Medicare Review Contractors Topics Reviews at the MAC

Medicare Review Contractors

Topics Reviews at the MAC Level Targeted Probe and Educate Important Update! Review Contractors in the Medicare program Operational tips/ Working with National Government Services 2 Proprietary and Confidential

National Medical Review Change Process The medical review process moved from a progressive corrective action (PCA) process to Targeted Probe and Educate (TPE) § Trail projects for inpatient services and home health § Proved successful in lowering providers payment error rates § This new model will change some of the process but not affect policy and procedures 3 Proprietary and Confidential

Basics of the new process ü 1. NGS will select the area of review based on existing data analysis procedures and CMS selected the area of review during the demonstration projects ü NGS can target the providers based on data rather than perform a 100% review of all providers. All providers were subject to review during the demonstration project ü NGS will perform prepay reviews § NGS will request between 20 -40 claims for probes and each Education between each round of review will be a primary focus 4 Proprietary and Confidential

Targeted Probe and Educate 5 Proprietary and Confidential

Data Analysis Trends Billing Comparisons Utilization patterns Data Analysis 6 Proprietary and Confidential

CMS Referral After three rounds of review and continued high denial rates CMS may instruct the MAC for additional action which might include: § Extrapolation § Referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC) § Referral to the Recovery Audit Contractor (RAC) § 100 % pre-pay review 7 Proprietary and Confidential

Medical Record Review Medical review of records for: § Technical components • Physician Certifications • Physician orders • Beneficiary election statements § Eligibility • Medicare coverage guidelines • Medical necessity • Documentation supports the services billed 8 Proprietary and Confidential

Detailed Provider Results Letter Detailed results letter at the conclusion of each round will include: § Outline the targeted probe & educate process § Reason for denials including the Medicare regulations § Denial rates (PER) § Release or retention from medical review • PER of less than 15% in order to be released from additional rounds of review § 1: 1 education information Read the letter in its entirety for important information regarding additional rounds of review 9 Proprietary and Confidential

You Tube Video Share with staff NGS You. Tube Video: Targeted Probe and Educate (TPE) Medical Review Strategy § Six-minute You. Tube video to learn about the new Targeted Probe and Educate (TPE) Medical Review Strategy Did you know that NGS has created many helpful videos on a variety of topics? § NGS You. Tube home page § NGS You Tube video list 10 Proprietary and Confidential

References NGS Website Part A Medical Review article: “Important Information and Instructions for Responding to Additional Development Requests” Part B NGSConnex User Guide: “View/Search for MR ADR Submission Documents” NGSMedicare. com > choose contract > Medical Policy & Review tab > Medical Review > Targeted Probe and Educate Change Request 10249, “Targeted Probe and Educate, ” effective 10/1/2017 CMS website: § Targeted Probe and Educate (TPE) § “Reducing Provider Burden” § CMS TPE Flow Chart 11 Proprietary and Confidential

Review Contractors in the Medicare Program

Medicare Review Contractor CMS estimates that about 11 percent of all Medicare Fee. For-Service (FFS) claim payments are improper. ( Over $41. 08 Billion – FY 2016 ) Several initiatives to prevent or identify improper payments before CMS processes a claim, and to identify and recover improper payments after paying a claim. The overall goal is to reduce improper payments by identifying and addressing coverage and coding billing errors for all providers types. 13 Proprietary and Confidential

Medicare Review Contractors Scope Medicare Administrative Contactors (MACs) Process claims from physicians, hospitals, and other health care professionals, and submit payment to those providers according to Medicare rules and regulations (includes identifying and correcting underpayments and overpayments) New targeted probe and educate Use of automated NCCI and MUE national editing Zone Programs Integrity Contractors (ZPICs) previously (PSC ) Perform investigations that are unique and tailored to specific circumstances and occur only in situations where there is potential fraud, and take appropriate corrective actions Supplemental Medical Review Contractors (SMRC ) Conduct nationwide medical review as directed by CMS Comprehensive Error Rate Testing (CERT) Collect documentation and perform reviews on a statistically valid random sample of Medicare FFS claims to produce an annual improper payment rate Medicare Recovery Auditors Review claims to identify potential over and under 14 payments in Medicare FFS, as part of the Recovery

MAC review programs National Correct Coding Initiative (NCCI) Goal is to promote national correct coding methods and to control improper coding that leads to inappropriate Part B Applied when incorrect code combinations are reported. NCCI edits are updated quarterly. The coding policies are based on the following coding conventions: American Medical Association (AMA) Current Procedural Terminology (CPT) Manual. Coding guidelines developed by national societies, standard medical and surgical practice, and current coding practice 15 Proprietary and Confidential

