Viewing posts categorised under: Payment Updates

Credit Balance Overpayment Refunds: Auditing and Documenting Best Practices

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Clinical Practices, Payment Updates

Credit Balance Overpayment Refunds: Auditing and Documenting Best Practices

Do you have Risk? High risk is not the way you want to start out in the New Year. Free Auditing & Best Practices Documentation Checklist!

 
Failure to return an overpayment can be a violation of the False Claims Act. CMS expects agencies to have indicators of overpayments in place. Ignorance is not an acceptable excuse. Agencies are to return an overpayment within 60 days of identification or face serious potential consequences. What is an Overpayment? According to the Social Security Act, Section 1128J, any funds that a person/agency receives or retains under Title XVIII or XIX to which the person, after applicable reconciliation, is not entitled, constitutes an overpayment. These can include claims for services after benefits have been exhausted, payment for non- medically necessary services, duplicate payments, and payment of claims that exceeded a reasonable charge. Watch out for Credit balances! These are usually caused by contractual “over adjustments,” misapplication of payments, and overpayments. Your agency should have policies and procedures in place to identify and analyze your current credit balance landscape. Create a report with the current aging balance, account identifiers such as account numbers, list all payors whose funds were credited to the account, list dates of service and all charges coupled with payment dates, names and amounts. Periodically perform an audit of your agency processes to be certain any overpayments in the credit balance landscape are identified. You must consider, if the individuals conducting the audit are qualified to do so, what methodology will be employed to identify the overpayments, and do you have a current process to return the overpayments? Do you have adequate QA and root cause oriented processes? Evaluate the sufficiency and effectiveness of the controls necessary to ensure refund and reporting within the 60 days of identification. Be certain your agency can validate the accuracy of the credit balance reports used for operational management and agency compliance oversight. Monitor on an ongoing basis. Be certain policies and procedures meet current regulation requirements. Make certain resolutions are accurate and be certain the controls are functioning as expected. Be certain to note how each error was found, as required in the 60 day repayment rule. Complete the Corrective Plan of Action and the reason for the refunding of the overpayment. Have the OIG Self Disclosure protocol in place with the description of the methodology used. Under the Final rule providers may use “an applicable claims adjustment, credit balance, self-reported refund or another appropriate process to satisfy the obligation to report and return overpayments.” Remember, lack of compliance with the regulation can result in fines of up to $11,000 for EACH improper payment received and not returned going back 6 years. To download the Auditing & Documentation Best Practices Checklist fill out the information below

For more information regarding Revenue Cycle Management and billing/collection for your agency, contact Carla Putnam at Select Data 1.800.332.0555
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Credit Balance Overpayment Refunds: Auditing and Documenting Best Practices. Starting the New Year Right!

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Audits, Clinical Practices, Compliance, Legislation, Payment Updates

Credit Balance Overpayment Refunds: Auditing and Documenting Best Practices. Starting the New Year Right!

Do you have Risk? High risk is not the way you want to start out in the New Year.

 
Failure to return an overpayment can be a violation of the False Claims Act. CMS expects agencies to have indicators of overpayments in place. Ignorance is not an acceptable excuse. Agencies are to return an overpayment within 60 days of identification or face serious potential consequences. What is an Overpayment? According to the Social Security Act, Section 1128J, any funds that a person/agency receives or retains under Title XVIII or XIX to which the person, after applicable reconciliation, is not entitled, constitutes an overpayment. These can include claims for services after benefits have been exhausted, payment for non- medically necessary services, duplicate payments, and payment of claims that exceeded a reasonable charge. Watch out for Credit balances! These are usually caused by contractual “over adjustments,” misapplication of payments, and overpayments. Your agency should have policies and procedures in place to identify and analyze your current credit balance landscape. Create a report with the current aging balance, account identifiers such as account numbers, list all payors whose funds were credited to the account, list dates of service and all charges coupled with payment dates, names and amounts. Periodically perform an audit of your agency processes to be certain any overpayments in the credit balance landscape are identified. You must consider, if the individuals conducting the audit are qualified to do so, what methodology will be employed to identify the overpayments, and do you have a current process to return the overpayments? Do you have adequate QA and root cause oriented processes? Evaluate the sufficiency and effectiveness of the controls necessary to ensure refund and reporting within the 60 days of identification. Be certain your agency can validate the accuracy of the credit balance reports used for operational management and agency compliance oversight. Monitor on an ongoing basis. Be certain policies and procedures meet current regulation requirements. Make certain resolutions are accurate and be certain the controls are functioning as expected. Be certain to note how each error was found, as required in the 60 day repayment rule. Complete the Corrective Plan of Action and the reason for the refunding of the overpayment. Have the OIG Self Disclosure protocol in place with the description of the methodology used. Under the Final rule providers may use “an applicable claims adjustment, credit balance, self-reported refund or another appropriate process to satisfy the obligation to report and return overpayments.” Remember, lack of compliance with the regulation can result in fines of up to $11,000 for EACH improper payment received and not returned going back 6 years. For more information regarding Revenue Cycle Management and billing/collection for your agency, contact Carla Putnam, VP, RCM, Select Data 1.800.332.0555
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more. Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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New Bundled Payment Projects

