new cms recovery audit contractor and medicaid integrity
TRANSCRIPT
CLICK ON EACH FILE IN THE LEFT HAND COLUMN TO SEE INDIVIDUAL PRESENTATIONS.
If no column is present: click Bookmarks or Pages on the left side of the window.
If no icons are present: Click View, select Navigational Panels, and chose either Bookmarks or Pages.
If you need assistance or to register for the audio portion, please call Strafford customer service at 800-926-7926 ext. 10
New CMS Recovery Audit Contractor and Medicaid Integrity Contractor Audits
Preparing for RACs and MICs and Appealing Unfavorable Findingspresents
Today's panel features:
Paula G. Sanders, Partner, Post & Schell, Harrisburg, Pa.
Danielle Trostorff, Shareholder, Baker Donelson Bearman Caldwell & Berkowitz, New Orleans, La.
Steve Lokensgard, Special Counsel, Faegre & Benson, Minneapolis
Thursday, May 21, 2009
The conference begins at:1 pm Eastern12 pm Central
11 am Mountain10 am Pacific
The audio portion of this conference will be accessible by telephone only. Please refer to the dial in instructions emailed to registrants to access the audio portion of the conference.
A Live 90-Minute Audio Conference with Interactive Q&A
May 21, 2009
New CMS RAC and MIC Audits Teleconference
Strafford Publications
Preparing For The Medicaid Preparing For The Medicaid Integrity Contractor Audits Integrity Contractor Audits
Overview
Purpose of the MIC audits Who are the MICs?Who will be subject to MIC audits and how are they selected?Best practices to prepare for a MIC audit Provider appeals from MIC actions
2
GAO Report on Improper Payments GAO-09-628T (4/22/2009)
•
GAO estimates improper MA payments in 2008 exceed $32.7 billion
$18.6 billion in federal funds$14.1 billion in state funds
3
GAO Report on Improper Payments GAO-09-628T (4/22/2009)
•
“This MA improper payment estimate represents the largest amount that any federal agency reported for a program in fiscal year 2008."
•
"...further work remains to put in place the internal controls necessary to effectively identify and detect improper payments."
4
GAO Report on Improper Payments GAO-09-628T (4/22/2009)
•
Most common causes of MA improper payments
Insufficient or lack of documentation (90% of errors)Pricing errorsNon-covered services
5
The MIP Philosophy
“The fraud control game is dynamic, not static. Fraud control is played against opponents: opponents who think creatively and adapt continuously and who relish devising complex strategies; this means that a set of fraud controls that is perfectly satisfactory today may be of no use at all tomorrow, once the game has progressed a little.”
Malcolm K. Sparrow
Quoted by CMS in the introduction to the “Comprehensive Medicaid Integrity Plan of the Medicaid Integrity Program,”
FY 2006-2010 and FY 2007-2011
6
http://www.hms.com/our_services/services_program_integrity.asp
7
Overview of Medicaid Integrity Program (MIP)
•
Created by the Deficit Reduction Act of 2005 (DRA), Section 6034; >$255 million in funding through FY 2008
•
$75 million per year thereafter•
$25 million annually to HHS OIG
•
Funds remain available until expended•
100 new CMS employees
•
Authority to hire contractors 8
MIP Goals
•
First national strategy to detect and prevent fraud, waste and abuse
•
Provide support and assistance to states to combat MA fraud, waste and abuse
•
Identify MA overpayments and decrease payment of inappropriate MA claims
9
MIP Goals
•
Balance roles between supporting criminal investigation of suspect providers while concurrently seeking administrative sanctions
•
“Deter those who would exploit the program”
•
Develop a “strategic auditing system which focuses on a high rate of return”
10
MIP Goals
•
“Shine a powerful spotlight”
on providers seeking “inappropriate”
MA payments
•
Educate on payment integrity and quality of care
•
Suspend payments to suspect providers while simultaneously seeking recovery of identified overpayments
11
MIP Goals
•
Make referrals of suspected fraudulent practices and providers to federal and state law enforcement agencies
•
Use DFRD to conduct state-of-the-art data mining and analysis to identify emerging trends in MA fraud and abuse
24 data algorithms (fraud detection computer programs) have already been developed
12
Three Types of MICs
•
Review-of-Provider
MICs•
Audit
MICs
•
Education
MICs•
Review-of-Provider and Audit
MICs
umbrella contracts (five each) were awarded in December of 2007
•
Umbrella contracts allow MIC to bid on individual task orders