MAC review Programs Medically Unlikely Edits ( MUEs ) An MUE for a code is the maximum units of service that a provider would report, under most circumstances, for a single beneficiary on a single date of service. MUEs are categorized into claim line edits and date-of-service edits based on policy or clinical benchmarks. CMS updates MUEs quarterly. Most MUEs are publicly available on the CMS website, CMS will not publish all MUE values because of fraud and abuse concerns. MLN Matters MM 8853 (revised ) 16 Proprietary and Confidential

Correct Coding / MUE contact Inquiries about the NCCI program, other than those related to NCCI (PTP, MUE and Add-On) edits, should be sent to the following email address: NCCIPTPMUE@cms. hhs. gov. Contact in writing: National Correct Coding Initiative Correct Coding Solutions LLC P. O. Box 907 Carmel, IN 46082 -0907 Attention: Niles R. Rosen, M. D. , Medical Director and Linda S. Dietz, RHIA, CCS-P, Coding Specialist 17 Proprietary and Confidential

Zone Program Integrity Contractor ( ZPIC ) Section 911 of the Medicare Modernization Act (MMA) of 2003 created the was signed into law. Program Safeguard Contractors (PSCs), to perform program integrity functions. PSC’s now ZPICs were created to detect and deter potential fraud, waste, and abuse in the Medicare program. Seven program integrity zones were created based on the newlyestablished MAC jurisdictions. New entities entitled Zone Program Integrity Contractors (ZPICs) were created to perform program integrity functions in these zones for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice and Medicare-Medicaid data matching. 18 Proprietary and Confidential

ZPIC Functions The primary goal of ZPICs is to investigate instances of suspected fraud, waste, and abuse. ZPICs develop investigations early, and in a timely manner, take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid. They also identify any improper payments that are to be recouped by the MAC. 19 Proprietary and Confidential

Actions to detect fraud include: - Investigating potential fraud and abuse for CMS administrative action or referral to law enforcement - Conducting investigations in accordance with the priorities established by CPI’s Fraud Prevention System; - Performing medical review, as appropriate; - Performing data analysis in coordination with CPI’s Fraud Prevention System; - Identifying the need for administrative actions such as payment suspensions and prepayment or auto-denial edits; and, - Referring cases to law enforcement for consideration and - initiation of civil or criminal prosecution. 20 Proprietary and Confidential

Northeastern Unified Program Integrity Contractor The NE UPIC performs fraud, waste and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims processed within the North Eastern Jurisdiction for the states of Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New York, Pennsylvania, New Jersey, Delaware, Maryland, District of Columbia, and the counties of Arlington and Fairfax and the city of Alexandria in Virginia. Mailing Address for NE UPIC: Safe. Guard Services, LLC Suite 200 1250 Camp Hill Bypass Camp Hill, PA 17011 21 Proprietary and Confidential

Supplemental Review Specialty Contractor (SMRC ) Strategic. Health. Solutions, LLC, was selected at the SMRC. The SMRC performs reviews to lower the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. Their efforts can be nationwide The SMRC evaluates medical records and related documents to determine whether Medicare claims were billed in compliance with coverage, coding, payment, and billing practices. The focus of the reviews may include, but is not limited to vulnerabilities identified by CMS internal data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations and Federal oversight agencies. 22 Proprietary and Confidential

SMRC information Strategic is currently performing medical record review on the following projects: 2015 -0225 — Blepharoplasty (10/16/17) TDL 2017 -0446 — Cardiac Rehabilitation (07/10/17) Y 3 P 0433 — Ambulance (03/14/17) Y 3 P 0440 — Hospice (03/15/17) Y 3 P 0439 — Bone Marrow and Stem Cell Transplants (04/11/17) Y 3 P 0441 — Outpatient Drugs (03/16/17) Y 4 P 0442 — Incorrect Place of Service (POS) (04/07/17) Y 4 P 0445 — Skilled Nursing Facility (SNF) (03/16/17) www. strategichs. com 23 Proprietary and Confidential

CERT start with www. ngsmedicare. com 24 Proprietary and Confidential

CERT Overview CERT contractor randomly selects sample of paid or denied claims from all Medicare contractors CERT reviews claims along with medical records to see if documentation supports all services billed § determine if claim or service processed correctly and in compliance with all Medicare policies, procedures and guidelines CERT findings are used for data analysis and possible review of additional claims and medical records by Medicare and the RAC § CERT can review claims that were reviewed by MAC to be sure of accuracy of contractor’s review § RAC is required to exclude CERT reviewed claims from their review samples but can do additional reviews based on CERT findings 25 Proprietary and Confidential

