PPS Alert for Long
Contents
1. Join us in Chicago for the only conference that covers long term care quality improve ment while focusing on reducing financial risk At this exciting conference HCPro s regulatory expert Diane L Brown BA CPRA will show you how to implement an action plan to effect real change Iden tify methods to improve resident care by avoiding adverse events and determine an action plan for reducing rehospitalizations Resident quality of care is always at the forefront of CMS initiatives as it focuses on the link between quality and appropriate reimbursement For SNFs identifying finan cial risk factors has become more complex so they must find ways to improve quality of care and reduce rehospitalizations Seminar participants will be able to e Identify common financial and clini cal risks within their facility with a focus on resident care e Recognize the signs of an adverse event and the steps to take to stop future adverse events e Implement an action plan within their facility to ensure quality resident care To learn more about this seminar visit www hemarketplace com ev 11169 Maximize Quality While Minimizing Financial Risk Implementing a LongTerm Care html wy Follow Us Follow and chat with us about all things healthcare compliance management and reimbursement HCPro_Inc Questions Comments Ideas Contact Editor Melissa D Amico at mdamico hcpro com or 781 639 1872 Ext 3505 Octobe2. Epstein Becker Green in Washington D C It has the potential to encourage over reporting putting providers in the situation where they face the potential for audits or investigations without a legiti mate factual basis and to incur expenses that are totally unnecessary he says Fraud detection over the last year The format change to the MSN is just the most recent tactic the government has utilized to uncover instances of fraud and abuse Over the last year various regula tion changes and calls for increased oversight have put fraud and abuse at the forefront Below is a list of issues to which SNFs need to pay particular attention e The Affordable Care Act ACA Although most of the discussions about the ACA have revolved around beneficiary coverage and the impact it will have on employers and taxpayers the ACA includes very ag gressive spending on identifying Medicare fraud The ACA provided mandatory funding of 1 7 bil lion for both fiscal year 2010 and 2011 including discretionary funding of 311 million for FY 2010 and 561 million for FY 2011 all of which went toward fraud enforcement efforts in a variety of federal programs including CMS and the Office of Inspector General Over the past four years the Obama admin istration has recovered over 14 9 billion in healthcare fraud judgments settlements and 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distri
3. primarily because the responsibili ties of LTCOs have varied so drastically from state to state and the responsibilities of the ombudsmen were often vague or unclear On the other hand there is some concern that new regulations will pressure ombudsmen to unnecessarily report facilities rather than working with them to resolve disputes says Mary Malone 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at copyright com or 978 750 8400 HCPRO COM 9 PPS Alert for Long Term Care a healthcare attorney and director of Hancock Daniel Johnson amp Nagle PC in Richmond Va We re not surprised at the timing because this has been out there as a proposed rule since 1994 Malone says It seems like the reason it has come for ward now for comment and finalizing is to address the need for consistency and to ensure that across the coun try there are some of the same types of programs that are intended to protect the interests of the elderly The comment deadline to the proposed rule was August 19 2013 In the interim facilities should famil iarize themselves with the proposed changes in order to gain a better understanding of how the LTCO will operate moving forward Redefining responsibilities The main impetus behind the proposed changes is the need for consistency within the LTCO program For that
4. LTC providers may consider adding management staff dur ing the weekends to communicate with residents and their family members Foster says Facilities should also ensure they have a pathway to address concerns or complaints from a resident or family member The better you re communicating and setting expectations with residents and family members the less likely you are to deal with issues from the ombudsman or surveyors or other types of outside sources and the better chance you have to increase your resident satisfac tion in the long term Malone says Building relationships with ombudsmen The relationship between LTC providers and LT COs can be viewed as adversarial however building a 10 HCPRO COM 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at copyright com or 978 750 8400 October 2013 relationship with your local ombudsman will improve communication with him or her should the ombuds man come in to resolve a complaint Adams says The facilities that we represent that have good relation ships with their local ombudsman there is just a greater sense of cooperation when issues do arise she says You really do want the ombudsman to be as helpful as possible and not antagonistic I think it just highlights the need to continue building positive relationships Malone s c
5. Presbyterian Communities of South Carolina Lexington S C PPS Alert for Long Term Care ISSN 1521 4990 print 1937 7428 online is published monthly by HCPro Inc 75 Sylvan St Suite A 101 Danvers MA 01923 Subscription rate 239 year e PPS Alert for Long Term Care P O Box 3049 Peabody MA 01961 3049 e Copyright 2013 HCPro Inc All rights reserved Printed in the USA Except where specifically encour aged no part of this publication may be reproduced in any form or by any means without prior written consent of HCPro Inc or the Copyright Clearance Center at 978 750 8400 Please noti fy us immediately if you have received an unauthorized copy e For editorial comments or questions call 781 639 1872 or fax 781 639 7857 For renewal or subscription information call customer service at 800 650 6787 fax 800 639 8511 or email customerservice hcpro com Visit our website at www hcpro com Occasionally we make our subscriber list available to selected companies vendors If you do not wish to be included on this mailing list please write to the marketing department at the address above Opinions expressed are not necessarily those of PPSA Mention of products and services does not constitute endorse ment Advice given is general and readers should consult professional counsel for specific legal ethical or clinical questions UICK HITS ONLINE Visit us in Chicago HCPro seminar coming in November
