SNF care related to the General Inpatient hospital/SNF care related to the terminal diagnosis terminal diagnosis VolunteerVolunteer

Hospice Benefit ReimbursementHospice Benefit Reimbursement►► The actual amount paid by Medicare is a per diem established on The actual amount paid by Medicare is a per diem established on a a

regional basis adjusted to the labor costs.regional basis adjusted to the labor costs.►► Four Levels of Care:Four Levels of Care:

Routine Home Care:Routine Home Care: Provided to patients at home (patient defines Provided to patients at home (patient defines home)home)Rate about $125 per dayRate about $125 per dayContinuous Care:Continuous Care: Covers care during crisis in the patients home for Covers care during crisis in the patients home for short durations. Rate hourly for 24 hours (no less than 8 hours short durations. Rate hourly for 24 hours (no less than 8 hours of of professional services up to 24 hours in a day).professional services up to 24 hours in a day).Rate for 24 hours about $750Rate for 24 hours about $750General Inpatient CareGeneral Inpatient Care: Covers acute episode of care in hospital or : Covers acute episode of care in hospital or SNF for pain and symptom management for short durations.SNF for pain and symptom management for short durations.Rate about $600 per dayRate about $600 per dayRespite Care:Respite Care: Cover a maximum of 5 days during a benefit period for Cover a maximum of 5 days during a benefit period for family relief.family relief.Rate about $130 per day Rate about $130 per day

Hospice ReimbursementHospice Reimbursement

►► Hospice Reimbursement is defined by MedicareHospice Reimbursement is defined by Medicare►► Enacted in 1982 under the Tax Equity Financial Enacted in 1982 under the Tax Equity Financial

Responsibility Act (TEFRA).Responsibility Act (TEFRA).►► Continues to be the most comprehensive benefit for endContinues to be the most comprehensive benefit for end--ofof--

life care available.life care available.

►► Covered by Medicaid in 43 states and the District of Covered by Medicaid in 43 states and the District of Columbia.Columbia.

►► Most commercial health plans have some type of hospice Most commercial health plans have some type of hospice coverage or will negotiate on a casecoverage or will negotiate on a case--byby--case basis.case basis.

►► Managed care also covers hospice typically at the same Managed care also covers hospice typically at the same reimbursement level.reimbursement level.

►► Veterans Affairs covers hospice through a contracted rate.Veterans Affairs covers hospice through a contracted rate.

Reimbursement RequirementsReimbursement Requirements

►► Establishment of Initial Plan of Care.Establishment of Initial Plan of Care.Verbal orders obtained within 48 hours of admission by attendingVerbal orders obtained within 48 hours of admission by attendingphysician and medical director.physician and medical director.Written signatures by attending physician and medical director Written signatures by attending physician and medical director within 8 days of admission.within 8 days of admission.

►► Notice of Election by Beneficiary Selecting Hospice.Notice of Election by Beneficiary Selecting Hospice.►► Consent for Hospice.Consent for Hospice.►► Notice of Election by state (Medicaid). Notice of Election by state (Medicaid). ►► Establishment of Level of Care for each day provided.Establishment of Level of Care for each day provided.

Beneficiary may have several levels of care within a 30 day Beneficiary may have several levels of care within a 30 day period.period.

►► Verification of coverage by either Medicare, Medicaid, CommerciaVerification of coverage by either Medicare, Medicaid, Commercial, l, HMO.HMO.

Specific payor authorizations may be needed.Specific payor authorizations may be needed.►► Invoices may be provided electronically to the Fiscal IntermediaInvoices may be provided electronically to the Fiscal Intermediary.ry.

LimitationsLimitations

►►Per Beneficiary LimitPer Beneficiary LimitCalculated annually representing the total that Calculated annually representing the total that may be reimbursed to a hospice for the total may be reimbursed to a hospice for the total number of beneficiaries served.number of beneficiaries served.2006 PBL Cap: $20,5852006 PBL Cap: $20,585

►►GIP CapGIP CapNo more than 20% of the days of care provided No more than 20% of the days of care provided by the hospice in total may be billed as General by the hospice in total may be billed as General Inpatient Care.Inpatient Care.

