Here they come: Two RACs post issues eligible for review

Editor’s note:  My colleague, Andrea Kraynak, does a great job staying on top of all the RAC news over at the Revenue Cycle Institute blog. The following is round-up of some of the news she has covered recently in regards to issues eligible for RAC review.

Two of the four RACs have posted issues eligible for RAC review on their Web sites, meaning that RACs can begin auditing in those areas at any time.

Connolly, the RAC for region C, has posted the approved issues for South Carolina and Florida. No word yet on the other states and territories that Connolly covers. However, many experts are advising providers to pay attention to these issues, regardless of whether they are within the Connolly’s jurisdiction.

Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc., says providers outside Connolly’s jurisdiction may want to review the issues as a clue to what RACs might audit in their area. However, she notes that providers should anticipate that RACs will audit for different issues for different jurisdictions although there certainly could be some overlap.

Connolly will focus on the following six issues for both states: [more]

The FY 2010 IPPS changes impacting case managers

On July 31, the Centers for Medicare and Medicaid Services (CMS) released the FY 2010 Inpatient Prospective Payment System (IPPS) Final Rule. Hospital payment rates will increase by an average of 2.1%, as opposed to the 0.2% proposed earlier in the year. CMS elected not to implement a 1.9% reduction, referred to as the coding and documentation adjustment. This coding and documentation adjustment accounts for changes in clinical documentation and coding patterns—not real changes in patient acuity.

Implications for case managers

The start of the Medicare Fiscal Year IPPS, which begins each October 1, brings a host of new coding, payment, and other regulatory changes including updated relative weights for the 745 MS-DRGs. Some MS-DRG relative weights increase—others decrease. Relative weights are a proxy for patient acuity. Higher relative weights signify higher acuity, providing for a higher level of reimbursement, while lower relative weights translate into lower acuity with less reimbursement.

In reviewing the Healthcare Financial Management Association’s (HFMA) recent overview of the Final 2010 IPPS Rule, an interesting point was made that certainly impacts hospitals and case managers. [more]

Have you mastered the HINN?

Last week, during the HCPro’s Master the HINN: Integrate Policies and Procedures into Hospital Operations audioconference, a poll question revealed that 87% of the facilities on the call designate case managers as the ones responsible for providing HINNs. Does this statistic ring true in your facility?

If so, please share your challenges, comments, and best practices when it comes to delivering HINNs properly and effectively. For example, how do you and your team identify cases where a HINN is necessary? How to you ensure the patient is notified of his or her liability in a timely manner? How do you educate your staff about which HINN is appropriate for a situation?

Documentation requirements for critcal care services

Editor’s Note: This blog was originally posted by Melissa Varnavas, CPC, the associate director of the Association for Clinical Documentation Improvement Specialists, for the ACDIS Blog. Read the original post here.

In the July 23 issue of CDI Strategies, Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, offered a tip to help CDI specialists gain physician support for improved documentation in the medical record regarding critical care. In a subsequent e-mail, Gold added comments from his “guru” on physician professional billing, Paul Dickson, MD.

Here is the amended information:

Critical care does not include ongoing monitoring of a patient who has stabilized, regardless of how many organs have failed in the past, but have now stabilized, how many lines and tubes were inserted, or how many devices were instituted. When the patient is stable, it is not critical care.

Too many physicians, however, do not realize that we can bill:

• Critical care delivery by time increments for the first encounter
• Additional critical care when the patient crashes again
• A level three subsequent visit for noncritical care in addition to the critical care delivery on the same day

Any usual evaluation and management (E/M) service appropriate for services and documentation provided may be billed prior to a critical episode, but not vice versa. Consider the following case study.

A patient presents to the cardiac care unit after a coronary artery bypass graft. The patient is intubated with a left ventricular assist device still in place but is not active and receives low-dose dopamine for renal perfusion. The patient’s vital signs are stable with a little hypotension due to lack of vascular tone due to residual effects of anesthesia, however, it is easily controlled. The external pacer is in place, chest tubes are in place to underwater seal, and diluted urine is flowing through the Foley. A physician accepts the patient onto the intensive care unit (ICU) and performs an evaluation. The patient is not critically ill. However, the patient is on a respirator, and the physician manages that respirator. This may be ventilator management 94002-3 alone, and no E /M service may be billed with these codes.

In this case, the patient does not have acute respiratory failure. Writing the words “acute respiratory failure,” means a condition exists that involves the respiratory tree due to a disease process. If, indeed, the patient does have acute respiratory failure due to a disease process when he underwent the surgery, then it is appropriate to document that, if it still exists. If this is not the case, then the presence of the words “acute respiratory failure” will give the heart surgeon a black mark since the condition would be considered a complication of the surgery. [more]

Guidance to ‘the most appropriate level of care’

Case managers serve as the patient’s advocate to promote safe, quality care during the patient’s stay in the hospital and after discharge. Sounds like the ideal job, right? For nurses who “live” the role, rather than “do” the job, it truly is. Grace’s story is one that conveys how complex, yet fulfilling living the role can be.