6. document contains privileged copyrighted informa tion If you have not purchased it or are not otherwise entitled to it by agreement with HCPro any use disclosure forwarding copying or other communication of the con tents is prohibited without permission HCPro EDITORIAL ADVISORY BOARD Assoc Editorial Director Todd Hutlock thutlock hcpro com Editor Melissa D Amico mdamico hcpro com Contributing Editor Evan Sweeney Diane L Brown BA CPRA Regulatory Specialist and Boot Camp Instructor HCPro Inc Danvers Mass Sandra Fitzler Senior Director of Clinical Services American Health Care Association Washington D C Bonnie G Foster RN BSN MEd Long Term Care Consultant Columbia S C Cindy Frakes Owner Winter Meadow Homes Inc Topeka Kan Julia Hopp MS RN NEA BC Executive Vice President of Reimbursement Paramount Health Care Company Garden Ridge Texas Steven B Littlehale MS GCNS BC Executive Vice President Healthcare Chief Clinical Officer PointRight Inc Lexington Mass Mary C Malone JD Healthcare Attorney Director Hancock Daniel Johnson amp Nagle PC Richmond Va Maureen McCarthy RN BS CPRA Vice President of Clinical Reimbursement National Healthcare Associates Goshen Conn Frosini Rubertino RN CPRA CDONA LTC Executive Director Training in Motion LLC Bella Vista Ark Holly F Sox RN BSN RAC CT MDS Coordinator
7. proof It helps to look at the GAO report in the context of other reports that have come out regarding Medicare in the last year says Beckley In addition to the GAO report Beckley continuously references the following e Office of Inspector General OIG report on Spec trum Rehabilitation LLC This report released by the OIG in June estimates that Spectrum improperly re ceived at least 3 1 million for outpatient occupation al and physical therapy services that didn t comply with Medicare requirements Of the 100 claims that OIG randomly sampled 83 were billed improperly and 44 contained more than one deficiency e Chapter 9 from the MedPAC Report The MedPAC Report released in June included a chapter entitled Improving Medicare s payment system for out patient therapy services In it MedPAC outlines recommendations including reducing the therapy cap for physical therapy and speech language pa thology services combined and the separate cap for occupational therapy to 1 270 The report also rec ommends collecting functional status information on therapy services using a streamlined standard ized assessment tool in order to classify patients across all therapy types This tool would provide support for development of an episode based or global payment system This is the therapy environment it s not just about one report Beckley says The big takeaway is the best thing that therapists can do on behalf of
8. systems says Margaret Surowka Rossi council at Hiscock and Barclay in Albany N Y This not only incentivizes people to make these complaints but it also should incentivize the providers to make sure they are focusing on regulating compli ance and really doing a lot of the internal auditing and internal vigilance that is required Rossi says il 6 HCPRO COM 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at copyright com or 978 750 8400 October 2013 PPS Alert for Long Term Care GAO report reveals flaws in manual medical review process The July report shows that Medicare Administrative Contractors lacked guidance but fails to include perspective from providers and beneficiaries During the final three months of 2012 in response to the growing concern regarding costs for outpatient therapy CMS implemented two types of manual medi cal reviews MMR These MMRs reviewed preapproval requests and reviews of claims submitted without pre approval for all outpatient therapy services that were above 3 700 The MMR requirement caused a stir within the therapy and long term care industry and CMS put con siderable resources toward educating providers on the process hosting four open door forums between March 2012 and October 2012 when the program began CMS cited statistics on the previous year s s
9. the therapy industry and on behalf of the beneficiaries is to really learn how to write good documentation I think that s so critical and I think it s also sorely lacking Acommon issue Beckley adds is that therapists can easily verbally explain everything that is going on with the patient but their documentation is sparse Therapists also need to hold their ground when they feel a patient no longer needs more therapy They need to really truly understand when it s no longer medically necessary for the patient to contin ue Beckley says It s okay take up that position with the family and the physician Many therapists feel bad or back down when the physician provides another order or the family says please do more therapy 8 HCPRO COM 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at copyright com or 978 750 8400 October 2013 Brewer recommends setting up an internal process in addition to routine chart auditing to track beneficiaries that are getting close to the cap and review the docu mentation to ensure it is fully supporting the services provided We set up our own internal levels of review to ensure documentation is defensible and services continuing be yond the threshold which are guaranteed to be reviewed will prove to be payable she says Particularly
