OIG releases its FY 2015 mid-year update
The Office of Inspector General (OIG) released its fiscal year (FY) 2015 Mid-Year Update last week. The update summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs during the current fiscal year and beyond.
The OIG’s job is to detect fraud, waste, and abuse; identify opportunities to improve healthcare program economy; and to hold "accountable those who do not meet program requirements or who violate Federal health care laws." The OIG conducts audits and investigation, and can impose civil monetary penalties where appropriate, so its Work Plan is often of great interest to those working with federal healthcare programs. As a summary of some of the OIG’s enforcement initiatives, the Work Plan can serve as a useful resource for companies when training and when planning internal audits.
The FY mid-year update includes several initiatives central to long-term care providers.
Medicare Part A billing by SNFs
The OIG will describe changes in SNF billing practices from FYs 2011 to 2013. Prior OIG work found that SNFs increasingly billed for the highest level of therapy even though beneficiary characteristics remained largely unchanged. The OIG also found that SNFs billed one-quarter of all 2009 claims in error; this erroneous billing resulted in $ 1.5 billion in inappropriate Medicare payments. CMS has made substantial changes to how SNFs bill for services for Medicare Part A stays.
CMS’ future plans include:
- phasing in bundling options
- continued growth and development of ACO models of reimbursement tied to outcomes and quality of care
- the elimination of using the amount of therapy delivered as an incentive for payment
- conducting outcome studies on therapy delivered under Medicare Part B
Diane Brown, director of postacute education at HCPro explains that, "These plans will likely contribute to better care and improved transitions in care as well as be linked to appropriate payment. When implemented, much of the time spent by facilities on navigating COTs and other labor intensive tasks could be eliminated."
As Kathy W. O’Neal, RN, RAC-CT, LNHA, from Crossroads Medical Management can attest to, "There were numerous changes with Part A billing practices associated with the implementation of MDS 3.0. Probably the most significant was that on the five-day assessment, projecting therapy minutes were removed. Another significant change is that a change of therapy (COT) assessment is required every seven days if a resident in a rehab RUG category that receives more or less therapy minutes and/or the number of modalities changes enough to cause the resident to fall into another RUG category. This practice was created as a response to the thought process that SNFs were being paid for a therapy that was not needed and/or provided. These changes have created a tremendous increase in the number of assessments needed, with the resulting billing rules associated that are confusing for providers. A large percentage of my time is consumed with audits and appeals associated with Part A stays, mainly Medicare replacement policies, and often it seems that the insurance companies providing the replacement policies do not understand PPS billing. It is very frustrating but has become a routine part of our industry."
State agency verification of deficiency corrections
The OIG will determine whether state survey agencies verified correction plans for deficiencies identified during nursing home recertification surveys. A prior OIG review found that one state survey agency did not always verify that nursing homes corrected deficiencies identified during surveys in accordance with federal requirements. Federal regulations require nursing homes to submit correction plans to the state survey agency or CMS for deficiencies identified during surveys. CMS requires state survey agencies to verify the correction of identified deficiencies through on-site reviews or by obtaining other evidence of correction.
Program for national background checks for long-term-care employees
The OIG will review the procedures implemented by participating states for long-term care facilities or providers to conduct background checks on prospective employees and providers who would have direct access to patients and determine the costs of conducting background checks. Further, the OIG will determine the outcomes of the states’ programs and determine whether the programs led to any unintended consequences. Section 6201 of the Patient Protection and Affordable Care Act (ACA) requires the Secretary of Health and Human Services to carry out a nationwide program for states to conduct national and state background checks for prospective direct patient access employees of nursing facilities and other long-term care providers.
The program is administered by CMS. To carry out the nationwide program, CMS has issued solicitations for grant awards. All states, the District of Columbia, and U.S. territories are eligible to be considered for a grant award. OIG is required under the ACA to submit a report to Congress evaluating this program upon its conclusion. This mandated work is ongoing, and an interim report will be issued prior to the program’s conclusion.
O’Neal approves of this initiative, saying that, "I agree with any additional background screening to ensure our residents are cared for in a safe and caring environment."
Although the OIG’s oversight extends to other programs under the U.S. Department of Health & Human Services, the majority of its resources go toward combating fraud, waste, and abuse in Medicare and Medicaid.