13
Review-of-Provider MICs
•
Analyze claims to identify potential vulnerabilities
•
Provide leads/target audits to Audit
MICs•
Use data-driven approaches to focus on aberrant billing practices
•
Work with CMS Division of Fraud Research and Detection (DFRD)
14
Audit MICs
•
Conduct post-payment audits of providers •
Perform combination of field audits & desk reviews
•
Identify overpayments
15
Education MICs
•
Develop training materials & awareness campaigns
•
Highlight value of education in preventing fraud & abuse
•
No contracts awarded yet
16
CMS Task Order 0001
•
Awarded in April 2008•
Audit MIC –
Booz
Allen
•
Review of Provider MIC –
AdvanceMed•
Territory –
CMS Regions 3 & 4
•
Approximately 10,000 audits projected
17
CMS Task Order 0002
•
Awarded in September 2008•
Audit MIC –
Health Management Systems
•
Territory –
CMS Regions 6 & 8•
According to HMS, audits will range between 2,000 -
10,000 depending on award level
•
Audits have not yet started in these regions
18
Current MIC Audit Targets
19
How Are Providers Selected For Audit?
•
MICs
select based on data analysis by other CMS contractors and/or referrals from state agencies
•
Efforts to ensure that MIC audits do not duplicate state MA audits or interfere with potential law enforcement investigations
•
No MIC/RAC audit is “random”
20
What are MICs Looking For?
•
Did MA pay for a “covered service?”•
Was the service actually provided?
•
Was the service properly billed?•
Was the service properly documented?
•
Was the service reimbursed appropriately according to state policies, rules and regulations?
21
Elements of MA Audit Development
•
Data sources include both Medicare and MA data
Strengthen ROI on MA-only audits“Common wisdom in health care holds that a provider defrauding the Medicare program is also likely to be defrauding the MA program”
22
Elements of MA Audit Development
•
Statistically valid random sampling and overpayment extrapolation
•
Focus on compliance with both MA program participation requirements and MA reimbursement requirements
23
The MIC Audit Process
•
Provider receives a Notification Letter that will include a list of requested documents
•
Entrance Conference, typically by phone •
Audit
MICs
have the authority to request
and review copies of provider records, interview providers and office personnel, and have access to provider facilities
24
Record Requests
•
Records are requested to be delivered within 10 business days
•
Requested records must be made available within the requested timeframes, although Audit
MICs
will
consider a reasonable request for extension, normally one more week, as long as neither the integrity nor the timeliness of the audit is compromised
25
Record Requests
•
Requests may include demand for color copies or scanned documents on CD
•
Unlike
RACs, no apparent limit on number of documents that may be requested
•
In Pennsylvania, requests have been made for documents back to 2004 (5 years)
26
What Happens After MIC Audit?
•
MIC prepares draft report, shares with state and then with provider
•
State and provider may comment on draft findings
•
CMS considers comments and prepares a revised draft audit report which is then shared only with state for final comments
27
What Happens After MIC Audit?
•
CMS issues final audit report and specifies overpayment, if any
•
State pursues collection of overpayment (remember state’s FMAP obligation)
•
Providers have full appeal rights under state law
No explicit federal right of appeal•
Audit MIC supports state during appeal process 28
Major Differences between MICs and RACs
•
MIC MA recoveries must be repaid by providers and by state Medicaid agency based on FMAP
•
States must repay FMAP within 60 days of notification
•
MIC appeals handled by states •
RAC appeals follow regular Medicare appeal process
•
RAC auditors paid on contingency based fee29
Best Practices: Review MA Compliance
•
Is this on your agenda?•
Examine existing reporting and record systems to identify potential operational challenges
•
Develop internal monitoring techniques and risk assessments with counsel
•
Enhance compliance initiatives, particularly related to documentation and coding education
•
DRA requirements for false claims education if MA payments ≥
$5 million
30
Best Practices: Review MA Compliance
•
Booz
Allen Hamilton’s MIC letter: “We ask that at least the Medicaid Compliance Officer and anyone you designate as your liaison for the audit participate during the entrance conference.”
