Healthcare AuditsHelping organizations understand audit

guidelines and requirements

Au·dit : efficiency check: a systematic check or assessment, especially of the efficiency or effectiveness of an organization or a process, typically carried out by an

independent assessorEncarta® World English Dictionary [North American Edition] © & (P)2009 Microsoft Corporation.

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Centers for Medicare and Medicaid Services• Federal programs with the most improper payments (2008)

– #1 - Medicaid ($18.6 Billion)– #2 - Earned Income Tax Credit ($12.1 Billion)

– #3 – Medicare ($10.4 Billion)

• CMS moving away from a single contractor to multiple single function contractors

• Over 10 separate types of audits for healthcare organizations to track and provide information/responses

• New update… Senate Healthcare Reform Bill– Medicaid RAC by Dec. 31, 2010– Expansion of Medicare RAC to Parts C & D

So many audits so little time… Medicare

QIO (Quality Improvement Organization)

CERT (Comprehensive Error Rate Test)

RAC (Recovery Audit Contractor)

ZPIC (Zone Program Integrity Contractors)

MAC (Medicare Administrative Contractors)

PSC (Program Safeguard Contractor)

OIG (Office of Inspector General Audits)

Goal = Protect the Medicare Trust Fund

So many audits so little time… Medicaid

MIP (Medicaid Integrity Program)

MFCU (Medicaid Fraud Control Unit)

RAC (Recovery Audit Contractor)

Others…. Ancillary Audits

Permedion (Independent Medical Review Organization)

Medicare – QIO (Quality Improvement Organization)

• Quality Improvement Organization (QIO) contractor

– Improve effectiveness, efficiency, economy and quality of services delivered to Medicare beneficiaries

– Concentrate on overpayments concerning higher weighted DRGs

– Tasked with oversight of the HACs (Hospital Acquired Conditions)

– Link payments to quality• Hospital Acquired Conditions (HACs)• National Coverage Decisions (NCDs)

– Never-Events (block Medicare payments for "preventable errors and conditions“)

r.

Medicare – CERT (Comprehensive Error Rate Testing)

• Monitors accuracy of the Medicare FFS program– Monthly random claims audit – processed correctly – Part A & B claims

• Observing all inpatient claims• Focusing on inpatient and outpatient consults (Cardiologists,

Pulmonologists, Neurologists and Internal Medicine)– Issues

» Consults should have been billed as visits» Not enough documentation

– Audit frequently used codes– May request $ back from provider– MAC (Medicare Administrative Contractors) use the results

Medicare – RAC (Recovery Audit Contractor)

• 3rd highest federal program with most improper payments– 3 year pilot program (6 states participated)

• $1.3 billion in total improper payments identified

• Correct improper payments under the Medicare Fee-For-Service program

• Healthcare organizations targeted – Medicare Parts A & B• By Dec. 31st, 2010 expansion to Medicare parts C & D

• RACs are paid a % of the $$ they recoup

• Anticipate permanent RAC to be more aggressive

OnBase RAC = AHA RACTrac Compatible Vendor

Schedule… Implementation nationwide January 1, 2010

Medicare – ZPIC (Zone Program Integrity Contractor)

• Combination of 2 previous audits… Program Safeguard Contractor (PSC) + Medicare Drug Integrity Contractor (MEDIC) = Zone Program Integrity Contractor (ZPIC)

• Oversee the RACs – help insure accuracy of the audits

• Check for fraud for all Medicare claims– Parts A & B (Hosp., HHC, DME, Providers and Skilled Nursing)– Part C (Managed Care)– Part D (Prescription Drug Plans)– 5 states = “hot spot” zones (CA, FL, IL, NY and TX)

• Quick response to fraud and administrative actions

• Coordinate Medicare-Medicaid data matches (Medi-Medi)– Partnership between states and CMS– Match Medicare and Medicaid claim data to detect fraudulent

patterns– Patterns appear when claims compared – difficult to identify

separately– CMS coordinates with Program Safe Guard (PSCs) to complete

Medi-Medi tasks• Current Medi-Medi states

– WA, CA, TX, IL, OH, PA, NY, NJ, FL, NC– CMS will award (ZPICs) who will consolidate Medicare Parts

A, B, C, D and Medi-Medi Benefit Integrity Activities

Medicare – ZPIC (Zone Program Integrity Contractor)

ZPIC Jurisdictions

Zone 3: Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, and Kentucky

Zone 3: Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, and Kentucky

Zone 6: Pennsylvania, New York, Maryland, Washington D.C., Delaware, Maine, Massachusetts, New Jersey, Connecticut, Rhode Island, New Hampshire, and Vermont

Zone 6: Pennsylvania, New York, Maryland, Washington D.C., Delaware, Maine, Massachusetts, New Jersey, Connecticut, Rhode Island, New Hampshire, and Vermont

Zone 1: California, Nevada, American Samoa, Guam, Hawaii, and the Mariana Islands

Zone 1: California, Nevada, American Samoa, Guam, Hawaii, and the Mariana Islands

