HCPro.com - Patient Access Weekly Advisor

Last issue of Patient Access Weekly Advisor

Wed, 27 Jun 2012 12:39:00 GMT

HCPro is sorry to report that this is the second to last issue of Patient Access Weekly Advisor. We thank you for being a loyal subscriber.

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Coming soon: Recovery auditor prepayment reviews

Wed, 27 Jun 2012 12:37:00 GMT

Last November, CMS unveiled three demonstration projects aimed at reducing improper payments in the Medicare program. A few months later on February 3, 2012, CMS announced that it would be delaying two of the three of these demonstrations, one of which is the Recovery Auditor prepayment review demonstration.

Though the CMS website lists the start date as “Summer of 2012,” the delay—which came as a result of comments and concerns from providers— originally pushed the official launch to June 1, 2012. If we are, in fact, in the midst of the Recovery Auditor prepayment review demonstration, there has been no official announcement. Despite this fact, if providers have not already begun doing so, they should take action, according to Sharon Easterling, MHA, RHIA, CCS, CDIP, CEO of Recovery Analytics in Charlotte, N.C.

“With the shift of the RAC to up-front documentation review, providers should implement concurrent processes in their case management and utilization review areas,” she says. “From there, you should have second level review done by a physician for these particular DRGs.”

She continued, “Facilities may also want to consider educating their physicians on these particular DRGs to identify key documentation points that help to meet medical necessity.”

When it comes to physician education, all doctors are different, and some are more receptive than others. In situations where it requires a bit more effort, Easterling suggests using a physician advisor.

“Having a physician that speaks with the other physicians about the required documentation for medical necessity—and the translation of that information—is very important.”

Other staff members to consider when ramping up efforts against prepayment reviews are clinical documentation improvement (CDI) nurses and professionals. In some cases, patients come in with more than one condition, so assigning the correct DRG becomes imperative, so these CDI nurses and professionals should—in addition to staying up to date on CMS guidance related to the program—be involved in the process of concurrent review as well. In addition, coders should also be educated and confirm the order and patient type prior to billing, suggests Easterling.

Though it may surprise no one to hear it, providers need to make sure that medical records are as complete as possible before they go out the door. Make sure that the records do not have any signature issues, make sure that they have been pre-reviewed, and make sure that they contain all the necessary documentation; as these are the most important aspects of the record, explains Easterling.

In addition, she mentions, if providers see denials come into their facility as a result of these prepayment reviews, they should look into appealing that determination.

“Appeal, appeal, appeal; when you read that [the recent CMS update that came out on appeals], you tend to think that providers aren’t appealing enough,” she says. “Continue to appeal and work on documentation efforts.”

For more information on the prepayment review demonstration program, click here: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Demonstrations.html

HCPro Watchdog Service

Wed, 27 Jun 2012 04:00:00 GMT

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CMS publishes improper payment figures and appeals statistics

Wed, 20 Jun 2012 04:00:00 GMT

In the last month, CMS posted two separate sets of data that provide nationwide statistics on its Recovery Auditor program. The first update contains improper payment figures as well as the top Recovery Auditor issue per region. In the second update, CMS provides appeals statistics for fiscal year 2011.

Improper payment figures and top issues

Recovery Auditor activity saw a huge spike in the latest quarter, as statistics for overpayments and underpayments both saw significant increases. For the time period January 2012 through March 2012, CMS identified $588.4 million in overpayments and $61.5 million in underpayments for a total of $649.9 million in corrections. These numbers are up from $397.8 million and $24.9 million from last quarter, respectively. These numbers have climbed considerably since the start of the permanent program.

Since the beginning, CMS has identified $1.86 billion in overpayments and $245.2 million in underpayments for a sum of $2.1 billion in total corrections.

The correction amounts of each quarter of the program are as follows:

October 2009–September 2010: $92.3 million
October 2010–December 2010: $94.3 million
January 2011–March 2011: $208.9 million
March 2011–June 2011: $289.3 million
July 2011–September 2011: $353.7 million
October 2011–December 2011: $422.7 million
January 2012 – March 2012: $649.9 million

Second to last issue of Patient Access Weekly Advisor

Wed, 20 Jun 2012 04:00:00 GMT

HCPro is sorry to report that this is the second to last issue of Patient Access Weekly Advisor. We thank you for being a loyal subscriber.

