J14 Surviving a Medical Review Sally.ppt [Read-Only] · PDF file • Reviews performed by...

Click here to load reader

  • date post

    03-Jun-2020
  • Category

    Documents

  • view

    0
  • download

    0

Embed Size (px)

Transcript of J14 Surviving a Medical Review Sally.ppt [Read-Only] · PDF file • Reviews performed by...

  • 1

    TMP-EDO-0006 V 1.0 07/06/2010 The controlled version of this document resides on the NHIC Quality Portal (SharePoint). Any other version or copy, either electronic or paper, is uncontrolled and

    must be destroyed when it has served its purpose..

    Surviving a Medical Review Sally Rosiello BSN

    June 1, 2012

    DISCLAIMER

    This information release is the property of NHIC, Corp., J14 AB MAC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NHIC, Corp. and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the NHIC, Corp. web site at www.medicarenhic.com and the CMS web site at www.cms.gov. The identification of an organization or product in this information does not imply any form of endorsement.

    Agenda Comprehensive Error Rate Testing (CERT)

    Office of Inspector General (OIG) Reviews

    Progressive Corrective Action (PCA) Process • Responding to an Additional Documentation Request (ADR)

    Documentation

    Home Health Advance Beneficiary Notice (HHABN)

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

  • 2

    CERT J14 Totals 55 claims reviewed

    3 claims denied

    2% Payment error rate

    Awesome!

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    CERT Denial reasons • Error code 21-Insufficient documentation submitted

    – Two claims

    • Error code 35-unallowable service – One claim

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    OIG Work Plan Trends in Revenues and Expenses • Significant increase in Home Health payments

    • Were billed services correctly paid?

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

  • 3

    OIG Work Plan Documentation must support the entries on outcome and

    assessment information set (OASIS) • Diagnoses

    • Upcoding

    OASIS must be accepted into the state repository timely • Include tracking sheet or transmission record with records in

    response to an ADR

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    Physician must date their signature

    Plan of care must include all required items

    Progressive Corrective Action Process developed by CMS for contractors to ensure Medicare

    guidelines are followed

    • Prioritize problems

    • Service specific or provider specific

    • Reviews performed by NHIC,Corp. staff

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    Progressive Corrective Action Providers chosen by analysis of billing data

    • Quarterly

    • High level

    • Comparison to peers – Number of visits

    – Diagnosis

    – Length of time on service

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    Length of time on service

  • 4

    Progressive Corrective Action Two types of reviews

    • Postpay

    • Prepay

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    Progressive Corrective Action Educational focus

    • Result letter

    • Additional review

    • Education regarding guidelines

    • Corrective Action Plan (CAP)

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    Corrective Action Plan Problems identified

    Action plan to correct each problem • Begin with each denial reason & work backwards to correct each

    issue

    Timeline for implementation of each action

    How corrective action will be monitored

    Name of person responsible for carrying out each action of plan

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    Name of person responsible for carrying out each action of plan

    Date you will implement plan

  • 5

    Corrective Action Plan Problem-Physical Therapy (PT) and Occupational Therapy (OT)

    services not reasonable and necessary • Educational conference call with NHIC,Corp. Provider Outreach &

    Education (POE) on 04/10/12 was attended by M. Jones PT and J. Smith OT. They each met with their therapists and assistants to review information.

    • M. Jones and J. Smith are assessing 20% of all therapy records to ensure patients meet guidelines and documentation is adequate

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    p g q beginning 4/1/12 through release.

    • Weekly staff meetings for all therapy staff to peer review documentation begun 3/21/12. M. Jones leads the meetings.

    Corrective Action Plan Problem-Nursing services not reasonable & necessary • Educational conference call with NHIC, Corp. POE on 04/10/12 was

    attended by all registered nurses and licensed practical nurses

    • N. Nurse, Director Patient Services (DPS) is reviewing 40% of assessments for patients admitted for nursing services effective 4/13/12

    • Nursing Supervisors are meeting every Wednesday to peer review nursing documentation and each follows up with nursing staff

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    nursing documentation and each follows up with nursing staff regarding suggestions. They report to DPS on specific findings effective 4/20/12

    Responding to ADRs Each ADR lists records to be sent • Double check to be sure all needed records are included

    –For correct patient

    –For correct episode

    –A visit note is included for each visit

    –Evaluations and progress notes from prior episode if indicated

    –Everything needed to “paint a complete picture” of patient

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    • ADR needs to be on top of records for claim

  • 6

    Submission of Records Records should be returned within 30 days of the date of ADR

    An additional 15 days allowed • Allows extra time for mail issues & scanning

    • Upon receipt of records the claim is “moved” – Claim will deny if not move

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    Electronic Submission Electronic Submission of Medical Documentation (esMD)

    Uses a CONNECT–compatible gateway to submit records • Develop own gateway • Health Information Handler (HIH)

    Transmits electronic records securely

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    Records Submission Errors Records not received timely • Results in 56900 reason code

    • Goal must be to have records received in our office by day 30

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

  • 7

    Records Submission Errors Insufficient documentation submitted • Missing visit note for one or more visits • Missing therapy evaluation and progress reports that occurred in

    prior episode

    • Documents submitted for wrong episode or wrong patient

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    OASIS Reviewers must ensure the OASIS was accepted into state

    repository timely

    Include tracking sheet or transmission record of OASIS when responding to an ADR

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    DOCUMENTATION

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

  • 8

    Face-to-Face Encounter Labeled as face-to-face

    Date of encounter

    Homebound status

    Services needed • PT, OT, Speech-Language Pathology (SLP), Nursing (NSG), home

    health (HH) aide

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    health (HH) aide

    Clinical information • Total knee replacement (TKR), difficulty ambulating, unsteady gait,

    shortness of breath (SOB)

    Certification statement

    Dated signature

    Face-to-Face Encounter Date of face-to-face encounter: 12/11/11

    Homebound status: difficulty ambulating, unsteady gait

    Services needed: • PT _X__ SLP ____ HH aide X

    • OT ____ NSG _X__

    Clinical information to support the need for services: Left total hip replacement (THR)

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    hip replacement (THR)

    Certification statement

    Signature: Dr. Jack Doe Date: 12/18/2011

    Face-to-Face Encounter Date of face-to-face encounter: January 4, 2012

    Homebound status: SOB

    Services needed: • NSG _X__ OT _____ HH aide _____

    • PT ____ SLP _____ Medical Social worker (MSW) _____

    Reasons patient requires services: congestive heart failure (CHF) and emphysema

    Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

    (CHF) and emphysema

    Certification statement

    Signature: Dr. W. Right Date: 1/4/2012

  • 9

    Face-to-Face Encounter Example:

    Dated timely

    Nursing services needed

    Certification statement