Zone 7: Florida, Puerto Rico, and the Virgin IslandsZone 7: Florida, Puerto Rico, and the Virgin Islands

Zone 2: Alaska, Washington, Oregon, Montana, Idaho, Wyoming, Utah, Arizona, North Dakota, South Dakota, Nebraska, Kansas, Iowa, and Missouri

Zone 2: Alaska, Washington, Oregon, Montana, Idaho, Wyoming, Utah, Arizona, North Dakota, South Dakota, Nebraska, Kansas, Iowa, and Missouri

Zone 5: West Virginia, Virginia, North Carolina, South Carolina, Georgia, Alabama, Mississippi, Tennessee, Arkansas, and Louisiana

Zone 5: West Virginia, Virginia, North Carolina, South Carolina, Georgia, Alabama, Mississippi, Tennessee, Arkansas, and Louisiana

Zone 4: Texas, Oklahoma, Colorado, and New MexicoZone 4: Texas, Oklahoma, Colorado, and New Mexico

Current Medi-Medi Programs

Medicare – MAC (Medicare Administration Contractor)

• Replace 48 FIs (Fiscal Intermediaries) – 23 MACs by 2011

– 15 processing Parts A & B claims– 4 processing DME claims– 4 processing HHC and Hospice claims

• MACs look for coding errors… patterns– Review outliers (compare to peers)

• Geographic location, state, nationally– Focus on high $ codes (Reclast and Ultrasound)

• MACs do not receive % of $ saved – Pre and Post payment reviews & Provider education– 2 levels of appeal– Identify fraud & abuse – potential jail, fines/payback

Medicare – PSC (Program Safeguard Contractor)

• Purpose to detect and deter fraud and abuse

– Review Medicare Parts A & B

– Obtain and review info from RAC auditors for suspected fraud

– PSCs analyze data • Moving beyond capabilities of MACs/FIs

– Refer cases to OIG • Possibly FBI

– May also refer cases to law enforcement

Medicaid – MIP (Medicaid Integrity Program)

• Established by the Deficit Reduction Act of 2005– Contractors hired to…

• Review provider actions• Audit claims / Identify overpayments (Claim error rate 10.5%)• Provide education about program integrity issues

• First federal program to perform Medicaid provider audits

- Identify inappropriate payments and fraud

• Contractors used (private companies)– Medicaid Integrity Review Contractors (Review MICs)– Medicaid Integrity Audit Contractors (Audit MICs)

• Most activity – can perform onsite reviews • Expected to recover more $ than the Medicare RACs

– Medicaid Integrity Education Contractors (Education MICs)

Medicaid – MIPs cont.

• Any provider who bills for Medicaid services can be audited– Including managed care organizations and fee for service providers– Utilize statistical data to target claims and identify potential

overpayments – – Identified by referrals or by the state

• No limited look back period– No limit on medical record requests (different from RAC)

• Can look back as far as the state Medicaid agency– Document submission to the auditor - approximately 2 weeks – No reimbursement for copies of medical records

• State is responsible for collecting payments– Federal govt. will collect $ from the state

• Measure improper payments– Medicaid – SCHIP (State Children’s Health Insurance Program)

• Comply with Improper Payments Information Act of 2002

• 3 contractors, performing several tasks…– Statistical calculations– Medical records collection– Medical/data processing review of selected State Medicaid and

CHIP FFS and managed care claims

• Most identified errors due to documents not submitted by deadlines

Medicaid – PERM (Payment Error Rate Measurement)

Medicaid – MFCU (Medicaid Fraud Control Units)

• Program arose from the Medicare and Medicaid Anti-Fraud and Abuse Amendments of 1977

– Authorized the establishment and Federal funding for the State Medicaid Fraud Control Units (SMFCUs)

– 49 states and the District of Columbia participate in the program through their SMFCUs

– Mission is to investigate and prosecute Medicaid provider fraud and incidences of patient abuse and neglect

– Investigative arm of the state Medicaid agency

OIG (Office of Inspector General)

• Combat fraud, abuse and waste of Medicare and Medicaid programs

• Obtain and process referrals – May seek…

• Criminal or civil prosecution• Monetary penalties• Administrative sanctions

– Responsible for looking at Fraud • Enforce accuracy in payment

- Will ask for records/documentation – in most cases– They can utilize the FBI, if needed

FBI

• Receive referrals from the OIG

• Handle Beneficiary Complaints

• Only handle fraud investigations/cases– Private and public healthcare programs

Other Audits - Permedion

• Contract with Medicare, Medicaid and State Insurance Departments

• Perform external and independent medical review services, to ensure:• Right care• Right setting• Services billed correctly• Verify provider credentials – Quality care and services