First of 2012: CMS announces supervision decisions for select services

Wed, 13 Jun 2012 04:00:00 GMT

In the 2012 outpatient prospective payment system (OPPS) final rule, CMS established a process to utilize the hospital outpatient payment panel to recommend the appropriate levels of supervision for individual hospital outpatient therapeutic services. Following panel meetings at or around March and August of each year, CMS said it would consider panel recommendations and post decisions regarding individual services on its website. From there, there would be a 30-day waiting period for providers to make comments on the decisions, which would then lead to the finalized decisions going into effect in July or January, depending on the panel meeting.

For the most recent panel meeting, however, the initial determination was not well announced, and the ability to request determinations and make comments may have slipped by unnoticed for many providers, according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc.

“I knew that determinations were supposed to be released for comment, yet I didn’t see anything on the website or hear anything on the open door forums, so I thought that perhaps the first panel meeting would be held in August due to the short time between the final rule and the first proposed meeting,” she says. “But CMS did display the recommendations for comment and finalize them, although it was not well publicized.”

Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc, agrees, saying that, “As a regulatory specialist [at HCPro], one of my responsibilities is to stay cognizant of the endless stream of CMS announcements, but I will admit that not only did this one slip by me, but any information related to the topic is also very difficult to find on the CMS website.”

According to the CMS release, the following services are now eligible to be performed under general supervision:

Specific mental health services from the range 90804-90828 which excludes codes for medical evaluation and management; 90846-90857; G0177; G0410 and G0411
Bladder catheter insertion 51701
Immunization administration 90471-90474
Smoking cessation counseling 99406-99407

Selection of approved services

As a result of what could in effect be a lack of provider input, the list above comes off as perhaps a bit unexpected, says Hoy.

“Well first, the list contains a number of psychotherapy codes, but one of the main providers of psychotherapy services—clinical psychologists—can themselves supervise these services, so their inclusion on the list comes as a bit of a surprise,” she says. “Also, the inclusion of immunization codes, but no other drug administration codes seems odd.”

Hoy continues, “Also, I would have assumed that observation may have been one of the very first issues that was addressed by the panel; either confirming or denying whether or not it’s a service that can be performed under general supervision. This continues to be an issue for critical access and rural hospitals that is not solved by the Non-Surgical Extended Duration Service exception CMS created.”

Critical access and rural hospitals

There had been hope that this panel and its recommendation process would help to alleviate some of the burden from smaller hospitals. For instance, in critical access hospitals—as CMS commentary reads now—physical therapy, occupational therapy, and speech language pathology are required to meet supervision requirements, meaning they must have a physician or NPP immediately available. However, for PPS hospitals, these services were exempted from the requirement because they are not paid under OPPS, explains Hoy.

“It’s interesting to me that this panel didn’t make the determination that PT, OT, and speech can be under general supervision, because this would have saved CAHs from having to have physicians immediately available, whereas other hospitals do not,” she says.

This puts CAHs and other rural hospitals in a tough spot, because their exception ends in January. The next opportunity for CMS to change supervision requirements is the August meeting, which would make any determinations effective on January 1. The problem here though, is that these hospitals won’t know until November or December whether or not they will be required to have supervision for some of these services starting in January leaving very little time to prepare, explains Hoy.

“This list does not address rural hospitals’ and critical access hospitals’ concerns at all. This process was supposed to address concerns that hospitals had with supervision requirements, but it doesn’t appear to have done much to alleviate their concerns for some of the most common services provided in hospital outpatient departments.”

To view CMS’ final decisions on the recommendations of the Hospital Outpatient Payment Panel on supervision levels for select services, click here:

http://www.cms.gov/Regulations-and-Guidance/Guidance/FACA/Downloads/PrelimSupervisionDecisions.pdf

Reader submission: Patient survey tips

Wed, 13 Jun 2012 04:00:00 GMT

Send your thoughts to Associate Editor James Carroll at jcarroll@hcpro.com. And you could be featured on our Patient Access Resource Center blog or perhaps in this e-newsletter.