10. when it comes to documentation thera pists and providers can also work with their MACs to get PPS Alert for Long Term Care more education and a better understanding as to what appropriate documentation should look like They can ask for education and ask for training they can seek to get further information and if the training is not sufficient or not in depth enough or simply is just quotes from Medicare manuals they have a recourse through the provider outreach and education councils of each MAC to say we need more Beckley says The therapy industry needs to move forward and really demand on behalf of the beneficiaries a clear under standing of what needs to be in the documentation ial HHS proposes updates to LTC Ombudsman program Proposed changes aim to strengthen the program and offer more consistency from state to state On June 14 the Administration on Aging and the Administration of Community Living ACL both within the U S Department of Health and Human Services HHS announced that it had posted a Notice of Proposed Rule Making in order to strengthen the Long Term Care Ombudsman LTCO program across the country The changes are designed to clarify how each state implements its program in order to establish more consistency regarding the duties and responsibili ties of the LTCO The LTCO in each state is a resource for LTC resi dents and serves as an advocate during instances of abuse neglec
11. 750 8400 October 2013 Some of the other changes included in the final rule e Monitoring the impact of policy changes from the FY 2012 including Recalibration of FY 2011 SNF parity adjustment Allocation of group therapy time across group allows only 25 to be captured for each of four patients Implementation of MDS 3 0 changes includes the Change of Therapy COT OMRA assess ment which intended to more accurately capture therapy services e Revising and rebasing the SNF market bas ket index from FY 2004 to FY 2010 which in cludes additional components and details to cost categories e Adding a new MDS item 00420 Distinct Calen dar Days of Therapy which aligns the MDS and RUG process to ensure high level therapy is pro vided five days per week Previously the payment grouper would add days of therapy regardless of whether those services were provided on distinct days e CMS included a PPS AIDS payment add on Cur rently SNFs that care for residents with AIDS or active HIV add an ICD 9 code 042 to the UB 04 form which activates the 128 add on After the transition to ICD 10 CMS will link the add on to code B20 Although there are many significant changes to the final rule the regulation does give an inside peek into the process that CMS uses regarding payment updates says Maureen McCarthy vice president of clinical reimbursement at National HealthCare Associates in Lynbrook N Y and presiden
12. COM 11 PPS Alert for Long Term Care PPS Q amp A Editor s note This month s PPS Q amp A was modified from the NEW HCPro book SNF Nursing and Therapy Collaboration Optimizing Compliance Reimburse ment and Documentation by Kate Brewer PT MBA GCS RAC CT and Theresa A Lang RN BSN RAC C WCC For more information about this book or to order call customer service at 800 650 6787 or visit www hemarketplace com prod 11202 To submit a question for upcoming issues email Editor Melissa D Amico at mdamico hcpro com Can you help explain what is considered an unscheduled assessment There are situations when a SNF provider must complete an assessment outside of the standard scheduled Medicare required assessments These assessments are known as unscheduled assessments The following are considered unscheduled assessments e Significant change in status assessment for swing bed providers this unscheduled assessment is called the swing bed clinical change assessment This assessment is completed when the SNF in terdisciplinary team has determined that a res ident meets the significant change guidelines for either improvement or decline See Section 2 6 of the MDS 3 0 RAI User s Manual for more information e Significant correction to prior comprehen sive assessment This assessment is completed if a significant er ror was made in the prior comprehensive assess ment See Section 2 6 of the
13. HCPro P5 7 PPS Alert for Long lerm Care P9 P11 P12 Volume 16 Issue No 10 OCTOBER 2013 CMS issues final payment changes for fiscal year 2014 The final regulation is almost identical to the proposed rate changes with a 1 3 overall increase and an addition to the MDS If you hate surprises then you were probably pleased with the final rule for the prospective payment system and consolidated billing for SNFs for fiscal year FY 2014 Released by CMS on August 1 the final rule is almost identical to the proposed changes that were released in May Although the proposed rate increase was originally set at 1 4 the final rule rounded out just shy at 1 3 2 3 update factor minus 0 5 market basket forecast error or adjustment minus 0 5 multifactor productivity MFP adjustment as part of the Affordable Care Act However that 1 cut translates to a 30 million overall decrease There are usually a lot of changes from the proposed rule to the final rule but this time it was almost exactly the same says Diane L Brown BA CPRA director of postacute education at HCPro Inc in Danvers Mass In fact given the fact that the sequestration took a 2 cut out of the Medicare budget back in April many view this payment update as a neutral change An Integrated Approach to the LTC Industry Redesigned Medicare Summary Notices add to focus on fraud and abuse Learn more about the changes and h