You can review the entire mid-year update to the 2015 Work Plan on the OIG’s website.
Medicare myths
Editor’s note: This article is excerpted from the book Long-Term Care Skilled Services: How to Document for Proper Medicare Reimbursement, by Elizabeth Malzahn-McLaren.
Throughout my years of educating providers on the inner workings of the Medicare program, whether it was a boot camp class for newcomers or a refresher course for those in the business for years, there are always instances where I am able to "myth-bust" Medicare. With any program, especially one that has been in existence for 60 years, there are bound to be some myths out there about how the program works.
Myth #1: A psychiatric resident will not qualify for Medicare Part A skilled services.
Although most psychiatric services will not qualify as Medicare Part A skilled services, there are some instances when a resident will qualify coming straight from the hospital, at least for a short period of time.
First you need to determine if the stay in the psychiatric hospital meets the three-day qualifying hospital requirement. If it does, the next area to review is whether the care meets the requirements for skilled services under Medicare Part A.
The resident may need to have his or her medications adjusted; there also can be potential for an adverse drug reaction if medications were changed. In addition, depending on the time spent in the hospital, there may have been some deterioration and the resident may have therapy orders upon discharge from the hospital. Other areas to review include hearing, speech, and vision (Section B of the Minimum Data Set [MDS]); cognitive patterns (Section C); mood (Section D); behavior (Section E); functional status (Section G); and medications (Section N) … just to name a few!
Myth #2: You can cover a resident for the first five days to observe and assess his or her condition.
The Centers for Medicare & Medicaid Services (CMS) provides no time frame of minimum or maximum time covered; however, there is the ability to use administrative presumption of coverage. Remember, though, that the use of the administrative presumption is reserved only for residents being directly admitted from a three-day qualifying hospital stay. In addition, this administrative presumption only covers up to and including the assessment reference date (ARD), if no skilled need is identified on the initial admission/readmission MDS. The regulation indicates that a resident can be skilled "until the condition of the patient is stabilized." Typically, skilled care for observation and assessment lasts for a few weeks or less.
Myth #3: A new diagnosis triggers a new benefit period.
This is one of the most dangerous Medicare myths out there. It can impact not only resident care, but also customer service, and it can have a significant financial impact as well. The only way a resident can earn a new 100-day benefit period under SNF Medicare Part A is to complete a 60-day period of wellness. The calculation for earning a new benefit period is based on two criteria:
- Determining when skilled services ended
- Counting days
There is no magic formula to earning a new benefit period. Let us review an example to illustrate how the calculation should work.
A resident completed a 100-day Medicare benefit period on December 31. The resident remained skilled under Medicare Part B, receiving therapy services until January 31. Beginning February 1, the resident was no longer at a skilled level of care. Based on the counting of 60 days, the resident would be eligible for a new benefit period on April 2 (assuming 28 days in February). However, we need to review each day between February 1 and April 2 to make sure none of the following occurred:
- Did the resident receive any services that would qualify the resident under a Medicare skilled level of care while in the SNF during that time period? For example, was the resident picked back up under a Medicare Part B plan of care that met the skilled level of care requirements?
- Did the resident have any inpatient admissions to the hospital during that time period?
If the answer to either of these questions is yes, then the resident did not earn a new 100-day benefit period based on either the provision of skilled services or failure to meet the 60-day period of wellness requirement.
There is one small wrinkle in this calculation of benefit periods. If a resident leaves the SNF and continues to receive a skilled service while residing at home, for example, this would not impact the benefit period. When reviewing skilled services received, Medicare is only looking at skilled services received while in a SNF or as an inpatient of a hospital. Skilled services rendered to a beneficiary in the home setting do not impact the Medicare Part A SNF benefit period calculation.
Myth #4: All residents who are receiving tube feeding are always skilled and always will be skilled.
This statement is both true and false. The caveat lies with the level of calories and fluid the resident is taking in through the tube. Residents who meet the 26%?50% of calories and 501 cc of fluid per day via the feeding tube, or residents who receive 51% or more of calories via the feeding tube will automatically qualify for Medicare Part A benefits in a SNF. Additionally, they are required to continue on Medicare to use a full 100-day benefit period until they drop below such levels on an MDS. These levels will also continue that spell of illness and prevent the resident from attaining the 60-day period of wellness to qualify for a new 100-day benefit period.