Charlene Chames, safety and compliance officer at Summit Oral and Maxillofacial Surgery in Warren, Mich., submitted the following list of tips on patient surveys:

I found a way to make sure surveys are handed out to all (mostly) patients are:

We pick a week every month, rotating this monthly, this helps to avoid staff complacency. Each patient that week, no matter if they came in on Monday, then return on Friday gets a survey. They are told that we are rating each visit to our facility.
Patient returns are entered in a monthly drawing for two premier AMC movie tickets, there is a cover letter explaining this in the survey to the patient.
Each location is color coded to make it easier to pick out the returns for each location.
Each survey is placed in a return envelope for the pts to return easily.
Each survey is placed in the chart the day before when the records are prepped and given to the patient by the assistant that assisted the provider that day explaining the survey.
Each staff member has email for corporation use, so they are all emailed to their calendar the reminder of each week for the year.
Last I note the survey weeks in the daily schedule to remind the staff & doctors when they print their schedules for the day, as they start 1 week prior to make sure they have necessary things until the day of.
We also keep a couple surveys in a brochure holder for patients to fill out at anytime in the waiting room if they would like with a sign on it saying, “Tell us how we are doing!”

With this our surveys have tripled in return rates!

Bounce ideas off your colleagues

Tue, 12 Jun 2012 04:00:00 GMT

Need some guidance on a front-end decision you need to make for your staff members? There's no better place to start a conversation than our Patient Access Resource Center.

People are buzzing about some recent posts, so now's the time to start a conversation with your colleagues.

CMS announces supervision levels for select services

Wed, 06 Jun 2012 04:00:00 GMT

On May 22, CMS announced the newly designated services that may be conducted under general supervision in accordance with the current Medicare regulations and policies. In the 2012 OPPS Final Rule, [76 Fed. Reg 74360]. CMS established a sub-regulatory process to adopt alternate levels of supervision, such as general or personal, for individual HCPCS codes. Hospitals can make requests twice a year to the Hospital Outpatient Payment Panel and upon further review, this panel makes recommendations to CMS for the alternative level of supervision. CMS posts these recommendations for comment on their website and then announces their final decision whereby the changes become effective on either July 1 or January 1.

As a regulatory specialist, one of our responsibilities is to stay cognizant of the endless stream of CMS announcements, but I have to admit that not only did this one slip by me, but any information related to this topic is also very difficult to find on the CMS website. [Well, more difficult than usual!] Because of this, we have included many of the links and citations in this article to help our readers find the information more easily.

Continue reading Debbie's note at the Medicare Mentor Blog.

2012 patient access goals

Tue, 05 Jun 2012 04:00:00 GMT

As we have nearly begun the second half of 2012, we’d like to give you and your staff the opportunity to talk about your goals and visions in patient access for the rest of this year.

Survive a recent audit? Handle a crisis effectively and efficiently?

We’d love to hear about it – and so would your colleagues. Send your thoughts to Associate Editor James Carroll at jcarroll@hcpro.com. And you could be featured on our Patient Access Resource Center blog or perhaps in this e-newsletter.

Good luck and have a great rest of the year!

New CoP addresses patient self-administration of medications

Wed, 30 May 2012 04:00:00 GMT

CMS put on display two rules on May 9 designed to reduce the regulatory burden on providers and save hospitals nearly a billion dollars a year in administrative costs. But at least one provision in the new rules is aimed at saving costs for patients as well.

A change to the Conditions of Participation (CoP) for hospitals specifically allows patients to self-administered drugs. Many hospitals already have a program for self-administration of medications on the outpatient side, specifically because of the Medicare policy of non-coverage of these drugs along with their administration.

The new CoP is included under the nursing services section at 42 C.F.R. 482.23(c)(6). It allows for self-administration of hospital issued drugs as well as drugs brought from home. The latter is often a significant issue because the price for individual doses in the hospital outpatient setting is often substantially higher than the patient can obtain the drug through their pharmacy insurance plan.

Continue reading on the MedicareMentor blog.

CMS identifies CERT, Recovery Auditor findings in latest quarterly compliance newsletter

Wed, 23 May 2012 04:00:00 GMT

Last month CMS released the seventh issue of its Medicare Quarterly Provider Compliance Newsletter. The newsletter contains official guidance on problematic billing errors that it has identified in the past quarter. Unlike all of the preceding releases, this issue contains comprehensive error rate testing (CERT) findings in addition to recovery auditor findings.

According to Donna Wilson, RHIA, CCS, CCDS, senior director at Compliance Concepts, Inc. in Wexford, PA., the inclusion of this new information should prove to be beneficial to providers.

“Including CERT findings is an added bonus to this priceless resource tool from Medicare,” she says. “Providers should consider adding these issues to their internal compliance monitoring. Governmental auditing agencies use CERT, RAC, PEPPER and OIG studies to detect suspicious billing practices.”

As has been the case, these documents are provided in order to propagate information on understanding claims submission problems while also providing guidance on avoiding such errors and improper billing activities moving forward. As auditing bodies continue to grow and evolve, the addition of CERT findings only makes sense.

