EXECUTIVE SUMMARY
The Recovery Auditor program is cranking back up again after almost a year’s hiatus, but despite the Centers for Medicare & Medicaid Services’ plans to improve the program and issue new contracts, the audits will be conducted by the same auditors under the same rules.
• Auditors are likely to target short stays and other weak areas the Medicare Administrative Contractors identified during Probe and Educate, according to Elizabeth Lamkin, MHA, chief executive officer and partner in PACE Healthcare Consulting, LLC, based in Beaufort County, SC.
• CMS has not made any clarifications to the two-midnight rule, and auditors may begin auditing hospitals for compliance beginning April 1.
• The Outpatient Prospective Payment System (OPPS) final rule clarified the requirement for physician certification, saying that the order to admit must be signed by the treating physician and the justification for the admission, the expected length of stay, the treatment plan, and the discharge plan do not have to be a separate document but can be part of the history and physical.
After almost a year’s reprieve, hospitals can expect to begin getting records requests from Recovery Auditors as the program goes into full swing again.
The Centers for Medicare & Medicaid Services (CMS) temporarily suspended the program in February 2014 “to allow CMS to refine and improve the Recovery Audit Program,” according to a news release issued at the time.
The auditors have been performing automated reviews since last summer and, beginning April 1, can perform complex patient status reviews, says Kurt Hopfensperger, MD, JD, senior medical director for Executive Health Resources, a Newtown Square, PA, healthcare consulting firm.
In early 2014, CMS announced plans to revamp the Recovery Audit program in response to industry feedback and issue new contracts with audits starting under the new program in Jan. 1, 2015. The agency made changes to the program and started to rebid the Recovery Audit contracts. However, the process has been held up by a lawsuit filed by a contractor who challenged the payment terms that prohibit an auditor from being paid until after the claim has cleared the second level of appeals, according to Elizabeth Lamkin, MHA, chief executive officer and partner in PACE Healthcare Consulting, LLC, based in Beaufort County, SC.
Until the new contracts are issued, hospitals will be audited by the same RAs, operating under the same rules, Hopfensperger says.
“In 2015, proving medical necessity is still very important, and documentation must contain evidence-based, objective information that the services provided the patients are necessary. Hospitals must have a robust utilization review process in place. They should still use screening tools and have a review on a second level by a physician advisor if there are any questions,” he says.
Lamkin predicts that auditors are likely to go after short stays and look for medical necessity and other weak areas uncovered by the Medicare Administrative Contractors (MACs) during Probe and Educate and by The Comprehensive Error Rate Testing (CERT) program, which CMS developed to measure improper payments. These include cardiac procedures and total joint replacement surgery, she adds.
The Medicare Fee for Service Improper Payments Report supplemental appendices list the Top 20 Service Types with the Highest Improper Payments for Inpatient Hospitals for Medicare Part A as determined by the CERT program.1 The top five diagnoses are chest pain; cardiac defibrillator implant without cardiac catheterization; permanent cardiac pacemaker implant; circulator disorders, except AMI, with cardiac catheterization; and peripheral vascular disorders. The majority of problems included insufficient documentation, medical necessity, and incorrect coding, Lamkin says.
She recommends that case managers review the information in the report and analyze their hospital’s Program for Evaluating Payment Patterns Electronic Report (PEPPER) to identify the highest opportunities for the RAs and focus on improving in those areas.
“Hospitals should conduct an ongoing analysis of denials and the reason for them. The CERT report is a general list. Each hospital may be different. Case managers should be evaluating the areas that need improvement in their own hospitals,” she says. In addition, case managers should adhere to the Medicare Inpatient Only List and use it as a defense to denials. Lamkin also recommends that hospitals appoint a committee to stay on top of all regulatory changes so everyone will be prepared and understand the areas of risk.
“Hospitals have to get everything right on the front end so there won’t be any problems on the back end,” Lamkin says.
CMS is winding down the Medicare Administrative Contractors Probe and Educate initiative but has made a major change, Hopfensperger says. When the Probe and Educate program began, if a hospital had a high error rate in the first two Probe and Educate audits, the MACs could request 10 times the original number of charts. CMS has announced that the third audit will call for the same number of charts as the MACs originally requested, Hopfensperger says.
Many hospitals did not improve when they underwent expanded reviews under Probe and Educate, says Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Services, a Shawnee, OK, healthcare consulting firm.