Top 4 CERT errors 1. No Documentation Providers fail to respond to repeated requests for the medical records or they do not have the requested documentation. 2. Insufficient Documentation Reviewers could not conclude that the billed services were actually provided, services provided at the level billed, and/or were medically necessary. Lack of physician signature. 3 Medical Necessity lacking This is based upon Medicare coverage and payment policies. 4. Incorrect Coding 26 Proprietary and Confidential

Most Common Error Missing or Illegible Signatures Signature attestation § Example attestation statement - “I, [print full name of the physician/practitioner], hereby attest that the medical record entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [insert provider credentials, e. g. , M. D. ] when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability. ” M. D. Signature __________ § Reference • CMS IOM Publication 100 -08, Chapter 3, Section 3. 4. 1. 1 D 27 Proprietary and Confidential

CERT Contractor §Beginning 10/7/2016, all CERT inquiries and medical records should be addressed to the following: §CERT Documentation Center 1510 East Parham Road Henrico, VA 23228 Fax: (804) 261 -8100 Customer Service: (443) 663 -2699 Toll Free: (888) 779 -7477 Email: certmail@admedcorp. com 28 Proprietary and Confidential

National Recovery Audit Program Mission - Recovery Audit Program’s mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states. Background – After a demonstration period, payment Recovery Audits were determined to a successful tool in the identification and prevention of improper Medicare payments. The demonstration was as set in Recovery Auditors under Section 1893(h) of the SSA Act in January 2010. 29 Proprietary and Confidential

RAC Time Frames Performant has 30 calendar days to complete the review and send a Decision Letter. Performant may look back up to three (3) years from the claim paid date to review claims. Performant will forward the adjustment to the MAC 30 days after the RRL/Initial Findings Letter or after a Discussion Period has been completed. Once the MAC has created the appropriate accounts receivable, they will initiate the Demand Letter. If you have any questions, contact NGS or all Customer Service at 1 -866 -201 -0580 30 Proprietary and Confidential

Current issues under review by the RAC Details are available Outpatient Service Overlapping or During an Inpatient Stay Critical Care Billed on the Same Day as Emergency Room Services Excessive Units - Untimed Therapy Complex PAP Devices for the Treatment of Obstructive Sleep Apnea Arthroscopic Limited Shoulder Debridement Complex Review of Hospital Readmission Same Day as Discharge Excessive Units of Nursing Facility Services Excessive Units of Initial Critical Care 31 Proprietary and Confidential

Review and not alter documentation prior to submission Documentation must be legible and complete: § Check the copy, scan or fax quality § Be sure to copy both front and back of document when appropriate § If penmanship is an issue, consider dictation requirements for those practitioners Each page must contain the patient’s name All orders must be dated and with a legible signature 32 Proprietary and Confidential

Documentation tips Documentation must be submitted for all dates of service on the claim Include any additional documentation needed to support the billed services such as: § Discharge note or consult from previous stay § Diagnostic work done prior to admission All orders, notes or reports in the medical record must include a legible signature with attribution identification It is important to note that the improper payment rate is not a “fraud rate, ” but is a measurement of payments that did not meet Medicare requirements. 33 Proprietary and Confidential

CERT Alerts 34 Proprietary and Confidential

RA Contractor NY, NE Performant 2751 Southwest Blvd. San Angelo, TX 76904 | (866) 201 -0580 March 8, 2017 Performant, Region 1 (which includes MI, IN, KY, OH, VT, NH, ME, MA, RI, CT and NY) has received CMS approval to begin audit activity. 35 Proprietary and Confidential

New Jersey HMS Federal RA Contractor Provider Services Information Toll Free Call Center Information Part A Providers, including Hospital, SNF Telephone: (877) 350 -7992 Fax: (702) 240 -5595 Part B Providers Telephone: (877) 350 -7993 Fax: (702) 240 -5510 Email racinfo@hms. com link opens the email application Discussion Fax # Part A Providers, including Hospital, SNF Fax: (702) 240 -5595 Part B Providers Fax: (702) 240 -5510 36 Proprietary and Confidential

Take Advantage of NGS Educational Programs Proprietary and Confidential

Connex is the solution for working with NGS Access Needed: § Internet access and email Provides: Submit claims - new features added § Claim status § Beneficiary eligibility/therapy caps - New Medicare Card!!! § Financial data/Provider demographics § Ability to order/download duplicate remittances § Redeterminations/ Reopenings § Inquiries § Submission of medical records (ADR request) Part B only Proprietary and Confidential