Triple Check: A Process for Preventing False Claims

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Annual Leadership InstituteAugust 25, 2016

Your presenter today is:Sophie A. Campbell, MSN, RN,

CRRN, RAC-CT, CNDLTCDirector, Clinical Advisory Services

Baker Tilly Virchow Krause, LLPSophie.campbell@bakertilly.com

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Learning Objectives1. Identify the items that are included in the

claim for billing services2. Identify the team members who should be

included in the Triple Check process3. Identify the steps to an effective Triple

Check process

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What should be included in the process?• UB-04 claim• MDS assessment• OCD-10 diagnosis list • Medical record documentation

- Rehabilitation therapy- Nursing

• Medicare certifications/recertifications• Medicare Secondary Payor forms

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Why is Triple Check important?1. Residents receive the benefits they are entitled to2. Accurate billing for skilled services provided3. Prevention of False Claims submission4. Reduction of denied or adjusted claims/reimbursement5. Correct data reported for the facility6. Clinical and financial data should correlate7. Support documentation is identified early

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Residents Receive the Benefits They are Entitled to• Protecting Medicare• Were there other payors? Is Medicare the primary/first payor?• Were technical eligibility criteria met? • Ensuring utilization of skilled services from admission through

stay and at discharge• Can the skilled services be identified based on Prospective

Payment System (PPS) criteria?

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Accurate Billing for Skilled Services• Focus has increased on the billing• Less than 50% of appeals are being overturned and the time it

takes to reach the Administrative Law Judge (ALJ) has increased

• Provider needs reimbursement for daily operations• Should receive reimbursement for delivered services • Reimbursement should represent the level of care and service

provided

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Prevention of False Claims Submission• Increased focus on false claims • Elements of false claims include that the defendant:

(1) Submit a claim (or cause a claim to be submitted)(2) To the “Government”(3) That is false or fraudulent(4) Knowing of its falsity(5) Seeking payment from the Federal treasury(6) Damages

• Health care violations that can lead to a false claim include:A) Upcoding andB) Unnecessary services

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Prevention of False Claims Submission• CMS, external audit and OIG focus on rehabilitation therapy

- Most recent actions have focused on rehabilitation services- Settlements have been significant- Specific and all regulatory requirements must be met

• False Claims information:- Look back period – 6 years- Identification – providers must exercise diligence in auditing- Investigation – 60 day clock to report which starts after full identification which can take no more than 6 months

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Reduction of Denied or Adjusted Claims/Reimbursement• Multiple external audits possible

- Additional Documentation/Development Requests (ADR)- Recovery Auditors (used to be RACs)- Zone Program Integrity Contracts (ZPICs)- Error Rate testing (CERT reviews)- Managed care audits- Default rates and provider liability days- Trends identified that could result in federal audit

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Correct Data Reported for the Facility• Represented in the many data mining reports that are available

through various government agencies, such as the PEPPER reports

• New Quality Measures that are collected from the claims data submitted including:- Percentage of short stay residents who were successfully

discharged to the community- Percentage of short stay residents who have had anoutpatient emergency department visit

- Percentage of short stay residents who were re-hospitalizedafter a nursing home admission

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Clinical and Financial Data Should Correlate• Clinical information includes:

- Daily skilled nursing and rehabilitation therapy services- MDS assessment data

• Financial information includes:- UB-04 claim data such as admission date, occurrence date- Billing dates

• Correlating dates:- Assessment reference dates- Admission and discharge dates- Leave of absence days- Hospital stay dates

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Support Documentation is Identified Early• Rehabilitation treatment days and minutes of service• Respiratory therapy minutes resulting in days• Medical diagnosis documentation and support• Clinical service documentation and support for the rationale • Reasonableness and necessity clearly noted and supported• RAI Manual instructions for prerequisites met• Regulatory requirements adhered to and noted• Identify before external auditors identify

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Who Should be Part of Triple Check?• Required team members include:

- Business/billing office representative- Rehabilitation therapy representative- Assessment nurse representative

• Additional team members who would be helpful- Clinical team member – clinical manager, DON/ADON- Administration team member – administrator, COO or other operational manager