Special ConsiderationsSpecial Considerations

►►Invoices will only be reimbursed in a Invoices will only be reimbursed in a chronological fashion.chronological fashion.

►►Additional documentation required for each Additional documentation required for each benefit period (90benefit period (90--9090--6060--6060--unlimited).unlimited).

►►Reviews of records may occur at any time Reviews of records may occur at any time known as Additional Request (ADRs). known as Additional Request (ADRs).

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Compliance Compliance –– Impact on Impact on ReimbursementReimbursement

Informed Consent (Informed Consent (unrelated to paymentunrelated to payment))

Election of the Hospice Benefit Election of the Hospice Benefit

Certification of Terminal IllnessCertification of Terminal Illness

Interdisciplinary Team (IDT) DocumentationInterdisciplinary Team (IDT) Documentation

Informed ConsentInformed Consent

►►Unrelated to reimbursement for servicesUnrelated to reimbursement for services

►►Indicates that a person has been given Indicates that a person has been given relevant facts and has the capacity to relevant facts and has the capacity to understand the facts and the implications of understand the facts and the implications of giving consentgiving consent

►►Protective for healthcare providersProtective for healthcare providers

Election of the Hospice Medicare Election of the Hospice Medicare BenefitBenefit

►►Signed by the beneficiary or his/her Signed by the beneficiary or his/her representativerepresentative

►►Specific elements are requiredSpecific elements are required

►►Signed election must be completed BEFORE Signed election must be completed BEFORE claim submissionclaim submission

Election Compliance ChallengesElection Compliance Challenges

►►No provisions for verbal electionsNo provisions for verbal elections

►►Claims may be denied if the election Claims may be denied if the election statement does not include the required statement does not include the required elementselements

Certification of Terminal IllnessCertification of Terminal Illness

►► Hospice providers are required to:Hospice providers are required to:

Obtain written certification of terminal illness (COTI) for Obtain written certification of terminal illness (COTI) for each benefit periodeach benefit period

If a written COTI cannot be obtained within 2 calendar If a written COTI cannot be obtained within 2 calendar days after a period begins, a verbal COTI must be days after a period begins, a verbal COTI must be obtained and DOCUMENTED within these same 2 daysobtained and DOCUMENTED within these same 2 days

Obtain the written COTI Obtain the written COTI beforebefore submitting a claim for submitting a claim for paymentpayment

COTI Compliance ChallengesCOTI Compliance Challenges

►►Obtaining and documenting the verbal COTIObtaining and documenting the verbal COTI

►►Ensuring timeliness of MD signatures Ensuring timeliness of MD signatures

►►Sufficient IDT documentation to support Sufficient IDT documentation to support eligibility throughout the course of care, eligibility throughout the course of care, including recert discussionsincluding recert discussions

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IDT DocumentationIDT Documentation

►►Hospices are required to designate an Hospices are required to designate an interdisciplinary group or groups composed interdisciplinary group or groups composed of individuals who provide or supervise the of individuals who provide or supervise the care and services offered by the hospice.care and services offered by the hospice.

►►--establish, review and update the plan of establish, review and update the plan of carecare

►►--supervise the care and servicessupervise the care and services►►--RN must coordinate the plan of careRN must coordinate the plan of care

IDT Documentation ChallengesIDT Documentation Challenges

►► DocumentingDocumenting care care planningplanning……not care reportingnot care reporting

►► DocumentingDocumenting resolution of problemsresolution of problems

►► DocumentingDocumenting individualized plans of careindividualized plans of care

►► DocumentingDocumenting input from all disciplinesinput from all disciplines

►► If isnIf isn’’t documented, it didnt documented, it didn’’t happen!!!!t happen!!!!

