cgi rac region b update - webinars, webcasts, lms...
TRANSCRIPT
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CGI RAC Region B UpdateAHCA Webinar
April 4, 2012
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Agenda
• Introductions
• Overview and Update
• Provider Options
• Update on Medicare RAC Approved Issues
• New Concept Process
• Medicare RAC in a MAC World
• Additional Documentation Limits
• Open Question and Answer
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Overview and Update: CGI RAC Mission
CGI’s mission for the RAC Region B is to identify improper payments through the detection and collection of overpayments, the identification of underpayments, and the implementation of actions that will prevent future improper payments.
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Overview and Update: RAC OperationsProcedures and TimelinesRecords and Review Information• 45 DAYS: RAC issues an ADR Letter requesting medical records
and provider has 45 days to send them.• 45 DAYS from receipt of records : RAC has 45 days to pay for
records requiring payment and First Class Postage.• 60 DAYS from receipt of records : Upon receipt of the medical
record, RAC has 60 days to review and send the Review Results Letter.
Discussion Information• Provider can initiate a Discussion as soon as they receive the
Review Results Letter and up to DAY 40 from the date of the Demand Letter.
• Providers using the discussion option will receive a Discussion Results Letter.
• Discussion Results Letters are issued in a scheduled and timely manner.
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Overview and Update: RAC OperationsProcedures and Timelines (cont’d.)Adjustment and Demand Information• Once a Review Result is generated, CGI sends an adjustment to
the claims processor.
• The adjustment is validated for data elements.
• If there are no errors, the adjustment will process quickly. In the event of errors, it may take 90 days or more to resolve the issue.
• 7 DAYS: Demand Letters are mailed within 7 days of the date of the AR and in accordance with the Medicare Financial Management Manual, Chapter 3 & 4, as well as instructions in CMS One Time Notifications and Joint Signature Memorandum.
Appeal Information• 120 DAYS: Providers have appeal rights for 120 days from the
date of the Demand Letter.
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Overview and Update: RAC B WebsiteAccess
• The RAC B website; http://RACB.CGI.com
• Providers authenticate by clicking on the Providers link and entering their Medicare ID or NPI, and a Letter ID from within the date range listed.
• Providers can access Address Maintenance, Claim Audit Status, ADR Limits and the Bulletin Board once authenticated on the website.
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Overview and Update: RAC B WebsiteBulletin Board
• A Bulletin Board is available for communicating important updates to the Provider community.
• Once authenticated to the website, click on the Home link to view the Bulletin Board. Important information is located in the What’s New box.
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Overview and Update: RAC B WebsiteClaim Status
• Providers can view the status of their RAC cases from the Claim Audit Status link.
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Overview and Update: RAC B WebsiteClaim Status Details
• Detailed information on cases is available from the Claim Audit Details link.
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Overview and Update: RAC B WebsiteAddress Maintenance
• Providers can update their contact information from the Address Maintenance link.
• Providers can only update contact information for addresses that share the Tax ID of the Medicare ID or NPI entered for the logon identity.
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Overview and Update: ESMD
• ESMD Project
• ESMD is the CMS project that enables Providers to send medical documentation electronically through approved vendors using a CONNECT-compatible gateway.
• RAC B is currently accepting medical records through this initiative.
• Providers will be paid for pages according to the SOW; however, there is no reimbursement of postage.
• Providers can visit https://www.cms.gov/ESMD/ for more information and a list of approved vendors.
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Provider Options
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Update on Medicare RAC Approved Issues
• As of March 29, 2012, the following is a count of CGI Federal approved issues:
• 55 Automated Issues
• 17 Semi-Automated Issues
• 194 approved issues encompassing Medical Necessity reviews and MSDRGs for DRG validation and clinical validation review
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New Concept Process: Requests
Facts:• CMS intends “complex review concept development” to mean that the
issue, while valid for review, has not yet been approved by CMS.
• RACs have the right to request additional documentation for complex reviews approved by CMS, and complex reviews being considered byCGI for submission to CMS for approval.
• Issue information for concept requests are not listed on the RAC B website until the issue is approved by CMS.
• Concept requests are included in the provider medical record limits.
• RACs may request up to 10 records for concept development.
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New Concept Process: Letter
Sample of an ADR Letter that contains requests for concept development:
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New Concept Process: New Issue Review Board (NIRB)
Facts:
• The new issue review process is not a regulatory or statutory requirement; it is a requirement effected by CMS to ensure the RACs are making accurate decisions.
• Identified new issues must go through an extensive process to obtain approval.
