Medicare Claims Review “Audits”
What you need to know …
President’s Goals for 2012
•
•
•
Reduce overall payment errors by
$50 billion
Cut fee-for-service error rate in half
Recover $2 billion in improper
payments
Rapidly Changing Environment
New Medicare audit
programs, including
prepayment audits,
seek reduction of
overall payment error
rates
Webinar goals
•
How did we get here?
•
How to document medical necessity
to avoid audits !
•
AAOS/AAHKS advocacy activities …
Audit Webinar Panel
•
David Halsey, MD
•
•
•
•
Brian Parsley, MD
•
•
AAOS Board of Specialty Societies
AAOS Coverage Determinations Project Team
AAHKS Health Policy Chair
AAHKS 2nd VP
David Templeman, MD
• AAOS Coverage Determination Project Team, Chair
•
•
AAOS Board of Specialty Societies
AAOS Board of Directors
Audit Webinar Staff
Matt Twetten
 AAOS Sr. Manager, Regulatory,
Quality & Medical Affairs
Ashlen Strong
 AAOS Manager, State
Government Relations
Medicare Auditing Environment
Recovery Audit
Contractors
Qualified
Independent
Contractors (QICs)
Medicare
Secondary Payer
Recovery Contractor
(MSPRC)
Beneficiary
Contact
Center (BCC)
ZPICs
Zone Program Integrity
Contractors
Medicare
Administrative
Contractors (MACs)
Healthcare Integrated
General Ledger
Accounting System
(HIGLAS)
Enterprise
Data
Centers (EDCs)
Comprehensive Error Rate
Testing Contractors (CERT)
Administrative
Qualified
Independent
Contractors
(Ad QICs)
7
“Alphabet soup”
MAC
CERT
LCD
Medicare Administrative Contractor
(MAC)
MACs are private companies that serve as
contractors performing claims
administration
MACs do not work on contingency basis
Medicare Auditing Environment:
Operations
 Receive and process Medicare A and B
claims
o Computer systems
o EDI
o Front-end claim review
o Pricing
o Enrollment
 Customer Service Call Center
 Appeals and Redeterminations
10
Medicare Auditing Environment:
Integrity Program
 Data analysis
 Medical review
 Local coverage policy
 Provider education
CMS definition:
Medical Necessity



Safe and effective
Meets, but does not exceed the patient’s
medical need
Performed in accordance with accepted
standards of practice
12
Comprehensive Error Rate Testing
(CERT)
•
•
•
Designed to monitor performance of
MACs and to ensure claims administered
properly
Audits result in annual reports of rate of
improper payments made to hospitals
High payment error rates  Part A claim
review (hospital)  Part B claim review
(physician)
What is a CERT error?
•
No documentation
•
Insufficient documentation
•
Medically unnecessary service
IN THE HOSPITAL CHART !!
How did we get here?
MAC-Generated
Prepayment Audits
•
MACs authorized by law to reduce
payment error rates
•
3 MACs initiated audits targeting
procedures with high error rates
•
High error rates shown for TKA/THA
(DRG 470)
MAC-Generated
Prepayment Audits
•
•
•
•
Begins with prepayment audit of hospital
claim (Part A)
If problematic, then hospital payment is
denied
Contractor looks to physician claim (Part
B) related to problematic hospital claim
If problematic, then money already paid
to physician is recouped
Documenting Medical Necessity for
Major Joint Replacement (Hip and Knee)
MLN Matters SE1236: Published by CMS in September,
2012
Described by CMS as “an educational guide to improve
compliance with documentation requirements for
major joint replacement surgery.”
To avoid denials, records should contain enough detailed
information to support the medical necessity of the
procedure.
“Painful DJD unresponsive to conservative treatment” is
not enough.
19
History
Description of pain
ADL limitations
Safety
Contraindications to non-surgical treatments
Failed conservative treatments, e.g.,
 Meds (e.g., NSAIDs)
 Weight loss
 Physical Therapy
 Intra-articular injections
 Braces, orthotics or assistive devices.
20
Physical Examination
Deformity
Range of Motion
Crepitus
Effusions
Tenderness
Gait description
21
Investigations
Results of applicable
investigations
 Plain films
 MRI
22
Clinical Judgment
Reasons for deviating from a steppedcare approach
 Intolerant of NSAIDs
 Refused injections
 Joint damage too severe to respond
(e.g., AVN femoral head)
Must be clearly documented
23
Simple game …
Documentation is the key … in your office
note, op note and discharge summary
How do you reach the decision for surgery?
Remember your chief resident or
fellowship presentations to your
attending staff !!
Reliable Resources
www.paymentaccuracy.gov
www.aaos.org/medicare101
www.ahhks.org/