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MAC Prepayment Reviews and Rebilling Denied Inpatient Claims Kathy - - PowerPoint PPT Presentation
MAC Prepayment Reviews and Rebilling Denied Inpatient Claims Kathy - - PowerPoint PPT Presentation
MAC Prepayment Reviews and Rebilling Denied Inpatient Claims Kathy Reep April 17, 2013 Medicare Administrative Contractor (MAC) Prepayment Review Why a MAC Issue? RAC reporting at MAC level Recompete of MAC contracts Pay it right, the
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Why a MAC Issue?
- RAC reporting at MAC level
- Recompete of MAC contracts
Pay it right, the first time…
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Executive Order 13520
- Reduce improper payments by –
– Refining error rate measurement processes – Improving system edits – Updating coverage policies and manuals – Conducting provider education efforts
- 50 percent error rate reduction
– To 6.2 percent by 2012
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Inpatient Claim Reviews
- Transition from QIO to FIs/MACs
– QIOs to focus on quality improvement
- Will no longer do payment accuracy measurement
- n inpatient claims
– FIs/MACs will review for inpatient medical necessity and coding
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Inpatient Claim Reviews
- Not random reviews
– Targeted based on analysis
- Pre- or post-payment basis
- To use “clinical judgment”
– No specific screening tool to be required – Will involve physicians as needed
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Inpatient Claim Reviews
- No payment for copying costs
- Appeal rights as with other denials
– However, filed at initial level with contractor that reviewed the claim and issued denial
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MAC Prepayment Review Process
- Data Analysis
– MACs identify provider billing practices and services posing greatest financial risk to Medicare – Use data analysis to identify issues to include in the medical review strategy
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Preliminary Findings
- InterQual criteria not met and record did
not otherwise support need for inpatient level of care
- Cases continue to show lack of severity of
illness and/or intensity of service
- MD orders observation services and case
manager writes inpatient status was appropriate and admission is converted
- Admit for 3-day qualifying stay
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And for 2013…
- Focus on elective surgical procedures
- Length of stay not an element in record
selection
- Pre-payment review (30-100%)
- Post-payment review for associated Part B
services
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DRGs Subject to Prepayment Review (FCSO)
- Added November 16, 2012:
- 069 | 254
- Added April 11, 2012:
- MS-DRGs w/1-day LOS
- Added March 21, 2012:
- 153 | 328 | 357 | 455 | 473 | 517
- Effective prior to March 1, 2012:
- 226 | 227 | 242 | 243 | 244 | 245 | 247 | 251 | 253 | 264 |
287 | 313 | 392 | 458 | 460 | 470 | 490 | 552 | 641
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Documentation Requirements
- Medical record must contain
– Documentation fully supporting medical necessity of the inpatient admission and justification of any procedures performed
- History and physical
- Discharge summary
- Physician progress notes
- Operative report
- Other relevant information addressing coverage
criteria for episode of care prior to hospitalization
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Other Contractor Interventions
- Exclusion of individual hospitals with
sustained low error rates from specific DRG edits beginning in June 2012
- Post-payment recoupment of surgeon,
assistant surgeon and co-surgeon claims if the surgical procedure is deemed as not medically reasonable and necessary
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Patient Status
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Observation vs. Inpatient Status
- CMS questions whether and how we might
improve our current instructions and clarify the application of Medicare payment policies…
– Whether it may be appropriate and useful to establish a point in time after which the encounter becomes an inpatient stay if the beneficiary is still receiving medically necessary care to treat or evaluate his or her condition;
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Observation vs. Inpatient Status
– Whether the agency should establish more specific criteria for patient status in terms of how many hours the beneficiary is in the hospital, or to provide a limit on how long a beneficiary receives observation services as an outpatient; – Whether the agency should provide additional clarity in the definition of an inpatient; and
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Observation vs. Inpatient Status
– Whether the agency should establish more specific clinical criteria for admission and payment, such as adopting specific clinical measures or requiring prior authorization for payment of an admission.
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Looking at Patient Status
- Proposed rule posted March 13
−Hospitals will only have limited time to refile
claims
- Timely filing
- Deadline for comments May 17, 2013
- Administrative ruling also posted March 13
− Interim policy effective with release − In effect only until final rule issued
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King & Spalding
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King & Spalding
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Medicare Audit Improvement Act of 2013 H.R. 1250
- Establish a consolidated limit for medical requests
- Improve auditor performance by implementing
financial penalties, and by requiring medical necessity audits to focus on widespread payment errors
- Improve RAC auditor transparency
- Restore due process rights under the AB rebilling
demonstration
- Require physician review for Medicare denials medical
necessity
- Allow denied inpatient claims to be billed as outpatient
claims when appropriate
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