HCPro.com - Billing Alert for Long-Term Care

Are you ready for a �Medicaid RAC audit?

Sun, 01 Jul 2012 04:00:00 GMT

Are you ready for a Medicaid RAC audit?

Although there may have been starts and stops along the way, Recovery Audit Contractors (RAC) may soon start looking at Medicaid payments, following the path already laid down by the Medicare program.

And while Medicare Recovery Auditors came first, the Medicaid version will exhibit much more variation, as each state is responsible for detailing the specifics of its program.

"You're going to have 50 flavors of vanilla when they're set up," says Diane Brown, BA, CPRA, regulatory specialist at HCPro, Inc., in Danvers, Mass.

The story so far

The Affordable Care Act mandated that RACs be extended to the Medicaid program. CMS originally wanted state plans to be implemented or submitted by December 2010-but the agency only published proposed rules in November 2010.

In February 2011, CMS pushed the implementation date out even farther as it worked through final rules, which came out last September. The effective start date was January 1, 2012.

To date, according to CMS' website, every state has either approved or submitted plans to implement RACs; roughly half the states have awarded contracts. In the near future, the states will likely take the next step of implementing the Medicaid RAC programs.

Believe it or not, the RACs are coming

In the SNF community, there's a general feeling that SNFs won't be affected by RACs-either through the Medicare or Medicaid program, says Janet Potter, CPA, MAS, manager for healthcare research at Frost, Ruttenberg & Rothblatt, PC, in Deerfield, Ill.

"Many SNFs still don't think the RACs, Medicare or Medicaid, will come after them. So far we've been seeing many RAC audits in the hospitals, but no activities in the SNFs," says Potter. "Therefore, SNFs and other provider types have gotten complacent and are not as concerned about the potential of RAC audits as they were at the beginning."

That bubble may be about to burst, adds Potter.

"Nursing homes will eventually appear on the RACs' radar and will be audited at some point," she says. "Since the largest percentage of nursing home income is from Medicaid, the Medicaid RACs will likely be a great force in SNFs."

And while each state will have its own flavor of RAC, compared to the standardized Medicare audits, Potter says she expects the actual audit process in the Medicaid system to be similar to the federal reviews.

"The auditors will want to verify supporting documentation and completed required forms to ensure they match with the as-submitted claim. Medical necessity, proper documentation, and adherence to clinical and technical criteria will play a huge role," says Potter. "All auditors, RAC and otherwise, are now requesting copies of all required notices be submitted with the medical records. Facilities should carefully review their notices process to determine if they are completing them all accurately and timely."

In the Medicare program, the auditors went after issues and entities most likely to produce results, adds Brown. It's expected the main focus in Medicaid RACs will be hospitals-at least to start, she notes, because the Affordable Care Act mandates the RACs to examine all areas.

What can you do to prepare?

The Medicare Recovery Audit Program is very transparent, says Brown, and she expects the Medicaid program to be much the same. That transparency is an essential tool for SNFs to determine where they should focus as they prepare for Medicaid RAC audits. Facilities should consider the following when making their preparations:

Go to the auditors for information. "Go to the auditor's website-they'll tell you what issues they're looking at, and where," Brown advises. "There's plenty of information out there."
Be proactive with policies. Facilities should take a proactive approach and begin reviewing their policies and procedures, documentation, and processes now, says Potter. "When the audit request letter arrives, it is too late." But in the case of a RAC automated review, she notes, a provider won't even know the review is happening until the demand letter arrives.
Documentation review is essential. Both clinical and financial documentation should be reviewed, preferably by someone who didn't prepare it. Clinical documentation should accurately reflect the resident's condition, treatment, needs, and services provided. "The picture that the documentation paints should be consistent from discipline to discipline, or inconsistencies should be explained," says Potter.

Michael H. Cook, partner at Liles Parker, PLLC, in Washington, D.C., says there's a lot that SNFs can do now to prepare for Medicaid RACs, and some of it boils down to business basics:

Identify a point of contact. "They need to make sure that when there is a record request or a determination made, there is one point of contact that has responsibility in the facility to make sure that those records are delivered on a timely basis and that they are complete," says Cook. "And they need to make sure that the state or RAC is aware of whom that point of contact is."
Establish a RAC response team. SNFs need to have a team in place to properly process the RAC requests. And while it can be expensive, Cook says, the team should be conducting a shadow audit of at least a portion of the claims the RAC is reviewing. This gives you a sense of what to expect, he explains. And, Cook adds, if there is a more endemic issue that arises, the SNF can initiate corrective actions. "In other words, you ought to be integrating your RAC response team with your quality assurance team and your compliance function," says Cook.
Build the right relationships. SNFs should also ensure that someone in the facility has a relationship with someone at the RAC, Cook advises. Generally speaking, facilities want to make sure there's an open line of communication to the auditor to straighten out any problems before they escalate-for example, if there's an odd request for records coming in, or if some other issue arises. "That doesn't mean you complain when the RAC is doing its job properly. It does mean if things start blowing up, you've got a contact that can do something," says Cook. "Informal relationships are always helpful, whether it's with a state or with a RAC, before issues get blown out of proportion."

Is VBP finally on its way for SNFs?

Sun, 01 Jul 2012 04:00:00 GMT

Is VBP finally on its way for SNFs?

In 2009, Wisconsin, New York, and Arizona participated in a value-based purchasing (VBP) demonstration for SNFs, a prototype program that was to lead the way in a national rollout.

In October 2011, CMS was supposed to issue VBP guidelines for SNFs, according to the Affordable Care Act (ACA)-although that still hasn't happened. Until those guidelines are issued, the industry holds its collective breath.

The impact on SNFs will be far-ranging, with key metrics used to measure performance-which will, in turn, affect payments. But to date, the industry hasn't heard a word about when CMS plans to move forward, at least with guidelines.

"Not a word, not a peep. That's where it's at," says Elizabeth Malzahn, national director of healthcare for Covenant Retirement Communities in Skokie, Ill. "Nobody's seen the report. We haven't really had any updated information in over a year in where this is going."

The industry was excited about VBP when discussions first started in 2008, Malzahn adds, and was ready for the next steps-which haven't come yet.

"We did a lot of hurry up and wait when this first came out," she says.

There was also a bit of panic, she says, with SNFs wondering how they would be able to do all that would be demanded of them. Malzahn says she thinks CMS also realized the size of the undertaking, and slowed the timeline down a bit.

Where is the movement headed?

Nicole O. Fallon, manager consultant healthcare at CliftonLarsonAllen, LLP, in Minneapolis, says CMS tends to focus on the acute care portion of the healthcare business, later looking at postacute care. That may be the case here, she suggests.

Fallon also notes that the final report from the three-state VBP demonstration hasn't yet been issued publicly, although the results were recently shared with the participants. She suggests that CMS plans to use data from the report to support the direction it's headed with VBP for SNFs, and that may be contributing to the overall delay.

CMS did not respond to requests for comment about the overdue report and when it might be issued. According to Fallon and Malzahn, it is unclear whether the recent release of a report on VBP for home healthcare to Congress means anything in terms of movement on the SNF front.

Unlike ACOs, VBP impacts everyone

While many providers are looking at the legal challenges to the ACA, wondering what might actually be in place when the dust settles, Fallon says SNFs should be prepared to handle a VBP program. And, she says, while there's been a lot of buzz about accountable care organizations (ACO), they won't affect every SNF-whereas VBP will.

"VBP is the one thing out of the ACA that's definitely coming to a theater near you-regardless of what kind of Medicare type of provider you are," says Fallon. "I don't see VBP going away. I don't believe they needed legislative authority, anyhow. If the law goes away, this goes forward-this is where we're headed."

A VBP world

The concept of VBP is woven throughout the ACA and boils down to some basic tenets, says Fallon. "Really what it is, is better care. In the event we have to provide care to you, we're going to make sure we're doing it utilizing best practices consistently," she says. "We'll avoid readmissions, hospitalizations, eliminate any preventable conditions, such as urinary tract infections, pressure sores, and wound infections. If you access care, you get best practices."

In a VBP world, CMS will reward providers for improved outcomes, according to Malzahn. The implied goal, she says, is to "run a more efficient operation with better outcomes." Broadly speaking, the factors the program will look at include:

Patient outcomes
Reduced costs
Reduced rehospitalizations
Staffing
Overall efficiency

As SNFs track these metrics and cut costs, the plan is to use the savings to pay for performance, Malzahn says.

