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  1. READY OR NOT: RAC Here We Come Donna D. Wilson, RHIA, CCS, CCDS Senior Director/Compliance Concepts PHIMA-May 9, 2011 PHIMA Annual Meeting

  2. How many hats do coders wear? CCI-Compliance Concepts, Inc.

  3. How many hats do coders wear? • Coder- assigning the most accurate code. • Finance–assigning the most accurate DRG. • Medical Record Clerk –pulling and reviewing records prior to audits. • IT- abstracting cases/RAC database. • Core Measures- educating on coding guidelines. • Case Manager- reviewing orders/ clinical indications. CCI-Compliance Concepts, Inc.

  4. How many hats do coders wear? • Medical Necessity- identifying correct diagnosis. • Clinician- reviewing labs/radiology/operative reports. • Discharge Planner-investigating correct discharge disposition status. • Educator-conducting roundtables. • Auditor- preparing for RAC Audits. CCI-Compliance Concepts, Inc.

  5. OBJECTIVES • Define the current governmental audits. • Review the record requests and limits. • Walk through the RAC discussion period and appeal deadlines. • Managing the audit process. • Describe various tools to assist in the audit. • Discuss appeal writing and discussions. PHIMA Annual Meeting 2010

  6. GOVERNMENTAL AUDITS • Medicare RAC • Medicaid RAC • MIC • MAC • CERT • ZPICS • HEAT • OIG PHIMA Annual Meeting 2010

  7. Medicare RAC Recovery Audit Contractor CCI-Compliance Concepts, Inc.

  8. Who are the RACs? RECOVERY AUDIT CONTRACTORS Detect and correct pastimproper payments to allow CMS, Carriers, FIs, and MACs to implement actions that will prevent future improper payments. CCI-Compliance Concepts, Inc.

  9. RAC Contacts at CMS: CCI-Compliance Concepts, Inc.

  10. Who will be affected by the RACs? Any provider who bills fee-for-service claims will be subject to review by the RACs. CCI-Compliance Concepts, Inc.

  11. Automated Complex Manual review: Suspected error Medical record needed 55 days to reply Site of service issue Proper documentation Electronic claim review: • Duplicate claims • Same patient • Same date of service • Duplicate payment • RAC withdrawal CCI-Compliance Concepts, Inc.

  12. Claims Excluded from a RAC Audit: Claims that have already been reviewed by another Medicare contractor. Claims involved in a potential fraud investigation. Self-disclosed claims-provider discovers an error. Claims for hospice and home health. CCI-Compliance Concepts, Inc.

  13. Self-Disclosure Quote: “If you are a compliance officer and your organization never made a disclosure of an overpayment, know that your compliance program is not working as effectively as it should be,” Sheehan said in an interview and in a July 14, 2010 webinar sponsored by the New York State Office of Medicaid Inspector General (OMIG).” CCI-Compliance Concepts, Inc.

  14. Current Coding Issues -Inpatient: • Sequencing of Principal Diagnosis. • Selection of a CC or a MCC. • Excisional Debridement. • Hepatic Encephalopathy. • Sepsis. • Transbronchial lung biopsies. *Not a complete listing- of issues -visit your RAC website for a complete listing* CCI-Compliance Concepts, Inc.

  15. Current Coding Issues- Outpatient Blood Transfusions. IV-Hydration. Neulasta. Once in a Lifetime Procedures. Oxaliplatin. Pediatric codes exceeding age parameters. Untimed Codes. *Not a complete listing- of issues -visit your RAC website for a complete listing* CCI-Compliance Concepts, Inc.

  16. DCS Denying Therapy Untimed Codes On June 17, 2010: DCS posted this issue: “ a potential vulnerability may exist if certain codes are billed for more than one unit. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.” CMS Pub 100-04, Ch. 5, 20.2 CMS Pub 100-04, Transmittal 1019,dated 3,2006, pgs, 7-11: (now incorporated in the Medicare Claims Processing Manual). CCI-Compliance Concepts, Inc.

  17. DCS Denying Therapy Untimed Codes There is no publication in any CMS transmittal against billing two separate & distinct untimed codes. For example, a speech therapy (ST) evaluation on the same day as a physical therapy (PT) evaluation. NCCI edits do not prohibit billing these codes together. DCS may be sending you denials-so please review . CCI-Compliance Concepts, Inc.

  18. Current Medical Necessity Focus: • Degenerative nervous system disorders . • Transient ischemia. • Chronic obstructive pulmonary disease. • Perc. CV proc. w/Non-DES. • Heart failure & shock. • Atherosclerosis. • Cardiac arrhythmia. • Syncope & collapse. • Chest pain. • Esophagitis, GI & digest. disorders. • Medical back. • Renal failure. • Red blood cell disorders. CCI-Compliance Concepts, Inc.

  19. Short hospital stays • George Mills, Dir. Provider Compliance Group in CMS: “ Defined short hospital stays as 4 days or less. • Account for 26% of the entire Medicare fee-for-service error rate.” CCI-Compliance Concepts, Inc.

  20. Current Medical Necessity Focus- Patient Status: Inpatient Admissions without a Physician's Inpatient Admit Order Description. Admissions to the inpatient setting require a physician's order in order to qualify and be paid as an inpatient stay. Provider Type Affected:   Inpatient Hospital CCI-Compliance Concepts, Inc.

  21. Patient Status: • Admit to a location is unclear from a medical necessity standpoint . • Is the location an OBS unit or an area to support an inpatient level of care? CCI-Compliance Concepts, Inc.