Grace read the physician’s orders for Diane to begin outpatient dialysis upon her return to her nursing home. Grace began looking for a dialysis center that would be close to Diane’s nursing home and had chairs available. However, the center that would accept Diane was quite a distance from the nursing home. If Grace were to receive treatment at the facility, she would need to be transported via ambulance three times each week for treatment. Unfortunately, this circumstance was not unusual, so Grace proceeded with making tentative arrangements.

When Grace entered Diane’s room to discuss her treatment, she saw Diane lying on her side. She was thin, drawn, and severely contracted with tunneling decubiti throughout her body. With the slightest movement, she cried out in pain. However she was alert, oriented and communicative. Throughout Grace’s long career as a case manager, she had symbolically seen Diane far too many times.

Grace approached Diane with a warm smile and a trusting, caring tone of voice. After explaining her reason for being there, Grace began to question Diane in order to determine her mental competency and ability to make decisions. After all, Grace was there to determine what Diane needed and wanted, not just to tell her to do what the physician had ordered. Grace sought Diane’s consent for the treatment plan. She explained the risks, benefits and alternatives of her plan for continuing dialysis as an outpatient. [more]

Do you use Milliman?

We are looking for case management departments that use Milliman Care Guidelines for a future project. If your facility uses Milliman, please get in touch with me.

Ben Amirault
bamirault@hcpro.com
781-639-1872 x3934

Surprise! Voluntary refunds don’t protect against RACs

For many providers, self-auditing has become an important RAC preparation tool. Certainly, internal audit results can show where additional education is necessary to ensure appropriate coding, billing, and documentation practices. And this will result in fewer RAC denials, because if practices are correct, the RACs will find fewer errors to deny.

But many providers also assume that reporting errors (and refunding identified overpayments) discovered while self-auditing will protect those claims from RAC review.

Not so, says CMS.

In a recently released FAQ on the CMS Web site, CMS clarified that only one type of self-audit will ensure RACs may not later review the claims, and it probably isn’t the kind of self-auditing that most providers are doing, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

The FAQ states:

There are two types of self audits. One is commonly called a voluntary refund and is claim based. If the required claim information is included along with the amount of the improper payment, the claim will be adjusted by the claim processing contractor. The RAC will be aware of the adjustment, but the refund does not preclude future review. The second type of self audit may involve the use of extrapolation. If extrapolation is used the claim processing contractor will review the case file to determine if it is acceptable. The claim processing contractor will accept or deny the extrapolation for the issue identified by the provider. If the claim processing contractor accepts the extrapolation, those claims in the universe will be excluded from RAC review.

In other words, if a provider uses an extrapolation that its MAC or FI accepts, the claims are off-limits for RACs. Otherwise, individual claims corrected after a self-audit are fair game.

“This will come as a surprise to a lot of providers,” says Mackaman. “Providers assume if they do a self-audit and correct and report errors, that [the claims] are excluded from future RAC audits. But they’re not.”

Those providers who review claims individually may feel a little less incentive to report errors and refunds they discover since the claims aren’t protected from RACs, but not doing so is a compliance problem. Ignoring a false claim is never a good idea, says Mackaman.

Nor should this news discourage providers from self-auditing in the first place. Providers can use audit results to better understand their risks, to change internal processes regarding areas of concern and to appropriately return reimbursements for claims paid in error, according to Mackaman.

ER case managers must have special skills

A nurse case manager is a definite asset in the emergency room (ER).  An ER case manager benefits the patients, the staff, and the hospital.  The role is multi-faceted and requires superior skills in:

• Quality
• Education
• Communication
• Customer service
• Negotiation
• Creativity
• Risk management
• Knowledge and understanding of insurance requirements and regulatory mandates

It also requires an ability to interact with patients, families, insurance representatives, and caregivers both in the ER and those who are treating the patients in the out-patient arena.

Visits to the ER may have one of several outcomes. Usually, the patient is treated and discharged home with a plan or the patient is admitted to the hospital. It is here that the ER case manager can be most effective to improve the quality of care and prevent readmissions to the ER.

An ER case manager can ensure that each patient who is discharged from the ER has an appropriate discharge plan that is viable and appropriate to assist the patient in recovering and maintaining their health.  A case manager is an expert in confirming the patient can afford any prescriptions provided , is able to be compliant with recommended follow-up visits with  specialists and can assist the patient in connecting with a primary care physician. The nurse case manager can be instrumental in  working with the patient  and their support system to make sure that they understand and have the interest and ability to be compliant with the discharge instructions.