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Medicare RAC in a MAC World:Change Request 7436
• Effective Date : January 3, 2012
• Action : The Centers for Medicare & Medicaid Services (CMS) is transferring the responsibility for issuing demand letters to providers from its Recovery Auditors to its claims processing contractors.
• Purpose : This change was made to avoid any delays in demand letter issuance.
• What this means : The RACs will submit adjustments to the MAC as usual, but the Demand will be issued by the MAC.
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Medicare RAC in a MAC World:Resulting Changes
• Demand Letters will be issued to the contact on file with MAC.
• Demand Letters will arrive in the standard MAC format.
• Letter IDs and RAC Case IDs will not be included on the Demands.
• The MAC will be the point of contact for any administrative concerns such as timeframes for recoupment and the appeals process.
• CGI will be the point of contact for Good Cause and review rationale.
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Medicare RAC in a MAC World:Demand
• Demand Spreadsheet provider receives from the MAC
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Medicare RAC in a MAC World:Demand Updates to Web Portal
• CGI has made enhancements to the web portal to accommodate providers
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Medicare RAC in a MAC World:Demand Updates to Web Portal• After the provider enters their Invoice Number from the Demand Spreadsheet, providers will be able to review the good cause language.
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Additional Documentation Limits for Medicare Providers - Update
• Effective Date: March 15, 2012• Maximum request amount is per campus
• Campus = one or more facilities under the same Tax Identification Number (TIN) located in the same area (using the first three positions of the ZIP code)
• Each limit is based on the provider’s prior calendar year Medicare claims volume.
• The limit is based on claims volume only.• The maximum number of requests per 45 days is 400
• Providers with over $100,000,000 in MS-DRG payments will have a cap of 600.
• The limit is equal to 2% of all claims submitted for the previous calendar year.
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Contact Information
Call Center for CGI Federal RAC B
Toll Free: 877-316-RACB
E-mail: [email protected]
Website:
http://RACB.CGI.com
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Questions
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Cleveland | Columbus | Indianapolis | Philadelphia | Shanghai | White Plains | Wilmington
www.beneschlaw.com
Medicare Recovery Auditor SNF Update: Region B
AHCA Webinar April 4, 2012
Alan E. Schabes, Esq.
Benesch, Friedlander, Coplan & Aronoff LLP
Cleveland, Ohio 44114-2378
(216) 363-4589
RAC Region B Statistics for4th Quarter of 2011 (10/01/11 – 12/31/11)
$422.7$422.7$24.9$397.8Nationwide Totals:
$72.1$72.1$6.5$65.6Region B: CGI
(CGI Federal)
FY TO DATE CORRECTIONS
TOTAL QUARTER CORRECTIONS
UNDERPAYMENTS RETURNED
OVERPAYMENTS COLLECTED
Preparation Before a RAC Audit Is Critical
• Develop effective policies and procedures by:
• Establishing company policy
• Training your employees
• Identifying your team
• Knowing the issues and your exposure
• Preparing for extensive document production
• Preparing for RAC audits should be part of a proactive comprehensive corporate compliance program
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Best Practices
• Identify facility and/or organization team –how will you communicate internally and with whom?
ITCompliance
Medical DirectorCounsel
NursingAdministrator
Medical RecordsFinance
• Select an Audit Coordinator to manage all inquiries and coordinate evaluation of all records sent out for audit/review
• Tell the RAC the name and address of your coordinator
• Make sure your MAC has the right address
• Need to instruct your mail room to forward all correspondence from CGI Federal to the proper individual for processing
Best Practices
• Examine existing reporting and record systems to identify potential operational challenges
• Develop internal monitoring techniques and risk assessments with counsel
• Enhance compliance initiatives, particularly related to documentation and coding education
• Identify the risk areas
Best Practices
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• Know your internal operations and use your Quality Assurance Committee
• Trends, spikes, claims denials, complaints
• Monitor external sources for issues and “hot” areas
• CGI Federal Website:https://racb.cgi.com/default.aspx
Best Practices
• AHCA RA website:http://www.ahcancal.org/facility_operations/medicarerac/Pages/default.aspx
• OIG Work Plan, advisory opinions, fraud alerts
• RAC, MIC and ZPIC reports and settlements
Best Practices
• Region B: SNF Consolidated Billing
• States affected: MN, WI, MI, IL, OH and KY
• Type of Review: Automated Overpayment
• Description: Services are being billed separately that should be included in the Skilled Nursing Facility consolidated billing. Consolidated billing is when services provided during the resident’s stay in a skilled nursing facility (SNF) are bundled into one package and billed by the SNF. Under the consolidated
Focus of Current RAC AuditsSNF RAC Approved Issues
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billing requirement, a Skilled Nursing Facility itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services).