Hot Topics in Hospice ComplianceHot Topics in Hospice Compliance

►► General Inpatient (GIP) level of careGeneral Inpatient (GIP) level of care--what what is for and where can it be provided?is for and where can it be provided?

►►Continuous CareContinuous Care--under utilization, under utilization, documented medical necessity?documented medical necessity?

►►Hospice in nursing facilities?Hospice in nursing facilities?

Compliance TrendsCompliance Trends

►►Closer scrutiny of Medicare Hospice Closer scrutiny of Medicare Hospice providers due to the tremendous growth in providers due to the tremendous growth in overall spending over the last few yearsoverall spending over the last few years

►►Increasing ADRs (Additional Development Increasing ADRs (Additional Development Request)Request)

►►Increasing frequency of Probe AuditsIncreasing frequency of Probe Audits

Know the Regulatory TrendsKnow the Regulatory Trends

►►TECHNOLOGYTECHNOLOGYProbe EditsProbe EditsMeasurable data (OASIS)Measurable data (OASIS)

►►Increase state survey scrutinyIncrease state survey scrutiny►►Recovery Audit Contractors (RACs)Recovery Audit Contractors (RACs)

Strong incentive to recoup $$$Strong incentive to recoup $$$

►►QUALITY & ACCESSQUALITY & ACCESSOutcomesOutcomesPay for Performance Pay for Performance

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Watch Government Watch Government ActivitiesActivities

►►What are hot topics for the GovernmentWhat are hot topics for the GovernmentCenters for Medicare Services (CMS)Centers for Medicare Services (CMS)Office of Inspector General (OIG)Office of Inspector General (OIG)Department of Justice (DOJ)Department of Justice (DOJ)State Attorney GeneralState Attorney General

►►OIG and DOJ recent investigationsOIG and DOJ recent investigationsMedical necessity of homecare therapyMedical necessity of homecare therapyBilling errors Billing errors –– MD Care Plan OversightMD Care Plan Oversight

2007 OIG WORK PLAN2007 OIG WORK PLANHome HealthHome Health

►►Home Health Outlier PaymentsHome Health Outlier PaymentsFrequency & cluster in HHRGsFrequency & cluster in HHRGs

►►Enhanced Payments for TherapyEnhanced Payments for TherapyAnalyze # and duration of visits/episodeAnalyze # and duration of visits/episode

►►Cyclical NonCyclical Non--Compliance of SurveysCompliance of Surveys►►Accuracy of Data on HH CompareAccuracy of Data on HH Compare►►Coding Accuracy for HHRGsCoding Accuracy for HHRGs►►Medical Necessity of TherapyMedical Necessity of Therapy

2007 OIG WORK PLAN2007 OIG WORK PLANHospiceHospice

►►Hospice Payments to SNFs Hospice Payments to SNFs -- continuedcontinuedDetermine whether dually eligible Determine whether dually eligible patients in SNFs receive proper servicespatients in SNFs receive proper services

►►Hospice Plans of Care and Hospice Plans of Care and Appropriate Payments Appropriate Payments -- newnew

Focus on if assessments completed are Focus on if assessments completed are reflected in the POCreflected in the POCMedical record reviews to determine if Medical record reviews to determine if services billed = services renderedservices billed = services rendered

Fiscal IntermediaryFiscal Intermediary

►►Focus AreasFocus AreasAnalysis of ADRs, Denials, DownAnalysis of ADRs, Denials, Down--codescodes

►►ResourcesResourcesWebsite & PublicationsWebsite & Publications►►Clarification of RegulationsClarification of Regulations►►Tips on answering OASIS $$ questionsTips on answering OASIS $$ questions

►►Directives from CMSDirectives from CMS►►““MedLearn MattersMedLearn Matters””

