$3700 Manual Medical Review: What Have We Learned? Your Speaker

8/16/2013
$3700 Manual Medical Review:
What Have We Learned?
Illinois Health Care Association
63rd Annual Convention and
Trade Show
Wednesday, September 11, 2013
10:00 a.m. – 11:30 a.m.
Your Speaker
Betsy Anderson, President
FR&R Healthcare Consulting, Inc. Frost, Ruttenberg & Rothblatt, P.C.
111 Pfingsten Road, Suite 300
Deerfield, IL 60015
Main: (847) 236‐1111 or (888) 377‐8120
Direct: (847) 282‐6307
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banderson@frrcpas.com
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Your Speaker
Marilyn Mines, RN, BC, RAC-CT
Senior Manager
g of Clinical Services
FR&R Healthcare Consulting, Inc.
Frost, Ruttenberg & Rothblatt, P.C.
111 S. Pfingsten Road, Suite 300
Deerfield, IL 60015
mmines@frrcpas.com
Main: (847) 236-1111 or (888) 377-8120
Direct: (847) 282-6416
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Your Speaker
Rick Speas PT MHSA
Sr. Vice President
The Comprehensive Group
A HealthPro Company
3703 West Lake Avenue
Suite 200
Glenview Il. 60026
rspeas@comprehensiveonline.com
847-904-5060
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An Overview
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Role of the Therapy Provider
 Therapy provider is an essential partner in the Manual Medical Review (MMR) process
 Communication is key to ensure timely submissions and reimbursement
 Roles and responsibilities of therapy and facility personnel should be clearly defined
 Participation on interdisciplinary team is mandatory
 Billing office
 Nursing
 Therapy department
 Medical Records  Administrator
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Rehab − The First Steps
 Educate, Educate, Educate
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Administration, Business Office, Social Services,
MDS, Residents/Families
Rehab and Administration have roles defined
Rehab and Business Office have clear lines of communication and paperwork
Clear processes for benefits verification and determination of prior utilization
Review and Auditing Processes
Triple Check 7
Keys to Success
 Assure that therapy documentation
 Justifies services
 Supports diagnosis and continuation of treatment
 Describes patient’s progress and response to intervention
 Supports appropriate reimbursement
 Protects provider’s legal interests
 Obtain prior therapy utilization information and dollars billed on admission and notify therapy department
 Project therapy utilization when evaluation completed
Project therapy utilization when evaluation completed
 Monitor utilization (dollars) within facility weekly
 Establish tracking process for therapy services that will exceed the $3700 threshold
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Keys to Success
 Education
 Establish policy and procedure for pre‐review of p y
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documentation prior to reaching $3700 threshold and re‐review at selected amount ($5000)
 Set mandatory review amount ($2200 ‐$2700)
 Identify team member(s) to audit documentation
 Identify point of contact for internal and external communication
 Coordinate the tracking system with a communication structure
 Audit, Audit, Audit!
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Documentation Preparation Process
 Develop a Documentation Submission Checklist that includes:
 Amount of Part B dollars used at date of submission
 MD orders for therapy
 Therapy evaluation with MD signature
 Daily and Progress Notes
 Recertification if applicable
 Service Log (dates of service with CPT codes and units)
Service Log (dates of service with CPT codes and units)
 Electronic signature page if applicable
 Number of visits requested for which dates
 Rationale for continuation of service
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Documentation Review Process  Qualified team member(s) reviews submitted documentation within pre‐determined time frame (48 hours)
 Audit review results returned indicating the following:
 If reason for request supports medical necessity and continued skilled intervention
 If all documentation is complete and accurate
 If supportive documentation (nursing notes) supports If supportive documentation (nursing notes) supports
additional therapy
 Comments regarding quality of documentation content
 Approval or denial of additional sessions (specify number)
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ABN Utilization
 CMS indicated that providers may not issue “blanket” ABNs to all patients when they reach the $1,900 cap or $3,700 medical review threshold
 Therapists must use clinical judgment to determine if care is medically necessary over the cap
 If service IS medically necessary, no ABN issued, use KX modifier on the claim
 If services is deemed not medically necessary, ABN should be issued and GA modifier 12
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ADR Process
 All claims submitted with Part B therapy services that 
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exceed $3,700 for PT and ST combined and OT separately are subject to Pre‐payment review in the state of Illinois
RACs will review the claims
ADR will be sent to the provider by the MAC with instructions to send records to the RAC
RAC will have 10 business days after receiving records to conduct prepayment review
Provider will receive review results letter
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Internal ADR Process
 Inform interdisciplinary team when records request 
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received
Provide copy of letter which includes dates of service being reviewed
Develop and follow an accountability checklist for each team member with responsibilities and completion dates
Utilize a record checklist to assure that all documents are present and reviewed to assure quality and compliance
Must return records in 30 days…DON’T WAIT!
