What are your agency case mix averages by admission: clinician: diagnosis?

Do you know your top five diagnostic patient profiles?

How do you set visit frequencies? Formula-based or what seems right?

Are you making visits that have no impact on patient outcomes?

Are you auditing for homebound status?

Are you auditing documentation for medical necessity?

What is your cost per visit by discipline?

What is your recertification percentage?

Do you know your supply utilization per patient?

Do supply usage have adequate supportive documentation?

Do you know what coding, operational, or billing edits you are routinely triggering?

How are you applying the data collected to your business processes?

The RACs, MACs, MICs, and Z-PICs are now in place. The auditors are expected to perform. They have been chosen based upon performance.

Algorithms and Matrices are in place using Predictive Analytics.

Per Wikipedia, predictive analytics “encompasses a variety of statistical techniques from modeling, data mining and game theory that analyze current and historical facts to make predictions about future events”.

CMS is using predictive models to identify patterns found in transactional data gathered to identify risks and potential future behaviors.  They are looking at diagnoses in relation to visit frequencies and recertifications. They are looking at HIPPS scores compared to visit frequencies and durations. They are looking at predictive models that capture relationships among many factors to allow assessment of risk or potential associated with a particular set of assessment/care frequency/payments expected. In other words, what are the guiding decision-making factors for agency transactions? This is one reason why there needs to be rhyme and reason for visit frequency and patient diagnoses and care needed.

Predictive analytics look at past performance to assess how likely an agency is to exhibit a specific behavior in the future. That behavior is then compared to other agencies’ behavior in order to calculate risk, then encompasses models that seek out subtle data patterns that  answer questions about that agency’s overall  performance. These analytics quickly become fraud detection models.

The MACs are using predictive models to perform calculations during live transactions to evaluate the risk or opportunity of a given agency transaction, in order to guide a decision. Individual agency modeling systems can simulate likely human behavior or reaction to specific situations.  The new term for animating data specifically linked to an individual in a simulated environment is avatar analytics. Hopefully, CMS is not there yet but gaming experts ARE employed by CMS.

The government is serious about attacking fraudulent behavior. The danger that exists is that some agencies not intending to commit fraud, but who are not auditing their data submitted, may be triggering alerts. Home Health Agencies can no longer afford to provide care without auditing the assessment, the care predicted, and the care provided.

The RACs have also identified that insufficient documentation for medical necessity will be one of the first area of focus for their audits. But, no agency should believe that only therapy documentation will be scrutinized. Skilled nursing with observation and assessment O/A continues to be high on the list for visit and episode denials.

What happens if compliance measures are not employed? Targeted Medical Reviews (TMRs)/(ADRs) Additional Documentation Requests will rise. There will be claim denials and Medicare audits.

CMS has Unleashed the Auditors

Annually, CMS receives 1.2 billion claims. That breaks down to 4.3 million claims per work day, 574,000 claims per hour, and 9,579 claims per minute. Fraud and abuse are on the rise and the pressure is on.

CMS has unleashed the age of the auditor with the advent of the RACs, MACs, CERTs, MICs, Z-PICs, and now, the HEAT.

RACs- The contingency motivated Recovery Audit Contractors (retrospectively focused). The RAC Demonstration Project of 2005-2007 recovered over $1.3 billion, mostly due to medically unnecessary services (45%), incorrect coding (35%), and insufficient documentation (10%). With four RAC approved firms covering specific geographic regions, these auditors are expected to continue their positive recovery program. The RAC demonstration project yielded a cost of only 22 cents for every $1.00 recovered. They are now in place and ready to go at measure. Certain RACs have been held back until all MACs were in place. That is now completed.

MACs – Medicare Administrative Contractors have been transitioning in and replacing the Regional Home Health Intermediaries (RHHIs). There are 15 MACs with 4 focusing only on DME claims. Though providers fear the RACs, they are well aware of the power of the MAC. This auditing body can impose “severe administrative action” such as up to 100% prepayment review, payment suspension, and use of statistical sampling for over payment estimation of claims (current and prospective focus). MACs have power and Congress is encouraging them to use it.

CERTS – (Comprehensive Error Rate Testing) To better calculate the performance of the FIs and MACs, as well as to look at the reasons for their errors, CMS decided to look at a number of additional rates. The additional rates include

—   provider compliance error (how well providers prepared claims for submission)

—   paid claims error rates (measures how accurately FIs and MACs make coverage, coding, and other claims payment decisions). CERTs randomly select a sample of about 100,000 claims each reporting period.

—  CERTs review the claims for proper Medicare coverage, coding, and billing rules, and if not in compliance, they assign an overall error rate.

