Predictive Analytics or Provider Profiling? Call it what you want, is your agency being monitored by CMS and/or state Medicaid etal? And, have you directly triggered an alert? Or, are physicians that sign orders for your agency patients being investigated? Should you be aware that your agency could trigger a PPS RAC, MAC, or Z-PIC audit and that a related party or a referral source under review could trigger an audit of your agency? Yes, that could be a reality. CMS and related agencies are using predictive analytics to identify aberrant care delivery and utilization patterns for PPS. At the time the claim is dropped, an assessment of multiple patient factors is conducted. These factors may include diagnoses, frequency, and disciplines involved in care. Your agency practice patterns are now being compared to peer groups and may include a comparison to validated benchmarks. Physicians who refer to your agency may be having their practice patterns monitored also, especially if the payor source is Medicaid. The Surveillance and Utilization Review Subsystem (SURS) is responsible for monitoring claims process for Medicaid, seeking indicators of fraud. They look for duplicate, inconsistent, or excessive visits in relation to diagnoses and visits provided in State systems. Section 456.25 of Title 42, Code of Federal Regulations writes that "States are required to have a post-payment review process that allows State personnel to develop and review: (1) recipient utilization profiles, (2) provider service profiles, (3) exception criteria; and (4) identifies exceptions so that the agency can correct misutilization practices of recipients and providers." No two state Medicaid systems are the same, thus, there are a variety of post- payment review SUR systems. Some state systems are routinely using tools that can statistically use random sampling with extrapolation for provider reviews. This allows the auditor to identify a current trend and apply the findings retrospectively for a specific past time point. Recoupment dollars can add up quickly using this methodology. The SURS are also using tools that flag inconsistencies and over-utilization of visits in relation to care delivered at those visits. At times, they may be focusing on specific discipline practices. States have different practices. Personnel in the New Hampshire Surveillance and Utilization Review Subsystem (SURS) monitor financial claims for the NH Medicaid plan. SURS review provider claims for fraud, waste or abuse and may refer cases under suspicion to the Medicaid Fraud Unit of the State Attorney General. The unit also recovers overpayments by using predictive analysis algorithms that search its data warehouse for aberrant claim information. "In addition, SURS in New Hampshire also conducts reviews to determine if recipients are inappropriately using certain types of medications." This can trigger other areas of investigative need. Some states are querying relational databases which provide flexible and easy access to years of paid claims and the ability to query real time data along with trending patterns and profiles. The SURS also use exception profiling as a starting point for case development. Ranked reports can quickly identify outliers. A sample profile might include the following elements: -Average patients per agency -Average reimbursement per agency -Average disciplines per patient -Average diagnoses per patient -Average number of patients with labs -Average number of patients with injections -Evidence of upcoding -Evidence of downcoding Medicaid is monitoring payment for care and now closely monitoring physician practices. Agencies need to be certain that they strictly adhere to the regulations for care provision. A physician who is being monitored now can bring review and audits to those for whom he or she may provide referrals. Compliance risks have always existed. But now, agencies need to expand those risk mitigation practices to their referral sources as well as their marketing departments. Be certain you and your referral source philosophies are similar. Quality oriented physicians are also seeking agencies with like philosophies. They too want to improve the patient transition of care. The bad press regarding 78 Texas home health agencies and the linked Texas physician has raised some physicians concerns nationally re this industry. Showcase your agency quality programs and excellent outcomes.
- Work to improve bi-directional communication flow.
- Establish points of accountability for sending and receiving patient information.
- Increase the use of case management and professional care coordination.
- Develop performance measures that encourage better transitions of care that are well documented.
- Let it be known that your agency supports a strong regulatory culture that offers accountability and effort toward solid patient outcomes.
And yet another RAC audit… Section 1902(a)(42)(B)(i) of the Social Security Act requires states to contract with Recovery Audit Contractors (RACs) to identify underpayments and to recoup overpayments as part of the state plan. The Patient Protection and Affordable Care Act required the states to have contracted with one or more RACs by December 31, 2010. Scheduled to begin April 1, 2011, the Medicaid RACs will be a bit different because of the different focus that could be seen by each state. There will be a large list of Medicaid auditors approved by each state. In the September, 2010 Federal Register, CMS posted an “information collection request” about Medicaid RACs. They identified that contracts should be similar to those of the Medicare program. However, states may tailor the Medicaid RAC activities to the specific aspects of the Medicaid program in each state and collectively “propose targeted areas of susceptibility regarding improper payments.” Each state was required to amend their state plans reflecting the RAC program and attesting to a plan in place. This plan must also include Medicaid waiver contracts. The RAC Medicaid requirements remain separate from the Medicaid Integrity Program (MIC) audits, which will continue. The RAC audits are additional Medicaid audits that the law requires to ensure plans under Parts C and D have claims examined for reinsurance payments to determine if the claims costs are in excess of allowable reinsurance costs. RACs are also to look at prescription drug plans for high cost beneficiaries. New York State Medicaid Inspector General is leading the charge in attacking waste, fraud, and abuse, recently reminding home health agencies they “cannot bill for excluded providers or accept orders from excluded providers.” He has identified that many agencies were not appropriately verifying physicians approved for Medicaid payment. In addition, the pressure is on to be certain that diagnosis codes, hospital admission and discharge codes, and procedure codes are all in order in all areas of health care. Coding, once again is at the forefront of audit review for all areas of healthcare. Health care entities should review the annual OIG workplan, and besides the understood areas of risk; diagnoses coding, rehabilitation services, medical necessity, and adequate documentation, they might wish to add Medicaid Hospice services and being certain a process is in place to verify physician orders are not taken from Medicaid excluded physicians. How frequently is the exclusion list reviewed? Risk areas identified by corporate compliance necessitate a policy and procedure to be in place with a method of verifying compliance to reduce corporate risk. Mandated corporate compliance programs are to become a reality in all areas of health care within the next few years. However, more and more organizations realize they need a corporate compliance program in place now. In case of a RAC, MAC, MIC, and especially in case of a Z-PIC or HEAT audit, establishing the view that you are compliance oriented with a compliance plan in place sends a far stronger positive message than you are waiting until a plan is actually mandated. The OIG recently announced they will be reviewing “Medicaid Program Integrity Best Practices” in state Medicaid agencies especially in the areas of coding and payment risks. You may well have Best Practices in clinical areas but do you know that your billing practices follow Best Practices in Medicaid billing? You need to have this assurance. For additional information: http://www.cms.gov/ www.cms.gov/RAC/01-Overview.asp www.RACmonitor.com www.oig.hhs.gov Reminder: RAC facts RACs can review via automated review (no medical record from the agency required) or a complex review which entails a medical record request. The four present CMS approved RACs include: RAC A: Diversified Collection Services www.dcsrac.com email@example.com RAC B: CGI Federal http://racb.cgi.com firstname.lastname@example.org RAC C: Connolly, Inc www.connollyhealthcare.com/RAC RACinfo@connollyhealthcare.com RAC D: HealthDataInsights http://racinfo.healthdatainsights.com email@example.com