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Why MMR?
 In 2011 Medicare insured 48 million people and paid $5.7 billion dollars to provide outpatient therapy services (PT,OT,ST) for 4.9 million beneficiaries
 In 2011 Medicare total spending was $565 billion  Between 1998 and 2008 Medicare expenditures for outpatient therapy increased at a rate of 10.1% per year while number of Medicare beneficiaries receiving th
therapy services increased by 2.9% per year
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 OIG and HHS previously reported that outpatient therapy us susceptible to improper payments and fraud
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Why MMR?
 2011
 Medicare spending for outpatient therapy has increased from $1.3 billion in 1999 to $5.7 billion in 2011
 80% of the 4.9 million Medicare beneficiaries who used OT and PT/SLP did not exceed annual cap of $1870.
 20% of Medicare beneficiaries using outpatient therapy (980,000 individuals) exceeded the cap and spent on average $3000 on outpatient therapy
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 Therapy in nursing homes and private practices offices accounted for over 70% of services
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What Have We Learned?
 Government Accounting Office (GAO) was mandated by the Middle Class Tax Relief and Job Creation Act of 2012 to report on the implementation of the MMR process.
 Report published in July, 2013 describes:
 CMS’s implementation of the 2012 MMR process
 Number of individuals and claims subject to MMRs and b
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the outcomes of these reviews
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What Have We Learned?
 MACs reviewed an estimated total of 167,000 preapproval requests and claims for outpatient therapy services above the $3700 threshold from 10/01/12‐12/31/12.
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 110,000 were for pre‐approvals affirmed  57,000 were claims submitted without prior approval
 MACs affirmed 73% of pre‐approval requests  MACs affirmed one third (34%) of claims submitted without prior approval
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 CMS estimated that over 115,000 beneficiaries affected by 2012 reviews
 Strong quality and compliance systems should have yielded 90+% preapproval affirmations
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What Have We Learned?
 MACs not able to process all pre‐approvals submitted in a 
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timely manner
MACs estimated they completed MMRs for about 52% of the total preapproval requests received within the 10 days required by CMS
MACs are still completing reviews of the claims submitted without preapproval requests and beneficiaries affected by the prepayment MMRs will continue to increase in 2013
Uncertainty remains about final outcomes of the mandated MMRs due to inconsistencies on how data collected, errors in calculations, time lag in claim submission and lengthy appeals process
Final outcome in 2014
Looking Ahead…
 Communication among interdisciplinary team members will be essential to assure compliant documentation and appropriate reimbursement
 Potential for inconsistency increases liability and risk
 Current Environment
 Government audits increasing in breadth and depth
 Increasing concern over necessary resources at provider llevel to respond lt
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 Increasing concern over financial capital at system and organizational level to coordinate responses
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Putting it into Action
Medically
Justified
Services
Billing Triple
Check
Ensure MMR
Reimbursement
PreSubmission
Approval
Process
Interdisciplinary
Communication
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RACs and Therapy Reviews
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Part B − Manual Medical Review
• The threshold remains at $3,700 for PT/SLP and OT for 2013
• All claims reaching the threshold are automatically sent an ADR
– Until March 31, 2013 the ADR was reviewed by the MAC or FI
– Beginning April 1, 2013 the Recovery Audit Contractors took over the review process
took over the review process
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Part B − Manual Medical Review
• The FI or MAC identifies the claims which exceed the threshold for therapy services and send the provider an ADR
• The documentation is sent by the provider to the RAC for review
• Pre‐payment review takes place in the Recovery Audit Prepayment Review Demonstration states, which include: Illinois, California, Florida, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania, and Texas
– Payment made after review and approval
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Part B − Manual Medical Review
 In all other states the review will be done post‐
