Day's Pearls

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CMS has re-issued 505 with transmittal 534.  Take a look as the MAC and ZPIC can do automated denials or request records but the H&P  and the surgery are at risk. As we watch this roll out, stay tuned for other types of ‘related’ recoupments.  It has started…


CMS Transmittal 534


CMS continues to struggle with how to begin the denials/recoupments for the professional /Part B claims that are ‘related ‘ to Part A.

CMS has again rescinded one transmittal/.534 and replaced it with 540.  It appears they tried to ‘fix’ the down coding of Inpt H&P to and OBS E&M.  They took this language out but are very vague on what they actually will do.  Possibly since hospitals cannot ‘auto’ down grade to obs, the providers can’t either?   Stay tuned as the surgeons are still highly at risk for inpt surgeries not on the inpt only list …and all procedures done as an inpt not on the inpt only list….and unknown:  H&Ps /inpt.  Employed providers – the hospital will get hit 2x.  Once for the Part A and again for the Part B.  Time to get very busy auditing and training.


Transmittal 540


68% sounds like a good deal? CMS has offered a 1x deal -with the deadline the end of Oct.
Providers with appeals pending - resolve ALL appeals with a 1x payment of 68% of denied claims and keep the pt portion if it has already been paid (If a pre-pay denial, no ability to bill for the inpt deductible as it is still considered a denied claim.) Timing is important as each provider should aggressively 'do their math' and determine the cost of proceeding with the appeal/attorney/vendor/staff time and the cost of loss of interest on money/as it has been recouped= does it make sense to take the offer?
Most importantly - if vulnerabilities were identified thru the denials, regardless of the appeal, have they been aggressively addressed with creative,correction action taken?
We can do this!!


Transmittal 541


Surgeons are now at risk for ‘related claim’ recoupment.  Each MAC has to post their issue to start auditing the related claims of the surgeon, but Transmittal 541,, effective 9-8-14, outlines that it is now allowed when a part A claim is denied.


Big focus:  Inpt surgeries.  Surgery scheduling should work closely with UR for each input Medicare surgery.  If the CPT code is not on the inpt only list, UR is immediately notified.  Contact with the surgeon is made with a question- why does this surgery require 2 MN to resolve/safely discharge?  If the surgeon cannot clarify/order, then discuss moving back to outpt , watch for an unplanned/unexpected event and then convert to a higher level of care as the condition warrants.  Now the surgeon is at risk – shared risk- for incorrect status.

Certification requirement has been lifted, effective 1-1-15
All other elements of defining and supporting an inpt – reason for admission, why 2 MN (or an additional MN after the 1st one) for the dx that is included with a discharge note. The pt story!
These elements are required but do not have to be signed prior to discharge.
The admit order must be signed prior to discharge.
UPDATE: It ‘appears’ that CMS is lifting the requirement for a mid level or resident ‘with admitting privileges’ to have the MD counter-sign/authenticate for the admission order. We will await further clarity but it ‘appears’ this is the case.
Better practice ideas to ensure Inpt only surgeries are done correctly --surgery scheduler joins the UR team!
Also, who is validating the CPT code that is being scheduled? That is the biggest challenge as we cannot ‘trust’ that the office who is scheduling the procedure to have the correct CPT codes as the hospital is 100% at risk for incorrect CPTs.
HIM should join the daily process of all ‘inpt only procedures’ to ensure that the CPTs are validated. Then UR compares against the Inpt only list – present? Scheduling is also the eyes of surgeries that are routinely done as an outpt being requested as an inpt. With UR ‘joined at the hip’ with surgery, this should be treated as an uncommon event/add ons. It takes a team to ensure there is not risk with inpt surgeries. Denials/self denials/recoupments result in huge losses to the hospital.

ICD -10 readiness includes testing with every payer to ensure they are ready to accept BOTH ICD-9 and ICD -10 claims post live. The big areas of impact will likely be the ER and inpt surgery claims.
New ICD –codes = new potential edits and rejections. It is important to have HIM designate a ICD -10 ‘cleaner uper’ to research all rejected ICD 10 claims and help the organization learn what needs changed internally or to help challenge the payers if inappropriate denials. Strong internal partnerships – with using the medical record to find the variances- HIM can work closely with PFS to reduce denials and rejections. Track and trend patterns and share them rapidly to prevent repeat rejections.
It is a brave new ICD -10 world.