•
Select a MIC coordinator to manage all inquiries and coordinate evaluation of all records sent out for audit/review
•
Identify facility and/or organization team –
how will you communicate internally and with whom?
31
Best Practices: Review MA Compliance
•
Identify the Audit MIC for your region and alert mailroom for letters
•
Implement systems for timely responses to audit
•
Develop a logTrack requests for information, deadlines, extensions and dates sentLog all contracts with MIC (names, dates, times and summary of conversation)Log notices of overpayments, dates for repayment, dates for appeals 32
CMS Regions
33
Review-of-Provider MIC Contractors
•
Safeguard Services; Plano, TX•
IMS Government Solutions; Falls Church, VA
•
AdvanceMed
Corp; Rockville, MD•
The
Medstat
Group, Inc.; Ann Arbor, MI
•
ACS Healthcare Analytics; Washington DC
34
Audit MIC Contractors
•
Booz
Allen Hamilton Inc; Rockville, MD•
Fox Systems, Inc.; Scottsdale, AZ
•
Health Integrity, LLC; Easton, MD •
Health Management Systems, Inc.; New York, NY
•
Island Peer Review Organization; Lake Success, NY
35
Resources
•
CMS Comprehensive Medicaid Integrity Plan:•
http://www.nasmd.org/issues/docs/CMS_Comp
rehensive_Medicaid_Integrity_Plan.pdf •
MIP Comprehensive Plan 2007-2011:
•
http://www.cms.hhs.gov/DeficitReductionAct/Do wnloads/CMIP2007.pdf
•
GAO Report on Improper Payments http://www.gao.gov/new.items/d09628t.pdf
36
Acronyms
•
BPI –Bureau of Program Integrity•
CMS –
Centers for Medicare and Medicaid
Services•
CMSO –
Center for Medicaid and State
Operations•
DRA –
Deficit Reduction Act of 2005
•
DFRD –
Division of Fraud Research and Detection (MIG/CMSO)
•
FMAP –
Federal Medical Assistance Percentages
37
Acronyms
•
MA –
Medicaid•
MAC –
Medicare Administrative Contractor
•
MFCU –
Medicaid Fraud Control Unit•
MIC –
Medicaid Integrity Contractor
•
MIG –
Medicaid Integrity Group•
MIP –
Medicaid Integrity Program
•
PERM --
Payment Error Rate Measurement Program
38
Questions?
Paula G. Sanders, Esq.Post & Schell PC
17 North 2nd
Street, 12th
Floor
Harrisburg, Pa 17101717-612-6027
39
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Best Practices to Prepare for the Audit and the Appeals
Steve LokensgardSPECIAL COUNSEL
2
AgendaAgenda• Responding to Record Requests• Responding to Denials
– Reviewing Denials– The Appeal Process– Appeal Strategy– Technical and Substantive Defenses
3
Responding to the Record RequestResponding to the Record Request• Stamp Date and Time Received
– 45 calendar days from date of letter– Can request an extension– Notify RAC if large discrepancy between
date of letter and date of receipt– Identify any internal issues in getting the
mail to you quickly
4
Responding to the Record RequestResponding to the Record Request• Was the request sent to the right place?
– Notify RAC of the correct contact person and contact info• Not necessarily your RAC Tsar, or your contact on the 855
– See CERT contact info process
• Did the RAC exceed the Record Request Limit?– Every 45 days (starting with the first request received)– 10% of average monthly inpatient claims (max of 200)– 1% of average monthly outpatient claims (max of 200)– Per NPI max of 200– What about hospitals with multiple NPI’s?
5
Responding to the Record RequestResponding to the Record Request• Record Request Limits Example:
Average monthly inpatient claims
Average monthly outpatient claims
Total records requested from hospital per 45 days
250 3,000 55
10% = 25 1% = 30
6
Responding to the Record RequestResponding to the Record Request• Process Options
– Treat as normal ROI request and HIM produces the records
• Cost effective– Normal ROI Process with some Clinical Review
• Ensure entire record is copied• Include copies of NCD, LCD, coding guidelines,
CMS guidance?– Review of all records before they are released
• Resource intensive• Allows for early identification of issues• Establishes priority for appeals• Opportunity to write an addendum?