14. MDS 3 0 RAI User s Manual for more information e Start of therapy Other Medicare Required Assessment SOT OMRA This assessment is completed in order to clas sify a resident into a RUG IV rehabilitation plus extensive services or rehabilitation group This is an optional assessment See Section 2 9 October 2013 of the MDS 3 0 RAI User s Manual for more information e End of therapy EOT OMRA This assessment is completed in two circumstances When a beneficiary who was receiving rehabilita tion services PT OT and or SLP was classified in a RUG IV rehabilitation plus extensive servic es or rehabilitation group and all therapies have ended but the beneficiary continues to receive skilled services When a beneficiary who was receiving rehabilita tion services PT OT and or SLP was classified in a RUG IV rehabilitation plus extensive servic es or rehabilitation group and did not receive any therapy services for three or more consecutive calendar days The EOT would be completed to classify the beneficiary into a non therapy RUG group beginning on the day after the last day of therapy provided e Change of therapy COT OMRA This assessment is completed when the inten sity of therapy including the total reimburs able therapy minutes RTM and other therapy qualifiers e g number of therapy days therapy disciplines change significantly enough to clas sify a beneficiary into a different RUG I
15. V cate gory from which the resident is currently being billed for the seven day COT observation peri od following the ARD of the most recent assess ment used for Medicare payment See Section 2 9 of the RAI User s Manual The requirement to complete a change of thera py assessment is reevaluated with an addition al seven day COT observation period ending on days 14 21 and 28 after the most recent Medicare payment assessment ARD and a COT OMRA is completed if the RUG IV category changes If anew assessment used for Medicare payment has occurred the COT observation period will restart beginning on the day following the ARD of the most recent assessment used for Medicare payment ial 12 HCPRO COM 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at copyright com or 978 750 8400
16. ave the biggest impact on residents categorized under rehab medium which re quires five distinct therapy days says Cheryl Field vice president of healthcare at PointRight Inc in Lexington Mass Since the proposed rule PointRight reviewed its database and found that the rehab me dium category makes up about 10 of its patients The take home message to providers really hasn t changed she says It just requires for that lower intensity group that there is conversation and plan ning around what days of the week treatment will be provided if you re not providing five day a week treatment McCarthy says she is concerned about residents that don t meet the qualifications for a short stay but still need rehab This could also affect residents that have just been admitted and are just gearing up for therapy or those that are gearing down because they are being discharged Tm concerned that those residents will potentially fall into the lower 14 nursing categories where some of the MACs out there do an automatic ADR just be cause they fell into the lower level category she says They may be appropriately working this patient up to a certain level but didn t have enough days where therapy was provided so they ended up falling into that 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Cente
17. bution or use in educational packets contact the Copyright Clearance Center at copyright com or 978 750 8400 HCPRO COM 5 PPS Alert for Long Term Care administrative impositions according to CMS Since the passage of the ACA in March 2011 CMS has revoked the ability of 14 663 provid ers and suppliers to bill within the Medicare pro gram Felony convictions wrong operational address or failure to comply with CMS regula tions were among the primary reasons for their dismissal from the program After putting in screening and review require ments set forth by ACA the number of revoca tions has quadrupled The ACA has also allowed CMS to devote more funds toward proactive da ta analysis to track and act upon potential fraud and abuse When there is that kind of money behind it it stands to reason that their intent is to increase the amount of recoveries says George Bodenger a partner at Saul Ewing LLP in Philadelphia and chair of the firm s Health Practice Group The ACA also included an important procedural change in the way CMS recovers Medicare payments Rather than utilizing a pay and chase model in which CMS would attempt to recover funds after it had already made pay ments to a provider the ACA adjusted the model to catch potential fraud before payments are released Really what they are trying to do is focus more on the front end and do more provider screening and more scru tiny up front s
18. ce Center at copyright com or 978 750 8400 October 2013 PPS Alert for Long Term Care Redesigned Medicare Summary Notices add to a growing focus on fraud and abuse Simplified notices aim to help beneficiaries identify fraudulent billing as the crackdown on Medicare fraud and false claims continues If 2013 has shown us anything it s that the govern ment is dead serious about reducing Medicare fraud and they ve decided to attack the issue from all angles In June CMS announced that it would be rolling out a new redesigned Medical Summary Notice MSN an additional effort by the Obama administration to elimi nate fraud waste and abuse The redesign will simplify the notice making it easier for beneficiaries to interpret their Medicare benefits and possibly uncover instances of fraud and abuse by providers The new Medicare Summary Notice gives seniors and people with disabilities accurate information on the services they receive in a simpler clearer way CMS Administrator Marilyn Tavenner said in a press release It s an important tool for staying informed on benefits and for spotting potential Medicare fraud by making the claims history easier to review This is a welcomed and long overdue change for beneficiaries says Wayne van Halem CFE AHFI president of The van Halem Group LLC in Atlanta For years health experts and beneficiaries have been asking for changes that would simplify MSNs These notice