Free OnFree On--line Educationline Education

OIG Compliance OIG Compliance GuidanceGuidance

►►Implement 7 Fundamental ElementsImplement 7 Fundamental Elements►►Need to coordinate your P & P with Need to coordinate your P & P with

appropriate training & educational appropriate training & educational programsprograms

►►Emphasis on areas of risk identified Emphasis on areas of risk identified by the OIG by the OIG

31 identified areas of concern31 identified areas of concern-- HHHH29 identified areas of concern 29 identified areas of concern -- HospiceHospice

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OIG Clinical Risk AreasOIG Clinical Risk Areas--Home HealthHome Health

►►Billing for services not providedBilling for services not provided►►Billing for medically unnecessary Billing for medically unnecessary

services or patients or not homeboundservices or patients or not homebound►►Insufficient documentation to support Insufficient documentation to support

reimbursementreimbursementOASISOASIS

►►False dating of amendments to nursing False dating of amendments to nursing notesnotes

►►Falsified Plans of CareFalsified Plans of Care

OIG Clinical Risk AreasOIG Clinical Risk Areas--Home HealthHome Health

►►Claim Development and Submission Claim Development and Submission ProcessProcess

MOST FREQUENT RECOVERIESMOST FREQUENT RECOVERIES►►Many have resulted in CIAs in addition Many have resulted in CIAs in addition

to paying $$$$.to paying $$$$.►►MUST have a process in place for MUST have a process in place for

reviewing basic reviewing basic billing requirementsbilling requirementsPrePre--andand--Post Submission ReviewsPost Submission ReviewsSarbanesSarbanes--Oxley (SOX) Audits requiredOxley (SOX) Audits required

OIG Clinical Risk AreasOIG Clinical Risk Areas--HospiceHospice

►►Admitting nonAdmitting non--terminally ill patientsterminally ill patients►►Falsified medical records or POCFalsified medical records or POC►►Untimely and/or forged physician Untimely and/or forged physician

certifications on POCcertifications on POC►►Inadequate services by IDGInadequate services by IDG►►Insufficient oversight of patients on service Insufficient oversight of patients on service

6 months or more6 months or more►►Overlap in services with nursing homeOverlap in services with nursing home►►Billing for higher level of serviceBilling for higher level of service

Use Your Compliance PlanUse Your Compliance Plan

►►Establish Strong Establish Strong Corporate CultureCorporate Culture

►►Support the cultureSupport the culture►►Provide Checks & Provide Checks &

BalancesBalances

Corporate CultureCorporate Culture

►►Code of ConductCode of ConductVerbal/Written expression of your Verbal/Written expression of your organizational cultureorganizational culture

►►Education and BuyEducation and Buy--in of Board & in of Board & Top ManagementTop Management

PoliciesPoliciesResponsibilitiesResponsibilities

►►The message needs to be clear:The message needs to be clear:““Do the Right ThingDo the Right Thing””

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Systems to Support CultureSystems to Support Culture►►Adequate StaffingAdequate Staffing

Oversight of case managementOversight of case managementAvoid the desire to cut cornersAvoid the desire to cut corners

►►TOOLS to do the job efficientlyTOOLS to do the job efficiently►►Documented ProceduresDocumented Procedures

Train to a procedureTrain to a procedureAllows staff to Allows staff to ““Say what they do & do Say what they do & do what they saywhat they say””

►►OnOn--going Educationgoing EducationTraining on new regulationsTraining on new regulationsReRe--training on existing regulationstraining on existing regulations

Checks & BalancesChecks & Balances

►► Data AnalysisData AnalysisMonitor trendsMonitor trendsUtilize accepted benchmarks for Utilize accepted benchmarks for ““early warningearly warning””

►► Internal AuditsInternal AuditsClinical record reviewClinical record reviewCross departmental auditCross departmental audit

►► Employee ReportingEmployee ReportingOpen lines of communicationOpen lines of communication

►► Exit InterviewsExit InterviewsInsist on completing as often as possibleInsist on completing as often as possible

►► SupervisionSupervision

Billing/ClaimBilling/ClaimStrategiesStrategies

Electronic BillingElectronic Billing►►FISS is a process that allows remote FISS is a process that allows remote

users online connectivity to the Fiscal users online connectivity to the Fiscal Intermediary Standard System (FISS), or Intermediary Standard System (FISS), or mainframe, used by RHHI to process mainframe, used by RHHI to process Medicare claims.Medicare claims.