payment
 MAC/FI will pay the claim and send the ADR to the provider
 Provider will send the documentation to the RAC
 RAC will notify the MAC/FI of the results
 If the claim is denied, the MAC/FI will recoup the money
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Responding to an Audit
 Establish a single point person for communications with auditor Establish a single point person for communications with auditor
(always have a backup)
 Review the request to determine appropriateness
 Many hospitals have reported RAC requests for medical records outside the allowed scope for RACs
 Also receiving medical review requests more frequently than allowed by law
allowed by law
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Preparing the ADR Packet
 Review the ADR letter carefully for what is being requested
 Before the information is submitted verify:
 Time periods
 All requested information has been included
 Correct beneficiary
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Preparing the ADR Packet
 Beneficiary name and HIC number on each sheet
 Time period on each sheet
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 Include a copy of ADR on top of the packet
 Include a copy of the as‐filed UB‐04
 Include a cover letter
 Make sure all copies are legible
 Include facility name, address, provider number, contact Include facility name address provider number contact
person name, and phone number in the packet
 Keep a copy of the entire packet
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ADR Guidelines
 In general, paper medical records must meet the following requirements:
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 Free of staples and paperclips
 Pages should be top faced and face up
 Photocopy must be of good quality and legible
 Include a copy of the Additional Documentation Request Letter (medical record request letter)
 Records may be copied on both sides; top faced and face up
 NOTE: always check the MAC/RAC requirements for ADRs before submitting
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Things to Remember Regarding Medical Documentation
 Send everything they ask for
 Don’t send extra documentation
 Send documentation for the correct time periods only
 Ensure MDSs that were utilized to establish the assessment reference date (ARD) are included
 If amending medical records, always sign and date the If amending medical records always sign and date the
amendment per facility policies
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Advance Beneficiary Notices (ABNs)
 Beginning January 1, 2013, providers were not to issue ABNs when the therapy cap or threshold will be reached
 There is no beneficiary liability for these services
 If the therapy claim is denied during manual medical review, it is provider liability only
 Issuing a voluntary ABN under previous guidance may actually be held liable for denied services
actually be held liable for denied services
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CMS‐R‐131
 SNFs should use the CMS‐R‐131 when a Part B service is discontinued
 Discontinuing one therapy modality
 Reducing the frequency of the therapy
 Discontinuing all Part B services (issue NOMNC as well)  Notice not needed if the discontinuation or reduction is due to a change in physician orders
 As a mandatory use, the CMS
As a mandatory use the CMS‐R‐131
R 131 is for Part B and is for Part B and
hospice only in a SNF
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CMS‐R‐131
 The form was recently updated; no significant changes were made
 The new form was required as of January 1, 2012
 The new form is recognizable by the “03/11” in the lower left‐hand corner
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Effective Delivery
 ABN delivery is considered to be effective when the notice is: 1 D li
1. Delivered by a suitable notifier to a capable recipient db
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and comprehended by that recipient. 2. Provided using the correct OMB approved notice with all required blanks completed.  Failure to use the correct notice may lead to notifiers being found liable since the burden of proof is on the notifier to show knowledge was conveyed to the
notifier to show knowledge was conveyed to the beneficiary according to CMS instructions. 3. Delivered to the beneficiary in person if possible. 34
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Effective Delivery
 ABN delivery is considered to be effective when the notice is: 4. Provided far enough in advance of delivering potentially noncovered items or services to allow sufficient time for the beneficiary to consider all available options. 5. Explained in its entirety, and all of the beneficiary’s related questions are answered timely, accurately, and completely to the best of the notifier’s ability. 6. Signed by the beneficiary or his or her representative.