19. ch MAC handled the process in a different way Although it was not addressed specifically in the report the incongruity with each MAC s process had a trickle down effect that impacted the beneficiaries as well says Nancy Beckley MS MBA CHC presi dent of Nancy Beckley and Associates in Milwaukee This was an incredibly disruptive process Beckley says It started with a tremendous effort to notify every beneficiary about what was going on and at the same time they were conducting four different open door forums and then relying on each MAC to roll out the training and the data collection instrument and rules for submission Ultimately from the perspective of the MACs the providers and the beneficiaries there was a lot of confusion and very little uniformed guidance which led to an imperfect process In some cases facilities that submitted post payment MMRs in December still haven t received a response Beckley says No one really understood or had a grip on what was going on she says The MACs provided instructions but if you compared each of them you would say how come there is one law and multiple different ways of providing this information Two missing pieces Although the report did highlight some of the major flaws with the MMR process Beckley argues that the GAO left out the perspective of two important charac ters providers and beneficiaries I don t think the GAO report gives Cong
20. essor answer key Below are the answers to the MDS professor on p 11 1 d MDS data is not used to determine Medicare Part B reimbursement 2 a This is usually the correct choice when a resi dent goes out to the hospital and the Admission As sessment has already been completed A resident s bedhold status is not taken into consideration when completing a discharge tracking form d All of the above d All of the above c Five to seven b 15 oO aP w October 2013 if it s a more efficient and effective way of providing care then they won t have to talk about this non ancillary component Evaluating the 2012 double hit In the final rule CMS also evaluated the potential double hit from the FY 2011 SNF parity adjustment and policy changes that included the COT OMRA At least one commenter asked CMS to reevaluate the negative impacts of COT OMRA as unnecessary and inflexible CMS responded that COT OMRA makes up just 11 of all assessments completed for SNF residents which it doesn t believe makes up a significant burden for providers In fact CMS argued the COT OMRA has helped ensure greater accuracy of SNF payments and ensure that providers are appropriately reimbursed for the level of care delivered to their residents McCarthy argues that although 11 may seem low it may represent a significant workload for small providers Those are 11 more assessments than we did in t
21. he past she says It s not a large number but it s a large addition for an MDS coordinator who is the only one in the building and now has to increase her productivity by 11 They are taking into consideration the numbers of MDSs but when you also add in discharge MDS and change of therapy that s a significant increase in work load for the average MDS coordinator How to prepare Fortunately SNFs probably won t need to change much in their own system to prepare for the updated payment system Providers should ensure they adjust their software to include the additional MDS code for distinct therapy days but they shouldn t need to change much in terms of policies or procedures However SNFs should discuss and review the updates through their compliance and ethics program and at least have a conversation about the details of the final rule particularly regarding distinct therapy days Field says They could simply add an agenda item to look at the rehab mediums or the unique days of the week that therapy is provided she says They could certainly add that to their compliance checks and their month end checks that are supporting their compliance initiatives It s just one more thing they can start monitoring within themselves i 4 HCPRO COM 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearan
22. o they aren t letting folks get into the pro gram that have a history van Halem says That s where were seeing more revocation and more activity because they have the funding to do it You re seeing audits but then they are also implementing predictive modeling e OIG guidelines for state false claims acts In March following a review of 28 different state laws the OIG released its Updated OIG Guidelines for Evaluating State False Claims Acts The guidelines incentivized states to restructure their false claims act to meet OIG s requirements in exchange for an ad ditional 10 on any amounts recovered According to OIG state laws must meet the following requirements in order to receive the additional recovery Establish liability to the state for false or fraudulent claims as described in the federal False Claims Act FCA with respect to Medicaid spending Contain provisions that are at least as effective in rewarding and facilitating qui tam actions for October 2013 false or fraudulent claims as those described in the FCA Contain a requirement for filing an action under seal for 60 days with review by the state attorney general Contain a civil penalty that is not less than the amount of the civil penalty authorized under the FCA Given the financial pressure that most states are facing this is an easy opportunity to provide some reprieve to their budgetary woes You have a situation whe
23. oncern with the specifics of the proposed changes is that it may put additional pressure on ombudsmen to make reports of elder abuse or exploi tation rather than trying to work with the facility to resolve the issue first MDS professor Test your knowledge of the MDS and long term care by answering the following questions To review the correct answers see the answer key on p 4 1 The MDS has the potential to impact all but one of the following a Medicare reimbursement b Medicaid reimbursement c Quality indicators measures d Part B Medicare reimbursement 2 A resident has been readmitted back to the hospi tal after spending 25 days in your SNF The cor rect discharge reporting form to complete would be which of the following a Discharge Return Anticipated b Death in the facility discharge c Discharge Return Not Anticipated d The answer depends on whether a bed hold was in place 3 The pain assessment interview for residents assesses pain a presence b frequency c effect on function and intensity d All of the above PPS Alert for Long Term Care Malone suggests inviting your local ombudsman to your facility for a walk through If you are planning a day to educate residents on advance directives offer to have the ombudsman come observe the process If you are planning to offer a new service send infor mation to the ombudsman about how this may impact resident care I think it s about looking for op