CERTs also identify if providers received overpayment letters or notices of adjustments to be made for claims that were overpaid and underpaid. CERTs are considered the Quality Improvement specialists who track and trend the performance of fiscal intermediaries and Medicare Administrative Contractors.

Z-PICs – Zone Program Integrity Contractors will perform Medicare Program integrity functions for CMS. They will interact with each MAC to handle fraud and abuse issues within their jurisdictions. ZPICs are seen to consolidate the work of present CMS Program Safeguard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs) and are divided into 7 zones.

The Z-PICs act with the Department of Justice and FBI and act as the investigators when fraud is very strongly thought to have been found. The Z-PICs have the power to suspend claims for up to a year and the agency has no appeal recourse during that time.  That power can cripple or financially devastate an agency.

HEAT –This auditing body is considered the more aggressive investigator of essentially DME and Home Health.  There has been expansion of DOJ/CMS/HHS Inspector General Medical Strike forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay and as recently as September, 2011, they have struck, arresting 91.

The HEAT is the technologically oriented auditing body using state of the art analytics to expand the CMS Medicaid provider audit program. This program leadership has meetings with top anti-fraud leaders in Congress/Law enforcement/Private sector.

CMS states that their mission includes, “providing additional resources to our civil enforcement efforts under the False Claims Act to increase dollars recovered; data sharing, including access to real time data; detect patterns of fraud through technology; strengthening partnerships among Federal agencies between public and the private sectors.”

Clearly, with all of the auditing bodies, CMS is making a bold statement; fraud and abuse will not be tolerated.. Unfortunately, in this kind of environment, innocent casualties can occur. Agencies need to take action now.

Can Audits be Prevented?

Maybe not, but exposure for paybacks can be limited by enacting solid compliance measures.

Prepare now. Be aware of what other providers have faced with auditors.

Be certain a clinical documentation chart audit is available for all disciplines for clinical records.

The following items should be included in every clinical note:

Homebound status: Identify what taxing effort was exerted if a patient left the house since the last clinical visit. Be certain all assistive devices are listed and/or the caregivers needed, the purpose for leaving the home, and if this was expected and/or a part of the careplan.

Identify what skilled the visit. If teaching was conducted, was it initial teaching, reinforcement teaching, or was it re-teaching? Identify in objective terminology measureable progress towards goals; ie for the psych nurse, what evidence toward cognitive structural behavior was identified? For physical therapy, how many feet were walked since the last visit and where does this relate to the plan? For the SN, did the patient identify at least two key side effects for their medications? Does the patient know what their medication is for and what it is expected to do for them? Do they know how to safely take their medications?

Compare the Visits to the POC: Compare the visit note to the plan of care that is developed by the clinician based upon the assessment. Have physician orders or notification for changes in condition. Note all change of condition clearly.

SN should be reviewing the body systems noting VS and pain assessments.

When Teaching: Note if the teaching is New, Reinforced Teaching, or Reteaching of the same subject to, perhaps, another caregiver. Note the caregivers willingness and capacity to learn and carry out the learning skills. Note the patient and caregiver’s learning in percentage; ie 70% or 80%.

Interdisciplinary communication: Comments to the physical therapist or the home health aide or other disciplines should be clearly noted. The visits should show the progress of the care in relation to the plan of care.

Specificity of wounds, skin conditions, falls risk, depression, and the focus of care are necessary. Auditors look for detail; for reasons that support skill. No skill can mean denial of visit payment.

For Diabetics Receiving Insulin

Be certain homebound status is clearly and adequately documented.

Skilled Visits must have skill identified such as specific instructions.

Return demonstration responses by the patient or caregiver should be documented. Note the patient or caregiver’s ability to follow their diet. Give examples to support diet and meal planning learning.

Caregiver willingness and availability should be specifically noted on each visit.

More Strategies

Review all claims against known edits prior to submission.

Have a system that prevents claims from being submitted without a signed physician order.

Counsel and hold clinicians accountable for accurate, complete, and concise documentation that matches the planned care expectation.

Clinicians must now be aware that surveyors are looking at their assessments, discipline specific plan of care, the overall plan of care, the visit documentation outlining care provided and patient response, and the outcomes at the episode conclusion. The diagnoses listed in M1020/M1022 must be compliant with ICD-9 coding guidelines, be unresolved, must read as the table of contents for the clinical record, and must be supported by the clinical documentation.

RAC auditors use clinicians and coders on their team to provide more specific auditing. Ask your clinicians: could their visits withstand that kind of auditing review?

Establish peer review sessions at your agency. Proud clinicians want their peers to think highly of them. Peer Review audits can be an excellent defense against an audit, not only because they can be enlightening to clinicians as to what is expected, but because they can be a motivation for excellence.