According to Fallon, if CMS is looking to reward SNFs that provide high-quality care efficiently, there are two main approaches the agency can take when distributing these rewards:

Rewards for top performers. This reward system says that the top 10%-25%-based on performance metrics-get rewarded. Anyone below a certain threshold would get no bonus, and maybe even a percentage withholding, says Fallon.
Rewards for performance year over year. Another possibility is to look at organizations with the greatest improvement in year-over-year performance, Fallon suggests, which would incent the lower performers to step up their game and not just ding them for being at the bottom of the list. "If they're low performers, the last thing you want to do is take more money away from them," she says.

According to Malzahn, there is a bit of guidance that can be had from the home healthcare report sent to Congress. The biggest takeaway, she says, is the strong focus on care paths in the report-something that may be in store for SNFs. Care paths would consider:

Why organizations are looking at certain conditions
What conditions facilities are treating
What regimens are established for the first 72 hours, 10 days, month, etc.

"It still doesn't give us the how. It gives us the what-we're going to measure X, Y and Z-but not how, and how it will impact reimbursement," says Malzahn.

Will you be ready when VBP hits?

That said, Malzahn and Fallon agree there are areas SNFs can begin to work on now to make things easier when VBP does arrive. These areas may include:

Pneumococcal immunizations. An easy metric to achieve is the number of residents given pneumococcal or flu immunizations, Fallon suggests. "If you're not at 100% on that, get to 100%," she urges. "It's been identified as a best practice. On that metric, you should be hitting 100%."
Improvement areas. Start looking at your nursing home comparisons, examine your statistics and your competitors' statistics, and identify the areas where you're not a high performer. Then start working on those areas, Fallon says. "It's just good business sense, with or without a value-based payment attached to it."
Hospital readmissions. One of the key areas to focus on-and most SNFs already are-is reducing hospital readmissions, says Malzahn. "If there are providers who don't think they're doing anything related to VBP in preparing, this is probably the one thing they're doing," she says.
Care paths. Organizations should look at the care paths within the SNF based on diagnosis. Most providers are examining care paths for pneumonia, chronic obstructive pulmonary disease, congestive heart failure, and joint replacement, Malzahn says, and are trying to manage more of that internally-rather than rehospitalize the resident.
Root cause analysis. "If we really want to lower costs, the goal is to keep people out of the hospital if they don't have to be there," adds Fallon. "Figure out what part you do control, do a root cause analysis. Get to the bottom of what's causing those readmissions. It's a good conversation starter with hospitals and physician groups."

Understand MDS basics to increase reimbursement and limit audit risk

Sun, 01 Jul 2012 04:00:00 GMT

Understand MDS basics to increase reimbursement and limit audit risk

Understanding the MDS structure is often left to the clinical side of a SNF-in particular, the MDS coordinator. However, the new MDS structure-and the continual changes made by CMS-calls for more widespread SNF involvement than just the clinical element, says Karen Connor, president and CEO at Connor LTC Consulting in Haverhill, Mass. If facilities limit their knowledge of the MDS, they may be losing out on greater reimbursement opportunities as well as increasing their audit risk.

"Each team within a facility-clinical, rehab and therapy, social service, and the business office-has a responsibility in the outcome for Medicare reimbursement," says Connor. "Knowing at least the basics of MDS is a key part of that."

Promoting the proper MDS education begins by identifying and defining the role each team within the facility plays when it comes to reimbursement.

The clinical team and reimbursement

There is no doubt that the primary focus of the SNF clinical team is on skilled needs and the services they provide to each patient. "After all, a patient's need for skilled services is why they are admitted to the SNF," Connor says.

While caring for the patient should remain the top priority, it is important to communicate to the clinical team that there are both quality of care and financial implications to their decisions when treating a patient.

A key issue many facilities face today revolves around therapy services. It is common practice for clinical staff to assign a resident to the highest therapy RUG even if it is not necessary, says Connor. "Not only may this not be the best decision for the patient, but it can become difficult to support for documentation purposes," she explains.

Staff members often get in a habit of pigeonholing specific types of patients (e.g., a post-hip replacement resident), having a predetermined plan in their minds of what that resident's Medicare Part A stay will look like, says Elizabeth Malzahn, national director of healthcare at Covenant Retirement Communities in Skokie, Ill. "Each time a resident comes in, they should be treated individually," she says.

The MDS coordinator needs to own the MDS process-even if therapy is the main reason for coverage. "All too often the Medicare meeting is basically a therapy meeting, driven by therapy, dictated by therapy, and the clinical needs are not addressed," Malzahn says. "The SNF is the provider and should take charge of the Medicare Part A program regardless of the reason for skilled coverage. The entire picture of the resident needs to be reviewed by each discipline, and knowledge of the impact of each discipline on the process is crucial to that process being seamless."

This practice-without supporting documentation-can be a serious red flag for auditors, notes Connor. "Facilities need to ask themselves, 'How well would you sleep tonight if you were being audited tomorrow?' " she says.

While there are some consistent trends in length of stay or plan of care for residents who are being treated for the same conditions, making sure the documentation is resident-specific is crucial.

A more effective approach

It is commonly thought that more intensive therapy or higher therapy hours yields greater reimbursement; this is not always true, Connor says.

"One of the best approaches recently implemented is to assess the patient from a nursing standpoint first and then gradually incorporate the therapy afterward," she says. "To rush into therapy right away can cost the facility significantly. For example, it may cost a facility $8,000 per month in staffing costs to gain $6,000 in reimbursement for those services."

Looking at resident outcomes, the ability to ramp up or scale down therapy has proven to be extremely successful with a majority of residents, says Malzahn. "It also allows time to provide clinical interventions to maximize the benefit of the skilled therapy and to further optimize the resident's function once they leave the SNF," she adds.

The focus of the MDS structure is directed toward the patient and ensuring that they receive the necessary services at the correct level. As a result, the clinical team plays an even bigger role-and this is where the team could really excel with supporting documentation. Ultimately, the clinical team should be matching the RUG level to the MDS and making sure the related diagnoses are listed.

The rehab team and reimbursement

Under the new MDS structure, the rehab team should play a slightly different role than it has in the past. Now is the time for the rehab team to reassess widely accepted best practices and take a different approach with patients. Doing so may strengthen the quality of care and boost reimbursement, says Connor.

"Previously, rehab best practices focused on giving the patient the most therapy available on day one-maximizing the most minutes for the highest reimbursement rate," she says. "Yet, with the changes we have seen, clinical services have higher reimbursement rates for focusing on specific care, then introduce therapy for the patient to rest. With this approach, the clinical team slowly steps back when therapy is introduced, and this philosophy can gain better outcomes for the best quality of care."

The rehab team's focus should be on how aggressively the facility will treat the resident-and how much staffing is required to provide "X" amount of reimbursement, says Connor. "This is a change in the original theory," she explains. "And it may also increase a resident's length of stay."

Being proactive with resident assessments, identifying relevant clinical issues, and structuring therapy to coincide with that care can really make a significant impact when it comes to care, MDS evaluations, and essentially creating a specific plan for a given resident, Connor suggests.

The reimbursement team

Billers are the last line of defense when it comes to proper reimbursement, and if the business office does not understand the MDS structure, reimbursement opportunities could be compromised. For example, there could be days billed under the incorrect RUG, which could decrease the amount of reimbursement that the facility is entitled to.

To increase reimbursement opportunities and limit the risk of claims processing mistakes, billers should have a firm grasp of the following MDS components:

Modifiers and assessment periods. Many billers do not know or understand the changes with the new assessment structures, and simply accept the information that populates their software at face value. "You can't just assume that the computer is correct," Connor says. An important component of verifying what the computer generates is going back to the validation report received once the MDS is successfully submitted-this is what should be checked and balance with the UB-04.
New changes in assessment. The change of therapy, end of therapy, and end of therapy resumption now play a significant role with the assessment schedule. "The assessments are no longer standard," Connor says. "Previously, we created assessments where the pay table had a schedule where they would pay 14, 16, 30, and/or 100 days-unless there was a change-in which there was a specific modifier that everyone was aware there was a change and therefore a break in pay cycle." Now with the new MDS structure, facilities have numerous modifiers and several assessments. While many people simply let the computer determine the days and the payment cycle, this information is something that should be monitored closely. Have regular discussions at the facility's Medicare and/or triple-check meetings to determine pay date, assessment cycles, and correct modifiers. This will ensure that the reimbursement team has accurate data prior to submitting the claim to CMS. "Education to billing staff is critical with the new changes that went into effect April 1, 2012-the old way of counting assessment days has been shaken up significantly," says Malzahn.