Source: Medicare Claims Processing Manual Chapter 30, Section 50.7.1 35
Other Delivery Options
 In circumstances when in‐person delivery is not possible, notifiers may deliver an ABN through one of the following means means
 Telephone contact  Mail  Secure fax machine
 Internet e‐mail  All methods of delivery require adherence to all statutory privacy requirements under HIPAA; the notifier must
privacy requirements under HIPAA; the notifier must receive a response from the beneficiary or his or her representative in order to validate delivery
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Other Delivery Options
 When delivery is not in‐person, the notifier must verify that contact was made in his or her records; in order to be considered effective, the beneficiary cannot dispute such contact
 Telephone contacts must be followed immediately by either a hand‐delivered, mailed, e‐mailed, or faxed notice  The beneficiary or representative must sign and retain Th b
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the notice and send a copy of this signed notice to the notifier for retention in the patient’s record 37
Communication
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Communication Issues
 Information must flow between therapy, billing and the clinicians
 How is this communication done in your organization?
 Medicare meeting?
 Other meeting?
 E‐mail or other communication?
 Consider HIPAA issues
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Therapy to Billing
 Therapy must communicate with billing all required information for on the UB‐04, such as
 HCPCS codes
 Dates of service
 Number of units
 Necessary modifiers
 Diagnoses for therapy
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Billing to Therapy
 Billing must let therapy know when a claim has been flagged for medical review and the status of the review
 Date ADR received and due date for medical records
 Status of review
 Due date for appeals, if appropriate
 How is your organization tracking prepayment reviews?
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Therapy and Clinical Staff
 Must communicate the discontinuation of therapy
 Also inform social services or billing to issue proper notice(s)
 When resident is discharging from Part A to Part B
 Is there a clinical need that can keep them in a Part A stay
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Therapy and the Triple Check
Process
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A Proactive Approach to Compliance
 A process conducted to review all data prior to submitting a Medicare or third party payer claim to ensure accuracy and appropriateness of the claim
 Includes both Part A and B claims as well as Medicare Advantage and managed care
 Especially important with therapy claims exceeding the caps  A system that ensures all elements required for third p yp y
party payer reimbursement are in place prior to billing
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Importance of the Triple Check
 With continued improvements and advances in technology, simple reviews can be conducted by contractors and third party auditors  With great ease, conflicts or inaccuracies can be identified, resulting in repayment issues and/or further scrutiny
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Importance of the Triple Check
 When aberrant billing patterns are identified, various auditors will look at the available information and choose a chart sample for review
 Diagnosis to support Medicare coverage
 Documentation to support skilled therapy
 RUG utilization
 Length of stays
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 Correct hospital stay dates and assessment indicators
 Ancillary charges
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Importance of the Triple Check
 Once a sample is chosen, the following will be reviewed
 Services reasonable and necessary
 Services billed were ordered by the physician
 Therapy was provided at the appropriate level
 Supporting documentation for all services reimbursed
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Importance of the Triple Check
 Once a sample is chosen, the following will be reviewed continued
 Therapy did not continue past the prior level of function
 Unless maintenance therapy warranted (per Jimmo settlement)
 Therapy was not continued with residents unable to participate
 Skilled nursing services were required on a daily basis
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Importance of the Triple Check
 Once a sample is chosen, the following will be reviewed continued
 Diagnosis is physician documented and active
 Physician orders are legible, dated by the physician, and appropriately indicate the need for coverage
 Proper beneficiary notices were given
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Importance of the Triple Check − Be Proactive
 Identify
 Technical errors, such as incorrect or missing dates
 Documentation errors, such as incorrect or missing therapy functional G‐codes
 Process errors, such as missing or late beneficiary notices
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Conducting a Triple Check  May be done as a group
 May be done individually by the various disciplines y
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and reviewed as a group
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Components of the Triple Check
 Choose staff members
 Identify claims for review
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 Review the details of the claims and supportive documentation
 Correct errors before submitting the claim
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Choose Staff Members
 Billing personnel
 Therapy representative
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 MDS coordinator (when an MDS completed for Part B 
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residents)
Medical records (optional)
Nursing personnel
Administrator
Ancillary service personnel such as supply coordinator
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Identify Claims for Review
 It is suggested that all of the claims be reviewed initially to determine if a pattern is identified
 Incorporate this process into the required monitoring and auditing element of your compliance program
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Selection of Claims
 Sample a variety of claims each month, both Medicare Part A d P t B d th thi d
A and Part B and other third party payers
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 Can include a focus on therapy claims which exceed the cap
 Be sure to include claims with each therapy discipline provided
 The number of claims to choose will depend on the size and volume of the census payer mix and the frequency or patterns of errors found
 If you find very few errors, a smaller sample can be selected for the next self‐audit
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Review Documentation
 When reviewing documentation it is important to check
 Is it being completed?