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Legislation, Payment Updates

 

New Bundled Payment Projects: Get Prepared Now or Risk being Passed Over by the Hospitals

Agencies should prepare NOW developing Cardiac and/or Orthopedic Best Practice programs if they are not already present. Conduct statistical analysis reflecting outcomes. Demonstrate your agency’s value and strengths to that acute care hospital. If you already have a program, run the analytics. Show the value of your Agency’s specific care.

 

On July 25, 2016, CMS released the proposed rule stating they intend to test new bundled payments to Hospitals for the following diagnoses: Myocardial Infarcts (MIs), Coronary Artery Bypasses (CABGs), and Surgical Hip/Femur fractures. This proposal is similar to the Comprehensive Care for Joint Replacement (CJR) model that began the Spring of 2016. That proposal made hospitals responsible for the first 90 days of cost following hospital discharge for that condition. CMS has been pleased with the results thus far.

The new models would run from July, 2017- 2021 and like the CJR model, the hospital providing the procedure would be held accountable for costs and quality of care from surgery through 90 days post acute care. Of course, the hospital will be able to choose the post acute providers.

Agencies should prepare NOW developing Cardiac and/or Orthopedic Best Practice programs if they are not already present. Conduct statistical analysis reflecting outcomes. Demonstrate your agency’s value and strengths to that acute care hospital. If you already have a program, run the analytics. Show the value of your Agency’s specific care.

How to Show YOUR AGENCY’s Value

Gather emergent and rehospitalization data such as number of patients cared for and the resulting rehospitalization admission rate. Be prepared to discuss what makes your Cardiac program successful and why your agency will be an excellent partner.

CMS will choose 98 markets by random selection. Those hospitals working with post acute care providers including physicians are expected, by CMS, to deliver care that is at a “quality adjusted target price, while meeting or exceeding quality standards, and would be paid the savings achieved.”

For the Surgical Hip/Femur Fracture Treatment, that model will be placed in 67 areas where the CJR is ongoing. This looks to be an add-on to the present project. This diagnosis is the eighth most common discharge diagnosis for Medicare fee for service patients in a hospital. CMS has noted that mortality rates associated with this diagnosis is 5%- 10% after 1 month and approximately 33% at a year.

Sources

Centers for Medicare & Medicaid (2016). Bundled Payments for Care Improvement (BPCI) Initiative: General Information. CMS.gov. Retrieved from: https://innovation.cms.gov/initiatives/bundled-payments/
For clinical record document review and coding services that can assist you with these models and more, CONTACT SELECT DATA at 1.800.332.0555

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Pre-Claim Review Demonstration

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Legislation, MACs, OASIS, Payment Updates

 

Pre-Claim Review Demonstration

Effective August 1, 2016, CMS institutes Pre-Claim review in Five States. The demonstration will begin no earlier than August 1, 2016 in Illinois, no earlier than October 1, 2016 in Florida, and no earlier than December 1, 2016 in Texas. The demonstration will begin in Michigan and Massachusetts no earlier than January 1, 2017.

 

Pre-Claim Review Begins in Five States: August 1st is the First Date, Illinois is the First State

Effective August 1, 2016, Home Health Agencies in five states will begin the three year Medicare pre-claim review demonstration by which an agency will complete the patient assessment, initiate procedures, and establish services then submit a request via fax, mail, or electronic submission of medical documentation to the respective MAC for approval prior to the submission of the final claim. The MAC is expected to provisionally approve or disapprove the services within 10 business days. If the MAC denies the payment, the agency can resubmit a new request

What is the Difference between Pre-Claim and Prior Authorization?

Per CMS, with a Pre-Claim review, services have already begun and the request is submitted after assessments and services have been completed or begun. Prior Authorization requires a request prior to services being initiated. CMS states this new requirement is not creating new documentation requirements. The agencies are to submit the same information they currently submit for payment, but do it earlier in the process.