ICD -10’s roll out must include payer testing. The healthcare industry needs to continue to work closely, demand testing, watch for all new edits as we move from 15,000 to over 70,000 new dx codes –including a major change to the coding of an inpt surgical case. The case mix index should be watched as each sample is tested – look for the reasons the case mix is lessened – are more specific codes missing? The surgical coding combinations should be re-grouped and closely monitored.

The payer’s may or may not be willing to test all patient types – ask for the hospital association to help if they refuse. Think Y2 K – why was it so ‘transparent?”


Watch closely for the potential change with Medicare’s definition o f an inpt. But just as importantly, the non-Medicare payers are continuing to create their own ‘highly questionable’ process for determining inpt and then doing post payment denials. As much as we ‘cuss and discuss Medicare’ – their regulations are at least in print with a formal appeal process.. What about Aetna’s new directive- after 24 hrs in obs, must call for a new pre-cert and they will determine if inpt or obs. United –must meet both clinical guidelines and 2 MN.. Part C Medicare. Humana is coming out of the woodwork—post payment denials after approved thru phone authorization. Telling a much more complete patient story with WHY AN INPT – will help support all type of payer audits. Stay tuned
Continue watching for CMS to clarify any changes to the 2 MN rule –especially if there is a HUGE change to ‘rare and unusual.’ We will see with the final OPPS regs – effective 1-1-15.
Also we have new auditors for the 0-1 MN stays – the QIOs. The goal is to have more physician review and only refer to RACs for high frequency of 0-1 MN stays. We will see how all this plays out but the best policy is to document WHY AN INPT and WHAT IS THE PLAN? This is missing from almost every audit we do and it has been required since Oct 2013. THE probe and educate findings continue to find approx 50% error rate with these missing elements which would clearly outline the rationale behind the Inpt admission. Tell the pt story!
ICD 10 IS HERE—READY OR NOT! As healthcare providers prepare the biggest change in payer communication- new DX codes – it is important to ensure there are ‘humans’ overseeing all the payment activity, especially with many Medicaid state agencies stating they are not ready and will just change 10 back to 9 and pay… SCAREY! Contracts needed revised, payment scheduled that are impacted by dx codes need closely monitored as well as new dx code combination with CPT code rejections. Medically necessary edits just got a new hit. Keep your internal team on their toes – involve PFS, operations, HIM, CDI, and all aspects of payer denials. Here we go!
ICD 10 is live! And the real hit is now to a) protect case mix index with ensuring all complications are identified and coded correctly and b) payer accuracy with new DRG assignments.
The ongoing unknown of new denials with the new codes is still to come. Stay tuned for Nov!
Watch for the case mix hit from DRGs being impacted by ICD-10.
It is the next issue --ensuring that all specific dx are present. Do a comparison of the pre-ICD 10 higher intensity inpt and then compare a similar case in Icd-10. Same level of DRG?
Watch as not all payers are on the same DRG version. Case Mix Index is at risk if we are not closely monitoring the payments from the payers. Little goodies but overall, more smooth of a conversion than anticipated.