Residents who meet the caloric and fluid requirements of 26%?50% of caloric intake and 501 cc of fluid daily via the tube or residents who receive 51% of more of caloric intake from the tube will remain at a skilled level of care for a full 100 days, as long as they remain at those levels. In addition, the resident will not qualify for a new 100-day benefit period unless he or she:
- Drops below the calorie and fluid levels previously identified for 60 consecutive days without any other skilled service in the SNF or inpatient hospital stay
- Remains at those calorie and fluid levels identified previously but discharges to home with skilled services being provided in the home for 60 consecutive days
Myth #5: As long as there is an inpatient hospital stay or Medicare Part A SNF stay within the last 30 days, we can pick the resident back up on Medicare Part A.
Although this is partly true, the most important criteria to using the 30-day window is relating the reason for coverage back to the original hospitalization or a condition that arose during treatment. If the reason to pick the resident back up under Medicare Part A is completely unrelated to the original hospitalization or subsequent SNF stay, the criteria outlined in the regulation regarding the 30-day transfer rules are not met, and the resident should not be put back on Medicare Part A.
Myth #6: A resident on Medicare Part A in a SNF can never leave the SNF for an overnight leave of absence.
Often, a resident is unable to leave the SNF due to the complexity of the services being rendered in the SNF. That said, a couple of items need to be reviewed before determining if an overnight leave of absence (LOA) is feasible:
- Can the resident safely be away from the SNF, and can the family or responsible party be taught to safely meet the resident’s needs while out of the SNF?
- Are the absences infrequent in nature and not for prolonged periods of time?
Obviously, the first question is important to make sure the resident can be properly cared for during the LOA. It is always necessary to consult with the resident’s physician to notify him or her of the LOA request and get some feedback from the physician’s point of view on whether the LOA is feasible. The second question relates more to being sure that the practical matter criteria also discussed in Chapter 3 is being met. If a resident is able to leave the SNF on a weekly basis for an overnight visit, or if the resident leaves for prolonged periods of time three times per week to attend an off-site bingo game, for example, it is doubtful that the practical matter criterion is being met. Remember, one of the four criteria related to meeting the skilled services requirement in a SNF is the practical matter criterion in Section 30.7 of the Medicare Benefit Policy Manual (Pub. 100-02):
As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF (see §30.7).
That said, although a resident may safely be able to go on LOAs frequently or for prolonged periods of time, the question becomes: Is the SNF the most appropriate place for that resident to receive those skilled services?
Myth #7: You never have to issue more than one notice regarding a Medicare stay at the same time.
If only that were a true statement. There are so many notices that it can be confusing trying to understand which notice is issued under what circumstances. To further complicate things, there are times when more than one notice will be issued at relatively the same time. Chapter 30, Section 261 of the Medicare Claims Processing Manual:
Delivery of the NOMNC does not replace the required delivery of other mandatory notices, including ABNs. Notice delivery must be determined by the individual NOMNC requirements per this section and ABN delivery requirements per §1879 of the Act and per guidance in this chapter. Both the NOMNC and an ABN may be required in certain instances.
This same manual section notes the following example of when both notices would be issued:
A beneficiary’s Part A stay is ending because skilled level care is no longer medically necessary and the beneficiary wishes to remain in the SNF receiving custodial care. The beneficiary must receive the NOMNC two days prior to the end of coverage. A SNFABN must also be delivered before custodial care begins.
Myth #8: There is never an instance where no notice is required at the end of Medicare coverage.
This is untrue! When a beneficiary exhausts his or her 100-day benefit period in the SNF, there is no notice required. The Beneficiary Notification Initiative (BNI) process allows beneficiaries to be notified and have the ability to appeal decisions being made by providers in relation to their Medicare coverage; the end of the 100-day SNF benefit period is not a provider decision, but rather a statutory end of coverage based on the Medicare guidelines, and there is nothing that the beneficiary can challenge or appeal. That said, it is recommended to communicate the end of the 100-day benefit period to the beneficiary, but no formal notice or form is required.