The case manager can enhance the care provided by a busy ER nurse and physician  by assessing situations and family dynamics, listening to the patient and helping them understand the rationale for various tests and the time needed to interpret results. The case manager can assist the ER nurse with patient education and  providing information necessary to maximize  the patient’s health status.

The case manager can also benefit the hospital by working with both ER physicians and admitting physicians to ensure that all acute care admissions meet medical necessity and are admitted to the appropriate level of care.  The case manager can assist with transfers to alternative levels of care such as skilled nursing or rehab when patients do not meet criteria for acute care but are unsafe to return home.  The case manager can arrange home healthcare, physical  and occupational therapy or other appropriate services to help a patient maintain their independence in the home.

Case managers are an integral part of the ER team to improve the quality of care and help maintain fiscal responsibility for resources both in the ER and on the hospital admitting units. Case managers coordinate care and provide patients will all the tools necessary to improve their quality of life and feel their best within any limits of their illness or disability.

“Voluntary refunds” to MACs/FIs

Many providers are taking a proactive approach to the arrival of the Medicare Recovery Audit Contractors (RAC) and performing their own audits. Using the RAC “hot topics,” providers are using those audit outcomes to understand their risks, to change internal processes regarding areas of concern and to return reimbursements for claims that were found to be paid in error.

Once a self audit has been performed and if an improper payment has been identified, what should be the provider’s next steps? CMS Frequently Asked Question (FAQ) #9503 was updated last week to clarify the process of notifying the RAC on self audit outcomes.  If an improper payment related to a specific claim is identified, the provider should report their findings to their Medicare Administrative Contractor (MAC) or their Fiscal Intermediary (FI) if their transition to a MAC has not been completed.

A “voluntary refund” based on the specific claim can be made and the MAC/FI will make the appropriate adjustment. For details regarding the required claim information that is necessary to complete a voluntary refund, contact your local MAC/FI.  According to CMS, the “RAC will be aware of the adjustment, but the refund does not preclude future review.” Providers should create an internal process to identify any claims that have been processed as a voluntary refund.

Editor’s note: This article was originally written for the MedicareMentor blog. Click here to read the original post.

Medicaid Integrity Contractors: Coming to a hospital near you

Nearly 500 Medicaid audits are under way in 17 states, and the program will roll out to the entire country through the end of the year, according CMS representatives who spoke on the Medicaid Integrity Program Special Open Door Forum on July 15.

CMS hopes to identify additional contractors within the next few days. These contractors, known as Medicaid Integrity Contractors, are firms CMS has chosen to carry out the following Medicaid Integrity Program goals:

• Review provider actions to determine whether fraud, waste, or abuse may have occurred
• Audit provider claims
• Identify overpayments
• Educate those involved in Medicaid administration, providers, managed care entities, beneficiaries and others with respect to payment integrity and quality of care

There are three types of contractors: Review, audit, and education MICs. The review MICs analyze data and identify issues to pass on to audit MICs to pursue, according to CMS. Education MICs will provide education to providers and others on Medicaid payment integrity and quality of care.

CMS acknowledged on the call that it could do a better job of provider outreach, and it is taking measures to increase educational efforts, now that it has finished building the Medicaid Integrity Program organization and developing the audit process.

Fortunately, additional resources will soon become available for providers. CMS plans to soon release FAQs, a procurement timeline, background on the program and its goals, as well as other information on the Medicaid Integrity Program Web site. CMS also plans to release Web-based training currently in development for pharmacies.

Hospitals aren’t the only providers that need to prepare: 44% of the current audits focus on hospitals, but 29% are on long-term care facilities, 21% of audits are on pharmacies, and the remaining 6% are on physicians, labs, transportation, and other types of providers, according to CMS.

RACs vs. MICs

MICs have been termed “RACs for Medicaid,” but there are certainly differences between the programs. For example, the RAC lookback period is three years, but MICs base the length of time on individual state lookback guidelines. Similarly, the number of days a provider has to produce medical record copies for MICs is dependant on state rules, unlike with RACs, where providers have 45 days regardless of their location. In addition, MICs have no set medical request limits, while RACs max out at 200. Also, CMS will not reimburse providers for the cost of copying records, which is also different from the RAC program.

And unlike RACs, MICs are not paid by contingency fee, but rather through a sort of fee-for-service model. The dollars MICs recover aren’t tied to their compensation, according to CMS, although they will be eligible for bonuses based on how “effective and efficient” they are. Finally, in some cases MICs will do desk audits, and in other instances, auditors will come on-site to do the reviews.

MICs will also attempt to coordinate with RACs so as not to audit the same facilities simultaneously, CMS Medicaid Integrity Program field director Rob Miller said on the call.