The importance of working together

Communication across the different teams is critical in using the MDS correctly and successfully. On a regular basis, all three teams should discuss:

The assessments. Reviewing the assessments is important because they will aid in developing the care plan for residents. Determine the skilled criteria of the resident and verify all aspects of care..
The treatment plan and the goals to keep a patient on Medicare-and a team approach to possibly increase the resident's length of stay. Review the barriers to care and goals for the resident. Monitor progression and regression to verify that skilled services are warranted and aid in the development of the resident.
Cohesive documentation between clinical and therapy. "All too often, the story told about a resident via documentation from clinical and that same documentation picture of the same resident from therapy can differ greatly," Malzahn says. Educate nurses on how to document and what observations are crucial for a resident being covered under therapy.
If a patient is on certain services (e.g., oxygen, lab, x-rays), the specific treatment. This discussion should include:
- The related outcomes or results.
- Additional follow-up to be completed. This information is essential to properly understand what the facility should continue to do to care for the patient.
- Required documentation to be completed. Data is essential to support the skilled need, the resident's stay in the SNF, and the reimbursement to follow. This discussion is important in order for the business office to understand what ancillaries should appear on the claim, as this will support the UB-04 claim submitted. The RUG and the ancillaries support the need for skilled care and tell the story of the resident and why he or she should be in the SNF.

During its Medicare meetings, a facility should address the assessments, modifiers, and pay date schedule. Another component to address during these meetings is medical appointments. Follow up on those visits, any ancillary services, and patient concerns. This will reduce the risk of errors related to the RUG that was chosen and the payment days to follow.

This information should then be verified during a triple-check meeting to ensure that the data submitted corresponds to the services provided by the clinical and rehab teams.

Prior to billing, facilities should conduct a triple check that includes safeguards such as:

Inspecting the validation report
Looking for signatures, dates, and appropriate narratives on the physician certifications
Checking for signatures and dates by the therapist and physician on the therapy plans of treatment
Checking for consistent diagnosis codes between the MDS and UB-04
Verifying that notifications were properly issued for residents who came off of Medicare

Documentation and audit risk

In a March notice regarding the Medicare Fee-for-Service Recovery Audit Program, CMS increased the number of medical records that Recovery Auditors can request from providers.

The annual limit, based on claims volume only, is now 2% of claims submitted in the prior calendar year, divided by eight (previously 1% of claims). Recovery Auditors are now allowed to request a maximum of 400 medical records in a 45-day period (up from 300).

SNFs must also provide documentation for Medicare beneficiaries' entire episodes of care-from admission to discharge-during a Recovery Auditor records request, according to the CMS notice.

Recovery Auditors may also receive permission to exceed the records request limit "by CMS's own initiative or from the Recovery Auditor requesting permission," according to the notice.

This recent update drives home the continual need not only for thorough documentation, but for documentation that correlates with the MDS and billed services, Connor says.

Skilled charting is critical

Skilled charting is a key component of proper documentation, according to Connor. A skilled note should include why you are skilling the resident (i.e., the diagnosis), followed by supporting data.

For example, if you are skilling a patient for pneumonia, the facility would want to have pneumonia listed as a possible primary diagnosis. The documentation may also include the following:

Any signs of wheezing and/or crackling.
The results shown in chest x-rays.
Saturation levels both on oxygen and without oxygen (i.e., on room air) after 15 minutes.
Any nebulizer treatments.
Other comorbidities. These comorbidities should be stated at a minimum of once per shift.

"Simply put, the nursing department should write a note that states clearly the issue, and if a note is done well, anyone who reads the note could clearly identify who the resident is just based on the skilled note," Connor explains.

Some key points to consider include:

Oxygen is a key in the MDS as it may get you in a special care skilled criteria.
For mood and cognitive behavior, certain verbiage can maintain a level. Documenting that a patient is "at baseline" is not sufficient if you want to maintain certain sections on the MDS. Behavior that is repeated, and the verbiage used can successfully alter the outcome of the MDS section, which affects reimbursement.

"Facilities don't want any red flags in their documentation," Connor says. "Make sure that all documentation tells the complete story of a patient and their provided services."

With a basic understanding of the MDS structure and a drive toward thorough and accurate documentation, facilities will expand their opportunities for reimbursement while simultaneously limiting their risk of an audit.

BALTC Q&A

Sun, 01 Jul 2012 04:00:00 GMT

BALTC Q&A

Editor's note: This month's "Q&A" was modified from the HCPro book Medicare Part B Billing Manual for Long-Term Care, written by Frosini Rubertino, RN, CPRA, CDONA/LTC. For more information or to order, call customer service at 800-650-6787 or visit www.hcmarketplace.com/prod-7856. To submit a question for upcoming issues, e-mail Associate Editor Melissa D'Amico at mdamico@hcpro.com.

QHow do the billing rules for Medicare Part B differ from Part A? What regulations should we be aware of?

AIn many ways, Part B billing rules are quite different from Part A rules. However, your SNF must obtain the same authorization to bill as it does for Part A. SNFs must also ensure that beneficiaries receive advance beneficiary notices for services they don't believe Medicare will view as reasonable and necessary.

In addition, nursing facilities billing Part B must be aware of the following requirements:

Bill types. Under Part B, there are two types of bills (TOB) that are reflected on the UB-04 Medicare claim form: 22X (inpatient) and 23X (outpatient). CMS has confirmed that the SNF should use TOB 22X for any inpatient, whether the person is in a Medicare-certified bed or a noncertified bed. Use TOB 23X only for patients who live in the community and receive outpatient services from your SNF. Code the TOB (22X or 23X) in form locator 4 of the UB-04.
Fee schedules. A fee schedule, also called a fee screen, is a complete list of fees used by Medicare to pay doctors, providers, and suppliers. This comprehensive list of fee maximums is used to reimburse a nursing home or other providers on a fee-for-service basis. CMS develops fee schedules for physicians, ambulance services, clinical laboratory services, and durable medical equipment, prosthetics, orthotics, and supplies. The following are the fee schedules that you will use when billing for Part B ancillaries:
- Medicare Physician Fee Schedule. This schedule includes the current fees for therapy services provided to SNF residents, along with flu and pneumonia vaccine fees. CMS updates this fee schedule annually.
- Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule. This schedule includes fees for surgical supplies, wound dressings, prosthetics, orthotics, colostomy, ostomy, and urological supplies. CMS updates this schedule quarterly.
- Clinical Laboratory Fee Schedule. CMS releases the rates for blood glucose testing under this schedule.
- Ambulatory Fee Schedule. CMS releases the rates for radiological services under this schedule.
Line-item billing. When Part B items/services are paid on a fee screen, your SNF has to do line-item billing, which means you bill by HCPCS code and date. If more than one unit of a HCPCS code is received on the same day, they can be grouped on one line. However, all other situations must be billed separately by line item. The line-item billing requirements can make Part B billing a tedious process. Under Part A, the SNF does not use line-item billing. It can lump similar services together without segregating them by HCPCS code, by date, or under one revenue code. For example, all physical therapy services can be added together on one line for the Part A claim, with total units and total charges lumped on one line. However, for a Part B claim, the units have to be separated by HCPCS code and date. The exception to this rule on a Part A claim is revenue code 0022 (RUG category). RUGs cannot be lumped, as they differ based on assessment type. For example, a resident may be in the category RHC for the entire month, but the assessment modifier will differ with each assessment.

You should become familiar with the following:

Deductibles and coinsurance. Part B-covered residents must pay a small deductible, which is adjusted upward each year. Medicare pays 80% of the fee schedule or the SNF's charge if a fee screen has not yet been developed. The resident or his or her supplemental insurer is responsible for a 20% coinsurance payment, except for blood glucose monitoring and vaccines. Don't forget to bill the coinsurance to Medicaid if the patient has both Medicare and Medicaid coverage.
HCPCS/CPT codes. SNFs must use HCPCS codes and the AMA's CPT codes to bill Medicare Part B services and items to the fiscal intermediary/MAC. For Part B billing, CPT codes can be viewed as a subset of HCPCS codes.

CMS will provide either a HCPCS or a CPT code for each service/item billable to Medicare Part B. These codes are updated annually.

SNFs must make sure to stay on top of the annual updates, as well as CMS program memorandums listing changes to HCPCS codes for consolidated billing purposes. For rehab, the therapist should use CPT coding definitions. For other services and supplies, double-check the accuracy of codes for services and items provided by the vendor.

QWhat are some of the key ancillary services and supplies that SNFs can bill to Medicare Part B?