Bolster billing compliance: Implement a Medicare Part A triple-check process
Medicare billing is a domain rife with payer offshoots and evolving regulations that can be difficult to navigate without a strategy to weather claim scrutiny and withstand the gaze of CMS’ various auditing contractors.
Enter the triple-check process, a time-tested internal auditing strategy used by proactive long-term care providers to facilitate billing accuracy and compliance the first time a UB-04 claim form is submitted. As its name suggests, triple check is a layered verification process that involves staff members from billing, nursing, and therapy departments?the three core disciplines required to submit a clean claim. But this sturdy foundation is also pliable, allowing a facility to easily adapt the procedure to the various types of claims it files.
Read on for an expert iteration of the triple-check process, which is modified from the HCPro book The Medicare Billing Manual for Long-Term Care, written by Frosini Rubertino, RN, BSN, C-NE, CDONA/LTC. This specific triple-check procedure is designed to mobilize key staff to ensure accuracy and timely submission of Part A claims.
Procedure
Each month, the SNF will collect all Medicare Part A billing information ready for submission and enlist the following individuals to carry out their designated roles in verifying the accuracy of these items: administrator, director of nursing, MDS coordinator, facility rehab director or designee, business office manager, medical records personnel, and central supply staff.
The following is a breakdown of each of these staff members’ responsibilities in the triple-check process:
Business office manager and medical records personnel
- Verify that the qualifying stay information recorded on the UB-04 aligns with that on the medical records face sheet.
Business office manager
- Verify that each resident has benefit days available in the HIPAA Eligibility Transaction System.
- Verify the admit date on the UB-04 aligns with the date in the manual census log.
- Verify covered service dates listed on the UB-04 align with those in the Medicare and manual census logs.
- Verify that a resident’s financial file contains a signed and completed Medicare Secondary Payer form whenever applicable.
Business office manager and MDS coordinator
- Verify that ADLs are correct and are supported by documentation. Confirm that staff have coded all other contributory items (e.g., mood, IVs).
- Verify that ARDs on each MDS align with the occurrence dates found at form locators (FL) 31?34 on the UB-04.
- Verify that the RUG level listed on each MDS aligns with that found at FL 44 on the UB-04.
- Verify that the assessment type for each MDS aligns with the modifier found at FL 44 on the UB-04.
- Verify that the number of accommodation units listed on the UB-04 aligns with the assessment type for each MDS. Verify that the total number of accommodation units aligns with corresponding covered service dates.
Facility rehab director, MDS coordinator, and business office manager
- Verify that physical therapy minutes listed on the daily treatment grid align with those noted in the service log. Align the days and minutes documented in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
- Verify that each principal diagnosis is accurate, that all secondary diagnoses support skilled care, and that every ICD-9 code corresponds to an appropriate diagnosis.
- Verify that occupational therapy minutes recorded on the daily treatment grid align with those in the service log. Align the days and minutes in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
- Verify that speech therapy minutes listed on the daily treatment grid align with those noted in the service log. Align the days and minutes in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
DON and medical records personnel
- Verify each resident’s need for Medicare skilled intervention by reviewing supporting clinical documentation that corresponds with the dates of service listed in the manual census log.
- Verify that each (re)certification form has been completed and signed by the appropriate physician.
- Verify that each physician order has been obtained and implemented.
- Verify that each chart reflects appropriate charting guidelines. Confirm that charting has been completed at least once in every 24-hour period, relates to skilled service provided, and supports therapy.
Facility rehab director
- Verify that physician orders include rehabilitation.
- Verify that each evaluation notes the prior level of function.
- Verify that clinical documentation contains a progress note establishing the need for continued skilled intervention.
Administrator
- Chair the triple-check meeting (detailed below), and ensure that the entire process is completed by appropriate staff each month before Medicare claims are submitted. Participation in the triple check will allow the administrator to monitor the effectiveness of key operational processes carried out by the facility’s interdisciplinary team (IDT) on an ongoing basis.
Triple-check meeting and audit tool
Each of the SNF’s triple-check participants should complete their respective duties prior to the Medicare triple-check meeting, which will be held monthly before the SNF bills for a given batch of services. In other words, the meeting is not an occasion for staff to complete their initial claim component(s). Instead, it’s a chance for IDT members to cross-check the work of their colleagues by verifying the accuracy of claim items that others have completed, thereby ensuring each element has been studied by multiple sets of eyes.