In the report, CMS identified the following findings, with affected provider types in parentheses:

CERT finding: Three-day qualifying hospital stay for skilled nursing facility stays (Inpatient hospitals, SNFs)
CERT finding: Inpatient hospital consultations (Inpatient hospitals)
Recovery audit finding: Cholecystectomy-incorrect secondary diagnosis (Inpatient hospitals)
Recovery audit finding: Kidney and urinary tract disorder - incorrect principal diagnosis (Inpatient hospitals)
Recovery audit finding: Transient ischemic attack - services rendered in a medically unnecessary setting (Inpatient hospitals)
Recovery audit finding: Craniotomy and endovascular intracranial procedures (Inpatient hospitals)
Recovery audit finding: Small and large bowel procedures (Inpatient hospitals)
Recovery audit finding: Spinal fusion (Inpatient hospitals)

One interesting finding—and something that providers should pay attention to—is the three-day qualifying hospital stay for skilled nursing facility stays, according to William Malm, ND, RN, CMAS, senior data projects manager at Craneware, Inc., based in Edinburgh, Scotland with a US office in Atlanta.

“It is unclear what CMS will do with this information in the longer term. In 2011, CMS conducted a number of conference calls on the impact of observation at facilities and part of that discussion was on the three-day inpatient requirement for SNF admission for a covered stay,” he says. “CMS indicated that they were aware of the concern and would monitor it, and we now have CERTs stating this is an issue and that physicians are trying to admit to ensure covered stays for SNFs. Clearly the regulation is a challenge to patients and facilities. We would hope that CMS would review this and amend the process for SNF admission to include the most appropriate settings including observation.”

As a result, providers should take a closer look at their records, says Malm.

“Providers should take a look at each record in which there was a discharge to a SNF and the transfer should be reviewed by at least two people—perhaps a coder and someone from internal audits, quality review or a physician advisor—to make sure it is compliant.”

To view the most recent quarterly provider compliance newsletter, click here:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp_Newsletter_ICN907927.pdf

To view an archive of the quarterly compliance newsletters, click here:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//MedQtrlyCompNL_Archive.pdf

Recent OIG reports show critique on CMS’ processes and programs

Wed, 16 May 2012 04:09:00 GMT

During the past few months, there have been a number of Office of Inspector General (OIG) reports released that seem to question some of CMS’ audit programs and perhaps find them lacking. It remains uncertain why the release of these audit reports have come within such a short window of time, but the fact that they are occurring should be an indication that CMS’ methods and processes are far from perfect.

The following is a look at some of the recent OIG critiques of CMS.

Audit MIC performance

One such report is an early assessment of the efforts of Audit Medicaid Integrity contractors (Audit MICs) to identify overpayments in Medicaid. The report, released on March 20, indicates that only 11% of the study-assigned audits were completed with findings of $6.9 million in overpayments, $6.2 million of which resulted from seven completed collaborative audits involving Audit MICs, Review MICs, states, and CMS. This leaves 81% of audits that the MICs were unable to or unlikely to identify any underpayments or overpayments. The OIG deduced that problems with the data used and analyses conducted by Review MICs and CMS to identify audit targets hindered the performance of the Audit MICs.

Hospital ED wait times reveal huge variations

Wed, 09 May 2012 04:00:00 GMT

Hospital leaders who believe their emergency room patients' wait times compare well with competitors may have to rethink those assumptions now that two ED wait time quality metrics are posted on the Hospital Compare website.

The times for the 74 hospitals—the first to volunteer their data—show wide variation across the country.

For example, for the first measure (ED-1)—the median time between when patients enter the ED door until they leave the ED for an inpatient bed—times range from 387 minutes at Niagara Falls Memorial Hospital in Niagara Falls, NY, and 358 minutes for Memorial Hermann Baptist Orange Hospital in Orange, TX, to 52 minutes at Perry Memorial Hospital in Perry, OK, and 90 minutes at Paynesville Area Hospital in Paynesville, MN.

Best-practice hospitals keep this time under four hours for all patients, not just as the median, says Sandra Schneider, MD, past president of the American College of Emergency Physicians who has studied the issue and visited EDs around the country. However, 18 of the 74 hospitals posted median times of four hours or longer.