7
Responding to the Record RequestResponding to the Record Request• Has the claim already been audited?
– Check HIM release history– RAC Data Warehouse
• Did the RAC follow the New Issue Review Process?– Initial requests may be part of the process– Letter should clearly state basis for the request– Look to the RAC’s website and confirm that issue
is listed
• Is this a RAC Request?– Confusion with so many Medicare contractors
8
Responding to the Record RequestResponding to the Record Request• Document Management
– Stamp number (Bates Stamp) on bottom of each page produced– Scan everything produced to RAC– Include cover letter itemizing contents of box of documents or CD– Send certified mail or, if regular mail, complete affidavit of service
by mail
9
Responding to the Record RequestResponding to the Record Request• Software to Manage Records Produced
– Storing Records v. Managing the Process• AHA website contains list of vendors
– Does it interface with your HIM or billing system?– Will other members of the RAC Team be able to access the records?
• Sharepoint portal– Allow you to report to AHA on RAC Track?– Capable of producing a dashboard for senior management?
10
Responding to the Record Request: Fields to Track Responding to the Record Request: Fields to Track
• Audit ID Number• Type of Audit• Reason for Audit• Date of Record Request• Date Received• Next Deadline
• Information about the production• Patient information• Status of case• Reimbursement information• RAC response• Status at each level of appeal
11
Responding to the Record RequestResponding to the Record Request• Monthly invoice for document production
– 12 cents plus postage for PPS providers– 15 cents plus postage for non-PPS and physician offices– 00 cents for critical access hospitals
• Records can be produced on a CD– Same reimbursement per image
12
RAC Appeals thru August 31, 2008RAC Appeals thru August 31, 2008• 525,133 claims with overpayments• 118,051 appealed at any level (22.5%)• 34% of appealed claims were overturned• 4.9% = overall percent of overpayment determinations overturned
on appeal• Average cost of appeal ranged from $2,500 - $3,500• American Hospital Association’s effort to track appeals
13
Reviewing the DenialsReviewing the Denials• Stamp the date received
– Appeal period begins when you receive the determination (“demand letter”), which is presumed to be five days after the date of the letter absent evidence to the contrary
– You have 120 days to appeal (i.e. request a redetermination)– File appeal within 30 days to avoid recoupment on day 41
• Automated Review– “The RAC shall communicate to the provider the results of each
automated review that results in an overpayment determination.” RAC Amended Statement of Work
• Be on the lookout for recoupments prior to letters
14
Reviewing the DenialsReviewing the Denials• Evaluate the Denial – Gatekeeper/ Traffic Cop
– Automated reviews– Lack of documentation (records not submitted timely)– Coding issues– Charging issues– Medical necessity denials
• Gatekeeper/ Traffic Cop ensures database used to track claims is updated
• Generate dashboard for senior management
15
Reviewing the DenialsReviewing the Denials• Medical Necessity Denials
– Case management/ utilization management nurse– Physician options
• Attending physician• Medical Director• Handful of internal experts• Outside physician advisors
– Document Conclusions– Contracts
• Stark• Anti-Kickback
16
Reviewing the DenialsReviewing the Denials• Essential Resources
– Case Management/ Utilization Management– Physicians/ physician advisors– Coders/ accounting firms– Chargemaster– Compliance– Law Department/ outside counsel
17
The Appeal ProcessThe Appeal Process• 15-Day Rebuttal Period
– Designed to detect errors in calculation of overpayment– Not designed to address substantive arguments relating to denial
• Discussion Period– Allows providers to discuss a medical necessity denial with the RAC– Continues through to recoupment date (41 days from notice)
18
The Appeal ProcessThe Appeal ProcessFirst Level = Request for Redetermination• Made to Fiscal Intermediary, Carrier, or the Medicare Administrative
Contractor• 120 days to file appeal, 30 to avoid recoupment• 42 CFR § § 405.940-.958• CMS Pub. 100-4, Ch. 29, § 310• No minimum amount in controversy requirement• Records review
19
The Appeal ProcessThe Appeal Process• Contractor has 60 days to issue redetermination• Use Form CMS 20027 (or your own form with same information)• Send to: (Example for Noridian)
Medicare Part AATTN: Claims/ RedeterminationsP.O. Box 6714Fargo, N.D. 58108-6714
20
The Appeal ProcessThe Appeal ProcessSecond Level = Request for Reconsideration• Made to Qualified Independent Contractor (MAXIMUS for Part A)• 180 days to file appeal, 60 to avoid recoupment• 42 CFR § § 405.960-.978• CMS Pub. 100-4, Ch. 29, § 320• No minimum amount in controversy requirement• Records review• Traditional success rate at MAXIMUS (pre-RAC):
– 20% for Part A; 36% for Part B; 28% for DME
21
The Appeal ProcessThe Appeal Process• Contractor has 60 days to issue redetermination• Use Form CMS 20033 (or your own form with same information)• Send to: Example for MAXIMUS
Qualified Independent ContractorMAXIMUS Federal ServicesP.O. Box 62410King of Prussia, PA 19406
22
The Appeal ProcessThe Appeal Process• Legal Review at Second Level?