24. ow they aim to help beneficiaries identify fraudulent billing practices GAO report reveals flaws in manual medical review process A recent report shows that Medicare Administrative Contractors lacked guid ance but fails to include the provider s and beneficiary s perspective HHS proposes updates to LTC Ombudsman program The changes aim to strengthen the pro gram and consistency between states MDS professor Think you re an MDS expert Test your knowledge with our quiz PPS Q amp A This Q amp A explains the role of a unscheduled assessment TRENDSPOTTING 1 7 billion The amount of mandatory funding the Afford able Care Act ACA provided for both 2010 and 2011 including discretionary funding of 311 million for 2010 and 561 million for 2011 all of which went toward fraud enforce ment efforts in a variety of federal programs including CMS and the Office of Inspector General 14 9 billion The amount that the Obama administration over the past four years has recovered in healthcare fraud judgments settlements and administrative impositions 14 663 The number of providers and suppliers since the passage of the ACA in March 2011 that have had their ability to bill within the Medicare program revoked by CMS Felony convictions wrong operational addresses or failure to comply with CMS regulations were among the primary reasons for dismissals SOURCE CMS PPS Alert for Long Term Care This
25. pending includ ing the 5 7 billion that Medicare spent on outpatient therapy services in 2011 for 48 million beneficiaries In June 2013 the Government Accountability Office GAO released a report on the Implementation of the 2012 Manual Medical Review Process The report showed a number of flaws within the system particu larly concerning the Medicare Administrative Con tractors MAC that were tasked with conducting the reviews The GAO reviewed relevant statutes and CMS policies and guidance and conducted interviews with officials from three MACs that accounted for almost 50 of the MMR workload CMS estimates that MACs affirmed roughly two thirds of the 110 000 preapproval requests and about one third of the 57 000 claims submitted without preapproval but the final outcome of the MMRs remains uncertain Specifically the GAO found a number of problems regarding how the MMRs should be processed CMS did not issue complete guidance on how to process pre approval requests before the implementation date and MACs were unable to fully automate their systems for tracking requests within the required 10 business day time frame Requests that were not reviewed within 10 days were supposed to be automatically approved Additionally MACs struggled to implement reviews of preapproval requests because CMS continued to issue new guidance on how to manage those requests after the MMR process started Because of the lack of guid ance ea
26. portunities to keep the ombudsman involved and knowledgeable about the quality of service you provide overall outside of the context of a specific complaint she says That s a great way to build that relationship and give the ombudsman a perception of the quality of your facility and how it operates tl 4 To complete a Significant Change in Status Assess ment SCSA there must be a decline or improve ment in a resident s status that a will not normally resolve itself without inter vention by staff or by implementing standard disease related clinical interventions is not self limiting b impacts more than one area of the resident s health may impact only one area but staff believe resident would benefit from a SCSA c requires interdisciplinary review or care plan revision d All of the above The ARD for the Start of Therapy OMRA must e seton days ____ after the start of therapy a one to three c five to seven a b two to six d seven to nine 6 The federal regulatory requirement at 42 CFR 483 20 d requires nursing homes to maintain all resident assessments completed within the previous___ months in the resident s active clinical record a 12 b 15 c 18 d 24 il 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at copyright com or 978 750 8400 HCPRO
27. pted fax or mailed submissions Benefi ciary documentation often exceeded 200 pages which was a tremendous burden for facilities that needed to print or fax records Even with that methodology the MACs were claim ing they weren t getting faxes or printed records and providers were saying they had fax receipts or had spent FedEx money Beckley says From the beneficiary s perspective the MMR process was a tremendous disruption to therapy In the report CMS told the GAO that the purpose of the preapproval process was to protect beneficiaries from being liable for payment of non affirmed services by giving the pro vider and beneficiary guidance as to whether Medicare would pay for the requested services However in some cases beneficiaries declined to continue coverage be cause of the potential financial burden of being denied therapy above the cap My frame of reference is always family members I know that are on Medicare Beckley says I like to put a human side to this and there is clearly a human side missing in the report This was about the Medicare beneficiaries yet the GAO made it about the MACs Emphasizing good documentation There are two things that providers can take away from the GAO report First providers can expect continued scrutiny as they are asked to prove the medical necessity October 2013 of therapy services Second therapy documentation is more important than ever to provide that