AAncillary services and supplies that can be billed to Medicare Part B include:

Therapies. Physical therapy, occupational therapy, speech-language pathology, and audiology services.
Durable medical equipment, prosthetics, orthotics, and supplies. Prosthetic devices (other than dental devices) that replace all or part of internal body organs or all or part of the function of a permanently inoperative or malfunctioning internal body organ.
Medical and surgical supplies. Surgical dressings, splints, casts, and other devices used for the reduction of fractures and dislocations, in addition to ostomy, colostomy, urological, tracheostomy, and miscellaneous supplies and services.
Laboratory services and tests.
Parenteral and enteral nutrition. Services and supplies delivered to residents who receive food intravenously or through a feeding tube.
Radiology services. Diagnostic x-ray, laboratory, and other diagnostic tests; and x-ray, radium, and radioactive isotope therapy.
Screening and preventive services.

Billing Alert for Long-Term Care, July 2012

Sun, 01 Jul 2012 04:00:00 GMT

Are you ready for a Medicaid RAC audit?

And while Medicare Recovery Auditors came first, the Medicaid version will exhibit much more variation, as each state is responsible for detailing the specifics of its program.

"You're going to have 50 flavors of vanilla when they're set up," says Diane Brown, BA, CPRA, regulatory specialist at HCPro, Inc., in Danvers, Mass.

The story so far

In February 2011, CMS pushed the implementation date out even farther as it worked through final rules, which came out last September. The effective start date was January 1, 2012.

Believe it or not, the RACs are coming

That bubble may be about to burst, adds Potter.

What can you do to prepare?

Go to the auditors for information. "Go to the auditor's website-they'll tell you what issues they're looking at, and where," Brown advises. "There's plenty of information out there."
Be proactive with policies. Facilities should take a proactive approach and begin reviewing their policies and procedures, documentation, and processes now, says Potter. "When the audit request letter arrives, it is too late." But in the case of a RAC automated review, she notes, a provider won't even know the review is happening until the demand letter arrives.
Documentation review is essential. Both clinical and financial documentation should be reviewed, preferably by someone who didn't prepare it. Clinical documentation should accurately reflect the resident's condition, treatment, needs, and services provided. "The picture that the documentation paints should be consistent from discipline to discipline, or inconsistencies should be explained," says Potter.

Michael H. Cook, partner at Liles Parker, PLLC, in Washington, D.C., says there's a lot that SNFs can do now to prepare for Medicaid RACs, and some of it boils down to business basics:

Identify a point of contact. "They need to make sure that when there is a record request or a determination made, there is one point of contact that has responsibility in the facility to make sure that those records are delivered on a timely basis and that they are complete," says Cook. "And they need to make sure that the state or RAC is aware of whom that point of contact is."
Establish a RAC response team. SNFs need to have a team in place to properly process the RAC requests. And while it can be expensive, Cook says, the team should be conducting a shadow audit of at least a portion of the claims the RAC is reviewing. This gives you a sense of what to expect, he explains. And, Cook adds, if there is a more endemic issue that arises, the SNF can initiate corrective actions. "In other words, you ought to be integrating your RAC response team with your quality assurance team and your compliance function," says Cook.
Build the right relationships. SNFs should also ensure that someone in the facility has a relationship with someone at the RAC, Cook advises. Generally speaking, facilities want to make sure there's an open line of communication to the auditor to straighten out any problems before they escalate-for example, if there's an odd request for records coming in, or if some other issue arises. "That doesn't mean you complain when the RAC is doing its job properly. It does mean if things start blowing up, you've got a contact that can do something," says Cook. "Informal relationships are always helpful, whether it's with a state or with a RAC, before issues get blown out of proportion."

Is VBP finally on its way for SNFs?

In 2009, Wisconsin, New York, and Arizona participated in a value-based purchasing (VBP) demonstration for SNFs, a prototype program that was to lead the way in a national rollout.

The industry was excited about VBP when discussions first started in 2008, Malzahn adds, and was ready for the next steps-which haven't come yet.

"We did a lot of hurry up and wait when this first came out," she says.

Where is the movement headed?

Unlike ACOs, VBP impacts everyone

A VBP world

Patient outcomes
Reduced costs
Reduced rehospitalizations
Staffing
Overall efficiency

As SNFs track these metrics and cut costs, the plan is to use the savings to pay for performance, Malzahn says.

According to Fallon, if CMS is looking to reward SNFs that provide high-quality care efficiently, there are two main approaches the agency can take when distributing these rewards:

Rewards for top performers. This reward system says that the top 10%-25%-based on performance metrics-get rewarded. Anyone below a certain threshold would get no bonus, and maybe even a percentage withholding, says Fallon.
Rewards for performance year over year. Another possibility is to look at organizations with the greatest improvement in year-over-year performance, Fallon suggests, which would incent the lower performers to step up their game and not just ding them for being at the bottom of the list. "If they're low performers, the last thing you want to do is take more money away from them," she says.

Why organizations are looking at certain conditions
What conditions facilities are treating
What regimens are established for the first 72 hours, 10 days, month, etc.

"It still doesn't give us the how. It gives us the what-we're going to measure X, Y and Z-but not how, and how it will impact reimbursement," says Malzahn.

Will you be ready when VBP hits?

That said, Malzahn and Fallon agree there are areas SNFs can begin to work on now to make things easier when VBP does arrive. These areas may include:

Pneumococcal immunizations. An easy metric to achieve is the number of residents given pneumococcal or flu immunizations, Fallon suggests. "If you're not at 100% on that, get to 100%," she urges. "It's been identified as a best practice. On that metric, you should be hitting 100%."
Improvement areas. Start looking at your nursing home comparisons, examine your statistics and your competitors' statistics, and identify the areas where you're not a high performer. Then start working on those areas, Fallon says. "It's just good business sense, with or without a value-based payment attached to it."
Hospital readmissions. One of the key areas to focus on-and most SNFs already are-is reducing hospital readmissions, says Malzahn. "If there are providers who don't think they're doing anything related to VBP in preparing, this is probably the one thing they're doing," she says.
Care paths. Organizations should look at the care paths within the SNF based on diagnosis. Most providers are examining care paths for pneumonia, chronic obstructive pulmonary disease, congestive heart failure, and joint replacement, Malzahn says, and are trying to manage more of that internally-rather than rehospitalize the resident.
Root cause analysis. "If we really want to lower costs, the goal is to keep people out of the hospital if they don't have to be there," adds Fallon. "Figure out what part you do control, do a root cause analysis. Get to the bottom of what's causing those readmissions. It's a good conversation starter with hospitals and physician groups."

Understand MDS basics to increase reimbursement and limit audit risk

Promoting the proper MDS education begins by identifying and defining the role each team within the facility plays when it comes to reimbursement.

The clinical team and reimbursement

While there are some consistent trends in length of stay or plan of care for residents who are being treated for the same conditions, making sure the documentation is resident-specific is crucial.

A more effective approach

It is commonly thought that more intensive therapy or higher therapy hours yields greater reimbursement; this is not always true, Connor says.

The rehab team and reimbursement

The reimbursement team

To increase reimbursement opportunities and limit the risk of claims processing mistakes, billers should have a firm grasp of the following MDS components:

Modifiers and assessment periods. Many billers do not know or understand the changes with the new assessment structures, and simply accept the information that populates their software at face value. "You can't just assume that the computer is correct," Connor says. An important component of verifying what the computer generates is going back to the validation report received once the MDS is successfully submitted-this is what should be checked and balance with the UB-04.
New changes in assessment. The change of therapy, end of therapy, and end of therapy resumption now play a significant role with the assessment schedule. "The assessments are no longer standard," Connor says. "Previously, we created assessments where the pay table had a schedule where they would pay 14, 16, 30, and/or 100 days-unless there was a change-in which there was a specific modifier that everyone was aware there was a change and therefore a break in pay cycle." Now with the new MDS structure, facilities have numerous modifiers and several assessments. While many people simply let the computer determine the days and the payment cycle, this information is something that should be monitored closely. Have regular discussions at the facility's Medicare and/or triple-check meetings to determine pay date, assessment cycles, and correct modifiers. This will ensure that the reimbursement team has accurate data prior to submitting the claim to CMS. "Education to billing staff is critical with the new changes that went into effect April 1, 2012-the old way of counting assessment days has been shaken up significantly," says Malzahn.