What States are Included in the Demonstration?

The demonstration will begin no earlier than August 1, 2016 in Illinois, no earlier than October 1, 2016 in Florida, and no earlier than December 1, 2016 in Texas. The demonstration will begin in Michigan and Massachusetts no earlier than January 1, 2017. (Pre-Claim Demonstration for HH FAQ, 6/8/2016)
The demonstration is expected to have minimal effect on beneficiaries per CMS. The Pre-Claim request is submitted after a RAP but before the submission of the final claim. However, some agencies have expressed concern, stating that in an already fragile bottom line market, any further delay of payment could be harmful to the agency’s financial health.
CMS states the five states chosen “show extensive evidence of fraud and abuse in the Medicare home health benefit for treatment performed in these states” (CMS Pre-Claim Demonstration for HH, FAQ, 6/8/2016).

Decision, Documents Needed, and Options

For pre-claim review, the MAC will make the determination using regulation, National Coverage Determination, and Local Coverage Determination requirements. The MACs will be expected to respond within 10 business days for an initial request and 20 business days for a resubmitted request following a denial.
Resubmissions may be sent an unlimited number of times as necessary, but obviously, the agency will want to get the appropriate information submitted up front to minimize payment delays. There will be a tracking number on each decision notice and that number will be used on the claim.
CMS states that, generally those claims that had the provisional review will not have additional review. However, note that Z-PICs conduct targeted prepayment and post payment review which will continue and CERTS review a stratified random sample of claims annually to identify improper payments. That CERT sample may include the pre-claim reviewed items also.
If an agency would be denied payment and after resubmission still receives denial, they could follow the appeal process. If an agency submits a claim without a pre-claim review, per CMS, if that claim is deemed payable, it will be paid at a 25% reduction of the full claim benefit. Obviously, an agency would have serious financial if that became the agency process.

Sources

Centers for Medicare & Medicaid (2016). Pre-Claim Review Demonstration for Home Health Services. CMS.gov. Retrieved from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html
For Start of Care document reviews that includes OASIS review, H&P, med profile, clinician visit assessment and visit documentation review, as well as F2F comment along with ICD-10 coding, CONTACT SELECT DATA at 1.800.332.0555

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Therapy Changes: Visit Counting and Case-Mix

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Case-Mix, Coding, Payment Rates, Therapy

January 1, 2015 found many changes occurring in the Home Health industry. Many of those changes involved therapy. The therapy reassessment changes of 409.44 became effective for episodes that began on or after January 1, 2015. The new regulations require a qualified therapist, not an assistant, to provide the Home Health beneficiary functional and therapy service reassessment at least every thirty (30) days. When fulfilling that assessment requirement, agencies should pay attention to documentation of BOTH long and short term goals. MACS, such as Palmetto, have been honing in on documentation and reinforcing that requirement.  Local Coverage Determination (LCD) of Palmetto states that long and short term goals must be stated in “objective measureable terms and the date of their accomplishment.” Be certain all components are present or risk denials of claims. January 1, 2015 also saw the end of case-mix attachment for nearly 200 diagnoses. Those included certain delusional disorders, depression, schizophrenia, profound impairment of both eyes, and dementia to name a few diagnoses losing that case-mix attachment. Certain blood disorders such as 281, 282 anemias, CA of the lip and CA in-situ, diabetes and specific GI disorders with ostomy have case-mix attached if there are 14+ therapy visits and OASIS items are answered in a specific manner: M1030 (1,3) M1342 (3), M100 (2,3,4), M1620 (2,3,4,5). The following diagnoses have been changed with no case-mix unless there are 0-13 therapy visits and specific OASIS answered items: diabetes 250, heart disease and HTN Ischemic heart disease 420, 411, 414 CAD unspecified vessel, 428, 403-405 (Early episode only). The following OASIS items also must have the following answers: M1242 (3,4), M1810 (1,2,3), M1860 (1,2,3). Therapy will play a key role this year for agencies clinically and financially and for patients and outcomes achievement. Educating clinicians will be vital, so that accurate OASIS answers are present. An incorrect OASIS answer and a coding error could cost your agency hundreds of dollars. For more in depth review: See Final Rule, Table 8 Case-mix Adjustment Variables and Scores Federal Register Vol 79, Number 215 November 6, 2014 Health and Human Services. Who is watching out for your agency? Contact Select Data for further information at (800) 332-0555.

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