 Is it being completed on time?
 Is it being completed correctly?
 Is it being completed correctly every time?
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Properly Completed
 How documentation is completed will vary by document but in general, the following should be reviewed
 Was it completed in the required time frame?
 Is it properly signed and dated?
 Is it filed correctly?
 Can it be immediately located if requested during an on‐site audit?
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Review Medicare Claims
 If any discrepancies are found, they need to be investigated then corrective action taken
 Adjustment claim
 Cancel claim
 Discussed with business office manager or CFO
 Compliance issues documented
 Process changes
 Additional education
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Correct Errors Before Submitting the Claim
 If there is any area of review that is inconsistent, correct as necessary
 If needed the MDS should be corrected, submitted and must be accepted prior to submitting the UB04
 Amend medical records and therapy documentation appropriately
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The Process – Part B Claims
Review
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Review the Details of the Claims and Supportive Documentation
 Each person should review the areas on the claim that are within their area of expertise
 Since the emphasis is slightly different for the Part A, Part B, and third party payer claims, the staff should be familiar with their responsibilities for each type of claim
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Billing Staff
 Part B/outpatient third party
 CWF verification
 MSP possibility has been examined and is on file
 Service dates agree with census dates
 Unit billing methods
 Modifiers 59/KX documented and included
 G codes documented and included
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Therapy Personnel
 Part A, Part B, third party payers
 Evaluation includes prior level of function
 Plan of treatment is signed and dated
 Therapy orders signed and dated
 Clarification orders completed as necessary
 Delivery of services matches the physician orders
 Documentation includes  Resident’s response to the modalities
 Number of minutes delivered
 Indication of progress toward established goals
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MDS Coordinator/DON or Nursing Representative
• Part B/third party outpatient
 If an MDS has been completed, deficits are indicated
 Units billed match those on the therapy logs for the modalities billed
 Services rendered were reasonable and necessary
– All services billed to the Medicare program were • Ordered by a physician
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• Provided as ordered
• Documented as provided
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MDS Coordinator/DON or Nursing Representative
• Part B/third party outpatient, continued
– The intensity of therapy services was medically necessary
– There are measurable goals
– Progress toward goals is clearly documented
– Therapies were not continued past prior level of function
– Residents on therapy were able to participate in therapy
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Billing Staff − Post‐Billing Checks
• Review FISS for return to provider (RTP) claims
• Review FISS for ADRs
• Record all payments in the accounts receivable
• Investigate all denials including partial denials
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Administrator Oversight
 Part A, Part B, third party payer
 Ensure the process is on‐going and timely
 Review results of nursing and therapy documentation findings and ensure corrective action has been put in place
– Review results of beneficiary notices reviews and ensure corrective action has been put in place
– Provide oversight and guidance as needed
Provide oversight and guidance as needed
– Incorporate findings into corporate compliance program
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Reviewing the Process
 Periodically review the entire triple check process to ensure it is being carried out and is working appropriately
 Everyone doing their assigned tasks?
 Errors being corrected timely and appropriately?
 Results being incorporated into day‐to‐day operations?
 Feedback given to those involved?
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Thank You
Questions?
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