– Last opportunity to submit contemporaneous documents– If an appeal to the third level is required, must show “good cause” to
submit additional documents
• If unsuccessful after Second Level, overpayment will be recouped
23
The Appeal ProcessThe Appeal ProcessThird Level = Administrative Law Judge (ALJ)• 60 days to appeal• 42 CFR § § 405.1000-.1064• CMS Pub. 100-4, Ch. 29, § 330• Minimum amount in controversy: $120• Hearing by video teleconference, teleconference, or in-person• The level when most RAC appeals have been successful
24
The Appeal ProcessThe Appeal Process• ALJ has 90 days from the request for hearing to issue decision• Use Form CMS 20034 A/B (or your own form with same information)• Send to:
Office of Medicare Hearing & AppealsMidwestern Field Office 200 Public Square, Suite 1300 Cleveland, OH 44114-2316
25
The Appeal ProcessThe Appeal ProcessFourth Level = Request for Review by the Medicare Appeals Council• 60 days to appeal• 42 CFR § § 405.1100-.1130• CMS Pub. 100-4, Ch. 29, § 340• No minimum amount in controversy• De Novo review• Record review, but may request oral argument• MAC will remand to ALJ if additional facts are necessary
26
The Appeal ProcessThe Appeal Process• Medicare Appeals Council has 90 days to act• Use Form DAB-101 to request review• Send to:
Department of Health & Human Services Departmental Appeals Board Medicare Appeals Council, MS 6127 Cohen Building Room G-644 330 Independence Ave., S.W. Washington, D.C. 20201
27
The Appeal ProcessThe Appeal ProcessFifth Level = Federal District Court• 60 days to appeal• 42 CFR § § 405.1136• CMS Pub. 100-4, Ch. 29, § 345• Minimum amount in controversy: $1,220
28
Appeals StrategyAppeals Strategy• Issues to Consider
– 30 days to avoid recoupment– 120 days to request reconsideration– 11.375% interest accrues from date of determination– Cash flow – can extend repayment for 180 days through the appeals
process– Six months of interest on a $6,000 claim = $341.25
29
Appeals StrategyAppeals Strategy• Aggressive
– Appeal all claims within 30 days
PROS
Preserve cash flow (for 180 days)
Discourage RAC from focusing on you?
CONS
Accrue interest
Frantic timetable to assemble appeals
30
Appeals StrategyAppeals Strategy• Moderate
– Appeal some claims within 30 days• Based on dollar amount?• Based on review of the merits? (Green and Yellow claims)
• Conservative– Appeal claims within 120 days
• Based on dollar amount?• Based on analysis of the merits?
31
DefensesDefenses• 1-year limit on reopening claims• Limitation of Liability (Section 1879 of the Social Security Act)• No Fault (Section 1870 of the Social Security Act)• Treating Physician Rule• Qualifications of Staff• NCD or LCD is unlawful
32
DefensesDefenses• Reviewer Used the Wrong Standards
– Coding clinic, LCD, NCD, other CMS guidance– Note: QIC and ALJ are bound by laws and regulations, NCD’s, and
Medicare rulings, but not by other CMS guidance (such as Medicare Claims Processing Manual or Transmittals)
• Reviewer Applied the Standards Incorrectly– Review Medicare Ruling 95-1 on medical necessity standards– Support argument with affidavit/ testimony of physician– Include any evidence of community standard– Include any scientific articles that support your position