The importance of working together

Communication across the different teams is critical in using the MDS correctly and successfully. On a regular basis, all three teams should discuss:

The assessments. Reviewing the assessments is important because they will aid in developing the care plan for residents. Determine the skilled criteria of the resident and verify all aspects of care..
The treatment plan and the goals to keep a patient on Medicare-and a team approach to possibly increase the resident's length of stay. Review the barriers to care and goals for the resident. Monitor progression and regression to verify that skilled services are warranted and aid in the development of the resident.
Cohesive documentation between clinical and therapy. "All too often, the story told about a resident via documentation from clinical and that same documentation picture of the same resident from therapy can differ greatly," Malzahn says. Educate nurses on how to document and what observations are crucial for a resident being covered under therapy.
If a patient is on certain services (e.g., oxygen, lab, x-rays), the specific treatment. This discussion should include:
- The related outcomes or results.
- Additional follow-up to be completed. This information is essential to properly understand what the facility should continue to do to care for the patient.
- Required documentation to be completed. Data is essential to support the skilled need, the resident's stay in the SNF, and the reimbursement to follow. This discussion is important in order for the business office to understand what ancillaries should appear on the claim, as this will support the UB-04 claim submitted. The RUG and the ancillaries support the need for skilled care and tell the story of the resident and why he or she should be in the SNF.

This information should then be verified during a triple-check meeting to ensure that the data submitted corresponds to the services provided by the clinical and rehab teams.

Prior to billing, facilities should conduct a triple check that includes safeguards such as:

Inspecting the validation report
Looking for signatures, dates, and appropriate narratives on the physician certifications
Checking for signatures and dates by the therapist and physician on the therapy plans of treatment
Checking for consistent diagnosis codes between the MDS and UB-04
Verifying that notifications were properly issued for residents who came off of Medicare

Documentation and audit risk

In a March notice regarding the Medicare Fee-for-Service Recovery Audit Program, CMS increased the number of medical records that Recovery Auditors can request from providers.

SNFs must also provide documentation for Medicare beneficiaries' entire episodes of care-from admission to discharge-during a Recovery Auditor records request, according to the CMS notice.

Recovery Auditors may also receive permission to exceed the records request limit "by CMS's own initiative or from the Recovery Auditor requesting permission," according to the notice.

This recent update drives home the continual need not only for thorough documentation, but for documentation that correlates with the MDS and billed services, Connor says.

Skilled charting is critical

Skilled charting is a key component of proper documentation, according to Connor. A skilled note should include why you are skilling the resident (i.e., the diagnosis), followed by supporting data.

For example, if you are skilling a patient for pneumonia, the facility would want to have pneumonia listed as a possible primary diagnosis. The documentation may also include the following:

Any signs of wheezing and/or crackling.
The results shown in chest x-rays.
Saturation levels both on oxygen and without oxygen (i.e., on room air) after 15 minutes.
Any nebulizer treatments.
Other comorbidities. These comorbidities should be stated at a minimum of once per shift.

"Simply put, the nursing department should write a note that states clearly the issue, and

Solve your biggest �consolidated billing issues

Fri, 01 Jun 2012 04:00:00 GMT

Solve your biggest consolidated billing issues

Consolidated billing isn't new, but that doesn't mean facilities aren't befuddled about which services are included or excluded. "Confusion over consolidated billing could result in missed reimbursement opportunities and rejected claims," says Maureen McCarthy, RN, BS, vice president of clinical reimbursement at National Healthcare Associates and president of Celtic Consulting in Goshen, Conn.

The following is a list of common consolidated billing questions facilities face and what your SNF can do to resolve these issues today.

1. I can't find the Medicare fee schedule for a given charge from the hospital. What do I do? How much do I owe the hospital?

When a facility receives a bill for consolidated billing from a hospital, it usually does not specifically list the fee-for-service reimbursement amount. Instead, it will list the complete amount, including the hospital's allowable markup for the services provided.

"Many facilities have a difficult time realizing how much they should be paying the hospital," says McCarthy.

Facilities often have trouble finding the codes to bill for the correct service. For example, a hospital bills a facility for hyperbaric chamber services. The bill amount is listed as $7,000. The questions the facility must consider are:

What exactly are we being billed for?
How much would Medicare pay for these services?

When faced with questions like these, the first step facilities should take is to determine where to look up the billing codes. Many facilities may access CMS' physician fee schedule lookup. This tool, which can be found at www.cms.gov/apps/physician-fee-schedule/overview.aspx, will help you understand many of the charges billed by the hospital.

It is important to note that there are numerous sources of Medicare allowable payments outside the physician fee schedule, says Bill Ulrich, president of Consolidated Billing Services, Inc., in Spokane, Wash. These include:

Ambulance services
Durable medical equipment, prosthetics, orthotics, and supplies
Parenteral and enteral nutrition
Drug services
Clinical laboratory services
Ambulatory payment classification
Splints, casts, etc.

For these services, there is no single or correct payment option, and there are a number of places facilities may need to look outside of the physician fee schedule.

In answering the question "How much do I pay?" many facilities are missing a critical first step: Put "under arrangement" transactions in place with outside providers of services, including hospitals, says Ulrich.

"CMS says that the entity shall look to the SNF for payment and they have told the SNF it must pay, but never has CMS said at what level," he explains. "It's the 'arrangement' that sets price, and absent that, state law controls cases where there is a payment dispute. Although we all encourage it, one cannot assume you pay the fee schedule or the fee schedule less copay."

2. Do I pay the technical component or the professional component of a provided service? What is the difference between these two components?

This question relates to any of the consolidated billing portion or Medicare Part B services. Under consolidated billing, the SNF is only responsible for paying the technical component of a bill-not the professional component, which is billed by the vendor straight to Medicare.

When billing Medicare, the vendor will receive payments under its own provider number because it is providing the professional service separately. That service is not taking place in the SNF. The SNF has an arrangement with the vendor to supply the service to the resident, so you are only responsible for the technical component.

"The most important thing you can do to avoid confusion in this area of consolidated billing is to provide education on what these two components are and how they involve the SNF," McCarthy says.

Along with a poor understanding of these components, a related issue facilities face is being asked to pay "facility fees," according to Ulrich. "While CMS says professional fees are not bundled, the hospital and ambulatory surgical center [ASC] bill for the facility portion of the professional services using the professional service code," Ulrich says. "It is important to understand that when the SNF is billed for one of these codes by the hospital or ASC, they are not seeking reimbursement for the professional component but rather for the facility overhead associated with the services."

3. Are all forms of chemotherapy excluded under consolidated billing? What happens if the resident changes the chemotherapy he or she receives after admission to the SNF?

While the physician fee schedule lookup for consolidated billing provides information on chemotherapy drugs, the variety of drug treatments can cause confusion for billers when using consolidated billing.

"If a patient is on one type of chemotherapy when they are admitted to a SNF, it does not mean that they will stay on the same chemotherapy treatment throughout their stay," says McCarthy. "Their treatments may change, and this is very important to understand."

Certain types of chemotherapy may be excluded under consolidated billing; however, other types are included and reimbursable. This often leaves billers asking, "Do I have to pay for it or not?"

"Many facilities may shy away from taking chemo patients because they were under the assumption that chemo was not paid for," McCarthy says. "This is incorrect-some of it is paid for, and facilities need to be aware of the differences."

When working with a chemotherapy patient, either the billers or the admissions staff-depending on who has the responsibility-should begin by contacting the provider that is administering the chemotherapy, whether a hospital, chemotherapy center, cancer center, or physician's office, to find out exactly which type of chemotherapy medication the patient is receiving.

"The provider was likely billing someone prior to that patient coming into the SNF, so if you can get the code that they are billing under, you can use that information to look up the type of chemotherapy provided," says McCarthy.

Speak to the patient's physician prior to admission to determine:

The likelihood that the doctor will switch the type of chemotherapy the patient is receiving
How long the patient will remain on his or her current chemotherapy medication and/or others

The goal of these questions is to help your facility understand what your cost will be for the length of the patient's stay.

4. How far back can the hospital or physician provider go to send my facility a bill for any given service under consolidated billing? Is there an expiration date for submitting a bill?

There is not actually a window or a closing date for bill submission, says McCarthy. "We only have 120 days to adjust a Medicare claim, but we are receiving bills for people who have had stays back in 2010."

In the past, SNFs did not receive a lot of bills because hospitals were being paid by a Medicare carrier and their business facilities were being paid by a fiscal intermediary. The records between the two did not overlap, so both facilities were billing and all of the claims, regardless of duplication, were being accepted.

Since billing has become more transparent through reform efforts, SNFs are seeing more bills from hospitals.

"When a hospital initially submits a bill, they may not be aware that the patient is or was a Medicare beneficiary," McCarthy says. "Then when their claim is denied, it's not until they get back around to dealing with it that the SNF will see the bill. It generally shouldn't take that long, but sometimes there are cases when it does."

Consider the following example: A person is in a no-fault auto accident. The no-fault insurance company says it is going to pay for the necessary medical services. The capitated amount the insurance company is providing runs out prior to all of the services being delivered and the resident is switched over to Medicare Part A. The facility does not find out about the transition to Part A until after the initial bill has been sent.