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Effective and Efficient Triple Check • Meetings should begin on time and be consistent

with date and time and location• Meeting participants should come prepared

- Pre-meeting work completed- Bring specific items

• If using a billing company don’t involve until step 2• Reduce or eliminate social conversations

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Effective and Efficient Triple Check • Business/billing office items for the Triple Check include:

- UB-04 claims for month being billed- Should be reviewed for accuracy with:- Bill type- Admission and occurrence dates- Correct payor(s)- Resident data: name, social security and Medicare numbers- Facility information

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Effective and Efficient Triple Check • Clinical or assessment nurse items for the Triple Check include:

- MDS assessments with RUG levels- Final validation reports- Physician certifications/recertifications- ICD-10CM diagnosis lists sequenced- Knowledge of or list of skilled services provided- Supporting medical record documentation

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Effective and Efficient Triple Check • Rehabilitation Therapy items for the Triple Check include:

- Rehabilitation treatment/service logs- Rehabilitation Plans of Care- Physician orders for rehabilitation services- Rehabilitation therapy start and end dates- Rehabilitation support documentation for reasonableness andnecessity

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Effective and Efficient Triple Check• Other items that can be evaluated during the process:

- Medicare Secondary Payor forms completion- NOMNC timeliness- Census data - Reconciliation of external vendor billing includinglaboratory, radiology, pharmacy and rehabilitation therapy

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Effective and Efficient Triple Check• Items to evaluate: starting with the claim

- Beneficiaries name, date of birth, Medicare and social securitynumbers

- Bill type (FL 04)- Admission date (FL 12)- Occurrence span: qualifying hospital stay dates (FL 35-36)- Correct payor (FL 50)- From and through dates of claim: billing period (FL 06)- Revenue codes: SNF PPS or therapy discipline codes (FL 42)

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Effective and Efficient Triple Check• Items to evaluate: staring with the claim

- Admitting, primary and secondary diagnoses (FL 67 then a-q)- Correlate to diagnosis list in EMR, section I of MDSassessment, MD admission history and physical, MD progress notes, MD orders and therapy Plans of Care

- HIPPS code (FL 45)- Correlate to RUG level from section Z of MDS assessment,final validation report and Assessment Indicator from MDS

- Covered days per MDS assessment or service units (FL 46)- From the days covered by each MDS assessment on claim

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Effective and Efficient Triple Check• Items to evaluate: looking at the MDS assessment

- Assessment Reference Date (ARD) within allowabletime frame for type of assessment

- Off cycle MDS assessments completed as neededbased on resident progression of services

- Skilled services coded on MDS assessments- Correlate section O rehabilitation therapy daysand minutes with the rehabilitation treatment/servicelogs

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Effective and Efficient Triple Check• Items to evaluate: checking rehabilitation therapy

- Each treating discipline should have a Plan of Care- POC should be signed by timely by MD- Each treating discipline should have MD orders for evaluation and treatment

- Review number of minutes documented per day onthe treatment/service logs

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Effective and Efficient Triple Check• Items to evaluate: support for billed skilled services

- Skilled services are documented in the medical record

- Reasonableness and necessity are identified - Regulatory requirements have been met for timeliness and support for coding of the MDSassessment items

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Effective and Efficient Triple Check• Complete Triple Check process a few days before

transmitting claims to allow time for checking on questions and correcting any errors that can be corrected

• Ensures timely submission of claims• Ensures “clean claims”• Improves reimbursement timeliness and accuracy• Reduces potential for audit or at least recoup of

reimbursement

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Why Should Triple Check be Completed?• Medicare provider agreement that requires

providers to bill accurately and be compliant with the regulations – whether Medicare or any of the other external agencies audit you or not

• Report errors, • Correct errors and • Educate to prevent future errors

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Why Should Triple Check be Completed?• Triple Check process is a system of internal

audits• Document these results as findings • Include Triple Check process findings as

part of internal audit findings in QAPI (Quality Assurance Performance Improvement) process

• Consider external audit process to validate

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ComplianCe is simply following the rules

ethiCs is Choosing to do so

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QUESTIONS?

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thanK you!

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