Auditors Whos Looking What Theyre Looking For Why

Auditors: Who’s Looking, What They’re Looking For & Why Presented by: G. Christopher Kelly

Who’s Looking? • OIG- Work Plan, Whistleblowers, etc • MACs (pre-pay and prior authorization) • Post Pay: • ZPICs • RACs • SMRC- Supplemental Medical Review Contractor: • Strategic Health Solutions • National contract- national claims data • ZPIC power! (can extrapolate damages) • Already looking at ambulance • https: //strategichs. com

Risks and Rewards: • Preparation: • Who and Why: • MACs- (Contract) • ZPICs- (Budget) • RACs- (Bounty) • HHS/OIG- (Job) • MICs- (Fed Match) • Qui Tam- (Reward) • Can’t stay under the radar • Dialysis • ALS • SCT • Peer Comparison Reports • Intent is every 5 years 09/29/11

New Tactics • OIG- Civil Investigative Demands • ZPICs- • Looking for date ranges • Taking one DOS but reviewing against others • Providing “Education” • Extrapolation only when • “High Rate of Error” • or • “Prior Education failed to correct”

Pre-Pay Review • MAC actions • TX (Novitas) • FL (1 st Coast) • GA/AL/TN (Cahaba) • Authority to Review • Completely Discretionary • Quarterly error rate • Appeal? Ha! • Strategy to Defeat • Dot the “i's” • ALS explanation • BLS justification

OIG Audits of the Ambulance Industry Medical Necessity 25% of all transports did not meet program requirements $402 Million in overpayments Non-emergent: 27% of dialysis patients and 20% of all other transports Emergent: 7% of transports Overpayments are the new Balanced Budget

Most Common Coding Issues Level of Service (ALS v. BLS) Immediate Response (was it an emergency) Medical Necessity of the trip Medical Necessity of the transfer Mileage

The “Errors”. .

• How can you show “contraindicated”? Documentation does not support • Objective conditions to support Subjective medical necessity/transpor conclusions t by other means • “Functional Assessments” possible. • Document details: Denial #1 • O 2 sat • Pillows and placement • Source & Scale of Pain • BLS skills required • Explain Why!

Denial # 2 No PCS on file. • Must keep track of these • Good for 60 days • BUT attach 1 for each claim

Denial # 3 • Auditors LOVE calendars PCS has invalid • Must be legible date. • Must have the YEAR • Should be done at the same time as the signature (typed dates are often questioned)

Denial # 4 PCS has invalid signature. • Auditors watch for: • • Legibility Printed names Credentials Exclusions • Draft Templates? ?

Denial # 5 Patient signature or alternate not captured. • Assignment of Benefits rule must be followed • Patient should sign if possible • If the patient can not sign, 5 alternates: • 1. Patient’s legal guardian • 2. Patient’s healthcare power of attorney • 3. Person who receives gov benefits on patient’s behalf • 4. Person who arranges patient’s medical appointments • 5. Representative of provider who cares for patient • Document which one it is! • If no alternate is available: • Crew signs explaining WHY patient didn’t sign • Crew must get receiving facility to sign

Denial # 6 ALS not justified (downcode) • Must document what ALS procedure was done • Must document why it was necessary • ALS crew must be present • ALS Assessment Rule

Denial # 7 • Was there an immediate Emergency not response justified • Did call justify an immediate (downcode) response • Were there dispatch protocols • H-H transfers

Denial # 8 Transport to destination not covered by Medicare. • Covered Destination Modifier? • Correct Destination Modifier? • Does the modifier match the narrative?

Denial # 9 • Did you bypass another facility? Transportation not to nearest appropriate facility • Could another facility have (downcode mileage) treated: • that patient ? • on that day? • Document out-of-the ordinary at the time of transport! • Locality Rule

Denial # 10 Transport to second facility not appropriate (no higher level of care indicated or patient preference indicated) • H-H transfers • What was needed? • What was not available? • Why was second facility the closest? • Rarely can you pass another facility- but it can happen and be paid • Was there an immediate need for the transfer?

Patient Documentation: What the QIC is Looking For • • • Concise explanation of symptoms from patient and other observers. Details of the patient’s physical assessments that demonstrates the need for an ambulance. Objective description of the patient’s physical condition, in detail, that demonstrates the patient meets Medicare limitation of coverage for ambulance services. Description of the traumatic event when trauma in the basis for suspected injuries. Detailed description of existing safety issues. Detailed description of special precautions taken, and an explanation of the need for the precautions. • • Description of specific monitoring and treatments required, ordered and performed, or administered such as O 2 and/or cardiac monitoring. For example, if O 2 is administered, the pretreatment capillary blood O 2 and clinical respiratory description should be recorded and be consistent to meet O 2 need. Statements, such as the following, without supporting information are not sufficient to justify Medicare payment for ambulance services: – – – Headache Hip Pain Back Pain Leg Pain Weakness Bed-confined

Why it Matters: Extrapolation Sample of 50 dates of service during 2 years Finding that 20 did not justify payment (40%) Actual overpayment of $5, 000 Actual transports during 2 years = 4, 800 Actual amount paid for 2 years = $1, 200, 000 40% of $1, 200, 000 = $480, 000 So a $5, 000 actual overpayment turns into a $480, 000 extrapolated overpayment.

Some Real Examples:

Appeals Process Audit Request/Decision (6 months+) Re-determination (2 months) Qualified Independent Contractor (6 months) Administrative Law Judge (2 years) Medicare Appeals Council (6 -9 months) U. S. District Court (6 months) 4+ years from time of initial audit *Repayments and Offsets Start at end of QIC

ALJ Date July, 2014 Aug, 2014 Feb, 2015 Apr, 2015 July, 2015 Aug, 2016 Apr, 2016 State Total # of Redetermination % QIC % ALJ % % Claims Favorable Lose Favorable Unfavorable Favorable TX 104 4 100 4% 4 96 4% 96 0 92% 100% TX 120 0% 0 120 0% 74 46 62% OH 67 0% 17 50 25% 2 15 3% 28% TX 40 0% 10 30 25% 5 25 13% 38% NC 39 0% 0 39 0% 3 34 8% 8% GA 27 8 19 30% 11 8 41% 8 0 30% 100% GA 40 4 36 10% 2 34 5% 34 0 85% 100% TX 210 0% 79 131 38% 129 2 61% 99% SC TX FL FL TX TX TX 17 132 64 58 118 45 43 30 350 144 711 996 2 0 6 7 0 1 0 0 15 132 58 51 118 44 43 30 340 144 996 12% 0% 9% 12% 0% 0% 4 12 0 0 0 0 1 11 120 58 51 118 44 43 30 349 143 24% 9% 0% 0% 1% 0% 0% 5 6 29% 0% 0% 0% 65%

Questions, comments, concerns: ckelly@pwwemslaw. com