It is particularly important to be aware of this when you are dealing with a situation where the payer source changes, says McCarthy. "Whether the resident is using auto insurance, workers' compensation insurance, or another form of insurance, if they then ran out of money and switched to Medicare while in a stay at the facility, you don't find that out until later," she explains.

5. Do I still have to pay a bill if the patient has expired or has already been discharged?

Yes, facilities must still pay for the billed services if the patient received the services while covered under Medicare Part A. "Even if the resident owes your facility money, the facility still has to pay these bills," McCarthy says.

6. Is the ambulance ride covered?

Ambulance services are not categorically excluded from consolidated billing, according to CMS. However, certain types of ambulance transportation are separately billable in specific situations. According to CMS, these situations include:

An ambulance trip that transports a beneficiary from the SNF at the end of a stay when it occurs in connection with one of the following events is not subject to consolidated billing:
A trip for an inpatient admission to a Medicare-participating hospital or critical access hospital (CAH)
A trip to the beneficiary's home to receive services from a Medicare-participating home health agency under a plan of care
A trip to a Medicare-participating hospital or CAH for the specific purpose of receiving emergency services or certain other intensive outpatient services that are not included in the SNF's comprehensive care plan
A formal discharge (or other departure) from the SNF that is not followed by readmission to that or another SNF by midnight of that same day
An ambulance trip from the SNF to the hospital for the receipt of excluded types of outpatient hospital services. Since a beneficiary's departure from the SNF to receive excluded outpatient hospital services is considered to end the beneficiary's status as a SNF resident for consolidated billing purposes, any associated ambulance trips are excluded as well. Moreover, once the beneficiary's SNF resident status has ended in this situation, it does not resume until the point at which the beneficiary actually arrives back at the SNF; accordingly, the return ambulance trip from the hospital to the SNF would also be excluded from consolidated billing.
When a beneficiary leaves the SNF to receive off-site services other than the excluded types of outpatient hospital services described previously and then returns to the SNF, he or she retains the status of a SNF resident with respect to the services furnished during the absence from the SNF. Accordingly, ambulance services provided in connection with these services would remain subject to consolidated billing, even if the purpose of the trip is to receive a particular type of service (such as a physician service) that is excluded from consolidated billing.
A beneficiary's departure from a SNF is not considered to be a "final" departure under consolidated billing if he or she is readmitted to that or another SNF by midnight of the same day. Thus, when a beneficiary travels directly from the first SNF and is admitted to the second SNF by midnight of the same day, that day is a covered Part A day for the beneficiary, to which consolidated billing applies. Accordingly, the associated ambulance trip would be bundled back to the first SNF since the beneficiary would continue to be considered a resident of that facility until the actual point of admission to the second SNF. However, when an individual leaves a SNF via ambulance and does not return to that or another SNF by midnight, the day is not a covered Part A day and consolidated billing would not apply.
If a SNF's Part A resident requires transportation to a physician's office and meets the general medical necessity requirement for transport by ambulance (i.e., using any other means of transport would be medically contraindicated), then the ambulance round trip is the responsibility of the SNF and is included in the PPS rate.
Medicare does not provide any coverage at all under Part A or Part B for any non-ambulance forms of transportation, such as ambulette, wheelchair van, or litter van. In order for the Part A SNF benefit to cover transportation via ambulance, the ambulance transportation must be medically necessary. This means that in a situation where it is medically feasible to transport a SNF resident by means other than an ambulance, ambulance service will not be covered.

As with other situations of noncoverage, where the resident may be financially liable, the SNF must provide appropriate notification to the resident of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.

7. Do I have to adjust my paid claims to show the charges for a late bill from a bundled service?

As mentioned previously, SNFs only have 120 days to adjust a claim, but it would be in the provider's best interest to ensure that all of the services paid for by the SNF for a particular resident under consolidated billing are stated, according to McCarthy. This is important because claim adjustments will accurately document the amount-in services and dollars-that your facility is spending on Medicare patients.

This information should be included in your cost report under the different revenue codes.

"A common problem we see here is related to ambulance services," McCarthy says. "The problem is that the ambulance providers don't send their billed claims until the SNF's bills have already gone out."

As a result, many facilities aren't ajusting their claims accordingly because the addional bill arrives significantly later-often after a claim is already paid.

Just remember that all of the charges that a resident incurs under Medicare Part A and B should be reflected on the claim.

8. Should I post all ancillary services my resident receives on my monthly claims?

Yes, all of the ancillary services should be included on monthly claims.

While ancillary service providers typically send the information to facilities much later, billers still need to show CMS all of the services that the facility is spending on Medicare covered patients. This is necessary to ensure that each patient is actually receiving the services he or she requires.

Is a common pay system across postacute care settings possible?

Fri, 01 Jun 2012 04:00:00 GMT

Is a common pay system across postacute care settings possible?

A common pay system across all settings of postacute care, including SNFs, home health agencies (HHA), long-term care hospitals (LTCH), and inpatient rehabilitation facilities (IRF), may be possible according to CMS' report to Congress on its Post Acute Care (PAC) Payment Reform Demonstration.

The goals of this demonstration, involving 140 general acute and postacute care providers, are broken down into two areas of focus:

1. The ability to compare patients across settings. Because similar patients can be treated in more than one provider setting, having a common evaluation and payment model and being able to "consistently measure patient acuity, resource use, and outcomes across settings will help to guide appropriate policies for these patient populations," says the CMS report.

Currently, there are three mandated assessments for SNFs, IRFs, and HHAs-the MDS, the Inpatient Rehabilitation Facility Patient Assessment Instrument, and the Outcome and Assessment Information Set, respectively. While these assessments measure similar concepts, they use different clinical terms and assessment time frames, as well as disparate measurement scales, to assess health, physical function, and cognitive status, according to the report.

2. Inconsistencies in case-mix systems and unintended consequences. "The current Medicare payment methods for PAC providers are designed largely as independent systems that measure within-setting variation, but they do not recognize the potential overlap in case mix or complementary service options available in other settings," says CMS. "More importantly, the variability in case-mix measurement and payment methodologies, including both units and adjustment approaches, makes it difficult to compare patient or facility cost differences in a standard way across settings and to create consistent incentives across payment systems."

"CMS has realized that they are paying differently for the same services depending on the setting they are performed in," says Terry Cichon, senior manager and director of healthcare operations at FR&R Healthcare Consulting, Inc., in Deerfield, Ill. "But streamlining the payment systems is just part of it. I think it goes deeper than that-to improve overall quality of care."

The CARE tool

In trying to reform the current system, CMS developed a uniform assessment instrument called the Continuity Assessment Record and Evaluation (CARE) tool. The data set for CARE includes:

Administrative items: Patient demographic information and basic insurance information
Pre-morbidity patient information: Baseline data on patient's preadmission status and status before the current spell of illness
Current medical information: Factors explaining medical or level of care needs
Interview items-cognitive status, mood, and pain: Patient-centered interview items that reflect the voice of the patient
Impairments: Screening and supplemental items identifying impairments, which may impact a patient's functional abilities or otherwise affect a patient's care needs
Functional status: The person's ability to perform specified motor tasks, ADLs, and instrumental ADLs
Discharge information: Patient discharge destination, discharge support needs, and other nonmedical, social support factors that might affect placement decisions and possibly improve care transitions

Benefits of a common tool

Implementing this assessment within CMS' demonstration was successful, according to the agency, as all five settings were able to use CARE items "to collect information in a consistent and comprehensive manner for their Medicare populations."

Identifying a tool that can be used across these settings is just the beginning of the benefits of widely using this tool. Some of the other notable benefits of the tool include:

Identifying transition issues quickly. The results of this demonstration indicate that the inter-rater reliability results showed very good agreement on most items. These results suggest that most of the standardized versions of the assessment items have strong reliability within and across settings, according to the report.

Accordingly, this tool could play a key role in identifying care transition issues and showing the breakdown in patient care over the short term, according to Cichon. "When a patient is discharged from the acute care setting to a SNF, the SNF's admission assessment should accurately match the acute care discharge assessment as long as the SNF admission occurs immediately. In turn, the same should be true if the resident is transitioned from a SNF to homecare and the homecare admission occurs on a timely basis," she says.

The inter-rater reliability helps create more accountability across the continuum of care, according to Cichon. "The admitting facility better be starting off where the last facility has left off or be able to explain why they aren't," she says.

Improved documentation and reimbursement. Unlike the current assessment tools, the CARE tool helps to:
- Accurately capture the acuity level of a patient
- Create a focus on the functional status and functional limitations of a patient

As a result, facilities will not only have improved documentation to support the need for services and reimbursement, but may identify reimbursement opportunities they weren't aware of in the past.