  22. Ticket to the Hospital: • Must accompany each patient to the hospital. • Fax with all pre-registration material. • Necessary to prevent future RAC denials! CCI-Compliance Concepts, Inc.

  23. TICKET TO THE HOSPITAL CCI-Compliance Concepts, Inc.

  24. RAC Risks: • Keep abreast of all new issues posted by your RAC. • Perform pre-bill audits on designated areas: • DRGs • Discharge Disposition Codes • Units of Service • Outpatient coding • Medical Necessity • Patient Status. • Educate applicable staff. CCI-Compliance Concepts, Inc.

  25. Coding Monitoring Risk: CCI-Compliance Concepts, Inc.

  26. Medical Necessity Risk: CCI-Compliance Concepts, Inc.

  27. RAC Deadlines CCI-Compliance Concepts, Inc.

  28. Review RAC deadlines Record requests and limits. RAC discussion period. Demand letters/Remittance Advice. Appeal deadlines. CCI-Compliance Concepts, Inc.

  29. Record Requests • Process record request timely. • Review each record for complete content. • Mail certified mail return receipt. CCI-Compliance Concepts, Inc.

  30. Summary of Medical Record Limits CCI-Compliance Concepts, Inc.

  31. Summary of Medical Record Limits: CCI-Compliance Concepts, Inc.

  32. CMS RAC FAQ: • Does the RAC limit on medical records apply per individual National Provider Identifier (NPI) or per group NPI? • The medical record limit is linked to the billing NPI number. If your practice is enrolled with Medicare and submits claims for all your practice’s physicians under its group NPI, then the RAC medical record limit is linked to your group NPI.  CCI-Compliance Concepts, Inc.

  33. Summary of Medical Record Limits: Other Part B Billers (DME, Lab, Outpatient hospitals) • 1% of the average monthly Medicare services (max 200) per NPI per 45 days. CCI-Compliance Concepts, Inc.

  34. Review Results Letter: • First written correspondence received. • Entitled “Review Results Letter-Findings.” • If you disagree, contact RAC auditor ASAP. • Contact Information for RAC Auditor is supplied on the letter. • Detailed information of the denial. CCI-Compliance Concepts, Inc.

  35. Demand Letter: • Second written correspondence from RAC. • No title-the middle of the letter will have the name and address for your FI. • Date of demand letter should correspond with the denial date on your remit. • Monitor all N432/N469 (RAC denial codes). • Detailed explanation of the denial. CCI-Compliance Concepts, Inc.

  36. Demand Letter: Explains 15 day rebuttal Process. Outlines Repayment plan options. Discusses Recoupment process. Mandates that appeal must be filed within 30 days of the date of the latter to avoid a recoupment. Next steps in the appeal process. CCI-Compliance Concepts, Inc.

  37. Be prepared and watch deadlines: • Master effective appeal letter writing skills. • Seek outside assistance. • Engage other experts in the organization. • Expedite RAC Discussions. CCI-Compliance Concepts, Inc.

  38. CCI-Compliance Concepts, Inc.

  39. Medicaid RAC CCI-Compliance Concepts, Inc.

  40. What is the Medicaid RAC? • The Patient Protection & Affordable Care Act of 2010 (ACA) requires by December 31, 2010 each state Medicaid program contract with one or more RACs to identify underpayments & overpayments. • Each state will have flexibility in the design of the Medicaid RAC program requirements. CCI-Compliance Concepts, Inc.

  41. Provisions to the Proposed Rule: • Deadline extended to April 1, 2011. • Contingency fees are capped at 12.5%. • Supplemental approach to the Medicaid program integrity (MIC). CCI-Compliance Concepts, Inc.

  42. Medicaid RAC • Must have an “adequate appeals process” for hospitals to challenge adverse Medicaid RAC determinations. • States may use their current Medicaid appeals process or develop a separate appeals process-pending CMS approval. • Employ trained medical professionals to review Medicaid RAC claims. • Unlike the Medicare RAC program, states are NOT required to pay Medicaid RAC on a contingency fee basis for identifying underpayments. CCI-Compliance Concepts, Inc.

  43. Potential savings-Medicaid RAC: CCI-Compliance Concepts, Inc.

  44. Practice Appeal Writing Coding & Medical Necessity CCI-Compliance Concepts, Inc.

  45. Practice appeal writing: • Coding • Medical Necessity • Automated CCI-Compliance Concepts, Inc.

  46. Defend your code assignments: • Apply correct coding guidance for each case based on the discharge date of the patient. Acceptable advice: • AHA Coding Clinic for ICD-9-CM. • AHA Coding clinic for HCPCS. • Unacceptable advice: • Faye Brown’s Coding Handbook. CCI-Compliance Concepts, Inc.

  47. MIC Medicaid Integrity Contractor CCI-Compliance Concepts, Inc.

  48. Who are the MICs? • MEDICAID • INTEGRITY • CONTRACTORS • Deficit Reduction Act of 2005 to combat fraud and abuse in the Medicaid federal entitlement program. • Identify and recover overpayments. CCI-Compliance Concepts, Inc.

  49. MIC Responsibilities: Identify overpayments. Audit provider claims. Review of provider actions to determine whether fraud or abuse has occurred or may have occurred. Educate state or local employees involved in Medicaid administration, and others, with respect to payment integrity and quality of care. CCI-Compliance Concepts, Inc.

  50. MICs are Successful: • Identified over $18.6 billion in improper payments in 2008. • Beat out Medicare at $10.4 billion and Medicare Advantage at $6.8 billion. CCI-Compliance Concepts, Inc.