Through FISS you can...Through FISS you can...

►► Enter UB92 claimsEnter UB92 claims►► Correct electronic claimsCorrect electronic claims►► Correct paper claimsCorrect paper claims►► Track all claims through Track all claims through

the processing systemthe processing system►► Access the Common Access the Common

Working File (CWF) Working File (CWF) through HIQH (Health through HIQH (Health Insurance Query for Insurance Query for HHAsHHAs

►► View check number, date, View check number, date, & amount of your last 3 & amount of your last 3 paymentspayments

►► Review files for inquiry Review files for inquiry purposes, i.e. diagnosis purposes, i.e. diagnosis codes, revenue codes, codes, revenue codes, ANSI reason codesANSI reason codes

►► View claims selected for View claims selected for additional review & additional review & information requestsinformation requests

Claims Summary InquiryClaims Summary Inquiry►►Weekly check of the Claims Summary Weekly check of the Claims Summary

Inquiry screenInquiry screenDisplays specific claim history information Displays specific claim history information for for all all pending pending and and processed processed claims.claims.Check for claims in pending status:Check for claims in pending status:

Return to Provider (RTP)Return to Provider (RTP)Medicare Secondary Payer (MSP)Medicare Secondary Payer (MSP)Medical Review claimsMedical Review claims

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Additional Development Request (ADR)Additional Development Request (ADR)

►► Definition: a billing transaction that fails a Definition: a billing transaction that fails a medical review edit while processing in FISSmedical review edit while processing in FISS

►► Bill suspends to S/LOC SB6001 Bill suspends to S/LOC SB6001 ►► Documentation requested to support services Documentation requested to support services

billedbilled►► Medicare medical review nurse will review Medicare medical review nurse will review

documentation to make payment determination.documentation to make payment determination.►► Print ADR letter and forward to the clinical Print ADR letter and forward to the clinical

department per your agency procedures.department per your agency procedures.►► Documentation must be submitted within 45 Documentation must be submitted within 45

days or the bill is days or the bill is automatically deniedautomatically denied..►► Check for ADR requests at least weeklyCheck for ADR requests at least weekly

Most Common Denial ReasonsMost Common Denial Reasons--Home HealthHome Health

►► Medical Review DownMedical Review Down--CodeCode►► Lack of response to ADRLack of response to ADR►► Documentation does not support medical Documentation does not support medical

necessitynecessity►► Denials related to Physician OrdersDenials related to Physician Orders

POC/Verbal Orders not signed and/or dated timelyPOC/Verbal Orders not signed and/or dated timelyNo physician orders for services providedNo physician orders for services providedIncomplete OrdersIncomplete Orders►► Discipline, Frequency/Duration, Treatment, PRNDiscipline, Frequency/Duration, Treatment, PRN

►► Visits/Supplies/DME billed not documentedVisits/Supplies/DME billed not documented

Most Common Denial ReasonsMost Common Denial Reasons--HospiceHospice

►► Not hospice appropriate based on Not hospice appropriate based on documentation submitteddocumentation submitted

►► Initial Certification not signed timely by both Initial Certification not signed timely by both the Medical Director and Attending Physicianthe Medical Director and Attending Physician

►► Certification did not cover all dates billedCertification did not cover all dates billed

►► Documentation submitted for review did not Documentation submitted for review did not include Certification of Terminal Illnessinclude Certification of Terminal Illness