28. r 2013 FROM THE FIELD Beneficiaries are a very important line of defense Particularly in situations where their identity has been stolen the Medicare Summary Notice may be the only way it s recovered It s about taking more time to educate them on what is truly fraud and abuse how to report it and making that notice easy to understand Wayne van Halem CFE AHFI STAY CONNECTED PPSA in Your Inbox Sign up for any of our 17 email newsletters covering a variety of healthcare compliance manage ment and reimbursement topics at www hcmarketplace com Don t miss your next issue If it s been more than six months since you purchased or renewed your subscription to PPS Alert for Long Term Care be sure to check your envelope for your renewal notice or call customer service at 800 650 6787 Renew your subscription early to lock in the current price Relocating Taking a new job If you re relocating or taking a new job and would like to continue receiving PPS Alert for Long Term Care you are eligible for a free trial subscription Contact cus tomer service with your moving in formation at 800 650 6787 At the time of your call please share with us the name of your replacement 2 HCPRO COM 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at copyright com or 978
29. r at copyright com or 978 750 8400 HCPRO COM 3 PPS Alert for Long Term Care lower nursing category I m worried about provider li ability in those circumstances McCarthy also notes that CMS provided a clari fication regarding Medicare holidays indicating that it s a misconception that CMS provides specific breaks in therapy for a prescribed list of national holidays You can have up to a two day miss for therapy but the holiday would be included in that two day miss she says For example Labor Day would not count as a break in coverage SNFs and therapists need to coordinate therapy time either on Saturday or Monday of that three day weekend in order to meet the requirements for distinct therapy days A number of commenters also brought up the issue of non therapy ancillaries NTA which called for CMS to expedite the research necessary for a new method to pay for NTAs cared for by SNF providers CMS re sponded without any specific changes but that it was looking forward to working with providers and stake holders in the future However Field doesn t expect any upcoming changes I think the reality is with the Accountable Care Act and the movement towards managed care and bundles and the profit sharing model there will be no reason to talk about non ancillary therapy she says It ll be part of the bundle I think they are go ing to wait for the bundles to show their validity and MDS prof
30. re states are faced with more budgetary pressure to deal with expanded Med icaid roles and they will have more incentive to pursue healthcare providers says Breen This clearly impacts the long term care industry which is heavily involved with Medicaid patients You can expect that states will have a bigger incentive to pursue actions against pro viders because it s clearly to their financial benefit e Increased whistleblower incentives In April CMS released a proposed rule that would sig nificantly increase the rewards for whistleblowers that provide information that leads to a recovery of funds from providers that have engaged in fraud and abuse The proposed changes include Increasing the potential reward amount from 10 to 15 of the final amount collected for informa tion that leads to a recovery of Medicare funds Increasing the reward cap from 1 000 to 9 9 million a maximum of 15 of the first 66 mil lion recovered With the increased reward CMS hopes to further incentivize whistleblowers to step forward and report fraud and abuse to the government Since 1998 CMS has recovered approximately 3 5 million but paid out just 16 000 for 18 rewards CMS proposed rule changes are modeled after the IRS whistleblower program which has seen significant recoveries following changes to its whistleblower reward program At the same time pro viders should be thinking about their internal reporting and auditing
31. reason some states may see some signifi cant changes to their program should the proposed rules be finalized But these changes may actually improve the way LTCOs and LTC facilities interact with one another says Bonnie Foster RN BSN MEd owner and president of Foster Consulting Inc in Columbia S C In some cases LTCOs may believe they have more power than they actually do Ombudsman is supposed to be the liaison between the resident and everyone else but I never personally thought that their role helped very much she says However the proposed updates also bring some potential concerns Typically new regulations are accompanied by a spike in enforcement says Jeannie Adams attorney on the administrative law team and director of the Richmond Va office of Hancock Daniel Johnson amp Nagle PC Subsequently facilities may experience LTCOs that are more aggressive than they may have been in the past One thing that LTC facilities need to be prepared to see is an ombudsman coming into their facility with greater frequency to investigate complaints and in the process accessing resident records Adams says There is also some concern that the changes will allow ombudsmen to unnecessarily persuade residents to file complaints LTC facilities are already one of the most regulated industries in the country and these changes could pile on an additional strain October 2013 From where we stand we certainly suppor
32. ress the whole picture of how this process works nor does it represent the time and effort by the providers as well as the concern of beneficiaries Beckley says From the provider s perspective the process was not only cumbersome but expensive Many providers designated money to gather data and submit requests 2013 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at copyright com or 978 750 8400 HCPRO COM 7 PPS Alert for Long Term Care Beckley says The larger providers often had to hire a full time employee to assist with the workload However the report does at least encapsulate the confusion with the entire MMR process that ultimately left providers guessing says Kate Brewer PT MBA GCS RAC CT president of Greenfield Rehabilitation Agency Inc in Milwaukee Providers were left to a trial and error method in many cases Brewer says From a provider stand point we spent countless man hours trying to figure out the process and comply when they just used this process for three months and then discontinued it It was even more confusing in early 2013 trying to figure out what to do many providers were trying to continue the 2012 process because no one was giving guidance Part of the problem was that even though CMS asked the MACs to allow CD or electronic documentation most only acce