Audit Limit Freq. MR Request Response

MR Reimburse

Discussion Period

Collect $ Appeal Rights

Mult.Audits

RAC 200 inpt 45 days 45 days $0.12/page 15 days 41st day 5 levels No

MAC Unknown Unknown Unknown Unknown Unknown Unknown 2 levels Unknown

PERM Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

ZPIC Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

CERT None Any 30 days None Unknown State Regulated

2 levels Yes

PSC Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

MIC/MIP None State Regulated

State Regulated

None State Provider MIC State CMS

State Regulated

State Regulate

d

Yes

MFCU Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

Permedion None Any 30 days N/A State Regulated

State Regulated

2 levels Yes

(RAC) Audit Administration Solution functionality• Designed to manage the provider’s appeal process to the RAC

auditor and the denial of medical claims– Management of inpatient and outpatient claims– Task Management

• Track responsible employee assigned to each task• Notifications / reminders

– Configurable Parameters– Tracking functionality

• Shipping information• Expected completion dates / appeal timelines• Medical record request costs• Interest due on recovered funds• Communication with RAC personnel

– Upload Claim History

Dashboard Views:• Administration/Management

• Financial

• Risk Analysis

• Process Improvement

OnBase RAC Administration Solution Webinars

Monday Tuesday Wednesday Thursday Friday 1

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General Audit 13Webinar 12pm EST Register Here

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RAC Solution Demo 153pm EST Register Here

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7 Steps 21 Webinar 3pm EST Register Here

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RAC Solution Demo 263pm EST Register Here

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References• CMS releases details on 2009 permanent Recovery Audit Contractors (RACs) program. Retrieved Jan. 21, 2009.

http://www.mgma.com/policy/default.aspx?id=23052

• Frequently Asked Questions. (Jan. 25, 2008). Retrieved Jan. 21, 2009, from http://www.aha.org/aha/content/2008/pdf/080125-racfaq.pdf

• Healthcare Compliance Quarterly Insights: Surviving RAC. Retrieved Jan, 22, 2008. http://www.hfma.org/forums/healthcare/Healthcare_Compliance_Tips_RAC_Audit.htm

• Center for Medicare & Medicaid Services (CMS) Recovery Auditor Contractor (RAC) Program, AAHAM Position. Retrieved 12/1/2008. http://www.txaaham.org/files/AAHAM%20Position%20Paper%202008.pdf

• Pennsylvania Physicians Facing CERT Audits. http://www.pamedsoc.org/CERT

• How to Survive a Medicare Audit. (May, 16, 2009). Retrieved October 13, 2009 from http://www.aace.com/advocacy/socio/HowtoSurviveaMedicareAudit.pdf

• Legal Note: Medicaid Integrity Contractors. (August 17, 2009). Retrieved October 13, 2009 from http://www.arkhospitals.org/Legal%20Note%20Archive.pdf/08-17-09%20Legal%20Note.pdf

• Medicaid Integrity Program Provider Audit Fact Sheet (November 2008). Retrieved October 13, 2009 from http://www.aparx.org/members/documents/MIPprovauditfactsheet-Nov2008.pdf

• Potential NCD Topics (July 30, 2008). Retrieved November, 2, 2009 from http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?id=19

• Office of Inspector General News (December 3, 2009). Retrieved December 11, 2009. http://oig.hhs.gov/w-new.asp

• Medicaid Integrity Program (MIP), Provider Audits Frequently Asked Questions (July 2009). Retrieved December 11, 2009. http://www.dpw.state.pa.us/Resources/Documents/Pdf/MIP_Provider_Audits_FAQs.pdf

• CMS RAC Review Phase-in Strategy (6/24/09). Retrieved November 2, 2009. http://www.cms.hhs.gov/RAC/Downloads/CMS%20RAC%20review%20strategy.pdf

• Medicare-Medicaid Data Match Program . Retrieved November 3, 2009.

nampi.org/members/2007presentations/MediMedi.pps

• Hospital Payment Monitoring Program (HPMP) Compliance Workbook (January 2006). Retrieved November 4, 2009. http://www.hpmpresources.org/Portals/1/Tools/HPMPCompWkbk_03-2008.pdf

• “Data mining programs” intensify scrutiny of Medicare claim.  National Psychologist, Vol. 17, No. 5, p. 9.. Retrieved November 5, 2009. http://www.centerforhealthyaging.com/Medicare_Audits_NP.htm

• Medicaid Integrity Program A to Z. Retrieved November 6, 2009. www.wsha.org/files/119/MIP_A_to_Z_for_Providers_Aug%2009.pdf

• Medicare Coverage Determination Process (6/08/2009). Retrieved November 10, 2009. http://www.cms.hhs.gov/DeterminationProcess/

• Quality Improvement Organizations (7/02/2009). Retrieved November 10, 2009. http://www.cms.hhs.gov/QualityImprovementOrgs/

• Senate Reform Bill Would Expand RAC Program (11/24/09). Retrieved November 25, 2009. http://www.healthleadersmedia.com/content/242585/topic/WS_HLM2_FIN/Senate-Reform-Bill-Would-Expand-RAC-Program.html

• Medicaid Fraud & Abuse: A New Era of Federal and State Enforcement (10/9/09). Retrieved Dec 9, 2009. http://wwww.healthlawyers.org_Events_Programs_Materials_Documents_FC09_smith_slides.pdf

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References continued…

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