Mgd care plans are the new audit challenge. Traditional Medicare Part A is totally separate from Mgd Care Part C Medicare. Each Part C plan establishes their own areas of coverage including the definition of an inpt. Ensure the contracts with ALL payers clearly identify a) how an inpt will be determined, b) how to address disputed pt status issues and c) how to rebill post discharge disputes? Many claims are being erroneously down coded to obs even with an excellent inpt order and a dynamic plan. No contract? Fully at the mercy of the payer. Get your attorneys ready! Track and trend patterns and abuses. The road is going to be hard as the ‘rules’ are not well known by the UR Team. Contract Mgt and revenue cycle leaders need to join UR in the new mgd care/payer challenges.
Mgd care denials are hitting the hospitals at an increasing alarming speed. The Mgd Care Medicare plans are the most concerning as the facilities are unprepared for the constantly changing ‘interrupts’ from the plans with the UR staff unprepared to deal with the payers. The contracts need immediately evaluated with language to protect the site: What is an inpt? Part C does not follow Traditional Medicare’s rules.
Time to closely align the denials, contracting and UR first point of contact team. Here we go again!
Watch for continuing updates on the change to the QIO for all 2 MN audits. There is still uncertainty as to what will constitute ‘referrals to RAC for additional auditing.’ However a RI hospital, in conversation with their QIO, indicated that after 3 failed audits/major concerns the referral would happen.
Hot news as this is not clearly identified in writing by CMS. Patterns should be identified to prevent repeat ‘at risk.’ ALWAYS HAVE A PLAN for why 2 MNs..
As the QIOs continue to audit short stays, the 2 MN rule should be well documented to avoid any potential denials. Laying out a plan for why 2 MN /presumption or why the 2nd MN after the 1st outpt MN/benchmark is essential to prevent the auditors from ‘hunting.’ The brave, new world is full of auditors from all payers. Telling the pt story and why an inpt will help with Traditional Medicare plus all the mgd care plans.
QIO is on pause. But that doesn’t mean that all documentation education to support 2 MN is on ‘pause.’ Bring your CDI team, your internal physician advisors, your utilization management team ==all together and coordinate an integrated clinical documentation improvement effort. You will be amazed at the consistency of the message with the provider community…and the depth of education internally.
Dr Maria Johar, Super Physician Advisor for Promedia in Toledo, Ohio recently gave us 2 pearls:
Look for the MEAT: Monitor, evaluate, assess Treat= excellent documentation. Plan for the day, Plan for the stay, Plan for the way and Plan for the pay.
Another gem!
Medicare Part C/Medicare Advantage is not Traditional/Original Medicare… all aspects are contract driven. There is significant confusion with treating everyone the ‘same’ but MA plans are very different. Take a look at this month’s Info Line as we will continue to share the huge issues providers are dealing with. PLUS the 2017 Boot camp…it will take a village!

CMS is continuing to look for ways to get a handle on the appeal backlog. Remember that Part C Medicare DOES have an appeal process that mirrors Part A unless the facility signs a contract that says otherwise…which no one should do –right? Ensure denial mgt, UM/Care mgt and other revenue cycle leaders are closely working with contracting to address the many areas of Mgd Care disputes and denials – beyond rates. Have a great one
THE NEW RACS ARE HERE! The RACs are still not allowed to identify short stay inpts for initiation of audit but with the new contracts, the handoffs between the QIO and the RAC will begin… time to beef up your documentation of –why an inpt!
With the massive uncertainty of healthcare reform and the new administration, it is imperative that each healthcare worker realizes the unique role they have to stay educated and teach – their family, their peers, along with their immediate circle of influence. It is going to be a bumpy road with many changes and a potential for a profound change in healthcare…with lots of confused patients … Stay tuned.
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2017 will be full of healthcare chaos with many patients more confused, anguish, and even angry as Congress continues to make changes to possibly the very basic of coverage - Medicare. Stay informed, be prepared to be a leader with knowledge and integrity. Our patients need us as their advocates more than ever.
Healthcare reform is yet again an issue for the country. Promises were made by President Trump that will be extremely difficult to keep -especially as it relates to low cost, healthcare for everyone. If the proposed changes are adopted -even some of them – huge changes to employer coverage, individual coverage, low income, self-employed, chronic illnesses/loss of job, and Sec HHS & Rep Ryan’s desire to move from traditional Medicare/coverage regardless of health status or ability to pay – to an insurance market driven voucher . WOW! Which Insurance plan is ready to offer a 77 yr old with 2 chronic conditions the same premium they have now with the same out of pocket.. Part A Medicare = NO PREMIUM monthly. Hold on! VERY BUMPY ROAD!
Huge concern over the GOP’s repeal and replace of a basic healthcare option for the under 50 employers, self-employed, retires with no insurance and not 65 yet –not to mention Medicaid. Did I mention 130,000 with pre-existing conditions that are at risk? Why is it that we mandate car insurance but not our ‘body ‘ insurance? Essential benefits – maternity, mental health and birth control – are all on the chopping block. Who knows better than healthcare workers the true reason we have insurance? Speak up and educate your family and friends. Healthcare professionals – all levels – see what healthcare really is! Not the political battle.
As we watch the multiple Medicare Advantage insurance plans being investigated for potential fraud in the billing for the management of Medicare patients thru the whistleblower case -we need to be diligent to monitor and report any areas of abuse and concern. We will always be looking for ways to streamline the very labor intensive process of working with the Medicare Mgd care plans. Plus remember – if you have a Medicare pt who is covered by a payer/insurance plan you do not have a contract with – then Traditional Medicare applies. Time to buckle down and track and trend concerns. Happy summer