Identifying fraud. Having more uniformed systems for assessments, documentation, and payments will be another step to limit and reduce the occurrence of healthcare fraud.
Impact on accountable care organizations (ACO). As ACOs continue to gain popularity, the CARE tool could become a tool to help facilities establish themselves as desirable ACO partners. With improved documentation, facilities have quantitative and qualitative information to demonstrate their value in providing quality care and improving the overall health of patients' during their stays.

"Facilities will have to show why their setting is appropriate, why their services couldn't be provided in other situations, and how this leads to cost savings overall," says Cichon.

Greater efficiency. The ease of use of the CARE tool makes it much more efficient, according to Cichon. "CMS reports that this tool only takes 30 minutes to an hour to fill out," she says.

Be aware of the acute care role

While this demonstration focuses entirely on therole of PAC facilities, it is essential to recognize thekey role that acute care hospitals play in the continuum of care.

"What's interesting about this demonstration project is that it states IRFs, SNFs, and HHAs are mandated to submit assessment data on the beneficiary's medical, functional, and cognitive status, but acute care hospitals are not," says Frosini Rubertino, RN, CPRA, CDONA/LTC, executive director of Training in Motion, LLC, in Bella Vista, Ariz. "CMS relies on the hospital's claims to indicate what the patient was treated for during their hospital stay."

Often residents are admitted to a SNF with multiple comorbidities and conditions that can complicate and hinder the rehabilitation process, but these conditions are not always noted in the admission paperwork, says Rubertino.

Consider this example: A Stage III pressure ulcer that was acquired in the hospital during an acute stay for pneumonia may not be known by CMS, as it wouldn't appear on the claim form. Since there is no assessment submitted by the hospital to CMS, cognitive deficits or physical deficits will not be recorded either.

"Hospitals are paid by DRGs, or diagnosis, not by the specific clinical qualifiers-the way SNFs are paid," Rubertino says. "It's obvious that the continuum of care is broken at that level-from hospital to SNF-since the hospital's assessment is not shared with the SNF."

As a result, once the patient arrives at a SNF, the scope of care is even wider, as the facility is dealing with the comorbidities and multiple risk factors. "This means the burden of proof, so to speak, for proving the skilled care is needed is bigger for SNFs than the hospitals," Rubertino explains.

Requiring hospitals to submit an assessment to CMS can benefit the SNF by enabling it to better prepare to meet the patient's needs, Rubertino says. "Until this changes, it is crucial that the SNF admission team obtain as much of the patient's history as possible-including the hospital care plan-to ensure a smooth transition from one provider to the other, and performing a thorough assessment at the time of the SNF admission. Not doing so may not only impact your facility's ability to properly care for residents, but have negative implications on documentation, supporting skilled services, and the resulting reimbursement."

Payment reform

CMS' report to Congress includes its demonstration results across the different PAC settings and lists recommendations for going forward with the payment system reform.

Evidence supports the potential for development of a common payment system for the three inpatient PAC settings: LTCHs, IRFs, and SNFs. This system would calculate the patient-specific resource expenditures portion of payment using the same acuity measures with the same weights and base rates.

Although there are similarities among the postacute settings, making a common pay system plausible, the demonstration results indicate that a payment model combining home health with the other types of PAC providers is not supported.

Where the CARE tool will lead

In its report to Congress, CMS states that it believes the CARE tool should have a "life beyond the demonstration"; however, next steps have not been formalized.

"Overall, the demonstration has shown that the CARE tool and a common payment system could be helpful, but first the tool needs to be in general use for a while," Cichon says.

One of the goals of healthcare reform is to provide the right care at the right time in the right setting to all patients. Having a common assessment tool can go a long way to making this a reality. n

Are you prepared for an audit?

Fri, 01 Jun 2012 04:00:00 GMT

Are you prepared for an audit?

Editor's note: The following is an excerpt from the HCPro book Medicare Audits in Long-Term Care: A Guide to MACs, RACs, and ZPICs, written by Wayne van Halem, AHFI, CFE. For more information about this book or to order a copy, call customer service at 800-650-6787 or visit www.hcmarketplace.com/prod-8471.

There has never been a time when the government has been more intent on reducing improper payments in the Medicare and Medicaid programs than now. That, coupled with current healthcare reform initiatives, has made auditing of healthcare providers that bill the federal government a primary focus. Current legislators have certainly realized the extent of improper payments in recent years, as evidenced by the increased scrutiny of CMS and what it determines to be a lack of oversight and inability to gain control of the growing problem.

The government's primary tool in detecting improper payments is analysis of claims data to detect aberrancies, followed by audits of the activities causing the abnormal behavior. Essentially, this means there will be more auditors conducting more audits. We are already seeing the effects of this with the expanded Recovery Audit Program and transition to Zone Program Integrity Contractors with expansion of the Medi-Medi program, which cross-analyzes Medicare and Medicaid data.

Ultimately, the likelihood of being audited is increasing.

Rather than focusing on avoiding an audit, providers should focus on preparing themselves for one when it does happen. To do so, facilities should implement elements that are consistent with a comprehensive and effective compliance program. These elements include written policies and procedures, standards of conduct, and effective training and education.

Written policies and procedures

The first step in preparing for an audit is developing internal policies and procedures that are specifically related to compliance issues. Most facilities probably already have numerous policies and procedures developed for normal day-to-day operations. There is no need to implement a new set of policies. Rather, review the policies in place to be sure vulnerabilities are addressed and to verify that they are current on compliance issues. If not, you can draft new policies and procedures and implement them into your current information.

If your facility already has well-developed policies pertaining to compliance, it is a good idea to review and update them accordingly. These policies and procedures should be shared with all employees and subcontractors or agents who may have involvement in clinical care or claim filings. One of the most important aspects of these policies should be implementing specific and appropriate standards of conduct.

Standards of conduct

All facilities, no matter how large or small, should draft specific and tailored standards of conduct for all employees of the facility. It must be clear to everyone who reads these standards that there is a strong commitment to compliance. This must be evident from the top down. If senior management at a facility does not stress the importance of compliance enough to its staff, the staff will not grasp the importance. On the contrary, if management is adamant about the significance of these policies, employees will adopt these same principles. Ultimately, this protects the individual employees, management, and the facility, as well as the government and Medicare trust fund.

These standards should clearly define the facility's mission, goals, and ethical principles. The message should portray integrity and foster trust between management and employees. Residents and their families will also notice the implementation of these values and principles. The standards should include broad principles that advise employees about how to act ethically and professionally when providing healthcare services and billing them to the federal government. Further, these standards should be provided to all employees, and the facility management should request that all employees sign a statement that they have read and understand the standards and agree to adhere to them. This makes staff members accountable if issues arise in the future.

Training and education

The next step in audit-proofing your facility is implementing a comprehensive and effective training program. Written policies and procedures are a necessity, but they are rendered ineffective and inadequate if you don't have a training program in place that educates your staff members. A training program should be developed that covers every staff member, from clerical and administrative personnel to billing and clinical staff members. All too often, training programs are designed solely for clinical staff. Several components of a successful training program are as follows:

Compliance program. One way in which a facility can take a more active role is by having a comprehensive compliance program. Therefore, your training program should include a significant amount of education about the compliance program itself. Staff members should be trained on what is considered a violation, how to report it, what to expect, what their protections are, and, of course, any penalties that may arise from compliance violations. Unlike other, more specific elements of a training program, this part should be administered to every employee of the facility and should be done immediately for all new employees.
General fraud and abuse training. When employees are hired, depending on their experience and background, they may not be aware of the fraud and abuse statutes and regulations. There are federal statutes, such as the False Claims Act, anti-kickback statute, and Stark Law, that should be discussed. There are also state regulations that will vary based on where your facility is located. These should also be covered in a general fraud and abuse curriculum within your overall training program. All employees should be aware of these regulations, what constitutes a violation, and what the penalties are. Management should stress that any violations of federal or state law will not be tolerated in any manner, individuals responsible will be terminated, and appropriate authorities will be notified.
Medical necessity guidelines and documentation requirements. For every service your facility bills, there should be comprehensive training on what the Medicare coverage policy says and under what circumstances the services are covered. By providing this training to both clinical and billing staff members, they can work together to make sure services are documented appropriately in the files. For example, a coverage policy for physical therapy requires that the plan of care address the condition for which the therapy is required, how it is expected to improve, and that the physician and/or therapist document the patient's functional limitations in terms that are objective and measurable during visits. If Medicare audits claims and none of these items are documented sufficiently, it could result in all these services being deemed medically unnecessary.