“The MACs found easy things to deny like the admitting physician didn’t sign the admission order prior to discharge. Case managers need to review documentation for short-stay patients in particular to make sure the physicians have clearly documented the medical necessity of services ordered and the need for continued care in the hospital setting,” she adds.
The language of the Inpatient Prospective Payment System final rule for fiscal 2014 was interpreted by some to require a certification statement that was duplicative of medical record content, Hale says.
“In the 2015 Outpatient Prospective Payment System (OPPS) final rule, CMS clarified that it was not looking for a separate certification form. The essence is, certification is achieved by a signed inpatient order and the usual content of the medical record should clearly describe the reason for the admission, the plan of care, and an individualized estimated length of stay and the discharge plan should be in the medical record,” Hale says.
Case managers can protect payment to the hospital by making sure the inpatient order is signed by the physician responsible for the admission of the patient to the hospital. The remainder of the certification requirement should be in the history and physical, progress notes and discharge summary, she says.
If case managers take a verbal order from physicians, they should make sure it’s signed before the patient is discharged and that the medical record includes the reason why the physician expected the patient to be in the hospital for two midnights or longer, says Joanna Malcolm, RN, CCM, BSN, consulting manager, Clinical Advisory Services for Pershing, Yoakley & Associates in Atlanta.
CMS has made it clear that only the physician can determine patient status, Malcolm points out. “Case managers should not be determining the status but they can assist the physicians by providing criteria and regulations in order to help the physician determine the status, and ensure that physicians sign the admission order and write the reason they think the patient will be in the hospital for two midnights. They should make sure that the physician is specific about why they are admitting patients and that the order says ‘admit to inpatient.’ Case managers need to make sure the physicians become accustomed to writing why the patient is going to be admitted in clear, concise language,” she says.
“If hospitals and physicians don’t have a clear understanding of the regulations and criteria, it could be financially devastating,” Malcolm adds.
“It all comes down to being consistent about admissions and ensuring that the documentation is complete and accurately represents the condition of the patient and the services provided so that the hospital can meet goals and receive the appropriate reimbursement for the services they provide,” she says.
It’s more important than ever for case managers to develop a close working relationship with physicians and communicate with them regularly, especially when it comes to patient status and documentation, she adds.
CMS is giving more scrutiny on outliers, Lamkin says. “Case managers and physicians need to work together to understand continued stay criteria and monitor patients closely every day,” she says.
“Utilization management is getting more and more important. The utilization management committee should create scorecards to help the frontline staff understand the patient population,” Lamkin says. She suggests monitoring the length of stay for inpatients and observation patients, tracking the percentage of observation patients and inpatients, the percentage of patients who meet medical necessity criteria, and other patient population data.
Look for patterns and use the data to develop performance improvement projects, she suggests.
Preparation for the recovery audits isn’t the only reason case managers should make sure that the documentation is detailed and accurate, Hopfensperger says.
Hopfensperger warns hospitals to prepare for the impact of Transmittal 541, which directs auditors, particularly the Medicare Administrative Contractors, to take back surgeons’ fees if a hospital case is denied for not being reasonable and medically necessary.
“Transmittal 541 means that if a surgeon’s documentation does not support the need for the procedure and the hospital’s inpatient claim is denied, the auditors can take back the surgeon’s professional payment in addition to taking back the hospital’s payment. This can have a huge impact on hospitals that employ a large number of surgeons,” he says.
It is very important for surgeons to understand that they must document thoroughly, Hopfensperger says. “We know that the auditors have been denying some orthopedic cases for lack of documentation. This is more generalized and broader and gives them the ability to take back the surgeon’s payments as well as the hospital’s,” he says.
Case managers should take an active role in helping physicians make sure their documentation is complete and accurate and supports the need for the surgery and the impatient stay, he says.
The HHS Office of the Inspector General is cracking down on cardiac procedures in part because of feedback from whistle-blowers, Malcolm says.
“They’re focusing on those big procedures that cost a lot and taking back money from the hospitals,” she says.
“Case managers should review the cases before the procedures and make sure they comply with Medicare regulations. This is another example of why documentation is so important. Case managers should ensure that the documentation for cardiac procedures is accurate and complete and that medical necessity for the procedures is documented,” she says.
Reference
- http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports-Items/Downloads/AppendicesMedicareFee-for-Service2014ImproperPaymentsReport.pdf?agree=yes&next=Accept
After almost a year’s reprieve, hospitals can expect to begin getting records requests from Recovery Auditors as the program goes into full swing again.
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