Times for the second metric in the database (ED-2)—the median time between the moment an ED doctor decides to admit patients to an inpatient bed and the time the patients actually left the ED for that bed—range from 170 minutes, both at Memorial Hermann Baptist Hospital in Beaumont, TX, and Niagara Falls Memorial, to no minutes at both Frio Regional Hospital in Pearsall, TX, and Pocahontas Memorial Hospital in Buckeye, WV.

Read the full story on HealthLeaders Media.

CMS issues minor edits to ABN instructions form

Wed, 02 May 2012 04:00:00 GMT

On April 19, CMS issued an update stating that minor edits have been made in the ABN instructions to clarify that the provider/supplier is responsible for inserting wording in all of the blanks labeled “D” on the notice including the “D” blanks that are within the “Options” section.

Please click the link in the list below to download the updated ABN instructions.

View the updated instructions.

Recovery auditor hot topics: Audit MICs struggling to identify overpayments

Wed, 25 Apr 2012 04:00:00 GMT

On March 20, the Office of Inspector General (OIG) issued a report that presents an early assessment of the efforts of Audit Medicaid Integrity Contractors (Audit MICs) to identify overpayments in Medicaid. Contained within the report are drastic figures that convey the fact that Audit MICs are having a difficult time identifying overpayments in their audits.

Only 11% of the study-assigned audits were completed with findings of $6.9 million in overpayments, $6.2 million of which resulted from seven completed collaborative audits involving Audit MICs, Review MICs, states, and CMS, according to the report. This leaves 81% of audits that the MICs were unable to or unlikely to identify any underpayments or overpayments. The OIG suggests that problems with the data used and analysis conducted by Review MICs and CMS to identify audit targets led to this performance. Another possible reason for this lack of success in finding overpayments is the lack of an overarching governing body over the Medicaid auditing landscape, suggests William Malm, ND, RN, CMAS, senior data projects manager at Craneware, Inc., based in Edinburgh, Scotland with a US office in Atlanta.

“States are having difficulty auditing on the Medicaid side due to the diversity and complexity of the regulations, and the lack of billing specifics in the individual state guidelines,” he says. “These business practices have not been well documented and there is no defensible source authority to proclaim that something is an overpayment or an underpayment.”

Data breach update: 780,000 affected in Utah data breach

Wed, 18 Apr 2012 04:00:00 GMT

The Utah Department of Health (UDOH) released an update April 9 regarding a data breach caused by a hacked server in the Department of Technology Services.

The hackers stole the Social Security numbers of an estimated 280,000 Medicaid beneficiaries, and made off with less-sensitive personal information of an additional 500,000 individuals. The March 30 breach affected 780,000 people, according to the update. The UDOH initially believed that hackers stole data from 24,000 claims, but has since learned that hackers accessed 24,000 files, each of which could contain hundreds of claims.

The department warned the public to be suspicious of any phone calls or emails requesting personal information. UDOH established a hotline for Medicaid clients looking to find out whether hackers compromised their information. The department is also working to identify victims of the hack and notify them of the data breach.

Source: Utah Department of Health

CMS provides additional guidance on proper billing when the Medicare Secondary Payer Rules apply

Wed, 18 Apr 2012 04:00:00 GMT

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., is the author of this note.

In a recent Special Edition MLN Matters Article (SE1217), CMS reminded providers of their responsibilities under the Medicare Secondary Payer (MSP) Rules. Under the MSP Rules, Medicare is secondary to certain other payers in the specific circumstance.

Continue reading Judith's note at the Medicare Mentor Blog

HHS proposes one-year delay of ICD-10-CM/PCS

Wed, 11 Apr 2012 04:00:00 GMT

HHS released a proposed rule April 9 announcing a one-year delay of the implementation of ICD-10-CM/PCS. If finalized, ICD-10 would become effective October 1, 2014.

“Many provider groups have expressed serious concerns about their ability to meet the Oct. 1, 2013, compliance date. The proposed change in the compliance date for ICD-10 would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets,” according to an April 9 press release.

“This is what I expected,” says Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, Mass. “But I am happy to hear that they didn’t seem to consider bypassing ICD-10 and going right to ICD-11. This goes to show that they do see the value in the system.”

Read the full report.

HHS issues Affordable Insurance Exchanges final rule

Wed, 11 Apr 2012 04:00:00 GMT

On March 27, HHS issued a final rule in the Federal Register that implements the new Affordable Insurance Exchanges, consistent with the Affordable Care Act. The Exchanges will provide competitive marketplaces for individuals and small employers to directly compare available private health insurance options on the basis of price, quality, and other factors.

View the final rule