33. s should add another layer of fraud detection but more importantly it will help Medicare beneficiaries better understand their coverage Even those well versed in Medicare language and regulation found the previous notices difficult to interpret I don t know if you ve seen the notice but they are fairly complex and difficult to understand he says Most patients get them and even me as someone who has worked with Medicare and deals with it on a regu lar basis I find it difficult to read at times Certainly someone with no experience in this realm would see this and wouldn t know what to do with it The simpler format will also provide an additional av enue in which the government can identify or investigate instances of fraud Beneficiaries are a very important line of defense van Halem says Particularly in situ ations where their identity has been stolen that notice may be the only way it s recovered It s about taking more time to educate them on what is truly fraud and abuse how to report it and making that notice easy to under stand I think it will result in more solid information coming from beneficiaries that could help uncover fraud I just don t know what took them so long to do this While the changes are certainly useful in helping beneficiaries better understand their bill they could also prompt more frivolous and unnecessary fraud investigations says George Breen a partner with
34. t and financial exploitation The LTCO often works as a middleman between the LTC facility and the resident in order to help fairly resolve disputes or complaints Elder abuse is expected to rise with the growing populating of elders according to an ACL press release Additionally elderly victims of even modest abuse have 300 higher morbidity and mortality rates compared to non abused residents the ACL says The proposed rule addresses the following issues e Responsibilities of the State Ombudsman State Agency on Aging and Representatives of the Of fice of the State LTCO related to the program operations e Consistent approaches to resolving complaints on behalf of residents e Appropriate role of ombudsmen in resolving abuse complaints e Conflicts of interest processes for identifying and remedying conflicts so that residents have access to effective credible ombudsman services HHS is committed to strengthening the ability of long term care ombudsman staff and volunteers to be effective problem solvers for older adults and people with disabilities who live in our nation s long term care facilities Assistant Secretary for Aging Kathy Greenlee said in a press release Long term care ombudsman programs are often a lifeline for victims of abuse and it is fitting to present these proposed changes as we recognize World Elder Abuse Awareness Day In one sense this is a welcomed change throughout the LTC community
35. t at Celtic Consulting LLC in Goshen Conn I like to know what makes up the market basket she says Some coordinators and nurses really don t necessarily understand what the market basket is and I really like to get in to the details of that You re looking at wages and salary employee benefits contract labor pharmaceuticals liability insurance from a cost report but they weigh it all a little bit differently Although it s likely the final rule will cause a lot of commotion among SNFs providers should begin PPS Alert for Long Term Care reviewing the final rule and at least have some discussions about preparing for the effective date of October 1 MDS addition The addition of the MDS code to track distinct therapy days should not be a huge adjustment for SNFs since it doesn t change any of the therapy requirements that already exist it simply streamlines the MDS form to capture more specific data For example if a resident receives physical therapy three times a week and occupational therapy two times a week MDS software will categorize it as five distinct therapy days even if that therapy was coor dinated over the course of three days CMS clarifies that low rehab is classified by three distinct therapy days With the addition of the MDS code software programs will be able to track distinct therapy days without inadvertently placing residents into a higher RUG category The ruling will probably h
36. t the pro tections of the elderly but it s putting the facilities that are trying to care for them under greater and greater strain Malone says We just hope these regulations aren t going to send a signal to the ombudsman who in the past in their role as advocates for the resident worked hard to resolve issues with the residents rather than just reporting them Improving resident communication One way that LTC providers can proactively address the proposed changes to the LTCO program is by focusing on Quality Assessment and Performance Improvement QAPI implementation and improving communication with residents and their families A comprehensive QAPI program will identify areas in where residents are dissatisfied with their care Foster says I think what s really going to have to im prove which I have always said is documentation she says It s not just documenting but managers need to be rounding and keeping a running tab of what resi dents say and are they concerned about anything Problems can also arise when family members don t have a full understanding of the care that is provided to the resident and what is covered during his or her stay This problem is often exasperated when residents are admitted on a Friday afternoon Subsequently there is no one to talk with the family or the resident until the following week Since complaints often come during the weekend when family members are visiting
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