• Region B: Test Claims for Ultra High RUGs.
Focus of Current RAC AuditsSNF RAC Approved Issues
Timeliness is Key
• Implement systems for timely responses to audit
• Develop a log• Date stamp all correspondence and monitor electronic remittance advices
• Track requests for information, deadlines, extensions and dates sent
• Log all contacts with the RA (names, dates, times and summary of conversation)
• Log notices of overpayments, dates for repayment, dates for appeals
Be Prepared for Additional Documentation Requests (ADR)
• According to the CGI website, annual limit for records requested every 45 days is 2 percent of all claims submitted in the previous calendar year, divided by eight, capped at 400 per 45 days
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Be Prepared for Additional Documentation Requests (ADR)
• For SNFs, 1 ADR represents a beneficiary’s entire episode of care
• Allmedical records for all services rendered from admission to discharge
• http://www.cms.gov/Recovery-Audit-Program/Downloads/Providers_ADRLimit_Update-03-12.pdf
The ADR Response
• 3 year look back: do you know where your records are?
• Storage, soft files, filing back log
• Request extension if needed
• Copy entire medical record and all relevant documents, and keep a copy
The ADR Response
• Follow DCS requirements http://racb.cgi.com/docs/
• Beginning 04/01/12, CMS will begin instituting a reimbursement cap of $25 per medical record. This includes both the $0.12 per page cost for photocopying and first class postage.
• Proof of mailing/proof of receipt
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The Results and Demand Letter
• CGI will make every effort to forward the claim to the MAC at the same time the Review Results Letter is sent out.
• Once CGI Federal has received the requested medical records, the audit team has 60 calendar days to review the supporting documentation, make a claim determination and send a Review Results Letter to the providers.
The Results and Demand Letter
• Providers may want to make use of the discussion procedure. This can be initiated from date of receipt of the Review Results Letter and up to Day 40 thereafter.
Appeal Considerations
• Discussion with RAC—within 41 days of demand letter
• Redetermination with MAC-- 120 days from original date of denial; to prevent recoupment on Day 41, the determination request must be filed within 30 calendar days
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Provider Options - RAC Overpayment Determination
A redetermination is the first level of appeal. A provider may request a redetermination when they are dissatisfied with the overpayment decision. A redetermination must be submitted within 30 days to prevent offset on Day 41.
The rebuttal process allows the provider the opportunity to provide a statement and accompanying evidence indicating why the overpayment action will cause a financial hardship and should not take place. A rebuttal is not intended to review supporting medical documentation nor disagreement with the overpayment decision. A rebuttal should not duplicate the redetermination process. (See 42 CFR 405.374-375)
The discussion period offers the opportunity for the provider to provide additional information to the RAC to indicate why recoupment should not be initiated. It also offers the opportunity for the RAC to explain the rationale for the overpayment decision. After reviewing the additional documentation submitted the RAC could decide to reverse their decision. A letter will go to the provider detailing the outcome of the discussion period.
Which option should I use?
RedeterminationRebuttalDiscussion Period
Provider Options - RAC Overpayment Determination
Day 1-120
Must be submitted within 120 days of receipt of Demand Letter. To prevent offset on Day 41 the Redetermination must be filed within 30 days.
Day 1-15Day 1-40Timeframe
A redetermination is the first level of appeal. A provider may request a redetermination when they are dissatisfied with the overpayment decision. A redetermination must be submitted within 30 days to prevent offset on Day 41.
Claim Processing Contractor
Recovery Audit Contract (RAC)
Who do I contact?
RedeterminationRebuttalDiscussion Period
Provider Options - RAC Overpayment Determination
Day 120Day 15Day 40 (offset begins on Day 41)
Timeframe Ends
Upon receipt of Demand Letter
Date of Demand LetterAutomated Review: Upon receipt of Demand Letter
Complex Review: Upon receipt of Review Results Letter
Timeframe Begins
RedeterminationRebuttalDiscussion Period
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Appeals Timeline
180 days from date of MAC determination; 60 days to suspend recoupment
Reconsideration to Qualified Independent Contractor (QIC)
120 days from original date of denial; 30 calendar days to suspend recoupment
Redetermination with MAC
< 41 days from Demand Letter
Discussion with RA
60 days from the date of the upheld appeals council decision
Judicial review in U.S. district court
60 days from the date of the ALJ decision
Medicare Appeals Council
60 days from the date of QIC decision; recoupment resumes
Administrative Law Judge Hearing
Appeals Timeline
Questions?