Whatever training program you implement, do not limit it to employees. Nursing homes often subcontract work out to independent contractors. As part of their contract with your facility, it is especially important that they be required to participate in your training program. If Medicare audits services billed by a facility that were performed by an independent contractor and identifies that they were improper, the facility must pay back the money. The independent contractor is paid by the facility, not by Medicare. If the auditors determine that the improper payments were fraudulent, although they may pursue action against the contractor, the nursing home can still be held liable because of negligence in overseeing the actions of the contractors. If your facility implements these suggestions for education and written policies, procedures, and standards of care, and prepares itself appropriately for an audit, then the post-audit processes will be minimal.

Selecting claims for review

Within the past decade or so, contractors have made a major shift in the way they identify claims for review. Rather than doing reviews of randomly selected claims, CMS requires its contractors to conduct more targeted reviews. To determine what type of claims to target, the contractor must conduct an analysis of data that results in claims filed to the program.

The contractor has the ability to analyze nearly every piece of information submitted with the claim. Most contractors employ specially trained data analysts who review the information and determine what a normal billing pattern looks like. Once that is determined, they can identify aberrancies in that pattern. These aberrancies represent abnormal billing behavior. Most providers think data analysis only compares providers to their peers. That is not the case.

The data analysis that is conducted compares data based on:

Geography
Patient demographics
Clinical conditions
Diagnoses
Procedures
Services

That doesn't mean they don't compare providers, too; they just don't rely solely on that type of analysis. Further, contractors don't only analyze claims data. They have access to data from a variety of sources. This includes other departments within the contractor or other agencies.

For example, they can review information from the contractor's provider education department to determine whether a particular facility or provider type has been formally educated on a specific issue. Or they can contact their customer service department or Program Safeguard Contractor/Zone Program Integrity Contractor to determine whether there have been complaints received or action taken against a facility in the past.

There are many different sources for analysts to research. These analysts compile the data and then provide leads to medical review management or personnel. At that point, the clinicians will review the leads. Just because something stands out in the data doesn't necessarily mean that it is inappropriate. The clinicians will determine whether there could be a logical clinical explanation of the abnormal behavior. If they are unable to do so, they may decide to review the information further. The medical review department must prioritize these leads and determine which ones would most likely result in inappropriate payments. It will then determine how to approach the audit.

BALTC Q&A

Fri, 01 Jun 2012 04:00:00 GMT

BALTC Q&A

Editor's note: This month's "Q&A" was modified from the HCPro book The Complete Guide to Long-Term Care Medicare Billing, written by Frosini Rubertino, RN, CPRA, CDONA/LTC. For more information or to order, call customer service at 800-650-6787 or visit www.hcmarketplace.com/prod-8391. To submit a question for upcoming issues, email Associate Editor Melissa D'Amico at mdamico@hcpro.com.

QMy facility has been experiencing an increase in system errors. What can we do to identify the source of the problem?

AA common system error can be caused by a lack of communication between the interdisciplinary team members. When there is no organizational structure to communicate the details of each resident's skilled need, claims may be denied due to errors in billing.

All SNFs should review their current systems for admissions, accuracy in documentation, coding, and bill submission. Start by considering the following questions. Answering "no" to any of them should prompt the facility to reevaluate the effectiveness of its Medicare system and staff knowledge:

Does someone verify benefits prior to admission or prior to services being provided?
Do your MDS coordinator and director of nursing know what the skilled need is prior to admitting the resident?
Do the nurses know what the skilled need is for each of the Medicare residents they are charting on and does the documentation reflect this skilled need?
Does your admissions or MDS coordinator have a clear understanding of what a principal diagnosis is?
Do your Medicare team members know the categories of skilled services?
Do therapy staff members communicate with nursing staff on at least a weekly basis?
Is progress toward goals discussed in your Medicare meetings?
Do your Medicare team members have a solid understanding of benefit periods?
Is there one go-to individual in your facility who brings current Medicare information from CMS to the team on an ongoing basis?
Is there one designated individual in your facility who is responsible for overseeing the management of care and facilitating communication between team members (e.g., nursing, therapy, social services, activities, restorative) for each resident on a Part A stay? n

Billing Alert for Long-Term Care, June 2012

Fri, 01 Jun 2012 04:00:00 GMT

Solve your biggest consolidated billing issues

The following is a list of common consolidated billing questions facilities face and what your SNF can do to resolve these issues today.

1. I can't find the Medicare fee schedule for a given charge from the hospital. What do I do? How much do I owe the hospital?

"Many facilities have a difficult time realizing how much they should be paying the hospital," says McCarthy.

What exactly are we being billed for?
How much would Medicare pay for these services?

Ambulance services
Durable medical equipment, prosthetics, orthotics, and supplies
Parenteral and enteral nutrition
Drug services
Clinical laboratory services
Ambulatory payment classification
Splints, casts, etc.

For these services, there is no single or correct payment option, and there are a number of places facilities may need to look outside of the physician fee schedule.

2. Do I pay the technical component or the professional component of a provided service? What is the difference between these two components?

"The most important thing you can do to avoid confusion in this area of consolidated billing is to provide education on what these two components are and how they involve the SNF," McCarthy says.

3. Are all forms of chemotherapy excluded under consolidated billing? What happens if the resident changes the chemotherapy he or she receives after admission to the SNF?

Certain types of chemotherapy may be excluded under consolidated billing; however, other types are included and reimbursable. This often leaves billers asking, "Do I have to pay for it or not?"

Speak to the patient's physician prior to admission to determine:

The likelihood that the doctor will switch the type of chemotherapy the patient is receiving
How long the patient will remain on his or her current chemotherapy medication and/or others

The goal of these questions is to help your facility understand what your cost will be for the length of the patient's stay.

4. How far back can the hospital or physician provider go to send my facility a bill for any given service under consolidated billing? Is there an expiration date for submitting a bill?

Since billing has become more transparent through reform efforts, SNFs are seeing more bills from hospitals.

5. Do I still have to pay a bill if the patient has expired or has already been discharged?

6. Is the ambulance ride covered?

An ambulance trip that transports a beneficiary from the SNF at the end of a stay when it occurs in connection with one of the following events is not subject to consolidated billing:
A trip for an inpatient admission to a Medicare-participating hospital or critical access hospital (CAH)
A trip to the beneficiary's home to receive services from a Medicare-participating home health agency under a plan of care
A trip to a Medicare-participating hospital or CAH for the specific purpose of receiving emergency services or certain other intensive outpatient services that are not included in the SNF's comprehensive care plan
A formal discharge (or other departure) from the SNF that is not followed by readmission to that or another SNF by midnight of that same day
An ambulance trip from the SNF to the hospital for the receipt of excluded types of outpatient hospital services. Since a beneficiary's departure from the SNF to receive excluded outpatient hospital services is considered to end the beneficiary's status as a SNF resident for consolidated billing purposes, any associated ambulance trips are excluded as well. Moreover, once the beneficiary's SNF resident status has ended in this situation, it does not resume until the point at which the beneficiary actually arrives back at the SNF; accordingly, the return ambulance trip from the hospital to the SNF would also be excluded from consolidated billing.
When a beneficiary leaves the SNF to receive off-site services other than the excluded types of outpatient hospital services described previously and then returns to the SNF, he or she retains the status of a SNF resident with respect to the services furnished during the absence from the SNF. Accordingly, ambulance services provided in connection with these services would remain subject to consolidated billing, even if the purpose of the trip is to receive a particular type of service (such as a physician service) that is excluded from consolidated billing.
A beneficiary's departure from a SNF is not considered to be a "final" departure under consolidated billing if he or she is readmitted to that or another SNF by midnight of the same day. Thus, when a beneficiary travels directly from the first SNF and is admitted to the second SNF by midnight of the same day, that day is a covered Part A day for the beneficiary, to which consolidated billing applies. Accordingly, the associated ambulance trip would be bundled back to the first SNF since the beneficiary would continue to be considered a resident of that facility until the actual point of admission to the second SNF. However, when an individual leaves a SNF via ambulance and does not return to that or another SNF by midnight, the day is not a covered Part A day and consolidated billing would not apply.
If a SNF's Part A resident requires transportation to a physician's office and meets the general medical necessity requirement for transport by ambulance (i.e., using any other means of transport would be medically contraindicated), then the ambulance round trip is the responsibility of the SNF and is included in the PPS rate.
Medicare does not provide any coverage at all under Part A or Part B for any non-ambulance forms of transportation, such as ambulette, wheelchair van, or litter van. In order for the Part A SNF benefit to cover transportation via ambulance, the ambulance transportation must be medically necessary. This means that in a situation where it is medically feasible to transport a SNF resident by means other than an ambulance, ambulance service will not be covered.