The triple-check meeting will also serve as the platform for the SNF’s business office manager to document the completion of each integral item on a billing claim using the triple-check audit tool, an internal checklist-type document that will be included in every month-end closing report.
Using this audit tool, the manager will denote items verified as correct during the triple-check meeting with an "X." He or she will mark items identified as incorrect with an "O" and, in the remarks section of the document, record the steps the team will take to obtain the correct information. Items initially found to be incorrect but rectified during the meeting should still be marked with an "O" to better track any practice patterns that could lead to billing slipups and inform future training activities.
The business office manager will call for any claim found to have errors during the triple-check meeting to be put on hold until it is amended. Once staff have made necessary revisions, the manager will indicate these correction(s) and the corresponding date(s) in the remarks section of the audit tool. He or she will then contact a corporate entity to review the changes and ultimately grant approval to submit the claim.
SNF therapy contracts: Your risks and what you need to know Q&A
Editor’s note: The following Q&A was written by Reginald Hislop III.
Q: When we receive proposals from various therapy companies, they all represented that they would increase our Part A and Part B billings. Should this somehow be incorporated into the contract?
A: Yes. Absolutely. If they’re willing to say that to you and they tell you, "That’s the reason why you’re going to go with us is because we’re going to do this," I am going to hold them accountable for that, and I first want to know how you determine that and how are you going to do that because I’m going to tell them right there before we even get to a contract, I’m going to say that they need to fundamentally prove it. How do you know it, how’s it going to happen, and be prepared because yeah, you’re going to put in the contract, you’re going to represent it, it’s going to be legal and you’re going to do it over what period of time? I’m then going to hold them accountable for it.
Otherwise, it becomes a common game of therapy contractors: "We’re going to make your world so much better than the last group that was in here." I’ve never seen a contractor come in and say, "We looked at your last experience with your last therapy contractor and the amount of stuff that they were doing, and by the way, we got to tell you, it really makes us nervous, and fundamentally if you go with us, we’re going to shrink your revenue by 15% because we think there’s a whole bunch of erroneous and falsely billed claims." I’ve never seen that happen. Everybody comes in and says, "Yes, we can improve your performance over this group, and we’re going to do it by a pretty impressive margin, and your revenue is going to go up, your claims are going to go up." I want to know how they’re going to do that, I want it in the contract, and I want full transparency. I want to know over what time period, because without that, they haven’t actually validated they will be able to do that. That’s a standard pitch, and they have never yet been expected in many cases to be accountable for those kind of numbers. It’s just a sales pitch, but, if they’re going to say it, I want it in the contract.
Q: Would the indemnification clause you mentioned, indemnification not just for the therapy component but the whole amount?how can the therapy company indemnify money they did not receive?
A: How can they indemnify money they did not receive? We’re not talking about necessarily indemnification for money they received. We’re talking about indemnification for services that they provided as part of the representation that all of our services that we provide are going to be compliant and in concert with the law. Since the SNF is responsible for that, my responsibility then is to negotiate with that company and say, "By the way, if in fact we’re involved in this work and you’re going to be part of this process and you’re going to have input in terms of what we RUG, what we bill, part of our triple check and all the rest of that other kind of stuff, there is dollars on the table, and anything that you did that was illegal, unethical, or improper that caused us to lose revenue as a result of your actions and your documentation, all those other kinds of things because you’re going to represent to me that you’re going to do this, you’re going to properly manage and supervise your employees and all those other kinds of things, that if in fact you didn’t do that, you’re going to be responsible not just for what we paid you but also for what your bad acts caused this facility." Yes, I can indemnify them for that because they are part and parcel to that. They’re going to represent to me that they’re going to do this the right way, and if they don’t, then they’re going to have shared risk for anything that occurs that they were responsible for or could be tied to them that cost my facility money or my organization money.
Q: How do we hold the therapy provider accountable for an 80% productivity level?
A: You actually monitor their productivity levels. Their treatment records should be open. Their minutes should be open. I should be able to see when they were on-site, what their time was spent on this site, what I was billed for because I’m being billed for their time. And I should be able to go to treatment logs and treatment records and look at what their billing time was and th