OASIS: Compliance PitfallsOASIS: Compliance Pitfalls

►►Most common areas identified with Most common areas identified with inconsistencies:inconsistencies:

Facility Discharge MO175Facility Discharge MO175Primary Diagnosis MO230Primary Diagnosis MO230Pain MO420Pain MO420Dyspnea MO490Dyspnea MO490Incontinence MO530Incontinence MO530Wounds MO450/460, MO476, MO488Wounds MO450/460, MO476, MO488

Basic Coding GuidelinesBasic Coding Guidelines►► Determine the principal diagnosisDetermine the principal diagnosis

Represents the most acute conditionRepresents the most acute conditionRequires the most intensive servicesRequires the most intensive services

►► All services/treatments should be substantiated by All services/treatments should be substantiated by a diagnosisa diagnosis

►► Code all documented diagnoses that coexist and Code all documented diagnoses that coexist and require or affect patient carerequire or affect patient care

►► Exclude secondary diagnoses that have no Exclude secondary diagnoses that have no bearing on current episode POCbearing on current episode POC

►► Avoid listing diagnoses that are of mere historical Avoid listing diagnoses that are of mere historical interestinterest

►► No surgical codesNo surgical codesMedical diagnoses only if still applicableMedical diagnoses only if still applicableV Code may be appropriateV Code may be appropriate

11

THERAPY MO825THERAPY MO825►►High Risk AreaHigh Risk Area►►Can affect reimbursement up to $2,000Can affect reimbursement up to $2,000►►Automatic DownAutomatic Down--Code for not meeting 10 Code for not meeting 10

visit thresholdvisit threshold►►Agency responsible for adjusting MO825 Agency responsible for adjusting MO825

if therapy threshold metif therapy threshold metGreatest potential for lost revenueGreatest potential for lost revenue

►►Inaccurate Management ReportsInaccurate Management ReportsOverstated average caseOverstated average case--mix weightmix weight

HOSPICE HOSPICE Compliance PitfallsCompliance Pitfalls

►► Election date not specified by beneficiary or Election date not specified by beneficiary or designeedesignee

►► CTI not signed/dated timelyCTI not signed/dated timely►► Initial POC not established by other IDG Initial POC not established by other IDG

membersmembers►► Documentation does not support terminal Documentation does not support terminal

illness illness Local Coverage Determination (LCDs)Local Coverage Determination (LCDs)

►► Bereavement POC at admission Bereavement POC at admission –– risk levelrisk level►► Fulfillment of professional managementFulfillment of professional management

Nursing Home & Inpatient FacilitiesNursing Home & Inpatient Facilities

FOCUS AUDITSFOCUS AUDITS►►Government & FI Focus Areas:Government & FI Focus Areas:

Probe EditsProbe EditsHH HH –– Therapy, CodingTherapy, CodingHospice Hospice –– GIP, LOS, Soft DX, NHGIP, LOS, Soft DX, NH

Definitive Billing RiskDefinitive Billing RiskHome HealthHome Health►►MD OrdersMD Orders►►Visit NotesVisit Notes

HospiceHospice►►Certification of Terminal Illness (COTI)Certification of Terminal Illness (COTI)►►Benefit ElectionBenefit Election

Question and Answer Question and Answer SessionSession

►► Robin N. Seidman, Robin N. Seidman, RN, BSN, MSN, MBA, LNCC RN, BSN, MSN, MBA, LNCC Director, Simione Consultants, LLCDirector, Simione Consultants, LLC

►► Betty BrennanBetty BrennanCEO, Beacon Hospice Inc.CEO, Beacon Hospice Inc.

►► Connie WoodworthConnie WoodworthCFO/Compliance Officer, Hospice of the North Shore, Inc.

►► Larry Vernaglia, ModeratorLarry Vernaglia, ModeratorPartner, Health Care Industry Team, Foley & Lardner, LLP