F.O.R.C.E. Healthcare Resources, LLC (Founded on Regulatory Compliance and Ethics)

1. F.O.R.C.E. Healthcare Resources, LLC(Founded on Regulatory Compliance and Ethics) CMS War on Fraud and Abuse 101 July 18,2012

2. About F.O.R.C.E.? • Home Health Consulting Firm – Founded 2005 Services Provided: • Home Health Billing Webinars • Home Health Outsource Billing • Home Health Outsource Medical Coding • Home Health Billing Clean-up Projects • Home Health Operation / Process Consulting • Home Health CLIA Billing & Recovery Project

3. Contact Information F.O.R.C.E Healthcare Resource, LLC. • Website: www.forcehealthcare.com • (Terri Ready, Chief Operations Officer) • Direct: 423-643-2256 ext.104 • Mobile: 423-593-1627 • tready@forcehealthcare.com • (Jonathan Sellers, Sales & Marketing) - Direct: 423-834-5334 - jsellers@forcehealthcare.com • (Lynn Alley, Billing Supervisor) • Direct: 423-834-5334 • lalley@forcehealthcare.com

4. CMS Anti-Fraud & Abuse Initiatives & Substandard Care 101

5. CMS War on Fraud, Abuse & Substandard Care • CMS has declared war on Medicare Billing Fraud & Abuse • CMS Issued new State Survey Instructions – May 2011 • HHA’s will see more deficiency citations on State Survey • HHA’s should be prepared for more pre-payment medical record requests • HHA’s should be prepared for post payment audits

6. Fraud Definition • An intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself / herself or some other person. • The most frequent kind of fraud arises from a false statement or representation that is material to entitlement or payment under the Medicare program.

7. Examples of Fraud • Billing for services or supplies that were not provided. • Altering claims to obtain higher payments • Soliciting, offering or receiving a kickback, bribe or rebate (paying for referrals) • Using another person’s Medicare card to obtain medical care • Provider completing Certificates of Medical Necessity (CME) for patients not known to the provider • Suppliers completing CME’s for the physician

8. Abuse Definition • Behaviors or practices of providers, physicians, or suppliers of services and equipment that, although normally not considered fraudulent, are inconsistent with accepted sound medical, business or fiscal practices. The practices may directly or indirectly, result in unnecessary costs to the program, improper payment, or payment for services that fail to meet professionally recognized standards of care, or which are medically unnecessary.

9. Examples of Abuse • Excessive charges for services or supplies • Claims for services that don’t meet CMS medical necessity criteria • Breach of the Medicare participation or assignment agreements • Improper billing or coding practices Note: Most provider billing errors fall into the category of abuse.

10. CMS Direction to State Surveyors – Effective May 1, 2011 • Data driven surveys • Patient outcome oriented • Less structure & process oriented • Focus on those standards most directly related to the patient care process • Increase use of information gathered from staff interviews

11. Survey “Continued” • Minimized review of non-clinical record documentation • More specific guidelines for expanding the standard survey to partial or extended status • Added guidance for issuing standard and condition-level deficiency citations

12. Survey “Continued” • Guidelines for Citing Standard Level deficiencies: Because the Level 1 highest priority standards are identified as those most related to the delivery of high-quality patient care a single problematic finding with an actual (or potential) outcome(s) which would support a determination of non-compliance …. • Guidelines for Citing Condition Level deficiencies: A COP may be considered out of compliance for one or more deficiencies, if, in a surveyor’s judgment, the deficiency constitutes a significant or a serious finding that adversely affects, or has the potential to adversely affect patient outcomes….

13. CERT Audits • Comprehensive Error Rate Testing • Around since 1996 • Designed to measure overall error rate for Medicare contractors claims processing divisions • Medical Records requested from provider’s • Overpayment determinations made

14. Probe Edit Audits • Pre-Payment Review of Claims at RHHI • May identify specific HIPPS to target • Late Episodes • Therapy • Slows Cash Flow / Increase Admin burden • Can result in 100% Medical Review • Referral to ZPIC / RAC

15. ZPIC Audits • Zone Program Integrity Contractors • SafeGuard Services, AdvanceMed, Health Integrity, and Integriguard • Active in southeast, southwest, northeast & west coast • Expect activity nationwide in 2012

16. ZPIC Audits • Surprise on-site visits to providers & Medicare beneficiaries • Targeted data analysis • Random Audits • Use extrapolation • Overpayments determined • 100% pre-payment holds

17. ZPIC Audits • Responsible to Safeguard the Medicare program • Pre or post payment reviews possible • Hi-tech data analysis capabilities • Benefit Integrity and / or fraud detection • Cost report audits • Provider education

18. ZPIC Audits • Know your appeal rights • 30 days to provide Medical Records at review onset • ZPIC Determination • RHHI overpayment Demand Follows • 30 days to submit redetermination (1st Level Appeal) • Reconsideration (2nd Level Appeal) • ALJ – Administrative Law Judge (3rd Level Appeal)

19. ZPIC Preparation • Documentation! Documentation! • Not Recorded, didn’t happen! • Conduct Internal Assessment to be sure compliance with Medicare regulations.

20. RAC Audits • Recovery Audit Contractors • CMS announced RAC’s activity to increase in HHA’s in 2012 • RAC’s funding for Medicaid Claims - 2012

21. RAC Audit Preparation • Conduct an internal assessment to identify if you are in compliance with Medicare rules • Contract with a third-party to perform the assessment • At any rate, identify corrective actions that need to take place to be in compliance • File corrected billing where appropriate

22. RAC Audit • Understand your rights and response timeliness guidelines • Be prepared to submit Medical Record sample requested • Know your appeal rights

23. RAC • OASIS / Coding Accuracy / Compliance • Homebound determinations • Skilled Need / Medical necessity • Therapy documentation • Maintenance

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